TO TEST OR NOT TO TEST? A CASE OF SARS-COV-2 AND INFLUENZA A VIRUS CO-INFECTION

Van Mecl, Amanda; Alzaiem, Firas; Dabage-Forzoli, Nemer

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Coronavirus Disease 2019 (COVID-19) has caused a global Pandemic with a likely zoonotic origin. The etiological agent of this disease has been identified as Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Testing has been scarce, leading to a highly selective criteria to administer the test. These factors have led to a standard of care mandating a rule out process of other infectious etiologies prior to testing for COVID-19. This highlighted the unpreparedness of the global healthcare infrastructure. We present a case of co-infection with SARS-CoV-2, Influenza A virus, and Haemophilus Influenza bacteremia infections. CASE PRESENTATION: 88 year old female with medical history of coronary artery disease, heart failure, COPD, VTE, presented to the hospital with fever and dyspnea for one week. Patient had been compliant with social distancing. Initial workup revealed a positive Influenza A and bilateral infiltrates on chest x-ray. Inflammatory markers were elevated, including Ferritin, C-reactive protein, Interleukin-6, Lactate Dehydrogenase and D-dimer. Due to continued hypoxia, patient was intubated. SARS-CoV-2 nasopharyngeal PCR was found to be positive. Blood cultures were also positive for Haemophilus Influenza. A course of Oseltamivir, Hydroxychloroquine and Ceftriaxone was completed. She responded well to therapy and was ultimately extubated on day nine. Patient was discharged making a full recovery. DISCUSSION: We highlight a case of SARS-CoV-2 with not only influenza A co-infection, but a Haemophilus influenza bacteremia of presumed respiratory source. Literature confirms that the most common superimposed bacterial infections related to Influenza A are bacterial pneumonias secondary to S. aureus, S. pneumoniae, and H. influenzae;and co-infection with Influenza A tends to be the most deadly. Rates of severe infection and mortality are highest in those aged greater than 65 and with co-morbidities. As SARS-CoV-2 is still a novel coronavirus being studied, there is limited literature regarding co-infection, however there are several case reports of influenza A coinfection with SARS-CoV-2. A positive influenza screen does not exclude SARS-CoV-2 infection, and a positive SARS-CoV-2 result does not preclude the development of bacterial superinfection. There is certainly a benefit in continued management of both influenza and potential coverage for bacterial causes until appropriate testing is obtained. CONCLUSIONS: This case demonstrates the probable underdiagnosis of SARS-CoV-2 given the under-reported rate of co-infections with other respiratory viruses. We recommend that clinicians take into consideration the likelihood of co-infection of pathogens along with SARS-CoV-2, both viral and bacterial. We also recommend higher volume testing for SARS-CoV-2, especially during this pandemic, as it will be crucial for not only controlling the spread, but improving clinical management. Reference #1: Rynda-Apple, A., Robinson, K.M., & Alcorn, J.F. (2015, October). Influenza and Bacterial Superinfection: Illuminating the Immunologic Mechanisms of Disease. Infection and immunity., 83(10), 3764-70. doi:10.1128/IAI.00298-15 Reference #2: Percival, S.L., Hatzifoti, C., & Heath, A.W. (2009). Influenza in the Elderly. Microbiology and Aging., 113-130. doi:10.1007/978-1-59745-327-1_6 Reference #3: Denise E. Morris, David W. Cleary, Stuart C. Clarke, Stuart C. Clarke, & Stuart C. Clarke (2017, June 23). Secondary Bacterial Infections Associated with Influenza Pandemics. Frontiers in Microbiology., 8. doi:10.3389/fmicb.2017.01041 DISCLOSURES: No relevant relationships by Firas Alzaiem, source=Web Response No relevant relationships by Nemer Dabage-Forzoli, source=Web Response No relevant relationships by Amanda Van Mecl, source=Web Response