Coinfection of other respiratory pathogens and HIV in COVID-19 patients: Is there a pattern?

The pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) has led to the elaboration of multiple studies to increase knowledge and understanding, hence, having the ability to accomplish an adequate and timely diagnosis and give an optimal treatment according to the patient's condition. The clinical manifestations of COVID-19 pose a series of challenges both in understanding and delimiting the disease secondary to the SARS-CoV-2 infection. This is due to the fact that the main axis of this disease is the endothelial compromise and the production of a "cytokine storm," triggering multiple organ failure and death. Given that a complete understanding of its pathophysiology and clinical behavior has not yet been achieved, we wondered if coinfection with other respiratory viruses modifies its performance and outcomes described so far. A literature search was performed, obtaining 68 articles, of which 25 were analyzed. The analysis showed us that there is a high variety both in the types of associated infections and in the clinical behavior of patients and their outcomes. Therefore, we consider that the search for other infections should be performed exhaustively, especially in those cases that may be susceptible to treatment such as Influenza A, human immunodeficiency virus, or bacterial infections. As well as optimize the analysis of these cases and establish if there are characteristics that allow establishing the possibility of carrying an additional infection to that of SARS-CoV-2 and the implications for the management and prognosis of the patient.

The pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) has led to the elaboration of multiple studies to increase its knowledge and understanding, hence, having the ability to accomplish an adequate and timely diagnosis and give an optimal treatment according to the patient's condition. This disease has increased exponentially to more than 13.4 million confirmed cases globally, with a current mortality rate of 4.3% (582 547 deaths).

The clinical manifestations of COVID‐19 pose a series of challenges both in understanding and delimiting the disease secondary to the SARS‐CoV‐2 infection. These manifestations have shown an important evolution, initiating with a respiratory tract infection that in its most severe form could progress to an Acute Respiratory Distress Syndrome or reach a multisystemic compromise. This is due to the fact that the main axis of this disease is the endothelial compromise and the production of a “cytokine storm,” triggering multiple organ failure and death. As a result of these changes in the comprehension of the disease and given that a complete understanding of its pathophysiology and clinical behavior has not yet been achieved, we wonder if coinfection with other respiratory viruses modifies its performance and outcomes described so far.

To elucidate this query, a literature research was performed through the “Pubmed” platform focused on coinfection reports (the terms “COVID‐19” “SARS‐CoV‐2” and “Co‐infection” were included with the Boléan “OR” operators for the first 2 terms and “AND” for the last one in all the fields). In every scenario, the research was restricted to English and Spanish written articles, published until 1 June 2020. We obtained 65 articles, of which 43 were excluded after reading its titles and abstracts, given the lack of focus on coinfections or an inadequate result description. The remaining 22 articles were chosen for the analysis, in addition to 3 studies of coinfection with human immunodeficiency virus (HIV), according to the recommendation of experts , , (Figure 1).

Figure 1

Flow chart of article selection

The analysis of these articles shows us that there is a high variety both in the types of associated infections and in the clinical behavior of patients and their outcomes. Most of the reports focused on coinfection with respiratory pathogens, however, we found reports of unusual concomitant infections, such as periorbital cellulitis. The general analysis, that includes a total of 300 patients, revealed that the most frequent pathogen associated with coinfection was Influenza A , , (mentioned in 8 of the 19 articles focused on coinfection with respiratory pathogens), possibly following a seasonal pattern; these studies showed a slight predominance of the male sex, without preference for any age group. A single patient was diagnosed with CMV by serology, and multiple bacterial infections including Legionella were described, but these were mostly related to health care in seriously ill patients.

The most common radiological finding was “ground glass,” nonetheless, it is not exclusive; the findings range from disseminated interstitial involvement to well‐defined consolidations without following a pattern associated with coinfections. Only one study related coinfection with an increase in the severity of the disease, but in general, there is no evidence of clinical findings or a particular prognosis in these patients. Cases of severity and mortality are related to variables such as age, presence of comorbidities, lymphopenia, and elevation of D‐dimer, and proinflammatory biomarkers (polymerase Chain Reaction [PCR], procalcitonin, or interleukin‐6), which are COVID‐19 risk factors, regardless of a coinfection.

