Age: 35.0
Sex: M
Vaccine: COVID19
Symptoms: Acute respiratory failure, Bronchoscopy normal, C-reactive protein increased, COVID-19, Chest X-ray abnormal
Clinical narrative: Case was vaccinated x2 for Covid by March 2021, then was hospitalized for Covid the first time in October 2021.  He was boosted for Covid in December 2021, then hospitalized two more times after being boosted.  Hospitalized.  Hospitalized 10/27/21 to 10/29/21: Symptomatic x2 weeks prior to first hospitalization of 3 days, treated with Dexamethasone and on oxygen for Acute hypoxemic respiratory failure.    Hospitalization 10/31/21 to 11/7/21 In summary, he is an immunocompromise patient on Rituxan, who was recently discharged from the hospital after being admitted for COVID-19 infection, patient was taking dexamethasone and requiring 2 or 3 L of oxygen at home, nonetheless respiratory failure got much worse and despite the fact that he received a couple of vaccines in the previous months he has no antibodies against COVID-19 for which he received monoclonal antibodies on this admission.   He was a started on Remdesivir and dexamethasone but quickly deteriorated for which after discussing pros and cons he received one-time dose of Tocilizumab with excellent response to the treatment. Patient was at some point requiring 40 L of oxygen by high flow nasal cannula in the intensive care unit and now is currently on room air saturating between 89 and 92% feeling comfortable.   He is going to go home with 5 more days of dexamethasone to complete a bit more of 10 days. He has 1 refill at hand and has been instructed to take it back immediately if he feels that the symptoms get much worse after he runs out of the medication.   In addition, respiratory therapist provided him with an oxygen tank in case that he needs it while walking.   Hospitalized: 12/28/21 to 1/2/22 * Acute hypoxemic respiratory failure due to COVID-19  Initially diagnosed late October after 3 weeks of symptoms. Prolonged recovery with readmission 12/16 after vaccine with persistently positive COVID test. On presentation, worsening exertional hypoxia as well as radiographic findings of worsening infiltrate with elevated CRP. Had been elevated at initial diagnosis, but normalized 11/6/21. ID team and pulmonology consulted. Underwent bronchoscopy. Cultures preliminary but smear looks consistent with respiratory flora, cytology negative for malignancy. Other studies pending from BAL as follows: legionella (pending), fungus (pending), AFB (pending), viral culture (pending), pneumocystis (negative).  Dexamethasone started 12/30 at 6 mg daily. Discharging with a week of dexamethasone. On 2L which can be weaned outpatient. Treating for other PNA as below.   Hospitalized 1/17/22 to 1/23/22 * Acute on chronic respiratory failure  Assessment & Plan Prolonged respiratory failure since COVID-19, last October. Treated in the past with remdesivir, Regeneron mab, and tocilizumab (November 2021) and dexamethasone. Multiple hospitalizations and serial imaging with waxing and waning ground glass opacities.  Bronchoscopy 12/29/21 also without etiology, and negative biofire 12/28/21. Recently started on treatment with bactrim and steroids for PJP 1/14 based on clinical symptoms and worsening CT findings, with subtle improvement in CT findings after some days of treatment.   Admitted 1/17. Persistent positive COVID test with CT 22 which suggests viable virus. Unclear if this is persistent infection for months presumably Delta variant, vs reinfection with Omicron.   Treated with remdesivir for 5 day course given the low CT and his high risk for worsening disease. Also giving sotrovimab as well. Discussed with patient this is not FDA approved; it is provided under an EUA, and this could in his case be off label (he is hospitalized for worsening respiratory failure, but unclear if the COVID-19 is the cause or not). I do think the potential benefit outweighs the potential risk in his case.  EUA fact sheet provided to patient, and he requests treatment with the drug.   Patient evaluated by pulmonology. Plan long steroid taper, with 40 mg prednisone for 2 weeks, then 30 mg for 2 weeks, then 20 mg for at least 2 weeks, with f/u with ID and pulmonology and completing treatment for PJP, and then using prophylaxis.   Unfortunately, worsened; Repeat Biofire also negative. Recommend lung biopsy.    Evaluated by CT surgery who offered biopsy; patient declined.  He improved with treating COVID-19 and with steroids.    Repeat COVID-19 swab on day of discharge, CT 33, suggesting significant decrease in virus. Additionally, clinically he is improved symptomatically and improved oxygen requirement (down to 1.5-2 L)   Plan discharge home on long steroid taper as above.   Warning signs of worsening reviewed. Outpatient ID follow up will be arranged. Anticipate repeat COVID-19 swab in 1-2 weeks; if low CT, send to Lab for sequencing. At some point, pending clinical course, anticipate repeat CT chest (non-contrast).   If he worsens again, consider move forward with biopsy, or start empiric therapy with antifungals and perhaps other antibacterials.