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ACADEMIA Letters HIV-TB co-morbidity in a resource-limited setting during covid-19 lockdown: a case report ikechukwu orji Abstract Tuberculosis is the most common opportunistic infection and the leading cause of death among people with HIV/AIDS. Objective: To highlight the negative effect of stigmatization and disrupted health services occasioned by Covid 19 pandemic-lockdown on the outcome of managing HIV-TB co-morbidity in a resource-limited setting. Case Presentation: This 40-year-old woman was hospitalized in 2020, with a complaint of recurrent fever, diarrhea, and rash for 6 months. Also, cough, chest pain, night sweat, weight loss, reduced appetite, and weakness, for 4 months. Then, abdominal and leg swelling, with facial puffiness of one-month duration. Moreover, her partner died one year before her presentation from a similar illness. On examination, she was febrile, pale, tachypneic with tachycardia and pedal edema. There was abdominal distension and generalized maculopapular rash.GeneXpert MTB/RIF detected mycobacterium tuberculosis in the sputum without Rifampicin resistance. Chest radiograph revealed right upper lobe opacity and bilateral crepitations. Abdominal ultrasound reported mesenteric lymphadenopathy, ascites, nephropathy, and hepatomegaly. Her HIV screening was positive with CD4 + of 187 Cells/µL. Anemia, deranged liver enzymes, high Electrolyte, urea, and creatinine values were reported. First-line anti-TB treatment was started, with HAART given 2 weeks later. She received 3-pints of blood among other treatments, during her 4week stay in hospital admission. She improved, was discharged, followed up weekly for one month with a total resolution of her symptoms, and then, resumed her work. However, as reported by her sister, she was stigmatized in her office, which drove her to seek spiritual help for supposed permanent healing. Because she believed she received spiritual healing and to prove the same to her colleagues, she stopped her medications. The situation was made worse because the hospital treatment support specialist was unable to reach her home due to the covid 19 lockdown restrictions. Her condition deteriorated Academia Letters, July 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0 Corresponding Author: ikechukwu orji, drtony2013@gmail.com Citation: Orji, I. (2021). HIV-TB co-morbidity in a resource-limited setting during covid-19 lockdown: a case report. Academia Letters, Article 1655. https://doi.org/10.20935/AL1655. 1 leading to her demise. Conclusion: HIV-TB co-morbidity can be successfully managed in a resource-limited setting, but there is a need for robust psycho-social support for the patients. Keywords: HIV/AIDS, Tuberculosis, HIV-TB Co-infection, covid-19-lockdown, resourceconstrained setting INTRODUCTION Tuberculosis (TB) is the most common opportunistic infection and the leading cause of death among people living with HIV/AIDS,[1] with 208,000 deaths recorded in 2020.[2] Nigeria is the country with the highest TB burden in Africa.[3] At the global level, Nigeria is ranked 6th among countries with the highest TB burden.[4] In terms of high burden countries for combined; Tuberculosis, TB/HIV co-morbidity, and Multi Drug-Resistant TB, Nigeria is ranked 14th globally.[5] It has been reported that HIV and multi-drug resistant TB has worsened the growing challenge of TB in Nigeria.[5] Among high burden countries, TB-HIV co-infection poses several challenges ranging from diagnosis, implementing guidelines of latent TB treatment, managing active TB cases, providing ideal patient-centered TB management, and HIV care and prevention.[6] Since the emergence of the HIV/AIDS pandemic, the loss of millions of lives and huge economic loss has been attributed to TB/HIV co-morbidity, due to the systemic interaction between the virus and epidemics of tuberculosis.