Age: 67.0
Sex: M
Vaccine: COVID19
Symptoms: Heart rate, Oxygen saturation, Physical examination, Respiratory rate, SARS-CoV-2 test
Clinical narrative: Covid-19 infection; This literature-non-study case was reported in a literature article and describes the occurrence of COVID-19 (Covid-19 infection) in a 67-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination.       Concurrent medical conditions included HIV infection (Patient was on ARV therapy with undetectable viral load), Panhypopituitarism, Hypothyroidism (central hypothyroidism), Adrenal insufficiency, Hypogonadism, DVT (recurrent DVT/PE on AC therapy), Pulmonary embolism (recurrent DVT/PE on AC therapy), Benign prostatic hyperplasia, Overactive bladder and Stable angina pectoris.    On an unknown date, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On an unknown date,  after starting mRNA-1273 (Moderna COVID-19 Vaccine), the patient experienced COVID-19 (Covid-19 infection) (seriousness criteria hospitalization prolonged and medically significant). The patient was treated with DEXAMETHASONE at an unspecified dose and frequency and ENOXAPARIN SODIUM (LOVENOX [ENOXAPARIN SODIUM]) at an unspecified dose and frequency. At the time of the report, COVID-19 (Covid-19 infection) had resolved.      DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On an unknown date, Alanine aminotransferase: 100u/l 100U/L. On an unknown date, Aspartate aminotransferase: 122 u/l 122 U/l. On an unknown date, Blood HIV RNA below assay limit: undetectable Undetectable. On an unknown date, Blood lactate dehydrogenase: 489 u/l 489 U/L. On an unknown date, Blood pressure measurement: 159/87 mmhg 159/87 mmHg. On an unknown date, Body temperature: 101 101. On an unknown date, C-reactive protein: 321 mg/l 321 mg/L. On an unknown date, CD4 lymphocytes: 67 cell/ul 67 cell/Ul, 568 cmm 2 weeks prior admission and 523 cmm 2 months later. On an unknown date, Chest X-ray: abnormal (abnormal) Bilateral patchy infiltrates. On an unknown date, Heart rate: 122 beats/min 122 beats/min. On an unknown date, Oxygen saturation: 79 percent 79 percent on room air and 96% on NRB mask and improved Improved after treatment. On an unknown date, Physical examination: unremarkable Unremarkable. On an unknown date, Respiratory rate: 18/min 18/min. On an unknown date, SARS-CoV-2 test: positive (Positive) Positive. On an unknown date, Serum ferritin: 585.8 ng/ml 585.8 ng/ml. On an unknown date, White blood cell count: 15.3 k/cmm 15.3 K/cmm.     The action taken with mRNA-1273 (Moderna COVID-19 Vaccine) (Unknown) was unknown.   For mRNA-1273 (Moderna COVID-19 Vaccine) (Unknown), the reporter considered COVID-19 (Covid-19 infection) to be possibly related.    Patient presented with 3 days of fever, chills, diarrhea and malaise to ER. He received first dose of Moderna vaccine 2 weeks before admission. Patient was treated with dexamethasone, therapeutic Lovenox and received 1 U of convalescent plasma. His oxygen saturation improved, overall course was uneventful and patient was discharged home. Author discussed that HIV infection does not increase the occurrence of COVID-19 and there is no increase in morbidity and mortality. The exact influence of COVID-19 on absolute T4 cells subset in HIV and their significance is presently unknown. Our patient had stable absolute CD4 count for years. He was compliant with ART and HIV viral load was undetectable. However, there was a drastic decline in his CD4 count that occurred during an acute COVID infection although he was on the same medications. CD4 recovered to baseline after COVID infection resolved.  Company Comment: This case concerns a 67 year-old, male patient with a history of HIV infection receiving antiretroviral therapy, Deep vein thrombosis, Pulmonary embolism, Angina pectoris and Panhypopituitarism (consisting of Hypothyroidism, Adrenal insufficiency and Hypogonadism), who experienced the serious (due to hospitalization) unexpected AESI of COVID-19. The event occurred approximately 2 weeks after the first dose of mRNA-1273 vaccine. Patient was treated with dexamethasone, therapeutic Lovenox and received 1 U of convalescent plasma. His oxygen saturation improved, overall course was uneventful and patient was discharged home. The rechallenge was not applicable. The medical history, of HIV infection receiving antiretroviral therapy, Deep vein thrombosis, Pulmonary embolism, Angina pectoris and Panhypopituitarism (consisting of Hypothyroidism, Adrenal insufficiency and Hypogonadism) remain as confounders for the event´s seriousness and hospitalization. The benefit-risk relationship of mRNA-1273 vaccine is not affected by this report.   Reporter did not allow further contact   Most recent FOLLOW-UP information incorporated above includes: On 25-Nov-2021: Follow up received by safety on 25-Nov-2021 included an Email and contains significant information regarding author.; Sender's Comments: This case concerns a 67 year-old, male patient with a history of HIV infection receiving antiretroviral therapy, Deep vein thrombosis, Pulmonary embolism, Angina pectoris and Panhypopituitarism (consisting of Hypothyroidism, Adrenal insufficiency and Hypogonadism), who experienced the serious (due to hospitalization) unexpected AESI of COVID-19. The event occurred approximately 2 weeks after the first dose of mRNA-1273 vaccine. Patient was treated with dexamethasone, therapeutic Lovenox and received 1 U of convalescent plasma. His oxygen saturation improved, overall course was uneventful and patient was discharged home. The rechallenge was not applicable. The medical history, of HIV infection receiving antiretroviral therapy, Deep vein thrombosis, Pulmonary embolism, Angina pectoris and Panhypopituitarism (consisting of Hypothyroidism, Adrenal insufficiency and Hypogonadism) remain as confounders for the event´s seriousness and hospitalization. The benefit-risk relationship of mRNA-1273 vaccine is not affected by this report.