Safety and Immunogenicity of a Single Dose of BNT162b2 COVID-19 mRNA Vaccine in a Warfarin-Treated Protein S Deficient Patient: A Case Report and Literature Review.

Patients with protein S (PS) deficiency possibly have a higher risk of developing severe COVID-19 disease. Therefore, vaccination against SARS-CoV-2 infections is recommended for PS-deficient patients. However, there are limited data regarding the safety and immunogenicity of the currently available COVID-19 mRNA vaccine in PS-deficient patients. We report a case of monitoring the antibody response of a 40-year-old female diagnosed with PS deficiency and on warfarin treatment following a single dose of BNT162b2 mRNA vaccine. Antibody against the receptor-binding domain (RBD) of the SARS-CoV-2 spike (S) protein (anti-S) was measured on days 7, 14, and 21 after vaccination. Seroconversion was detected on day 21 but was possibly lower than the anti-S level previously reported in healthy individuals after receiving the first dose of the BNT162b2 mRNA vaccine. There were no local and systemic events reported up to 7 days in this patient after vaccination. This case highlights that the administration of the BNT162b2 vaccine had a favourable safety profile, and the second dose of the vaccine is required to provide the optimal protection against SARS-CoV-2 infection in PS-deficient patients.

Prevalence and Determinants of COVID-19 Vaccine Acceptance in South East Asia: A Systematic Review and Meta-Analysis of 1,166,275 Respondents.

Despite its importance in guiding public health decisions, studies on COVID-19 vaccination acceptance and its determinants in South East Asia (SEA) are lacking. Therefore, this study aims to determine the prevalence of COVID-19 vaccine acceptance and the variables influencing the vaccine's acceptance. This review is registered under PROSPERO CRD42022352198. We included studies that reported vaccination acceptance from all SEA countries, utilising five academic databases (Pubmed, MEDLINE, Cochrane Library, Science Direct, and Google Scholar), three Indonesian databases (the Indonesian Scientific Journal Database, Neliti, and Indonesia One Search), two pre-print databases (MedRxiv and BioRxiv), and two Thailand databases (ThaiJo and Thai-Journal Citation Index). The analysis was conducted using STATA 17.0 with metaprop commands. The prevalence for COVID-19 vaccination acceptance in SEA was 71% (95%CI 69-74; I2 99.87%, PI: 68.6-73.5). Myanmar achieved the highest COVID-19 vaccination acceptance prevalence, with 86% (95%CI 84-89), followed by Vietnam with 82% (95% CI 79-85; I2 99.04%) and Malaysia with 78% (95%CI 72-84; I2 99.88%). None of the ten determinants studied (age, sex, education, previous COVID-19 infections, smoking and marriage status, health insurance, living together, chronic diseases, and healthcare workers) were significantly associated with acceptance. This result will be useful in guiding vaccination uptake in SEA.

Factors associated with side effects of COVID-19 vaccine in Indonesia.

PURPOSE: As coronavirus disease 2019 (COVID-19) continues to spread rapidly causing approximately 186 million confirmed cases around the world, the urgency to reach herd immunity through vaccination is increasing. However, vaccine safety is a top priority to limit the occurrence of adverse events. Henceforth, this study aims to recognize and perceive COVID-19 vaccine safety in Indonesia during the pandemic. MATERIALS AND METHODS: This is a cross-sectional study and was conducted in Indonesia during the COVID-19 pandemic using an online survey of demographic information and a qualitative questionnaire. Responses were recorded and the association between demographic characteristics from survey questions was tested using chi-square with a risk estimate and 95% confidence interval. RESULTS: A total of 311 participants from 33 out of 34 provinces in Indonesia participated in this study. Recorded responses showed multiple side effects of the COVID-19 vaccine both short- and long-term experienced by the participants. Significant associations were found between demographic factors and COVID-19 vaccine side effects such as female gender with short-term puncture site (odds ratio [OR], 0.463; 95% confidence interval [CI], 0.263-0.816) and short-term other reactions (OR, 0.463; 95% CI, 0.263-0.816), domicile outside Java island with long-term puncture site (OR, 4.219; 95% CI, 1.401-12.701) and immune reactions (OR, 3.375; 95% CI, 1.356-8.398), also between married marital status and long-term vagal reaction (OR, 4.655; 95% CI, 1.321-16.409). CONCLUSION: Gender, domicile and marital status factors were associated with COVID-19 vaccine side effects in Indonesian people.

