Age: 53.0
Sex: F
Vaccine: COVID19
Symptoms: Blood cortisol, Blood creatinine, Blood culture negative, Blood glucose normal, Blood lactate dehydrogenase increased
Clinical narrative: 53 yo woman with no PMH was diagnosed with COVID-19 by PCR on 5/7/21. She had a mild illness with cough and fevers but did not require hospitalization. Her symptoms lasted about 1 week. She got her first dose of Pfizer COVID vaccine on 5/29 around 11 am. Within 4 hours (around 3 pm) she started to develop extreme fatigue, which she attributed to vaccine. This was followed by nausea, vomiting and diarrhea later that same day. The symptoms got worse on 5/30. Her diarrhea/GI symptoms resolved on 5/31. That day, she had a fever to 101.3. She continued to have fatigue, and started to have dyspnea, and presented to hospital on 6/1/21. On arrival to ED her vitals were 88/41, 36.1, 125, 18, 95% on RA (13:22). She become more hypotensive with nadir BP 63/48, HR 109 at 17:30, at which time she was started on norepinephrine. Physical exam at admission was notable for clear lungs, tenderness to palpation in the midepigastric and LUQ areas, and the absence of rash. Admission labs: WBC 31.3, Hb 14.2, Hct 43.0, Plt 144, MCV 96, 85% neutrophils, BNP 3117, Na 132, K 3.8, CO2 19, Cl 95, BUN 35, Create 4.62, gluc 133, protein 6.1, alb 2.2, TB 5.5, DB 2.9, Alk phos 159, ALT 47, AST 33, lactate 4.2, troponin I 0.047, random cortisol 93. Strep pneumo and legionella antigens negative. Hepatitis serologies, HIV test, all negative. COVID test by PCR was positive on 6/1/21. She was admitted to the ICU. The day following admission (6/2) CRP 32.4, ESR 106, LDH 399, ferritin 1626, procalcitonin 54.85. CT A/P unremarkable except for bilateral patchy airspace opacities. RUQ US unremarkable, including Dopplers. Echocardiogram (TTE) with LV systolic function mod-severely globally reduced, EF 35%, no valvular disease. Dopplers of LE showed small non-occlusive thrombus in R common femoral. The patient was seen by Infectious Diseases on HD#2 (6/2/21) and IVIG was recommended and administered due to suspicion for MIS-A. She had also been started on cefepime, vancomycin and metronidazole on admission. Blood, urine and resp cultures were negative. She continued to have high norepinephrine requirements, reaching 0.34 mcg/kg/min on 6/3. Due to ongoing shock (cardiogenic vs septic), a Swan-Ganz was placed on 6/4/21. RAP 11 mmHg, RV 38/10 mmHg, PA 40/20 (27) mmHg, PCWP 19 mm Hg, CO 5.75, CI 2.8, SVR 1100, MvO2: 70%. These were consistent with distributive/septic shock rather than cardiogenic.  The patient was able to be weaned from pressors on 6/5/21 at 11:55. Throughout her entire hospital stay, she was comfortable with no respiratory distress, and no abnormalities in mentation. She was transferred to the general medical floor and completed 7 days of antibiotics for empiric sepsis treatment. Labs at discharge on 6/8 showed procalcitonin 5.43, CRP 8.8, LDH 362, Ferritin 1511, TP 5.9, ALT 17, AST 29, Alk phs 158, TB 1.3, Alb 1.6, Create 0.98, WBC 32.5, Hb 7.8, Hct 22.9, Plt 100, neutrophils 70%. She was feeling well without complaints, and will follow up as an outpatient. She was prescribed Xarelto for DVT.