Respiratory virus co-infections have been suggested to happen frequently and exacerbate patients’ conditions, but little is known about the detailed rates and the combinations of viruses during the COVID-19 pandemic period. A total of 255 symptomatic patients who underwent multiplex PCR tests were analyzed, and it was found that 6 (6/255=2.4%) patients were infected with multiple viruses. The patients ranged in age from 1 to 38 years, and one female patient was pregnant. Of the 6 patients, 4 had fever, and 5 had human rhinovirus/enterovirus and another virus. These data suggested that the rate of respiratory virus co-infection was low, and the combination of SAS-CoV-2 and other viruses was rare even during the COVID-19 pandemic.

The pulmonary characteristics of Staphylococcus aureus (S. aureus) co-infection with respiratory viruses, such as SARS-CoV-2 and influenza virus, are still unclear. Case series: Two patients with methicillin-susceptible S. aureus (MSSA) infection in the lungs co-infected with either SARS-CoV-2 or influenza virus are reported. Case 1 was a 66-year-old woman who was admitted with SARS-CoV-2 infection. Her chest X-ray and computed tomography (CT) showed multiple cavity formations with infiltration shadows, and MSSA was detected from her sputum and blood, suggesting COVID-19-related bacterial pneumonia and pulmonary embolism. No catheters had been used, but she had skin eruptions and a history of SARS-CoV-2 vaccination. Ampicillin/sulbactam (ABPC/SBT) was administered, and she finally improved. Case 2 was an 87-year-old man with a history of atopic dermatitis who was admitted with moderate pneumonia, and influenza virus co-infection was found. He showed multiple cavitary shadows, and MSSA was isolated from both his sputum and blood. He was diagnosed with influenza-related bacterial pulmonary embolism. No catheters had been used, but he had a history of influenza vaccination. He was also treated by ABPC/SBT and finally improved. Conclusions: These cases suggest that MSSA showed affinity to the lungs when co-infected with either SARS-CoV-2 or influenza virus, and it presented as septic emboli without catheter use. We should consider MSSA infection when patients have SARS-CoV-2 or influenza virus co-infection, and multiple cavity formation and skin disorders are seen, even though they were vaccinated and no catheters were used.

Introduction: Concurrent infections or co-infections in patients diagnosed with Coronavirus Disease-19 (COVID-19) are not uncommon and predict a pejorative prognosis. A co-infection accounts for 1 out of every 5 cases of COVID-19 and increases the likelihood of adverse health outcomes such as mechanical ventilations, ICU admissions, and death. Specifically, Legionella spp. co-infection presents additional challenges in COVID-19 patients because of its rarity, similar clinical presentation to SARS-CoV-2, and poorer outcomes without prompt treatment. Cases Presentation: Case 1. A 62-year-old female presented with a 3-day history of subjective fever and worsening shortness of breath. Room air saturation (saO2) was 70% and improved to 100% on noninvasive positive- pressure ventilation (NIPPV). Lung auscultation revealed rales BL. Chest X –Ray (CXR) showed patchy airspace opacities bilaterally (BL), SARS-CoV-2 PCR and urine legionella antigen tests were positive. The diagnosis of hypoxic respiratory failure secondary to COVID-19 and Legionella pneumonia was made. Patient was admitted to intensive care unit (ICU) and managed with decadron, remdesivir, one unit of convalescent plasma for COVID-19 and Azithromycin for Legionella. Patient subsequently developed acute respiratory distress syndrome (ARDS). ARDS protocol was initiated. 13 days after, the patient was compassionately extubated. Case 2. A 41-year-old male presented with 5-day history of fever, worsening shortness of breath, cough and diarrhea. Patient admitted history of ethanol abuse. SaO2 was 88% and improved on oxygen canula. Lung auscultation revealed rhonchi BL. CXR showed extensive left lung consolidation. Urine test for legionella antigen was positive. COVID-19 PCR was negative, but SARS-CoV-2 IgG was reactive. The diagnosis of Legionnaire disease was made. Despite initial treatment with Azithromycin, patient's hypoxia continued to worsen requiring NIPPV, and subsequently mechanical ventilation in the ICU. The adjunction of empiric treatment for COVID-19 with convalescent plasma, remdesivir and steroids improved both clinicals and laboratory findings. Discussion: The cases illustrated the practical challenges of managing COVID-19 and legionella co- infection. Legionella spp and SARS-CoV-2 overlapping incubation periods and similar clinical presentations and complications. In the absence of diagnosis and treatment, legionella pneumonia has an intrinsic mortality rate of up to 80%. As some COVID-19 mitigation strategies, such as the closure of businesses, have enhanced the conditions for Legionella spp proliferation, the incidence of Co-infection with COVID-19 may increase. We recommend clinicians to have high-indexed suspicion of COVID-19 and Legionella co-infection in order to obtain complete work up at patient’s initial presentation.

Mucormycosis or black fungus although a rare fungal infection but has potential to be lethal and thus requires immediate treatment. The immune system is weakened due to SARS-CoV-2 and the body becomes susceptible and vulnerable to other infections as people are immune compromised. The immune system becomes weakened due to COVID-19 treatment especially in patients who are taking steroids making the body prone to attack by black fungus. As the black fungus cases are increasing in India, the country is facing shortage in medicaments in face of dual crisis. An epidemic of black fungus is sweeping India in the wake of a severe surge in COVID-19 cases. Experts are of the opinion that the cause is a combination of factors. These factors might include contaminated oxygen equipment and use of steroid drugs to treat certain COVID-19 patients.