Antibody response after a third dose mRNA-1273 vaccine among vaccinated healthcare workers with two doses of inactivated SARS-CoV-2 vaccine.

BACKGROUND: Health care workers (HCWs), a high-risk group for contracting COVID-19 disease, are being prioritized to receive COVID-19 vaccination. A third dose messenger RNA (mRNA) vaccine, mRNA-1273 (Moderna), after 2 doses of inactivated vaccine (CoronaVac), has been used to increase the level of protection against SARS-CoV-2 among Indonesian HCWs. However, data regarding antibody response after mRNA-1273 booster dose are limited. OBJECTIVE: To evaluate the receptor-binding domain (RBD) of the SARS-CoV-2 spike (S) protein (anti-S) titers induced by the third mRNA-1273 vaccine among fully vaccinated HCWs with CoronaVac. RESULTS: A total of 90 HCWs with no history of SARS-CoV-2 infection and who had received the third dose of vaccination were included in this study. The mRNA-1273 vaccine booster was administered 6 months after completing primary vaccination with CoronaVac. After the third dose, the anti-S antibodies level significantly increased, from a median of 41.7 U/mL (interquartile range [IQR], 22.4-92.5) to 28 394 U/mL (IQR, 20 837-41 646) (p <0.0001). After the third dose, seropositivity with the anti-S antibodies level >210 U/mL was observed in all HCWs. Age was negatively associated with the anti-S antibodies level after the mRNA-1273 booster. CONCLUSION: The heterologous prime booster with CoronaVac and mRNA-1273 vaccine booster elicit a pronounced antibody response against SARS-CoV-2 infection.

Insulin Therapy and Outcome of Coronavirus Disease 2019 (COVID-19): A Systematic Review, Meta-Analysis, and Meta-Regression.

BACKGROUND: Currently, the relationship between insulin therapy and COVID-19 outcome is not yet established. Our study aims to evaluate the possible association between insulin and the composite poor outcome of COVID-19. METHODS: We systematically searched the PubMed and Europe PMC database using specific keywords related to our aims until December 12th, 2020. All articles published on COVID-19 and insulin were retrieved. Statistical analysis was done using Review Manager 5.4 and Comprehensive Meta-Analysis version 3 software. RESULTS: Our pooled analysis showed that insulin use was associated with composite poor outcomes of COVID-19 [OR 2.06 (95% CI 1.70 - 2.48), p < 0.00001, I2 = 83%, random-effect modelling], and its subgroup which comprised of risk of COVID-19 [OR 1.70 (95% CI 1.40 - 2.08), p < 0.00001, I2 = 34%, random-effect modelling], severe COVID-19 [OR 2.30 (95% CI 1.60 - 3.30), p < 0.00001, I2 = 88%, random-effect modelling], and mortality [OR 2.14 (95% CI 1.47 - 3.10), p < 0.0001, I2 = 85%, random-effect modelling]. Meta-regression showed that the association was influenced by age (p = 0.008), but not by diabetes p = 0.423) and cardiovascular disease (p = 0.086). CONCLUSION: Physicians should be more aware and take extra precautions with diabetes patients who use insulin therapy.

Mental health problems in Indonesian internship doctors during the COVID-19 pandemic.

BACKGROUND: All new graduate medical doctors in Indonesia will work in government healthcare facilities for one year as internship doctors. Problems such as the shortage of PPE, no specific treatment guidelines, and inadequate support from authorities, contributed to mental health problems. This study aimed to determine mental health problems and associated demographics and concerns of Indonesian internship doctors in the COVID-19 pandemic era. METHODS: This cross-sectional study was performed from 1-31 Januari 2021 via Google Form questionnaire to collect data. Logistic regression analysis was used to identify the association between demographic data, concerns in internship doctors' working place, and mental health using Depression Anxiety Stress Scale 21. RESULTS: Depression, anxiety, and stress in internship doctors were 32.6, 44.1, and 19.5% consecutively. Multivariate analysis showed that the only demographic factor associated with depression was female sex. Concerns of internship doctors were the most factors associated with mental health. Working in triage was associated with depression and stress. Donning and doffing training of PPE, difficulty to practice physical distancing and hesitancy to attend patients were associated with depression and anxiety. Difficulty to practice physical distancing in hospital w associated with anxiety and stress. LIMITATION: Firstly, some difficulties in data collection. Secondly, the self-reported tools of mental health are not always aligned with the psychiatric assessment. Lastly, possibility of recall biases from each batch. CONCLUSIONS: To minimize mental health problems of internship doctors, their concerns must be tackled. Medical schools have an important role to manage concerns of these internship doctors.

