Age: 50.0
Sex: F
Vaccine: COVID19
Symptoms: Illness, Immunosuppression, Leukopenia, Lung infiltration, Mean cell volume increased
Clinical narrative: Hospitalized (12.23.21 - 12.27.21); COVID-19 positive (12.23.21); Fully vaccinated  - J&J x1 D/c summary: Discharge Summary MD (Physician) ? ? General Medicine BRIEF OVERVIEW: Discharge Provider: MD Primary Care Provider: NP Admission Date: 12/23/2021 Discharge Date: Dec 27, 2021   Active Hospital Problems   Diagnosis Date Noted POA ? COVID-19 virus infection 12/25/2021 Yes ? Fever in adult 12/25/2021 Yes ? Pulmonary infiltrates 12/23/2021 Yes   Resolved Hospital Problems No resolved problems to display.   Pre-Existing Active Problems   Diagnosis Date Noted POA ? Abnormal CT of the chest 10/14/2021 Unknown ? Granulomatosis with polyangiitis  03/09/2018 Unknown ? Microscopic polyangiitis  02/07/2018 Unknown ? Tracheal stenosis 02/07/2018 Unknown ? LPRD (laryngopharyngeal reflux disease) 11/29/2017 Unknown   Discharge Disposition:  home or self care  DETAILS OF HOSPITAL STAY: PRESENTING PROBLEM: Pulmonary infiltrates [R91.8] Hemoptysis [R04.2] Immunosuppressed status  [D84.9] Fever, unspecified fever cause [R50.9] COVID-19 virus infection [U07.1]   HOSPITAL COURSE:  Patient is a vaccinated (J&J 4/10/21, no booster) and immune suppressed 51 yo woman who was admitted to Hospital with fever and shortness of breath. She was sent to the hospital from her Rheumatologist's office, Dr., during a visit for a second dose of rituximab; he and staff advised she present to the emergency department after report of ongoing fever at which point she was admitted.   She carries dx of complex tracheal stenosis (hx dilation w/ mitomycin and Kenalog) and microscopic polyangiitis, ANCA-associated vasculitis, for which she has been working with Rheumatology, Dr., and taking Imuran, recent steroid, and recent first dose of Rituximab. She arrived taking oral estrogen for menopausal symptoms.   Fever persisted for most of her stay, typically in the early morning hours around 4-6 AM with her last recorded fever at 12/26/21 AM, the day prior to discharge.  Her shortness of breath was mild, O2 saturations remained at 90 and above, and supplemental oxygen was never used but her CXR w/ mild pulmonary infiltrates were noted a negative nasal swab source for Covid PCR, but was positive on BAL from bronchoscopy 12/23/21. No diffuse alveolar hemorrhage (DAH) was confirmed by bronch so infiltrates were though possibly due to Covid pneumonia. She was given prednisone 20 mg daily, an increase from recent start of 15 mg daily for her vasculitis.   Symptom start of most current fever and sense of illness was 12/19/21 based on her calendar, and was distinct from prior once monthly fevers since summer 2021.  Pulmonology recommended monoclonal antibody which was arranged 12/25/21. ID weighed in and did not express confidence infection was the reason for fevers over past 6 mos, that it is possible recent sx are from Covid infection. It was recommended: o she have COVID-19 antibody levels collected in approximately 3 months to determine if she developed nuclear capsid antibodies following this infection. o She should receive at least 1 booster vaccine, preferably mRNA vaccine either Pfizer or Moderna.  She will need to wait at least 90 days after her monoclonal antibody infusion before booster vaccine can be given. o If she does not develop antibodies following her current infection, she may be a candidate for prophylactic monoclonal antibody administration.  Her immunologist can contact the Infectious Disease office or the monoclonal antibody infusion clinic at that time to determine if there are any clinical trials that would be beneficial for this patient. These recommendations were provided in writing in her DC material for her reference. Dr., her Rheumatologist, then weighed in and recommended continued HOLD on Imuran at discharge and wanted her to be, 1) 2-3 weeks out from antibiotic treatment for possible bacterial pneumonia, and 2) feeling well.   CRP was high on admission and it was not clear if this was a useful measure in the setting of chronic inflammation.   Rocephin and azithro empiric for CAP to be completed orally if discharged  CAP tx was completed in hospital but her probability of bacterial pneumonia was in question.  Leukopenia resolved during her stay, with hold on Imuran, despite Covid infection, etc. Bactrim PJP ppx, Hydroxychloroquine, Valtrex, Lyrica and PPI continued   Hot flashes from acute-onset menopause due to HOLD on oral estrogen in setting of Covid infection (indication to avoid adding to any hypercoagulable state from Covid infection).  She was able to tell the difference between hot flashes and illness, especially fever given she got cold with fever, not hot.   Dysuria had been intermittent per her report. UA 12/22/21 contained calcium oxalate crystals, and neither this nor a second collection 12/23/21 contained support for infection. Had there been infection, abx for CAP would likely have offered coverage.   She discharged home 12/27/21 feeling well compared to prior (but we appreciate she had not suffered fever the morning of discharge) with plan to follow up with her Rheumatologist. A leukemia / lymphoma w/u was pending at discharge and will require follow-up Prednisone was to resume at dose prior to admission, 15 mg daily. She has had close follow-up since admission with her Rheumatologist, Dr. and plans to f/u after discharge CONSULTS: Pulmonology Infectious Disease Rheumatology by phone   PROCEDURES: Bronchoscopy 12/23/21   BP 113/73  | Pulse 73  | Temp 36.6 °C (Oral)  | Resp 22  | Ht 1.651 m  | Wt 80 kg  | SpO2 97% Comment: back in bed | BMI 29.35 kg/m²    Physical Exam Constitutional:      General: She is not in acute distress. HENT:     Nose: Nose normal.  Eyes:     Extraocular Movements: Extraocular movements intact.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds.  Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness.  Musculoskeletal:     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.  Neurological:     General: No focal deficit present.     Mental Status: She is alert. Mental status is at baseline.     Cranial Nerves: No cranial nerve deficit.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.