Age: 58.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Liver function test, Melaena, Multiple organ dysfunction syndrome, Nitrite urine present, Oesophagogastroduodenoscopy abnormal
Clinical narrative: Patient with 2 Pfizer COVID vaccinations, last dose 04/27/21, who admitted to the hospital for wound complications and incidentally tested detected for COVID during admission testing.  Patient died of septic shock from complications of MRSA infection.  Provider d/c note below:  "59 year-old male with past medical history of HFrEF with EF 40-45% by TEE (09/2021), CAD s/p stents (x3, most recent 2019), hypertension, hyperlipidemia and osteomyelitis s/p R 4th toe amputation (10/29/2021). Notably, during his hospitalization for amputation of R 4th digit he had MRSA, Acinetobacter, and E faecalis bacteremia treated with 2 weeks of Cefepime and Vancomycin.    ED course was remarkable for hypotension with SBP ranging from 67- 98 mmHg despite 3.0L IVF. Central line was placed and he was started on NE. He was also noted to be tachycardic with HR: 118 bpm. CBC demonstrated macrocytic anemia of 6.8; he was given 1U PRBC. He was noted to be hypokalemic with K: 2.6; he received KCl with IVF resuscitation.  Hypomagnesemia was repleted with 2g IV MgSO4 (x2). LFTs were notable for AST:ALT >2, elevated TBili of 3.7. ESR and CRP were elevated. Lactate was elevated. CXR was unremarkable. R foot XR demonstrated soft tissue swelling with osteomyelitis of L great toe. CT A/P demonstrated R inguinal hernia. UTI demonstrated positive nitrite, moderate leukocyte, moderate bili, 40 WBC; he was started on Zosyn and Vancomycin. ID was consulted and he was subsequently admitted to CCU for treatment and evaluation of septic shock.    Left great toe amputation was completed on 2/15 without complications. He was transferred to the floor on 2/16.  Hospitalization was complicated by septic arthritis, s/p I&D of right wrist on 2/19. Additional complications included acute kidney injury with associated acidosis and hyperkalemia. He was started on lasix and bicarb with minimal improvement. Vancomycin was changed to Daptomycin for continued coverage of MRSA bacteremia.    On 2/22 he was noted to have multiple melanotic stools. GI was consulted and he was subsequently started on twice daily IV PPI. EGD was completed on 2/25 and demonstrated gastric ulcer without signs or symptoms of bleeding noted. However, he developed stigmata of bleeding overnight. Hgb was noted to be 6.6 and he was subsequently transfused. He was re-admitted to the ICU. Pressors were re-started due to hemorrhagic shock.    Nephrology was consulted for worsening renal failure and the patient was started on CRRT, which continued until discharge.    NM blood scan on 2/26 demonstrated suspected GI Bleed from mid to upper abdominal small bowel. IR was consulted and completed embolization of the gastroduodenal artery on 2/27.  His clinical status deteriorated with up-trending lactic acid and increased pressor needs. CTA A/P was completed and was negative for infarcted bowel. EGD was repeated on 2/28 and demonstrated stigmata of recent bleeding. Surgery was consulted for possible surgical intervention. However, due to his clinical status surgery was held at that time.    Patient had stabilization of his Hgb following EGD on 2/28 for approximately 48 hrs, able to wean down from four pressors to one. However, on 3/5 he again developed stigmata of bleeding. GI repeated EGD, which demonstrated large peptic and duodenal ulcers with large amount of blood in the gastric body. Repeat NM blood scan was non-contributory. He required additional blood products. Surgery completed ex-lap with duodenal ulcer oversew, gastroduodenostomy, and pylorplasty with truncal vagotomy of anterior branch overnight. He had initial improvement in clinical status following surgery.    Of note, during surgery cirrhotic liver with ascites was noted. Imaging prior to surgery indicated hepatic steatosis. TBili was elevated and continued to up-trend during his hospitalization.  Multiple RUQ U/S were negative for biliary obstruction. Ursodiol was started on 03/05, however discontinued following surgery due for bowel rest.   Patient again required additional pressor support. In the setting of multiple organ failure and worsening clinical status, family transitioned to comfort care. He was terminally extubated and placed on comfort care. Patient expired on 3/9 at 1943 with family by his side. "