How Does Mucorales Benefit from the Dysregulated Iron Homeostasis During SARS-CoV-2 Infection?

Mucorales is the cause of mucormycosis, an emerging opportunistic infection in the era of coronavirus disease 2019 (COVID-19) pandemic. Condition of hyperglycemia, diabetes mellitus, and acidosis; dysregulated iron homeostasis in the form of hyperferritinemic syndrome, and high concentration of iron in circulation; and endothelial injury related to abundance glucose regulated protein 78 (GRP78), which are present in severe COVID-19, could favor Mucorales infection. In this short communication, we summarized how the dysregulated iron homeostasis in severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection benefits Mucorales.

Antibody response to the inactivated SARS-CoV-2 vaccine among healthcare workers, Indonesia.

BACKGROUND: As healthcare workers (HCWs) are at high risk for infection with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), they have priority for receipt of the coronavirus disease 2019 (COVID-19) vaccine. The inactivated SARS-CoV-2 vaccine has been used in Indonesia to induce an antibody response against SARS-CoV-2 infection in HCWs. However, information regarding the kinetics of antibodies induced by this vaccine remains scarce. OBJECTIVE: To investigate the magnitude and durability of antibodies against the spike (S) protein (anti-S) in fully-vaccinated HCWs using an electrochemiluminescence immunoassay. RESULTS: Seroconversion of anti-S antibodies was observed among 159 (99.4%) of 160 HCWs without prior SARS-CoV-2 infection 14 days after full-dose vaccination. The level of anti-S antibodies decreased significantly by day 42 post-vaccination compared with day 14 post-vaccination, but persisted for up to 98 days post-vaccination. In contrast, vaccinated HCWs with prior SARS-CoV-2 infection had significantly higher, stable levels of anti-S antibodies compared with vaccinated HCWs without prior SARS-CoV-2 infection. CONCLUSION: The remarkable decline and lower level of anti-S antibodies among HCWs without prior SARS-CoV-2 infection may indicate the need for an additional booster dose of SARS-CoV-2 vaccine for protection against COVID-19. This study of antibody responses induced by the inactivated SARS-CoV-2 vaccine among HCWs may contribute to future policy decisions regarding vaccination.

The role of COVID-19 survivor status and gender towards neutralizing antibody titers 1, 2, 3 months after Sinovac vaccine administration on clinical-year medical students in Indonesia.

BACKGROUND: Sinovac was the first vaccine used in Indonesia against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). However, data regarding the effects of certain variables such as clinical demographics on antibody levels in individuals vaccinated with Sinovac are scarce. This study aimed to investigate the impact of gender and previous SARS-CoV-2 infection status on neutralizing antibody titers 1, 2, and 3 months after administration of the Sinovac vaccine. METHOD: A cross-sectional study was conducted from February to May 2021. Data on neutralizing antibody levels, previous SARS-CoV-2 infection status, and gender were retrieved from the monthly quantitative serology evaluation database of Siloam Hospitals Lippo Village, Tangerang, Indonesia. The role of each variable was analyzed using the t-test or Mann-Whitney U test, depending on data distribution. RESULT: Data from 350 participants were collected for the study. Participants with a history of a positive SARS-CoV-2 RT-PCR test had significantly higher neutralizing antibody titers in the first (144 U/mL, p = 0.036) and second months (144 U/mL, p = 0.005) after vaccination compared with those without a history of positive RT-PCR test. Female participants also had significantly higher neutralizing antibody titers in the first, second, and third months (43 U/mL, 42 U/mL, and 39 U/mL, respectively; p = 0.001, p = 0.002, and p = 0.003, respectively) after vaccination compared to males. CONCLUSION: COVID-19 survivor status and the female gender were associated with higher neutralizing antibody titers after Sinovac vaccine administration.

Social media exposure and mental health problems during coronavirus disease 2019 pandemic in Indonesia.