[7] The objective of this report is to highlight the negative effect of stigmatization and disrupted health services occasioned by Covid’s 19 pandemic-lockdown on the outcome of managing HIV-TB co-morbidity in a resource-limited setting. TB/HIV co-morbidity when managed following approved guidelines results in a good outcome as reported by Călărașu et al in 2019,[7] however, the outcome may be influenced by other extraneous factors as described in this report. CASE PRESENTATION This is the case of a 40-year-old woman who was hospitalized in 2020 on account of recurrent fever, diarrhea, and generalized body rash, all of six months duration. And chronic cough of 4 months duration associated with chest pain, night sweat, weight loss, reduced appetite, extreme weakness, mouth sores, and pain in swallowing. Furthermore, there was a one-month history of abdominal swelling, bilateral leg swelling associated with facial puffiness, occasional hiccups, and breathlessness on mild exertion. The patient had been treating the above Academia Letters, July 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0 Corresponding Author: ikechukwu orji, drtony2013@gmail.com Citation: Orji, I. (2021). HIV-TB co-morbidity in a resource-limited setting during covid-19 lockdown: a case report. Academia Letters, Article 1655. https://doi.org/10.20935/AL1655. 2 complaints with over-the-counter medicines from local medicine vendors with little or no improvements. Native and local concoctions were also used all to no avail. There was a history of unprotected sexual intercourse with her male partner. Moreover, her partner died one year before her presentation from a similar illness. She is a non-smoker and there is no history of illicit intravenous drug use. General examination: She was chronically ill-looking, cachectic, in obvious respiratory distress, febrile (38.50c,) with severe palpebral pallor and anicteric. There was bilateral pedal edema up to the mid-leg, with generalized peripheral lymphadenopathy (cervical, submandibular, axillary, inguinal). Her blood pressure was 100/60mmHg with a Pulse Rate of 110bpm, and a Respiratory Rate of 52cpm. She weighed 50kg with a height of 1.55meters and a BMI of 21kg/m2. Chest examination revealed equal chest expansion, central trachea, and no chest wall deformity. She was Tachypneic (Respiratory Rate = 54cpm) with dull percussion notes and bronchial breath sounds on the anterior right upper lung zone. Bilateral crepitations were also observed. Cardiovascular System examination found tachycardia (110 bpm) and normal 1st & 2nd heart sounds without murmur. The examination of the digestive system revealed oral thrush, buccal cavity ulcers, abdominal distension, mild tender hepatomegaly, and ascites. Skin examination found generalized maculopapular rash affecting the face, the limbs, and the trunk. She was conscious and alert with good orientation in person, place & time during the CNS examination. With the differential diagnosis of Koch’s disease (1. pulmonary tuberculosis, 2. extrapulmonary (abdominal) tuberculosis), full-blown AIDS (WHO stage 4), nephropathy, malaria, to rule out viral hepatitis, the following laboratory and radiographic investigations were carried out: Acid-fast bacilli (AFB) smear from sputum was positive and GeneXpert MTB/RIF detected mycobacterium tuberculosis in the specimen without Rifampicin resistance. Sputum bacterial culture did not yield any organism and the erythrocyte sedimentation rate (ESR) was high, at 109 mm/1st hour. Chest radiograph revealed patchy opacity at the right upper lobe while Abdominal Ultrasound reported Mesenteric Lymphadenopathy, Ascites, Nephropathy, and Hepatomegaly. Screening for HIV 1 & 2 antibodies was confirmed positive and the CD4 count reported 187 Cells/µL which was very Low. Both the Creatinine and Urea reported high values and the Electrolytes were deranged as well. The Liver Enzymes (aspartate transaminase (AST)=78 U/L and alanine transaminase (ALT)=69 U/L) were moderately increased while Hb (9.8g/dl), Leukocytes (3,000 cells/µL), and platelets (102) were all low. The malaria Parasite test was positive whereas Hepatitis B and C Screening tests were both negative. Following the confirmation of diagnosis, she was counseled before the commencement of treatment as well as periodically while on admission. The patient voluntarily disclosed her HIV status to Academia Letters, July 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0 Corresponding Author: ikechukwu orji, drtony2013@gmail.com Citation: Orji, I. (2021). HIV-TB co-morbidity in a resource-limited setting during covid-19 lockdown: a case report. Academia Letters, Article 1655. https://doi.org/10.20935/AL1655. 