# A Case of Persistent KSHV Viremia in the Context of HIV, SARS-CoV-2, and Other Co-Infections

## TL;DR

A man with HIV and other infections had persistent high KSHV virus levels, which could increase his risk for severe KSHV-related diseases.

## Contribution

This case study reports persistent lytic KSHV viremia in a PLWH patient co-infected with SARS-CoV-2 and tuberculosis.

## Key findings

- The patient had unusually high KSHV viral load before and after SARS-CoV-2 infection.
- Inflammatory markers CRP and IL-6 increased steadily during the 2-year follow-up.
- HIV viral load remained controlled, but CD4 count was near immunosuppression levels.

## Abstract

Despite the high prevalence of latent Kaposi’s sarcoma-associated herpesvirus (KSHV) infections in patients from endemic areas with a high human immunodeficiency virus (HIV) prevalence, KSHV lytic reactivation in the context of other co-infections is not well understood. Lytic KSHV infections can contribute to severe inflammatory symptoms and KSHV-associated pathogenesis. We have previously reported on KSHV reactivation upon severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) exposure in a non-hospitalised cohort of people living with HIV (PLWH). From this cohort, we identified a 34-year-old male who presented for routine HIV care in May 2021 with an unusually high KSHV viral load (VL) of 189,946.3 copies/106 cells, before SARS-CoV-2 infection. The patient was invited into a 2-year follow-up study where his peripheral blood was analysed for selected virological, clinical, and inflammatory parameters every 6 months. He remained highly viremic for KSHV throughout the 2-year study period, during which he was infected with SARS-CoV-2 and developed disseminated tuberculosis, with steadily increasing levels of the inflammatory markers C-reactive protein (CRP), and interleukin-6 (IL-6). His HIV VL remained controlled (<1000 copies/mL) and his CD4 count bordered immunosuppression (±200 cells/µL), suggesting some responsiveness to antiretroviral treatment (ART). However, the patient’s uncontrolled lytic KSHV infection may increase his risk for developing a KSHV-associated pathology manifesting with inflammation which should be closely monitored beyond the study period.