Pillay Somasundram, Magula Nombulelo
Department of Internal medicine, Faculty of Health Sciences, University of KwaZulu-Natal, Durban, South Africa.
South Afr J HIV Med. 2021 Jan 28;22(1):1192. doi: 10.4102/sajhivmed.v22i1.1192. eCollection 2021.
Human immunodeficiency virus (HIV), Tuberculosis (TB) and coronavirus disease (COVID-19) infections independently possess the ability to trigger formation of venous thromboembolism (VTE) and pulmonary embolism (PE). To the authors' knowledge, this is the first case report describing the presence of PE in a patient with all three aforementioned infectious co-morbidities.
A patient living with HIV with virological failure secondary to defaulting antiretroviral therapy (ART) presented with hypoxia, clinical and radiological features suggestive of community-acquired pneumonia (CAP) with raised inflammatory markers and D-dimer levels.
She was commenced on prophylactic anticoagulation, supplemental oxygen and empirical antibiotics targeting CAP and pneumocystis jiroveci pneumonia, swabbed for COVID-19 infection and had sputa sent for Gene Xpert® TB testing. A day later, COVID-19 results returned positive and the patient was transferred to isolation and added onto dexamethasone and therapeutic anticoagulation. Sputa returned positive for mycobacterium TB a day later, and anti-tuberculosis therapy was added. She remained persistently hypoxic, with a Well's score of 3 placing her at moderate risk for PE, which prompted for a computed tomography pulmonary angiogram (CTPA) being ordered, which demonstrated left lower lobe subsegmental PE. Warfarin was added to her regimen. She was discharged on day 18 with a therapeutic international normalised ratio (INR) and not requiring oxygen therapy.
This scenario is relevant in low to middle-income countries. The utilisation of a raised D-Dimer in the setting of all four coexisting conditions in arriving at a definite diagnosis remains uncertain. We noted that despite our index patient being on thrombo-prophylaxis, she developed PE highlighting the need for increased vigilance in all COVID-19 patients, even those on prophylactic anticoagulation.
人类免疫缺陷病毒（HIV）、结核病（TB）和冠状病毒病（COVID-19）感染各自都有引发静脉血栓栓塞（VTE）和肺栓塞（PE）的能力。据作者所知，这是首例描述一名患有上述所有三种感染性合并症的患者出现肺栓塞的病例报告。
一名感染HIV的患者因未坚持抗逆转录病毒治疗（ART）导致病毒学失败，出现缺氧症状，临床和影像学特征提示社区获得性肺炎（CAP），炎症标志物和D-二聚体水平升高。
开始给予预防性抗凝治疗、补充氧气，并使用针对CAP和耶氏肺孢子菌肺炎的经验性抗生素，进行COVID-19感染检测拭子采样，并将痰液送去进行GeneXpert®结核检测。一天后，COVID-19检测结果呈阳性，患者被转移至隔离病房，并加用地塞米松和治疗性抗凝治疗。一天后痰液结核分枝杆菌检测呈阳性，开始给予抗结核治疗。她持续缺氧，Wells评分为3分，提示有中度肺栓塞风险，这促使安排了计算机断层扫描肺动脉造影（CTPA），结果显示左下叶亚段肺栓塞。在她的治疗方案中加用了华法林。她在第18天出院，国际标准化比值（INR）达到治疗水平，且无需吸氧治疗。
这种情况在低收入和中等收入国家具有相关性。在所有四种并存疾病的情况下，利用升高的D-二聚体来做出明确诊断仍不确定。我们注意到，尽管我们的索引患者接受了血栓预防治疗，但她仍发生了肺栓塞，这凸显了对所有COVID-19患者，即使是接受预防性抗凝治疗的患者，都需要提高警惕。