BACKGROUND: Several preventive measures were used by governments around the world to suppress the transmission of SARS-CoV-2, including quarantine. During quarantine more people are at risk of developing mental health problems as social media exposure was increasing. OBJECTIVES: The objective is to investigate the impact of social media exposure during coronavirus disease 2019 (COVID-19) pandemic on depression, anxiety, and stress. MATERIALS AND METHODS: A cross-sectional study was conducted between April and May 2020 during the large scale social restriction in Indonesia using online questionnaire Indonesian citizens over 18 years of age were invited to take part by answering online questionnaire through Google forms (http://bit.ly/duniamayaCOVID). Data gathered were demographic data, depression, anxiety, and stress that were assessed using Depression Anxiety Stress Scale-21, duration of social media usage, and social media platforms used during COVID-19 pandemic. Data was analysed using Pearson Chi-square and ANOVA. Statistically significant variables and additional risk factors was analyzed using multinomial logistic regression. RESULTS: The median age was 24 years (range 17-56 years), 121 (55,0%) samples were female. The three most frequent social media platforms used by participants were Instagram, WhatsApp, and YouTube. Female were more likely to suffer from mild-moderate depression compared to male (odds ratio [OR]: 2.344; 95% confidence interval [CI]: 1.105-4.972; P = 0.026) and more likely to suffer from severe-extremely severe anxiety (OR: 2.066; 95% CI: 1.019-4.187; P = 0.044). Social media exposure was associated with less likelihood to suffer from severe-extremely severe depression, mild-moderate, and severe-extremely severe anxiety, mild-moderate stress. CONCLUSION: Social media exposure was associated with less depression, anxiety, and stress in the COVID-19 pandemic era. Medical professionals and government officials could use social media to disseminate knowledge about COIVD-19 to bring positive psychological effect.

Post-vaccination cases of COVID-19 among healthcare workers at Siloam Teaching Hospital, Indonesia.

BACKGROUND: Healthcare workers (HCWs) are at increased risk of exposure to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), the cause of coronavirus disease 2019 (COVID-19), compared with the general population. Therefore, they are given priority for the COVID-19 vaccine in the national COVID-19 vaccination campaign in Indonesia. However, while the daily number of new COVID-19 cases remains high, and data regarding the efficacy of the vaccine in healthcare settings remain unavailable, vaccinated HCWs remain at risk of COVID-19 infection and further transmission. OBJECTIVE: To identify cases of COVID-19 among vaccinated HCWs at Siloam Teaching Hospital, Indonesia via active and passive surveillance conducted by the hospital's COVID-19 infection prevention and control unit. RESULTS: Of 1040 HCWs who had received two doses of the COVID-19 vaccine, 13 (1.25%) tested positive for SARS-CoV-2 RNA on reverse transcriptase polymerase chain reaction between 2 and 11 days (median 5 days) after the second vaccination. CONCLUSION: Laboratory-confirmed COVID-19 among vaccinated HCWs soon after the second vaccination indicates that HCWs remain at risk of COVID-19. Therefore, the presence of symptoms soon after full vaccination cannot be considered as vaccine-related symptoms, and regular COVID-19 testing should be conducted among HCWs.

Is procalcitonin a part of human immunological response to SARS-CoV-2 infection or "just" a marker of bacterial coinfection?

Elevated PCT level in COVID-19 was associated with higher risk of severe disease and higher risk of overall mortality. An increased PCT level of PCT in COVID-19 patients especially in severe cases would be assumed as bacterial coinfection. Could PCT level increase in SARS-CoV-2 infection without bacterial coinfection? Several SARS-CoV-2 proteins activate STAT3-dependent transcriptional pathways particularly in monocytes, that could lead to increased PCT production. STAT3α isoform could cause increased ACE2 expression, resulting more SARS-CoV-2 infected cells and further production of PCT.

Human Immunodeficiency Virus (HIV) and outcomes from coronavirus disease 2019 (COVID-19) pneumonia: A Meta-Analysis and Meta-Regression.

