Objectives To describe the presentation and outcome of SARS–CoV2 infection in an African setting of high non–communicable co–morbidity and also HIV–1 and tuberculosis prevalence. Design Case control analysis with cases stratified by HIV–1 and tuberculosis status. Setting A single–centre observational case–control study of adults admitted to a South African hospital with proven SARS–CoV–2 infection or alternative diagnosis. Participants 104 adults with RT–PCR–proven SARS–CoV2 infection of which 55 (52.9%) were male and 31 (29.8%) HIV–1 co–infected. 40 adults (35.7% male, 30.9% HIV–1 co–infected) admitted during the same period with no RT–PCR or serological evidence of SARS–CoV2 infection and assigned alternative diagnoses. Additional in vitro data from prior studies of 72 healthy controls and 118 HIV–1 uninfected and infected persons participants enrolled to a prior study with either immune evidence of tuberculosis sensitization but no symptoms or microbiologically confirmed pulmonary tuberculosis. Results Two or more co–morbidities were present in 57.7% of 104 RT–PCR proven COVID–19 presentations, the commonest being hypertension (48%), type 2 diabetes mellitus (39%), obesity (31%) but also HIV–1 (30%) and active tuberculosis (14%). Amongst patients dually infected by tuberculosis and SARS–CoV–2, clinical features could be dominated by either SARS–CoV–2 or tuberculosis: lymphopenia was exacerbated, and some markers of inflammation (D–dimer and ferritin) elevated in singly SARS–CoV–2 infected patients were even further elevated (p less than 0.05). HIV–1 and SARS–CoV2 co–infection resulted in lower absolute number and proportion of CD4 lymphocytes, with those in the lowest peripheral CD4 percentage strata exhibiting absent or lower antibody responses against SARS–CoV2. Death occurred in 30/104 (29%) of all COVID–19 patients and in 6/15 (40%) of patients with coincident SARS–CoV–2 and tuberculosis. Conclusions In this South African setting, HIV–1 and tuberculosis are common co–morbidities in patients presenting with COVID–19. In environments in which tuberculosis is common, SARS–CoV–2 and tuberculosis may co–exist with clinical presentation being typical of either disease. Clinical suspicion of exacerbation of co–existent tuberculosis accompanying SARS–CoV–2 should be high.
Few studies from Africa have described the clinical impact of co-infections on SARS-CoV-2 infection. Here, we investigate the presentation and outcome of SARS-CoV-2 infection in an African setting of high HIV-1 and tuberculosis prevalence by an observational case cohort of SARS-CoV-2 patients. A comparator group of non SARS-CoV-2 participants is included. The study includes 104 adults with SARS-CoV-2 infection of whom 29.8% are HIV-1 co-infected. Two or more co-morbidities are present in 57.7% of participants, including HIV-1 (30%) and active tuberculosis (14%). Amongst patients dually infected by tuberculosis and SARS-CoV-2, clinical features can be typical of either SARS-CoV-2 or tuberculosis: lymphopenia is exacerbated, and some markers of inflammation (D-dimer and ferritin) are further elevated (p < 0.05). Amongst HIV-1 co-infected participants those with low CD4 percentage strata exhibit reduced total, but not neutralising, anti-SARS-CoV-2 antibodies. SARS-CoV-2 specific CD8 T cell responses are present in 35.8% participants overall but undetectable in combined HIV-1 and tuberculosis. Death occurred in 30/104 (29%) of all COVID-19 patients and in 6/15 (40%) of patients with coincident SARS-CoV-2 and tuberculosis. This shows that in a high incidence setting, tuberculosis is a common co-morbidity in patients admitted to hospital with COVID-19. The immune response to SARS-CoV-2 is adversely affected by co-existent HIV-1 and tuberculosis.
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