In addition, six of the studies included analyzed HIV patients (for a total of 63 reported cases). Even in patients with adequate CD4 count, undetectable viral load and receiving antiretroviral management, the reported mortality is once again related to age and comorbidities such as hypertension, dyslipidemia, obesity, and diabetes mellitus. It is noteworthy that four of these patients reported a delayed serological response for immunoglobulin M and immunoglobulin G (beyond day 20), regardless of their immunity state; as well as a varied radiological finding between consolidation and peripheral compromise with a predominance of the “ground glass” pattern , (Table 1).

Table 1

Synthesized data of COVID‐19 and coinfection articles

Title	Type of study	Journal	DOI	Number of cases (patients)	Country	SARS‐CoV‐2 diagnostic method	Results and findings	Conclusions
Co‐infection with respiratory pathogens among COVID‐2019 cases	Descriptive	Virus Research	10.1016/j.virusres.2020.198005	257	China—Jiangsu Province	rRT‐PCR‐SARS‐CoV‐2	128 Out of 183 infected men, 113 out of 119 infected women ‐ bacterial co‐infection was the most frequent, mainly by pneumococcus. Under 15 y; 11 pathogens found as a cause of co‐infection, metapneumovirus was found exclusively. 16 to 44 y; 22 pathogens, pneumococcus and klebsiella pneumoniae being the most frequent. 45 to 64 y; 19 pathogens, Chlamydia pneumoniae and Rhinovirus being the most frequent Over 65 y; 14 pathogen with pneumococcus and klebsiella pneumoniae	Bacterial and fungal co‐infections were higher in critically ill patients, but there was no statistically significant difference. No clear relationship between co‐infection, ICU admission or mortality. No differences in length of stay and age between the proportions of infection and type of pathogen.
Multicentre Italian Study of SARS‐CoV‐2 Infection in Children and Adolescents, Preliminary Data as at 10 April 2020	Descriptive	Eurosurveillance	10.2807/1560‐7917.ES.2020.25.18.2000600.	168	Italy	rRT‐PCR‐SARS‐CoV‐2	Reports that includes 11 pediatric hospitals and 51 PICUs—reports 10 patients with co‐infection 3 RSV ‐ 3 Rhinovirus ‐ 2 VEB ‐ 1 Influenza A ‐ 1 Streptococcus pneumoniae	Children and adolescents had a more favorable clinical evolution compared to adults. Consequently, the diagnosis and even the therapeutic approach in children could be more conservative than in adults.
Clinical Characteristics and Co‐Infections of 354 Hospitalized Patients With COVID‐19 in Wuhan, China: A Retrospective Cohort Study	Descriptive	Microbes and Infection	10.1016/j.micinf.2020.05.007	354	China—Renmin Hospital of Wuhan University	rRT‐PCR‐SARS‐CoV‐2	Co‐infection in 24 patients; identified 13 different pathogens, identified as a risk factor for severity (p: 0.014), higher when there is lymphopenia (p: <0.001) and elevation of D‐dimer (p: <0.001)	Co‐infection can worsen the clinical course of the disease, but other risk markers such as lymphopenia, elevation in D‐dimer and decrease in IL‐10 levels were also identified in these patients.
False‐Negative Results of Real‐Time ReverseTranscriptase Polymerase Chain Reaction for Severe Acute Respiratory Syndrome Coronavirus 2: Role of Deep‐Learning‐Based CT Diagnosis and Insights from Two Cases	Case Series	Korean Journal of Radiology	10.3348/kjr.2020.0146	2 (1 with coinfectiown)	China—Beijing Haidian Hospital	rRT‐PCR‐SARS‐CoV‐2 (3 samples to be positive)	10‐mo‐old male patient with Influenza A (diagnosed 2 wk earlier with PCR‐DNA) with radiological findings: CT ground glass lesions ‐ pneumonia with an occupancy rate of 13.3%	A case series with negative rRT‐PCR had radiological findings with a high suspicion of COVID‐19, which was later confirmed with the repetition of the test.
Cluster of Coronavirus Disease 2019 (COVID‐19) in the French Alps, 2020	Case Series	Clinical infectious diseases: an official publication of the Infectious Diseases Society of America.	10.1093/cid/ciaa424	12 (1 viral co‐infección)	France (Alpes Hotel)	rRT‐PCR‐SARS‐CoV‐2	Viral co‐infection with Influenza A and Picornavirus (rhinovirus/enterovirus) in the only pediatric patient confirmed by PCR, with favorable evolution and outpatient management	Similarities were found between the viral load of symptomatic and asymptomatic patients, which suggests a potential transmission within the asymptomatic. The fact that an infected child did not transmit the disease despite close interactions within schools suggests a different transmission dynamic in children.