3 her biological sister who is her caregiver. The first-line anti-TB treatment with isoniazid (INH), rifampicin (RIF), ethambutol (EMB), and pyrazinamide (PZA) was started. The doses were calculated for the patient’s weight and closely monitored for adverse reactions. The highly active antiretroviral therapy (HAART) was delayed until 2 weeks after starting anti-TB drugs because the CD4 count was below 200 cells/µ according to WHO guidelines. While on admission, she received other drugs such as antibiotics, anti-malaria, hematinic, transfused 3 pints of blood, given several pints of intravenous fluid, and she improved markedly during the four weeks of hospital admission. She was discharged and followed up weekly over the next one month at the outpatient clinic and discharged from the clinic, only to be coming for her routine monthly appointment for ARV and anti-TB drug refill. According to her sister, the patient returned to her work, but experienced discrimination and stigmatization, as the news of her HIV status leaked. She could not cope psychologically and sort spiritual help for the permanent healing of her medical condition. With the assurance that she has been healed spiritually, she stopped taking her medications and proclaimed to her co-workers that she was free of any lifelong illness. Following her serial clinic appointment default, the treatment support specialist was not able to visit her since her discharge due to covid 19 lockdown. Thus, her health condition deteriorated over the next two and half months. One fateful morning, she was brought unconscious to the hospital after she collapsed in her bathroom. All efforts to resuscitate her failed and was declared clinically dead. DISCUSSION This case report describes a patient who presented with signs and symptoms of active tuberculosis and retroviral disease with associated renal complications. Our case unlike some published case reports[7,8] did not pose diagnostic difficulty usually experienced in some HIV-TB co-infection. A history of contact raised the index of suspicion coupled with the fact that the laboratory findings were a pointer to the diagnosis. Managing active tuberculosis as well as HIV/AIDS also was not associated with expected difficulty in contrast to some published reports.[7] The resultant effect is the good clinical outcome achieved while the patient was hospitalized and during the first one month of weekly clinic follow-up management. This good outcome may be associated with the close monitoring achieved while the patients were on admission and during the short weekly clinic appointments. However, the importance of good management of other extraneous factors such as stigmatization at the workplace comes to light in consideration of the downturn of events that followed. This case also emphasizes the need for a strong treatment support specialist who can give the needed psychosocial supAcademia Letters, July 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0 Corresponding Author: ikechukwu orji, drtony2013@gmail.com Citation: Orji, I. (2021). HIV-TB co-morbidity in a resource-limited setting during covid-19 lockdown: a case report. Academia Letters, Article 1655. https://doi.org/10.20935/AL1655. 4 port, follow-up defaulting patients, and succeed in bringing them back to continue prescribed treatment. After about two months, the non-adherence of the patient to the treatment led to the speedy deterioration of her condition resulting in her demise…a preventable death. The literature had proven that the Human immunodeficiency virus amplifies mycobacterium tuberculosis and vice versa, at both the cellular and molecular levels inhibiting certain defense mechanisms of the body, thereby accelerating the disease condition.[7] This may be the explanation for the sudden deterioration of this patient. Other challenges experienced in the co-management of tuberculosis and HIV/AIDS may be pill burden, drug interactions, and toxicities, and complications like IRIS and multi-drug resistant TB.8 These were mitigated by the close monitoring of the patient during the first one month of hospitalization in addition to weekly appointment over the next one month after discharge from hospital admission. Close monitoring is vital because the adherence of the patients to the prescribed treatment plays a key role in recovery.