Age: 58.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Hyperglycaemia, Hypophagia, Hypotension, Immunoglobulin therapy, Immunosuppression
Clinical narrative: Narrative: Admission Date: Oct 21,2021 Discharge Date: Nov 25,2021 Condition of patient at discharge: Stable Primary Diagnosis during Admission/Treatment: Acute hypoxic respiratory failure Secondary Diagnosis(es)during Admission/Treatment: Sepsis, acute hemolytic anemia, steroid induced hyperglycemia 58yM w/ beta-thalassemia trait, atrial fib/flutter not on anticoagulation, OSA, COPD, COVID-19 Pneumonia in 12/2020 complicated by cryptogenic organizing PNA and presumed COVID related auto-immune hemolytic anemia presenting with worsening dyspnea and fever. Patient states he began having fevers around 1 week prior to ED visit, up to Tmax 103.7 at home. He developed significantly worsened dyspnea from baseline on Sunday 10/17/21 along with productive cough. He was unsure what the sputum looked like but he does not produce sputum at baseline. Reported generalized malaise and poor PO intake, diffuse weakness and barely able to get from bedroom to bathroom due to DOE and weakness. Had continued to wear 5-6L NC at home since discharge from hospital for COVID Pneumonia 10/15/21 and had not tried to increase this at home for dyspnea. States his DOE gets better when he rests. Of note was admitted to our facility 10/9-10/15/21 for AIIRF secondary to COVID with brief ICU stay at that time for O2 requirement as high as 10L oxymizer in addition to Afib RVR requiring diltiazem infusion briefly. He completed 5 day course of remdesivir 10/14/21 and was discharged on PJP treatment dose bactrim and continuedd on home prednisone 40 mg daily for AIHA. Completed treatment for CAP with rocephin/azithromycin during that admission as well. Reports compliance with all medications. In the ED, Tmax 102.8,HR97, BP 105/62. Labs notable for WBC 8 w/neutrophilic predominance, PLT 263, BNP<100, ferritin>6k, CRP 10, Cr 1.1 (baseline ~0.8), procal 0.08. CXR with bilateral opacities, slightly worse that prior. Patient was admitted for COVID pneumonia despite 3 vaccinations with Pfizer COVID vaccine on 3/17/21, 4/8/21, and 8/31/21. ICU COURSE 10/22 - 10/25 Covid-19 Precautions were lifted on 10/25/21. HOSPITAL FLOOR COURSE 10/25-10/27: Patient came to the floor 10/25/21 on 5-6L O2 via NC. Abx coverage included Zosyn/Bactrim. On 10/26 he continued to fever with temp of 102.3 so he was broadened to Merrem/Bactrim. CT scan was ordered which showed chronic changes with worsening consolidation right base greater than the left. On 10/26/21, patient continued to fever, so Micafungin was added in the setting of immunosuppression from chronic steroid use. Morning of 10/27, pt was desatting to the 70's on 6L, so he was placed on 10L oxymizer with improvement to mid 90s spO2. BP at that time was 80s/40s. Patient was stabilized and transferred to ICU. ICU COURSE 10/27-11/23: Intermittently febrile with increasing O2 requirement and continued hypotension throughout admission prompting return to ICU 10/27. Concern for prolonged COVID infection vs. potential PE? BDG negative (10/14), COVID IgG/IgM negative (10/23), procal 0.06 10/27. RVP negative on admission. s/p Vanc (10/23-10/24) - neg MRSA nares. s/p zosyn (10/23-10/26), azithro (10/23-10/25). TTE w/ EF 50-55%, grade II diastolic dysfunction, RSVP 33. Blood cx (-). Sputum cx (10/27) w/ GPC in clusters- staph hemolysis , BD(-),strep/legionella/aspergillosis/histo: negative. ID consulted 10/30, with initial suspicion low for infection. CTPE 11/8 negative for PE. S/p meropenem (10/26-11/2), s/p Micafungin (10/26-28), s/p vanc(10/28-11/3). Hematology was consulted due to concerns for HLH, so patient started on high dose solumedrol and apply) received IVIG (10/29-11/2). Patient has not fit criteria for HLH, so hematology recommended weaning to home prednisone 40 mg for which pt is currently on 60 mg of solumedrol daily. He fevered on 11/7, so he was restarted on Mica (11/8-11/9), merrem (11/7-11/13), and vanc (11/8-11/9) due to CXR concerning for pneumonia. ID was reconsulted on 11/8 due to patient's immunosuppression (steroids + rituxan in 7/2021) and repeatedly positive COVID PCR. This led to inability to form antibodies to covid and is now in an acute infection. Immunodeficiency panel (IgG, IgM, IgA, IgE)- all low. s/p monoclonal antibodies 11/12CD19 ordered (B-cell panel) - Low at 203 - Holding transplant evaluation work up due to improved clinical status. Of note, he's been treated with therapeutic dose enoxaparin due to his COVID pneumonia. ID has recommended retesting every 5-7 days to trend cycle times (most recent being 36) to help determine when patient can d/c contact precautions. A lung transplant was considered in early November, but has now been put on hold due to patient's clinic improvement. Of note, pt underwent LHC/RHC both of which were normal. Patient has also had a tenous course of afib/flutter while in the ICU, but he has been well controlled and in NSR on metoprolol 12.5 mg q8h and digoxin 0.25 mg qd (was dig loaded 11/6/21). He was transferred back to the floor. During floor course, his IV steroids were converted to oral prednisone 40mg QD, which he will continue on until he follows up with hematology. #Acute on chronic hypoxic respiratory failure in s/o recent COVID PNA, prior COVID complicated by COP - improving. He is now on home oxygen requirements of 4-6L. Discharged to home on home oxygen, prednisone 40mg daily,