COVID‐19 associated pulmonary aspergillosis	Case Series	Mycoses	10.1111/myc.13096	5	Germany—Hospital of Cologne, Cologne	rRT‐PCR‐SARS‐CoV‐2	Two women and three men between 73 to 53 y old with identification of Aspergillus by many methods (tracheal aspirate with PCR‐DNA, Ag Galactomannan and culture). All had cardiometabolic comorbidities ‐ COPD and CKD. The radiological finding in all cases was" ground glass "" and in some cases nodular infiltrates and emphysema were evident. All the patients developed ARDS, required ICU management and 1 required ECMO support.	In patients with ARDS due to COVID‐19, invasive pulmonary aspergillosis should be considered and a thorough search for this co‐infection should be made.
Co‐infection of Coronavirus Disease 2019 and Influenza A: A Report From Iran	Case Series	Archives of Iranian Medicine	10.34172/aim.2020.04	4	Iran—Shiraz University of Medical Sciences in southern Iran	rRT‐PCR‐SARS‐CoV‐2	Two women and two men between 40 and 74 y old, all with Influenza A co‐infection. Only 1 with comorbidities (HT). The radiological findings were disseminated bilaterally in the chest X‐ray and ground glass CT. They have lab results with mild transaminase elevation, only 1 with lymphopenia. Management in hospitalization, general room without complications.	The co‐infection of COVID‐19 and influenza A shows the importance of considering the SARS‐CoV‐2 PCR analysis regardless of other pathogens positive findings.
Co‐infection with SARS‐CoV‐2 and Human Metapneumovirus	Case Report	Rhode Island Medical Journal	PMID: 32192233	1	USA—Emergency Department in Rhode Island	rRT‐PCR‐SARS‐CoV‐2	Case of a 57‐y‐old woman with a history of OSAHS (requiring CPAP management), HT and Hyperlipidemia. Metapneumovirus coinfection was identified in the panel of respiratory pathogens with lymphopenia and chest X‐ray without significant findings. Symptomatic, ambulatory management without complications.	A rare coinfection is reported in an adult patient and it is considered that the algorithms of diagnosis and treatment include the search of other respiratory pathogens.
Co‐infection with SARS‐CoV‐2 and Influenza A Virus in Patient with Pneumonia, China	Case Report	Emerging Infectious Diseases	10.3201/eid2606.200299	1	China‐Japan Friendship Hospital	rRT‐PCR‐SARS‐CoV‐2	A 69‐y‐old man without comorbidities required 3 RT‐PCR samples for SARS‐CoV‐2 to be positive with a difference of 1 wk, coinfected with Influenza A. The patient had lymphopenia, and CT findings with massive ground glass consolidation in the right lower lobe of the lungs. The disease progressed to ARDS and required ICU.	The case highlights possible joint detection with other respiratory viruses. In addition, rRT‐PCR ‐ SARS‐CoV‐2 showed a low sensitivity, which might complicate the recognition COVID‐19 disease.
A Case of Coinfection with SARS‐COV‐2 and Cytomegalovirus in the Era of COVID‐19	Case Report	European Journal of Case Reports in Internal Medicine	10.12890/2020_001652	1	Italy—Chieti Hospital	rRT‐PCR‐SARS‐CoV‐2	A 92‐y‐old female patient, with a history of HT and diabetes mellitus, had lymphopenia and bilateral pneumonia. She also had a positive CMV serology (IgG and IgM), no viral load was measured. The disease progressed to ARDS and dies in the ICU	COVID‐19 is a global disease that has compromised the clinical care and health systems of many countries. Currently there is no concrete evidence in the management of patients and in many cases comorbidities and coinfections complicate the clinical scenario, particularly in the elderly.
Co‐infection with SARS‐CoV‐2 and influenza A virus	Case Report	IDCases	10.1016/j.idcr.2020.e00775	1	Japan—Tokio	rRT‐PCR‐SARS‐CoV‐2	A 78‐y‐old woman with a history of dyslipidemia and hypothyroidism and was positive to Influenza A coinfection. With radiological findings of crosslinked interstitial radiopacities and ground glass CT scan in right pleura (localized). She did not have major alterations in her lab results, requiring general hospitalization management.	As COVID‐19 cases increase, it will be necessary to thoroughly evaluate the images and other clinical findings to consider possible co‐infections with other respiratory viruses.
