question: Background: Coronavirus disease 2019 (COVID-19) is caused by SARS-CoV-2, a novel coronavirus that was first discovered in Wuhan, China in December 2019. With the growing numbers of community spread cases worldwide, the World Health Organization (WHO) declared the COVID-19 outbreak as a pandemic on March 11. Like influenza viruses, SARS-CoV-2 is thought to be transmitted by contact, droplets, and fomites, and COVID-19 has a similar disease presentation to influenza. Here we present a case of influenza A and COVID-19 co-infection in a 60-year-old man with end-stage renal disease (ESRD) on hemodialysis. Case presentation: A 60-year-old man with ESRD on hemodialysis (HD) presented for worsening cough, shortness of breath, and diarrhea. The patient first developed a mild fever (100 °F) during hemodialysis three days prior to presentation and has been experiencing worsening flu-like symptoms, including fever of up to 101.6 °F, non-productive cough, generalized abdominal pain, nausea, vomiting, and liquid green diarrhea. He lives alone at home with no known sick contacts and denies any recent travel or visits to healthcare facilities other than the local dialysis center. Rapid flu test was positive for influenza A. Procalcitonin was elevated at 5.21 ng/mL with a normal white blood cell (WBC) count. Computed tomography (CT) chest demonstrated multifocal areas of consolidation and extensive mediastinal and hilar adenopathy concerning for pneumonia. He was admitted to the biocontainment unit of Nebraska Medicine for concerns of possible COVID-19 and was started on oseltamivir for influenza and vancomycin/cefepime for the probable bacterial cause of his pneumonia and diarrhea. GI pathogen panel and C. diff toxin assay were negative. On the second day of admission, initial nasopharyngeal swab came back positive for SARS-CoV-2 by RT-PCR. The patient received supportive care and resumed bedside hemodialysis in strict isolation, and eventually fully recovered from COVID-19. Conclusions: : Our case demonstrated that co-infection of influenza and SARS-CoV-2 can occur in patients with no known direct exposure to COVID-19. The possibility of SARS-CoV-2 co-infection should not be overlooked even when other viruses including influenza can explain the clinical symptoms.