[7] CONCLUSION Our clinical case demonstrated that HIV-TB co-morbidity can be successfully managed in a resource-limited setting, as evidenced by the initial improvement, but, revealed the critical need for psycho-social support at the hospital setting, home, and workplace for the successful management of such HIV-TB co-morbidity. REFERENCES 1. Tiewsoh JB, Antony B, Boloor R. HIV-TB co-infection with clinical presentation, diagnosis, treatment, outcome and its relation to CD4 count, a cross-sectional study in a tertiary care hospital in coastal Karnataka. J Family Med Prim Care 2020; 9:1160-5. Available at http://www.jfmpc.com 2. Chakaya J., Khan M., Ntoumi F., Aklillu E., Fatima. R., Mwaba P., et al. Global Tuberculosis Report 2020 – Reflections on the Global TB burden, treatment and prevention efforts. International Journal of Infectious Diseases, 2021. ISSN 1201-9712. Available at: https://www.sciencedirect.com/science/article/pii/S1201971221001934 3. Adepoju P. Nigeria’s widening tuberculosis gap – The Lancet. 2020 Jan; 20. www.thelancet.com /infection. Doi PIIS1473-3099(19)30712-1 Academia Letters, July 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0 Corresponding Author: ikechukwu orji, drtony2013@gmail.com Citation: Orji, I. (2021). HIV-TB co-morbidity in a resource-limited setting during covid-19 lockdown: a case report. Academia Letters, Article 1655. https://doi.org/10.20935/AL1655. 5 4. World Health Organization. Global Tuberculosis Report 2019. Available from https:// www.who.int/teams/global-tuberculosis-programme/global-report-2019 5. Kanabus, A. Information about Tuberculosis. GHE, 2020. Available from www.tbfacts.org 6. Letang E., Ellis J., Naidoo K., Casas E., C., Sánchez P., Hassan-Moosa R., et al. TuberculosisHIV Co-Infection: Progress and Challenges After Two Decades of Global Antiretroviral Treatment Roll-Out. Archivos de Bronconeumología, 2020; 56 (7): 446-454, ISSN 03002896. https://doi.org/10.1016/j.arbres.2019.11.015. 7. Călărașu C., Niţu M., Olteanu M., Golli A., L., Dumitrescu F., Olteanu M. Pulmonary tuberculosis with the atypical presentation because of unknown previous HIV infection – case report. Sciendo, pneumonologia. 2019 (68): 41 -45. DOI: 10.2478/pneum-20190011 • 68 • 2019 • 41-45 8. Montales M.T., Chaudhury A.B.A., Patil N. Mycobacterium tuberculosis infection in an HIV-positive patient. 2015 Oct 27; 16: 160–162. doi: 10.1016/j.rmcr.2015.10.006 Academia Letters, July 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0 Corresponding Author: ikechukwu orji, drtony2013@gmail.com Citation: Orji, I. (2021). HIV-TB co-morbidity in a resource-limited setting during covid-19 lockdown: a case report. Academia Letters, Article 1655. https://doi.org/10.20935/AL1655. 6
ACADEMIA Letters HIV-TB co-morbidity in a resource-limited setting during covid-19 lockdown: a case report ikechukwu orji Abstract Tuberculosis is the most common opportunistic infection and the leading cause of death among people with HIV/AIDS. Objective: To highlight the negative effect of stigmatization and disrupted health services occasioned by Covid 19 pandemic-lockdown on the outcome of managing HIV-TB co-morbidity in a resource-limited setting. Case Presentation: This 40-year-old woman was hospitalized in 2020, with a complaint of recurrent fever, diarrhea, and rash for 6 months. Also, cough, chest pain, night sweat, weight loss, reduced appetite, and weakness, for 4 months. Then, abdominal and leg swelling, with facial puffiness of one-month duration. Moreover, her partner died one year before her presentation from a similar illness. On examination, she was febrile, pale, tachypneic with tachycardia and pedal edema. There was abdominal distension and generalized maculopapular rash.GeneXpert MTB/RIF detected mycobacterium tuberculosis in the sputum without Rifampicin resistance. Chest radiograph revealed right upper lobe opacity and bilateral crepitations. Abdominal ultrasound reported mesenteric lymphadenopathy, ascites, nephropathy, and hepatomegaly. Her HIV screening was positive with CD4 + of 187 Cells/µL. Anemia, deranged liver enzymes, high Electrolyte, urea, and creatinine values were reported. First-line anti-TB treatment was started, with HAART given 2 weeks later. She received 3-pints of blood among other treatments, during her 4week stay in hospital admission. She improved, was discharged, followed up weekly for one month with a total resolution of her symptoms, and then, resumed her work. However, as reported by her sister, she was stigmatized in her office, which drove her to seek spiritual help for supposed permanent healing. Because she believed she received spiritual healing and to prove the same to her colleagues, she stopped her medications. The situation was made worse because the hospital treatment support specialist was unable to reach her home due to the covid 19 lockdown restrictions. Her condition deteriorated Academia Letters, July 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0 Corresponding Author: ikechukwu orji, drtony2013@gmail.com Citation: Orji, I. (2021). HIV-TB co-morbidity in a resource-limited setting during covid-19 lockdown: a case report. Academia Letters, Article 1655. https://doi.org/10.20935/AL1655. 