Age: 66.0
Sex: M
Vaccine: FLUA4
Symptoms: Acute kidney injury, Angiogram pulmonary abnormal, Anti-cyclic citrullinated peptide antibody negative, Anti-glomerular basement membrane antibody negative, Antineutrophil cytoplasmic antibody negative
Clinical narrative: 66 yo vaccinated man with medical history notable for stage IV mantle cell lymphoma (in remission), melanoma, CKD, COVID-19, and BPH who was admitted on 12/10/21 for syncope and hypoxemic respiratory failure c/f infectious vs infl process.   Patient initially underwent induction therapy with rituximab, bendamustine, Ara-C in 8/2021 for bone marrow transplant (in anticipation of relapse), but tested positive for COVID in 8/2021. Received Regeneron at the time. Admitted 11/29-12/3 for community-acquired pneumonia and COVID pneumonia, treated with antibiotics, steroids, remdesivir. Patient present cough, fever 103.3, hypoxia. Patient initial CTA showed RLL. Started on Vanc/cefepime/doxy. Extensive pulm workup neg including beta-glucan, mycoplasma, chlamydia, crypto, cocci. Patient was retreated with remdesivir on 12/11. Second course of regeneron on 12/13. Patient weaned to 4L NC at one point, but started to have progressive worsening once the Vanc/cefepime were stopped. Patient placed back on HFNC on 12/23 and was restarted on vanc/mero/vori (+fungi in lungs/urine). Admitted to ICU on 12/27 for iNO. CXR showed worsening pneumonia R>L. CTPA on 12/27 neg for PE but with worsening consolidations and GGOs as well as bronchiectasis and small b/l pleural effusions seen. Also shown to have mediastinal adenopathy. Started on Solumedrol and Bactrim for PJP PPx. Bactrim was later transitioned to atovaquone due to thrombocytopenia and intrinsic AKI after G6PD was ruled out. Patient was between CPAP and HFNC.  Immunology consulted as Ig panel low and started on IVIG (12/28-1/1). S/p vanc course (12/22-29), meropenem (12/22-29), and voriconazole (12/23-29). ANCA, ANA, nuclear Ab panel, RF, anti-CCP, anti-GBM neg. Confirmed to be persistently COVID+ based on mRNA strand test. Patient intubated on 12/31. He was initially sedated with propofol (but developed elevated triglycerides so this was switched to dilaudid), precedex, and fentanyl (discontinued due to facility shortage). Required phenylephrine for blood pressure support. CXR showed L pneumothorax and a pigtail tube was placed. Patient desatted to 80s% on 1/1 with worsening pneumothorax on CXR so a surgical chest tube was also placed in the left lung. Both pigtail and chest tube had air leaks. Daily CXR initially showed slight improvement of pneumothorax, but subsequent CXR showed worsening pneumothorax. Patient developed subcutaneous emphysema in his neck bilaterally on 1/5. Patient also had elevated CO2, but ventilation settings were unable to be increased significantly given pneumothorax. Discussed patient's illness with family daily and family decided to change code status to DNR with no escalation of care on 1/6. After the patient's wife and children were able to visit patient, his ventilation settings were changed to room air (FiO2 21%) and phenylephrine was stopped. Patient was pronounced death at 2132 1/8/22. Family notified. As this was covid-related, death was reported to coroner