Age: 71.0
Sex: M
Vaccine: COVID19, UNK, UNK
Symptoms: Tachycardia, Tachypnoea, Troponin increased, Walking distance test abnormal, White blood cell count normal
Clinical narrative: I was on methotrexate and Actemra for rhematoid arthritis with Pfizer vaccines.  With the second Pfizer dose, my right hand swelled two days later with painfull itchy zoster-like lesions on the back of my hand.  There was resolution in a week.  For this reason, I chose Moderna for my third vaccination off of all immunosuppressants. Two days after the Moderna shot, I woke up with flu-like symproms, a dry cough and tachypnea. Three days later, the cough and tachypnea got worse.  I also developed precordial chest pain and a bout of near syncope with a systolic BP of 70.  The hypotension lasted about an hour.  On day #4, I woke up with worse non-radiating heart pain with dyspnea.  My SpO2 was 75% and I called Emergency. Additional information for Item 18: There was never any fever.  The rescue squad called in an elevation of my ST segments in V2 and V3, then gave me aspirin.  In the ER, I received SoluMedrol 125 mg IV.  My chest pain improved in 6 hours.  My cardiologist called me to stop taking dofetilide since my QT interval was >500 and that my troponins were elevated but not high enough to suspect a heart attack.   CXR in the ER showed bilateral infiltrates with ground glass appearance.  Since the D-dimer was elevated, a chest CTA was done.  There was no pulmonary emboli, but ground glass infiltrates were noted.  Doxycycline was started IV since WBC's showed a marked shift to the left.  I also received high flow nasal O2 and later heparin. Later that day, I was transfered to an isolation room.  The COVID nasal swab was done in the ER and then on the floor a few days later; both were negative. On Sept 13, I went into atrial fibrillation.  Dofetilide was restarted and my rhythm converted to NSR.  On 9/14, an echocardiogram showed an ejection fraction of 60% and a pericardial effusion was not seen.  Prednisone 20 mg qd was started on the 15th to be continued for five days with a rapid taper.  I was off of O2 on that day with a SpO2 in the 90's.  On September 16 (the day of discharge) a 6 minute walk test was performed.  The SpO2 dropped into the low 80's, and the pulse went up to 135 BPM.  I also experienced some chest discomfort.  On my own, I gave myself an injection of anakinra.  I was discharged with an oxygen concentrator.  I continued doxycycline for two weeks. Anakinra daily injections were continued for 10 days, then Actemra (tocilizumab) was resumed.  Five days after discharge, I no longer had tachycardia or dyspnea with brisk walking.  I still have an occasional dry cough which does not interfere with sleep.  A high resolution CT of my chest is ordered for November 17th with follow-up with my pulmonologist.  I do have a history of myopericarditis following an ablation for atrial fibrillation in 2016.  The ablation lead to hemorrhagic tamponade and a pericardial window to drain 1100 cc of blood.  The pericarditis was treated with prednisone and colchicine.  Seronegative rheumatoid arthritis involving the hands and heart was diagnosed shortly thereafter.  Methotrexate did not control the arthritis.  As an immunologist, I researched treatment for rheumatoid pericarditis and found anakinra.  The effect was remarkable, and it was continued for two years.  There were occasional breakthroughs with high exertion cardio activities requiring resumption of anakinra.  I kept two weeks of treatment  "just in case".   I brought one week of anakinra with me in the ambulance and left it in the hospital refrigerator.