Case Report: The Importance of Novel Coronavirus Disease (COVID‐19) and Coinfection With Other Respiratory Pathogens in the Current Pandemic	Case Report	The American Journal of Tropical Medicine and Hygiene	10.4269/ajtmh.20‐0266	1	USA—Illinois	rRT‐PCR‐SARS‐CoV‐2	A 56‐y‐old female patient with a history of HT in whom group A Streptococcus is identified (rapid test). The chest X‐ray showed small bilateral opacities ‐ CT with small consolidations and ground glass. Patient required ECMO support with subsequent recovery.	The evidence of coinfection between various respiratory pathogens and SARS‐CoV‐2 suggests the use of algorithms where tests for viral respiratory and bacterial pathogens are carried out concomitantly with the SARS‐CoV‐2 test.
Coinfection With COVID‐19 and Coronavirus HKU1 ‐ The Critical Need for Repeat Testing if Clinically Indicated	Case Report	Journal of Medical Virology	10.1002/jmv.25890	1	Singapore	rRT‐PCR‐SARS‐CoV‐2 (three samples to be positive)	A 38‐y‐old female patient without comorbidities with coinfection with coronavirus HCoV‐HKU1 detected through the FilmArray respiratory panel test, required 3 RT‐PCR samples to detect SARS‐CoV‐2; without laboratory alterations and poorly defined bi‐basal chest X‐rays.	Physicians require a high index of suspicion to detect SARS‐CoV‐2 infection and have to be aware of possible infections among SARS‐CoV‐2 to contain and control the spread of COVID‐19.
Co‐infection with Influenza A and COVID‐19	Case Report	European Journal of Case Reports in Internal Medicine	10.12890/2020_001656	1	USA	rRT‐PCR‐SARS‐CoV‐2	A 66‐y‐old female patient with history of HT, DM, obesity, heart failure, coronary heart disease, and CKD. Laboratory results without alterations, chest X‐ray with radiopacities in the right base. Influenza A co‐infection was detected by panel of respiratory pathogens. Transfer to ICU where mechanical ventilation was required.	COVID‐19 can coexist with other viral infections and cause similar clinical manifestations. Some of these coinfections have active treatments, others will require supportive management.
SARS‐CoV‐2 and Legionella Co‐Infection in a Person Returning From a Nile Cruise	Case Report	Journal of Travel Medicine	10.1093/jtm/taaa053	1	Japan—Asahi General Hospital	rRT‐PCR‐SARS‐CoV‐2	An 80‐y‐old male patient with a history of diabetes mellitus and benign prostatic hypertrophy with Legionella pneumophila (urinary antigen ‐ serotype 1) infection is in a deleterious course with respiratory failure and dies in the ICU.	Expand the research for co‐infections that may occur with the COVID‐19 disease, especially those susceptible to treatment.
Co‐Infection with SARS‐COV‐2 and Parainfluenza in a young adult patient with pneumonia: Case Report	Case Report	IDCases	10.1016/j.idcr.2020.e00762	1	USA—Florida	rRT‐PCR‐SARS‐CoV‐2 (two samples to be positive)	A 21‐y‐old male patient with a history of consumption of psychoactive substances and an active smoker, with Parainfluenza 4 infection in a panel of respiratory pathogens, presented with elevation of C‐reactive protein, procalcitonin and ferritin, chest X‐ray showed bilateral opacities that progressively worsened and showed CT scan with multiple consolidations and ground glass. He had respiratory failure and required transfer to ICU and noninvasive mechanical ventilation‐ adequate recovery.	The case represents the importance of rapid diagnosis and recognition of possible co‐infections with other respiratory viruses.
A Case of COVID‐19 and Pneumocystis jirovecii Co‐infection	Case Report	American Journal of Respiratory and Critical Care Medicine	10.1164/rccm.202003‐0766LE	1	USA—Boston, MA	rRT‐PCR‐SARS‐CoV‐2	An 80‐y‐old female patient with a history of ulcerative colitis and mitral valve prolapse, presents lymphopenia, elevated C‐reactive protein and evidence of bilateral ground glass, atelectatic bands, nodular infiltrates, and CT consolidation. In addition, she had elevated levels of β‐ D‐glucan, reason why tracheal aspirate was performed with detection of Pneumocystis jirovecii by PCR. With deterioration to ARDS, required transfer to ICU and mechanical ventilation.	A high risk of coinfection is found in patients with COVID‐19 including Pneumocystis jirovecii, which should be suspected in patients with a suggestive risk or clinical history, not only to adjust the management but to define the relevant isolation.