1 leading to her demise. Conclusion: HIV-TB co-morbidity can be successfully managed in a resource-limited setting, but there is a need for robust psycho-social support for the patients. Keywords: HIV/AIDS, Tuberculosis, HIV-TB Co-infection, covid-19-lockdown, resourceconstrained setting INTRODUCTION Tuberculosis (TB) is the most common opportunistic infection and the leading cause of death among people living with HIV/AIDS,[1] with 208,000 deaths recorded in 2020.[2] Nigeria is the country with the highest TB burden in Africa.[3] At the global level, Nigeria is ranked 6th among countries with the highest TB burden.[4] In terms of high burden countries for combined; Tuberculosis, TB/HIV co-morbidity, and Multi Drug-Resistant TB, Nigeria is ranked 14th globally.[5] It has been reported that HIV and multi-drug resistant TB has worsened the growing challenge of TB in Nigeria.[5] Among high burden countries, TB-HIV co-infection poses several challenges ranging from diagnosis, implementing guidelines of latent TB treatment, managing active TB cases, providing ideal patient-centered TB management, and HIV care and prevention.[6] Since the emergence of the HIV/AIDS pandemic, the loss of millions of lives and huge economic loss has been attributed to TB/HIV co-morbidity, due to the systemic interaction between the virus and epidemics of tuberculosis.[7] The objective of this report is to highlight the negative effect of stigmatization and disrupted health services occasioned by Covid’s 19 pandemic-lockdown on the outcome of managing HIV-TB co-morbidity in a resource-limited setting. TB/HIV co-morbidity when managed following approved guidelines results in a good outcome as reported by Călărașu et al in 2019,[7] however, the outcome may be influenced by other extraneous factors as described in this report. CASE PRESENTATION This is the case of a 40-year-old woman who was hospitalized in 2020 on account of recurrent fever, diarrhea, and generalized body rash, all of six months duration. And chronic cough of 4 months duration associated with chest pain, night sweat, weight loss, reduced appetite, extreme weakness, mouth sores, and pain in swallowing. Furthermore, there was a one-month history of abdominal swelling, bilateral leg swelling associated with facial puffiness, occasional hiccups, and breathlessness on mild exertion. The patient had been treating the above Academia Letters, July 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0 Corresponding Author: ikechukwu orji, drtony2013@gmail.com Citation: Orji, I. (2021). HIV-TB co-morbidity in a resource-limited setting during covid-19 lockdown: a case report. Academia Letters, Article 1655. https://doi.org/10.20935/AL1655. 2 complaints with over-the-counter medicines from local medicine vendors with little or no improvements. Native and local concoctions were also used all to no avail. There was a history of unprotected sexual intercourse with her male partner. Moreover, her partner died one year before her presentation from a similar illness. She is a non-smoker and there is no history of illicit intravenous drug use. General examination: She was chronically ill-looking, cachectic, in obvious respiratory distress, febrile (38.50c,) with severe palpebral pallor and anicteric. There was bilateral pedal edema up to the mid-leg, with generalized peripheral lymphadenopathy (cervical, submandibular, axillary, inguinal). Her blood pressure was 100/60mmHg with a Pulse Rate of 110bpm, and a Respiratory Rate of 52cpm. She weighed 50kg with a height of 1.55meters and a BMI of 21kg/m2. Chest examination revealed equal chest expansion, central trachea, and no chest wall deformity. She was Tachypneic (Respiratory Rate = 54cpm) with dull percussion notes and bronchial breath sounds on the anterior right upper lung zone. Bilateral crepitations were also observed. Cardiovascular System examination found tachycardia (110 bpm) and normal 1st & 2nd heart sounds without murmur. The examination of the digestive system revealed oral thrush, buccal cavity ulcers, abdominal distension, mild tender hepatomegaly, and ascites. Skin examination found generalized maculopapular rash affecting the face, the limbs, and the