Age: 73.0
Sex: F
Vaccine: COVID19, COVID19, COVID19, COVID19, COVID19
Symptoms: Hypertension, Hypoxia, Immunosuppression, Intensive care, Leukopenia
Clinical narrative: Believe that this may be a duplicate report. Patient has died (9.24.21);  Hospitalized (8.31.21);  Fully Vaccinated including 3rd dose (immunocompromised) Preliminary cause of death listed as Respiratory Failure.  Severe acute hypoxemic respiratory failure. Multifactorial from severe acute lung injury and severe ACR (temporally related to third COVID vaccine received on 8/17/21) as well as bilaterally pulmonary embolism. Intubated 9/4/21.  Tracheostomy 9/14/21.  Infectious studies negative to date. COVID Ab negative on 9/9/21. Submitted to VAERS on 9/15/21 per Dr. HOSPITAL COURSE: Patient is a 73 y.o. female with a past medical history of veno-occlusive dx and ILD s/p bilateral lung transplant (09/2020), high risk EBV status, A. Fib not on anticoagulation, HTN and OSA. She received her 3rd dose of the COVID vaccine on 8/17/21. Admitted 8/31/21 for fatigue, dyspnea, nonproductive cough, subjective fevers and chills, and hypoxia. Recent bronch by transplant team identified A2 acute cellular rejection associated with declining lung function (FEV1 down 10% from best). On 9/4/21 she was transferred to the MICU for worsening hypoxemia with increased work of breathing. CT chest showed bilateral PE and subsequent doppler showed DVT in Right posterior tibial and Left peroneal veins. She received targeted thrombolytic therapy with IR and was continued on a heparin drip. She was started on broad spectrum antibiotics, pulse dose steroids and continued with her transplant medications and prophylaxis.  9/5 Continued low volume protective ventilation, some vent dyssynchrony improved with sedation on propofol. Had acute reaction to thymoglobulin, resolved with tylenol and benadryl- continued with pretreatment. 9/6 Weaning PEEP, remains on low dose sedation buit awake and alert. Continued diuresis with Lasix. Restarted home metoprolol and diltiazem for hypertension. BAL with GPC and GNR; MRSA nares negative- d/c vancomycin and continued on cefepime. 9/7 Tolerated PEEP 10 overnight, weaned down this morning with good oxygenation but CXR shows worsening bilateral effusions. Plan to increase diuresis and maintain current ventilator settings. Holding further thymo doses given leukopenia and thrombocytopenia. Insulin increased for steroid induced hyperglycemia. 9/8 CXR improved, stable respiratory status, net positive fluid balance. Sedation weaned. Passed SBT but had increased WOB after requiring increased FiO2 and PEEP. Plan to diurese with increased lasix and trial tomorrow. Better glucose control with increased insulin. Having multiple bowel movements after aggressive regimen yesterday, now held. 9/9 SBT overnight but switched to pressure control for increased work of breathing and perceived shortness of breath. Repeat SBT failed with similar issues after 10 minutes, returned to pressure support. Met fluid net negative goal, continue diuresis. Increased insulin for hyperglycemia. Awake and interactive on the vent. Transplant team restarted valgancyclovir.  9/10 Episodes of desaturation requiring 100% FiO2 for resolution. CXR unchanged and meeting negative fluid goal. Bedside bronch shows clear airways, BAL collected for culture and testing. Concern worsening respiratory status is related to cellular rejection with no clear infectious source and otherwise medically optimized. Transplant and infectious disease following. Thymoglobulin continues to be on hold. Complaints of suprapubic pain, Foley exchanged and UA collected, no signs of infection.  9/11 remains intubated and sedated. ID concern for possible PTLD given increased LFTs and Cre, CT A/P with nonspecific findings. Transplant team continues to hold thymoglobulin as EBV viral load has increased. Scheduled insulin increased for hyperglycemia. 9/12 Continues to have episodes of desaturations, requiring increased FiO2 for recovery. Fluid balance ever after 60 lasix TID yesterday, increasing Cre and contraction alkalosis. Lasix BID and one time diamox. Transplant team to restart thymoglobulin today and possible repeat bronchoscopy with biopsy later this week. Due to persistent ventilator requirements, tracheostomy was performed.  This allowed for weaning of the patient's sedation in the patient tolerated minimal pressure support with low peak pressures.  Over the next 2 weeks, the patient had persistent high FiO2 recover min in PEEP requirement chest x-ray remained more or less unchanged without improvement in her infiltrates likely secondary to her acute cellular rejection.  There was continual effort made to keep the patient as dry as tolerated to remove any component of fluid overload from her respiratory failure.  Similarly, repeat cultures, BAL, cell free DNA sequencing, and universal PCR were all sent without any evidence of infectious etiology for the patient's respiratory failure.  Due to continued aggressive immunosuppression, rituximab was administered prophylactically to prevent PTLD in the setting of the patient's EBV positive donor status.  Finally, the decision was ultimately made to sedate and paralyze the patient to help achieve optimal lung protective ventilation as the patient had been generating excessive tidal volumes of her own volition while on pressure support ventilation.  Unfortunately, despite all these changes, the patient's ARDS continued to worsen, her lung compliance continue to decrease, and her O2 requirement continued to increase. Given the patient's overall worsening respiratory failure, conversation was had between the transplant team and family regarding consideration of ECMO.  Due to the overall poor prognosis given the ongoing cellular rejection, family did not feel that this measure was consistent with the patient's wishes, and did opt to make the patient comfort care.