Orbital cellulitis, sinusitis and intracranial abnormalities in two adolescents with COVID‐19	Case Series	Orbit	10.1080/01676830.2020.1768560	2	USA—New Jersey	rRT‐PCR‐SARS‐CoV‐2	A 12 and 15‐y‐old male patients with bacterial sinusitis infection, without clear identification of the germs. One of the patients had Streptococcus B‐hemolytic group C in the throat, require management in general hospitalization.	We present 2 cases of periorbital cellulitis with an unusual evolution concomitant to SARS‐CoV‐2 infection. It is unknown if this association is mere coincidences or reflects a potentiation or exacerbation of bacterial infection secondary to COVID‐19.
Co‐infection With COVID‐19 and Influenza A Virus in Two Died Patients With Acute Respiratory Syndrome, Bojnurd, Iran	Letter to the Editor	Journal of Medical Virology	10.1002/jmv.26014	2	Iran—Bojnurd	rRT‐PCR‐SARS‐CoV‐2	Two patients between 78 and 75 y old, (woman and man) the first with a history of COPD, both with isolation of influenza A (H1N1) had lymphopenia and the CT scans showed bilateral multifocal ground glass opacities with peripheral distribution with mild interlobular septal thickening, and opacification of the acinar center ground glass with peripheral distribution and interlobular septal thickening. Both patients died.	The findings consider other respiratory viruses in patients with suspected COVID‐19 since coinfection can worsen the evolution of the patients and even lead to death.
HIV/SARS‐CoV‐2 Coinfected Patients in Istanbul, Turkey	Case Series	Journal of Medical Virology	10.1002/jmv.25955	4	Istanbul Turkey	rRT‐PCR‐SARS‐CoV‐2; two patients with SARSCov2 IgM + IgG serology (seventh day)	4 male patients between 34 and 44 y old with history of HIV diagnosed between 12 and 2 y earlier, one without treatment with a history of bipolar affective disorder, another with obesity and diabetes, the rest without comorbidities. Patients treated with adequate disease control, normal CD4 count ‐ undetectable viral load. All with evidence of ground glass lesion on CT, in addition to this one of the patients had alveolar‐occupying viral pneumonia with a tendency to bilateral consolidation. 3 of them required management in general hospitalization with favorable evolution including the patient without treatment for his HIV disease, one patient died in ICU	Antibody formation to SARS‐CoV‐2 is found in survivors, similar to HIV‐free patients. The presence of comorbidities is likely an important factor in mortality in HIV/SARS‐CoV‐2 co‐infected cases. Therefore, to reduce mortality, it is necessary to control them mainly in patients who are aging.
Early virus clearance and delayed antibody response in a case of COVID‐19 with a history of co‐infection with HIV‐1 and HCV	Case Report	Clinical infectious diseases: an official publication of the Infectious Diseases Society of America.	10.1093/cid/ciaa408	1	China—Shenzhen Third People's Hospital	SARSCov2 IgM + IgG rRT‐PCR‐SARS‐CoV‐2 (three negative samples)	A 38‐y‐old male patient with a history of treated HVC, and HIV, had a suggestive clinical history of COVID‐19 with negative RT‐PCR but seroconversion, normal laboratories including lymphocyte counts with a finding pneumonia on CT. Favorable evolution required general hospitalization.	The first case of COVID‐19 with co‐infection of HIV‐1 and HCV is reported, with a rapid virus clearance possibly mediated by antiretroviral drugs and a delayed response in the detection of specific antibodies for possible immune dysfunction mediated by HIV‐1.