AIDS Research and Human Retroviruses officially retracts the Instant Online/Just Accepted version of the article entitled, "Human Immunodeficiency Virus (HIV) and Outcomes from Coronavirus Disease 2019 (COVID-19) Pneumonia: A Meta-Analysis and Meta-Regression" (epub 27 Jan 2021; doi.org/10.1089/AID.2020.0307). A technical issue caused the accepted version to post online before all plagiarism checks were finalized. Those checks determined that there was too much duplication from previously published sources which prevented the continuance to final publication. The technical issue that caused the premature posting has since been corrected. AIDS Research and Human Retroviruses and its Publisher are committed to upholding the standards of scientific publishing and the community it serves. BACKGROUND: The number of positive and death cases from coronavirus disease 2019 (COVID-19) is still increasing until now. One of the most prone individuals, even in normal situations is patients with HIV. Currently, the evidence regarding the link between HIV and COVID-19 is still limited and conflicting. This study aims to analyze the relationship between HIV and poor outcomes of COVID-19 infection. METHODS: We systematically searched the PubMed and Europe PMC database using specific keywords related to our aims until January 12th, 2021. All articles published on COVID-19 and HIV were retrieved. The quality of the study was assessed using the Newcastle Ottawa Scale (NOS) tool for observational studies. Statistical analysis was done using Review Manager 5.4 and Comprehensive Meta-Analysis version 3 software. RESULTS: A total of 38 studies with 18,271,025 COVID-19 patients were included in this meta-analysis. This meta-analysis showed that HIV was not associated with composite poor outcome [OR 1.08 (95% CI 0.95 - 1.23), p = 0.26, I2 = 68%, random-effect modelling]. Meta-regression showed that the association with composite poor outcome was influenced by hypertension (p < 0.00001) and diabetes (p = 0.0007). Subgroup analysis which involves only studies from African region showed that HIV was associated with composite poor outcomes [OR 1.11 (95% CI 1.03 - 1.21), p = 0.01, I2 = 0%, random-effect modelling]. CONCLUSIONS: Patients with HIV should still be considered as a population for whom precautions are needed to prevent the COVID-19. The availability of antiretroviral therapy should be ensured.

Inflammatory and hematologic markers as predictors of severe outcomes in COVID-19 infection: A systematic review and meta-analysis.

BACKGROUND: Laboratory testing is commonly performed in patients with COVID-19. Each of the laboratory parameters has potential value for risk stratification and prediction of COVID-19 outcomes. This systematic review and meta-analysis aimed to evaluate the difference between these parameters in severe and nonsevere disease and to provide the optimal cutoff value for predicting severe disease. METHOD: We performed a systematic literature search through electronic databases. The variables of interest were serum procalcitonin, albumin, C-reactive protein (CRP), D-dimer, and lactate dehydrogenase (LDH) levels in each group of severity outcomes from COVID-19. RESULTS: There were a total of 4848 patients from 23 studies. Our meta-analysis suggest that patients with severe COVID-19 infections have higher procalcitonin, (mean difference 0.07; 95% CI 0.05-0.10; p < 0.00001), CRP (mean difference 36.88; 95% CI 29.10-44.65; p < 0.00001), D-Dimer (mean difference 0.43; 95% CI 0.31-0.56; p < 0.00001), and LDH (mean difference 102.79; 95% CI 79.10-126.49; p < 0.00001) but lower levels of albumin (mean difference -4.58; 95% CI -5.76 to -3.39; p < 0.00001) than those with nonsevere COVID-19 infections. The cutoff values for the parameters were 0.065 ng/mL for procalcitonin, 38.85 g/L for albumin, 33.55 mg/L for CRP, 0.635 µ/L for D-dimer, and 263.5 U/L for LDH, each with high sensitivity and specificity. CONCLUSION: This meta-analysis suggests elevated procalcitonin, CRP, D-dimer, and LDH and decreased albumin can be used for predicting severe outcomes in COVID-19.

Experience of using tocilizumab for treatment in Indonesian patients with severe COVID-19.

COVID-19 is a public health emergency of international concern with millions confirmed cases globally including in Indonesia with more than two hundred thousand confirmed cases to date COVID-19. (1) COVID-19 has wide clinical manifestation ranging from asymptomatic, acute respiratory illness, respiratory failure that necessitates mechanical ventilation and support in an ICU, to MODS. (2) Several comorbidities have been demonstrated to be associated with the development of severe outcomes from COVID-19 infection, such as hypertension, diabetes, cardiovascular disease, dyslipidemia, thyroid disease, and pulmonary disease. (3)-(5) Severe COVID-19 is associated with increased plasma concentrations of IL-6, resulting in cytokine storm. (6) Tocilizumab, an interleukin-6 inhibitor, might alleviates the cytokine storm, prevents significant lungs and organs damage, thus improving clinical outcomes. (7) Therefore, tocilizumab, might be one of the promising therapies for severe COVID-19. (8) However there were limited studies regarding the efficacy in COVID-19 patients, especially with control group. We would like to report our experience in using tocilizumab as treatment in severe COVID-19 patients in Indonesia, which is the first in Indonesia to the best of our knowledge.