trunk. She was conscious and alert with good orientation in person, place & time during the CNS examination. With the differential diagnosis of Koch’s disease (1. pulmonary tuberculosis, 2. extrapulmonary (abdominal) tuberculosis), full-blown AIDS (WHO stage 4), nephropathy, malaria, to rule out viral hepatitis, the following laboratory and radiographic investigations were carried out: Acid-fast bacilli (AFB) smear from sputum was positive and GeneXpert MTB/RIF detected mycobacterium tuberculosis in the specimen without Rifampicin resistance. Sputum bacterial culture did not yield any organism and the erythrocyte sedimentation rate (ESR) was high, at 109 mm/1st hour. Chest radiograph revealed patchy opacity at the right upper lobe while Abdominal Ultrasound reported Mesenteric Lymphadenopathy, Ascites, Nephropathy, and Hepatomegaly. Screening for HIV 1 & 2 antibodies was confirmed positive and the CD4 count reported 187 Cells/µL which was very Low. Both the Creatinine and Urea reported high values and the Electrolytes were deranged as well. The Liver Enzymes (aspartate transaminase (AST)=78 U/L and alanine transaminase (ALT)=69 U/L) were moderately increased while Hb (9.8g/dl), Leukocytes (3,000 cells/µL), and platelets (102) were all low. The malaria Parasite test was positive whereas Hepatitis B and C Screening tests were both negative. Following the confirmation of diagnosis, she was counseled before the commencement of treatment as well as periodically while on admission. The patient voluntarily disclosed her HIV status to Academia Letters, July 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0 Corresponding Author: ikechukwu orji, drtony2013@gmail.com Citation: Orji, I. (2021). HIV-TB co-morbidity in a resource-limited setting during covid-19 lockdown: a case report. Academia Letters, Article 1655. https://doi.org/10.20935/AL1655. 3 her biological sister who is her caregiver. The first-line anti-TB treatment with isoniazid (INH), rifampicin (RIF), ethambutol (EMB), and pyrazinamide (PZA) was started. The doses were calculated for the patient’s weight and closely monitored for adverse reactions. The highly active antiretroviral therapy (HAART) was delayed until 2 weeks after starting anti-TB drugs because the CD4 count was below 200 cells/µ according to WHO guidelines. While on admission, she received other drugs such as antibiotics, anti-malaria, hematinic, transfused 3 pints of blood, given several pints of intravenous fluid, and she improved markedly during the four weeks of hospital admission. She was discharged and followed up weekly over the next one month at the outpatient clinic and discharged from the clinic, only to be coming for her routine monthly appointment for ARV and anti-TB drug refill. According to her sister, the patient returned to her work, but experienced discrimination and stigmatization, as the news of her HIV status leaked. She could not cope psychologically and sort spiritual help for the permanent healing of her medical condition. With the assurance that she has been healed spiritually, she stopped taking her medications and proclaimed to her co-workers that she was free of any lifelong illness. Following her serial clinic appointment default, the treatment support specialist was not able to visit her since her discharge due to covid 19 lockdown. Thus, her health condition deteriorated over the next two and half months. One fateful morning, she was brought unconscious to the hospital after she collapsed in her bathroom. All efforts to resuscitate her failed and was declared clinically dead. DISCUSSION This case report describes a patient who presented with signs and symptoms of active tuberculosis and retroviral disease with associated renal complications. Our case unlike some published case reports[7,8] did not pose diagnostic difficulty usually experienced in some HIV-TB co-infection. A history of contact raised the index of suspicion coupled with the fact that the laboratory findings were a pointer to the diagnosis. Managing active tuberculosis as well as HIV/AIDS also was not associated with expected difficulty in contrast to some published reports.