One Case of Coronavirus Disease 2019 (COVID‐19) in a patient coinfected by HIV With a Low CD4+ T‐cell Count	Case Report	International Journal of Infectious Diseases	10.1016/j.ijid.2020.04.060	1	China—Wuhan Huo Shen Shan Hoapital	rRT‐PCR‐SARS‐CoV‐2 (5 samples to be positive) IgM SARS‐CoV‐2	A 34‐y‐old male patient with a history of HIV in treatment presented with suggestive COVID‐19 symptoms. He had a low CD4 count, C‐reactive protein, high LDH, and GGT, with subsequent elevation in IL‐6; he required multiple RT‐PCR samples to detect SARS‐CoV‐2. CT showed ground glass lesions ‐ small scattered consolidations. Requires general hospitalization, and was finally discharged.	Patients infected with SARS‐Cov‐2 and HIV have longer periods of illness and slower generation of specific antibodies. In case of suspicion of COVID‐19, detection by RT‐PCT and subsequent detection of antibodies allow confirming the diagnosis. SARS‐Cov‐2 can especially damage T lymphocytes, further compromising immunity in this type of patient.
Description of COVID‐19 in HIV‐infected individuals: a single‐centre, prospective cohort	Cohort Study	The lancet. HIV.	10.1016/S2352‐3018(20)30164‐8	51	Spain—Hospital Universitario Ramón y Cajal	RT‐PCR‐SARS‐CoV‐2 in 35 patients 16 compatible clinical manifestation	Adult patients (53 ± 9.5 y) with a ratio of 5.3 men for each woman, 55% required hospitalization, 12% had a severe condition, and 4% (2 patients died). Patients coinfected with HIV/SARS‐CoV‐2 showed a higher proportion of comorbidities (HT, diabetes and CKD), as well as higher body mass index. They were treated with Tenofovir. In confirmed cases there was evidence of elevation in transaminases, LDH and dimer D, as well as progression to respiratory failure, compared to suspicious cases.	HIV infection does not protect against SARS‐CoV‐2 infection or reduces the risk of serious disease. Comorbidities continue to be a determining factor in the severity of patients.
Clinical features and outcome of HIV/SARS‐CoV‐2 coinfected patients in the Bronx, New York City	Serie de Casos	Journal of Medical Virology	10.1002/jmv.26077	9	USA—New York City, Bronx	rRT‐PCR‐SARS‐CoV‐2	Seven men and two women between 31 to 76 y old, all with comorbidities including, HT, diabetes mellitus, obesity and dyslipidemia. 7 died, all of them carried an undetectable viral load. The CD4 count was between 425‐636 in survivors and between 179 to 1827 among patients who died.	They report a higher mortality in patients with HIV‐SARS‐CoV‐2 co‐infection with a possible inversely proportional relationship between CD4 count and mortality, but all patients had comorbidities as risk factors.
Computed Tomography Imaging of an HIV‐infected Patient with Coronavirus Disease 2019 (COVID‐19)	Case Report	Journal of Medical Virology	10.1002/jmv.25879	1	China—Guiyang	rRT‐PCR‐SARS‐CoV‐2	24‐y‐old male patient with a history of HIV 2 y ago in antiretroviral management, did not have alterations in the laboratories results and the CT findings showed irregular shaded lesions in the peripheral lung, compromising the interlobar fissure, with a tendency to complete resolution in 15 d.	This report works as a reference for other possible chest tomography findings other than the ground glass pattern reported in HIV and SARS‐CoV‐2 co‐infection.

Abbreviations: HIV, human immunodeficiency virus; IgG, immunoglobulin G; IgM, immunoglobulin M; IL, interleukin; PCR, polymerase chain reaction; SARS‐CoV‐2, severe acute respiratory syndrome coronavirus 2.

The previous analysis does not show a pattern of clinical behavior or characteristic outcomes between SARS‐CoV‐2 infection and other pathogens. Therefore, we consider that the search for other infections should be performed exhaustively, especially in those cases that may be susceptible to treatment such as Influenza A (oseltamivir), HIV (antiretroviral therapy), or bacterial infections.

We also suggest that reports of coinfections should be divided according to their origin, for instance, if it is a coinfection with a respiratory virus at the beginning of the disease, or if it is an opportunistic bacterium associated with health care; all with a detailed description of the evolution of the patient, changes in laboratories and at radiological level. The foregoing, to optimize the analysis of these cases and establish if there are characteristics that allow establishing the possibility of carrying an additional infection to that of SARS‐CoV‐2 and the implications for the management and prognosis of the patient.

CONFLICT OF INTERESTS

The authors declare that there are no conflict of interests.