Age: 25.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Complement factor normal, Coxiella test, Crepitations, Culture throat negative, Culture urine negative
Clinical narrative: A 24 year old female with G4 P3 pregnancy 25+/-2 weeks presented with 5 day history of fever, bilateral chest pain pleuritic in nature, exertional shortness of breath, sweating and palpitation,1 day  after receiving the second dose of PFIZER Biontech COVID vaccine. She had recovered from COVID-19 infection [RT-PCR RT value :25.7]requiring home isolation 9 months prior to the current admission and is on thyroxine 100 mcg for hypothyroidism. In the emergency department, she was afebrile, hypotensive and desaturating-SPO2-80-85% requiring high flow nasal oxygen therapy. She had bilateral bronchial breath sounds and crepitations. Chest X ray revealed right lower lobe consolidation with extensive diffuse infiltrates. Computerised tomogram pulmonary angiogram scan had shown dilated pulmonary trunk[3.35 cm], right lower lobe consolidation with associated bilateral diffuse area of ground glass consolidation with a few enlarged mediastinal  lymph nodes and mild pleural effusion with no major pulmonary embolism. White blood cells count 22.09 x10^9/L with neutrophils % 77 %, lymphocytes 10 %, monocytes 4 %, band forms 8.0 % and atypical lymphocytes 1.0 % and C-reactive protein level of 344.66. Thyroid stimulating hormone, electrolytes, platelets count, coagulation profile, liver function and renal function tests were in normal limits. Echocardiogram on day 2 showed normal left ventricular systolic function, ejection fraction>55%, normal chamber dimension, normal valves with no evidence of raised pulmonary artery pressure, left ventricular clot or pericardial effusion. The cardiology referral team recommended initiation of  therapeutic dose of enoxaparin for myocarditis in view of non specific ST-T changes and mild rise in troponin-I [4.700 ng/Ml]. On day 2 of hospital admission, due to persistent tachypnea and a PaO2/FiO2 ratio of ?100 (PEEP ? 5 cmH20)on high flow nasal cannula and non invasive ventilation, she was electively intubated. Antibiotics were escalated to meropenem and vancomycin in view desaturation, white blood cells count 22.09 x10^9/L and C-reactive protein 356. She was also initiated on prednisolone at 1mg/kg/day once daily. Three serial endotracheal tube secretion cultures, two serial blood cultures and urine culture were sterile. Mycobacterium tuberculosis RT-PCR , acid fast bacilli smear and pneumocystitis jirovecii antigen from deep tracheal aspirate were negative.4 serial samples for COVID-19 RT PCR and 2 COVID -19 antigen samples were negative. Legionella pneumophilia ,Mycoplasma Pneumoniae, Coxiella Burnettii, Chlamydia Pneumoniae, Adenovirus, respiratory syncitial virus, Influenza A, Influenza B, Parainfluenza IgG and IgM antibodies were seronegative. GROUP A, C, G-Streptococcus were not isolated from the throat swab culture. Trichomonas vaginalis, Gardnerella Vaginalis, Candida Species and Group B Streptococcus were not isolated from high vaginal swab. Cytomegalovirus, Epstein-Barr virus, hepatitis B serology, Hepatitis C and human immunodeficiency virus serology were negative. Anti nuclear antibody, complements, anti-cardiolipin, anti ß2-glycoprotein,anti phospholipid antibody,total immunoglobulins and rheumatoid factor screening test were negative. Consecutive procalcitonin levels from the deep nasal swab and endotracheal tube sent for ten days were negative. She was extubated on day 8 of ICU admission. Consent for lung biopsy and broncheoalveolar lavage was refused in view of her improving parameters. Steroid was tapered and stopped over two weeks with no relapse.S he was discharged to the ward on day 11 of ICU admission on nasal cannula 3L/min and discharged from the hospital on day 14 on room air with good fetal movements.