[7] The resultant effect is the good clinical outcome achieved while the patient was hospitalized and during the first one month of weekly clinic follow-up management. This good outcome may be associated with the close monitoring achieved while the patients were on admission and during the short weekly clinic appointments. However, the importance of good management of other extraneous factors such as stigmatization at the workplace comes to light in consideration of the downturn of events that followed. This case also emphasizes the need for a strong treatment support specialist who can give the needed psychosocial supAcademia Letters, July 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0 Corresponding Author: ikechukwu orji, drtony2013@gmail.com Citation: Orji, I. (2021). HIV-TB co-morbidity in a resource-limited setting during covid-19 lockdown: a case report. Academia Letters, Article 1655. https://doi.org/10.20935/AL1655. 4 port, follow-up defaulting patients, and succeed in bringing them back to continue prescribed treatment. After about two months, the non-adherence of the patient to the treatment led to the speedy deterioration of her condition resulting in her demise…a preventable death. The literature had proven that the Human immunodeficiency virus amplifies mycobacterium tuberculosis and vice versa, at both the cellular and molecular levels inhibiting certain defense mechanisms of the body, thereby accelerating the disease condition.[7] This may be the explanation for the sudden deterioration of this patient. Other challenges experienced in the co-management of tuberculosis and HIV/AIDS may be pill burden, drug interactions, and toxicities, and complications like IRIS and multi-drug resistant TB.8 These were mitigated by the close monitoring of the patient during the first one month of hospitalization in addition to weekly appointment over the next one month after discharge from hospital admission. Close monitoring is vital because the adherence of the patients to the prescribed treatment plays a key role in recovery.[7] CONCLUSION Our clinical case demonstrated that HIV-TB co-morbidity can be successfully managed in a resource-limited setting, as evidenced by the initial improvement, but, revealed the critical need for psycho-social support at the hospital setting, home, and workplace for the successful management of such HIV-TB co-morbidity. REFERENCES 1. Tiewsoh JB, Antony B, Boloor R. HIV-TB co-infection with clinical presentation, diagnosis, treatment, outcome and its relation to CD4 count, a cross-sectional study in a tertiary care hospital in coastal Karnataka. J Family Med Prim Care 2020; 9:1160-5. Available at http://www.jfmpc.com 2. Chakaya J., Khan M., Ntoumi F., Aklillu E., Fatima. R., Mwaba P., et al. Global Tuberculosis Report 2020 – Reflections on the Global TB burden, treatment and prevention efforts. International Journal of Infectious Diseases, 2021. ISSN 1201-9712. Available at: https://www.sciencedirect.com/science/article/pii/S1201971221001934 3. Adepoju P. Nigeria’s widening tuberculosis gap – The Lancet. 2020 Jan; 20. www.thelancet.com /infection. Doi PIIS1473-3099(19)30712-1 Academia Letters, July 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0 Corresponding Author: ikechukwu orji, drtony2013@gmail.com Citation: Orji, I. (2021). HIV-TB co-morbidity in a resource-limited setting during covid-19 lockdown: a case report. Academia Letters, Article 1655. https://doi.org/10.20935/AL1655. 5 4. World Health Organization. Global Tuberculosis Report 2019. Available from https:// www.who.int/teams/global-tuberculosis-programme/global-report-2019 5. Kanabus, A. Information about Tuberculosis. GHE, 2020. Available from www.tbfacts.org 6. Letang E., Ellis J., Naidoo K., Casas E., C., Sánchez P., Hassan-Moosa R., et al. TuberculosisHIV Co-Infection: Progress and Challenges After Two Decades of Global Antiretroviral Treatment Roll-Out. Archivos de Bronconeumología, 2020; 56 (7): 446-454, ISSN 03002896. https://doi.org/10.1016/j.arbres.2019.11.015. 7. Călărașu C., Niţu M., Olteanu M., Golli A., L., Dumitrescu F., Olteanu M. Pulmonary tuberculosis with the atypical presentation because of unknown previous HIV infection – case report. Sciendo, pneumonologia. 2019 (68): 41 -45. DOI: 10.2478/pneum-20190011 • 68 • 2019 • 41-45 8. Montales M.T., Chaudhury A.B.A., Patil N. Mycobacterium tuberculosis infection in an HIV-positive patient. 2015 Oct 27; 16: 160–162. doi: 10.1016/j.rmcr.2015.10.006 Academia Letters, July 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0 Corresponding Author: ikechukwu orji, drtony2013@gmail.com Citation: Orji, I. (2021). HIV-TB co-morbidity in a resource-limited setting during covid-19 lockdown: a case report. Academia Letters, Article 1655. https://doi.org/10.20935/AL1655. 6