Age: 43.0
Sex: F
Vaccine: COVID19
Symptoms: HIV test negative, Haemoglobin decreased, Hormonal contraception, Hypoxia, Illness
Clinical narrative: Clinical Summary Patient is a 44 year old  female with a history of Multiple Sclerosis on immunosuppression (Ocrelizumab), recently hospitalized at hospital 10/20/22-10/21/22 for sepsis, pneumonia, Colitis. Presented to Hospital 10/25/22 w worsening diarrhea and weakness. Found to have sepsis and worsening Pneumonia on admit. Hospital course complicated by progressive hypoxia requiring transfer to ICU 10/30/22, found to be COVID positive 10/31/22; required intubation / mechanical ventilation 11/2/22, extubated 11/5/22. Consulted for transfer out of ICU 11/10/2022    1. Acute Hypoxemic Respiratory Failure: due to pneumonia, COVID, PE, pleural effusion. Required intubation as above, since extubated, resolved now on room air. 2. Severe Sepsis without Shock: with fever and tachycardia. Blood cultures, Urinalysis, bronchoscopy studies negative apart from COVID and light growth yeast (which is likely not pathogenic). Treated for COVID and hospital acquired pneumonia as below. Sepsis resolved. 3. COVID: negative respiratory PCR on admit, positive COVID on respiratory PCR from 10/31/22 bronchoscopy. S/p remdesivir, dexamethasone ended 11/11/22. Managed by critical care team. 4. Pulmonary embolism: bilateral lower extremities dopplers 11/7/22: bilateral DVTs up to R popliteal, L common femoral vein. 1/8/22 CT PA: acute sub-occlusive RLL PE, without R heart strain. In setting of both COVID, critical illness, oral hormonal contraceptive (now discontinued).  Cardiology followed, recommended no invasive intervention. Started Eliquis, continue for at least 6 months total. 5. Pneumonia: In setting of immunocompromised due to Ocrelizumab. Initial symptoms 1 week prior to admission, seen at hospital 10/20/22-10/21/22 discharged on Augmentin. CT Abdomen/Pelvis 10/20/22: inferior LUL consolidation. CT Abdomen/Pelvis 10/26/22: LLL consolidation. Initial Resp PCR and urinary antigens negative, bronchoscopy 10/31/22 studies negative apart from light growth yeast (which is likely not pathogenic), also negative MRSA probe, fungal studies, cryptococcal antigen, CMV / HIV. Completed course of vanc/cefepime/azithromycin. Infectious disease followed. 6. Pleural effusion: persistent L pleural effusion, s/p thoracentesis (VIR) 11/10/22, fluid studies: exudative pleural effusion, cultures negative. Thought to be parapneumonic. Chest x-ray 11/15/2022 without pleural effusion reaccumulation.  7. Pneumothorax: 3 cm pneumothorax L apex on chest x-ray 11/10/22, related to thoracentesis as above. S/p chest tube, removed 11/14/22, chest x-ray 11/15/2022 no pneumothorax. Pulmonology followed  8. Hypogammaglobulinemia: likely acquired due to Ocrelizumab, known B cell depleting therapy. IgG 317, IgM 38, IgA 80 10/30/22. S/p IVIG 11/1 and 11/6/22.  9. Urinary retention: with significant bladder retention on several bladder scans. Pt declined catheter. Stopped home Detrol. Recommend urology follow up outpatient  10. Colitis: CT Abdomen/Pelvis  10/20/22 suggestive of infectious/inflammatory enterocolitis. Stool PCR, C. Diff negative. Potentially was due to COVID enteritis? Symptoms resolved  11. Anemia: Hb  13.8 on admit. Down to ~10. Suspect decreased due to multifactorial: phlebotomy, acute illness, IV fluids. hemoglobin has been stable ~10 from 10/9-11/15/2022. 12. Multiple Sclerosis: Relapsing Remitting per history. Follows with Dr. On Ocrevus Q6 months, last in summer of 2022. Continued Baclofen and Zanaflex. No symptoms of flare during admit. 13. OCP Use: On norgestimate-ethinyl estradioL prior to admission, stopped in setting of DVT/PE. Pt to discontinue at discharge. 14. Elevated LFTs: unclear etiology. Trending down