The prevalence of uninvestigated dyspepsia and the association of physical exercise with quality of life of uninvestigated dyspepsia patients in Indonesia: An internet-based survey.

BACKGROUND: Epidemiological data on the prevalence of uninvestigated dyspepsia (UD) and its impact on the health-related quality of life (HRQOL) in Indonesian population are still lacking. There is no study investigating the association between exercise and the HRQOL in UD patients. We aimed to investigate the prevalence of UD and its association with physical exercise, and its impact on HRQOL in Indonesian patients with UD. METHODS: This was a population-based, cross-sectional study, conducted using an internet-based questionnaire which was randomly distributed throughout Indonesia using the social media. The questionnaire contained socio-demographic details, exercise levels, Rome III criteria for dyspepsia, and SF-NDI (Short Form-Nepean Dyspepsia Index). The frequency, duration, the intensity of exercise, and the classification of exercise according to ACSM (American College of Sports Medicine) were included in the assessment. The screening for UD was conducted using the Rome III criteria and the SF-NDI score was calculated to assess the HRQOL in patients with UD. RESULTS: A total of 2725 valid responses were collected. The overall prevalence of UD in the study was 49.75%. Multiple logistic regression analysis showed that gender (female) and lack of exercise were independently associated with UD (OR 2.07, 95% CI 1.74-2.47, p < 0.001 and OR 1.72, 95% CI 1.42-2.07, p < 0.001). The median SF-NDI score among 1295 UD subjects in non-exercising and exercising groups was 21.00 and 18.00 (p < 0.001), respectively. CONCLUSION: This study demonstrated the prevalence of UD and the association between exercise and HRQOL among UD patients in Indonesia.

Coronavirus disease 2019 and cardiovascular system: A narrative review.

At the end of 2019, a viral pneumonia disease called coronavirus disease 2019 (COVID-19), which is caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV2), emerged in Wuhan, China. This novel disease rapidly spread at an alarming rate that as a result, it has now been declared pandemic by the World Health Organization. Although this infective disease is mostly characterized by respiratory tract symptoms, increasing numbers of evidence had shown considerable amounts of patients with cardiovascular involvements and these were associated with higher mortality among COVID-19 patients. Cardiac involvement as a possible late phenomenon of the viral respiratory infection is an issue that should be anticipated in patients with COVID-19. Cardiovascular manifestation in COVID-19 patients include myocardial injury (MI), arrhythmias, cardiac arrests, heart failure and coagulation abnormality, ranging from 7.2% up to 33%. The mechanism of cardiac involvement in COVID-19 patients involves direct injury to myocardial cells mediated by angiotensin-converting enzyme 2 (ACE2) receptors as suggested by some studies, while the other studies suggest that systemic inflammation causing indirect myocyte injury may also play a role. Combination of proper triage, close monitoring, and avoidance of some drugs that have cardiovascular toxicity are important in the management of cardiovascular system involvement in COVID-19 patients. The involvement of the cardiovascular system in COVID-19 patients is prevalent, variable, and debilitating. Therefore, it requires our attention and comprehensive management.

The dilemma in a case of immune thrombocytopenia in a patient with human immunodeficiency virus on antituberculosis treatment for miliary pulmonary tuberculosis.

The multifactorial mechanisms of immune thrombocytopenia (ITP) in patients with human immunodeficiency virus (HIV) and tuberculosis (TB) could be caused by HIV, TB or anti-TB drugs. No patients with HIV and opportunistic infection of miliary pulmonary TB who developed thrombocytopenia after treatment with anti-TB drugs have been reported. A 47-year-old woman with HIV/acquired immunodeficiency syndrome and miliary TB with normal platelet count (229 000/µL) started anti-TB drugs (rifampicin, isoniazid, pyrazinamide and ethambutol). After 10 days of treatment, her platelet count was low (17 000/µL). As rifampicin and isoniazid were stopped and intravenous methylprednisolone was given, her platelet count began to increase. After more than a month, her platelet count was normal (192 000/µL) and she started antiretrovirals. This improved platelet count after high-dose methylprednisolone is suggestive of ITP; however, the dilemma is whether it was rifampicin alone that caused ITP or did HIV and disseminated TB infection also play a role?