Age: 61.0
Sex: F
Vaccine: COVID19
Symptoms: Amino acid level, Antinuclear antibody negative, Asthenia, Blood folate normal, Blood homocysteine normal
Clinical narrative: Discharge Provider: MD Primary Care Provider:  NP Admission Date: 6/26/2022 Discharge Date: Jul 11, 2022  PRESENTING PROBLEM: Hypoxia  Severe sepsis  COVID-19 virus infection  COVID-19    HOSPITAL COURSE: Patient is a 61-year-old female with PMH significant for iron deficiency anemia  (and later determined- positive HIV status-off treatment > 10 years), recent recent issues with pancytopenia (WBC 2, hemoglobin 11, platelets 118, pneumonia in 03/2022 presents to the hospital on 06/26 with a symptom complex including steady decline at home, with generalized weakness, reduced oral intake, continued weight loss, worsening mental status, intermittent fevers.  She appeared cachectic, oriented x1.  Was febrile, tachypneic and hypoxic in ER.  She was tested positive for COVID-19, chest x-ray showed increased diffuse bilateral interstitial prominence, started on IV antibiotics and admitted.  Patient was admitted with bilateral pulmonary infiltrates, hypoxic respiratory failure likely related to COVID-19 pneumonia and possible superimposed bacterial pneumonia.  Infectious Disease was consulted.  Patient finished 5 day course of Rocephin/azithromycin.  Completed a 10 day course course of dexamethasone and 5 days of remdesivir.  As concern for PCP was high in setting of positive HIV status patient was started on Bactrim. CT thorax showed diffuse ground-glass opacities bilaterally and a 7 mm left upper lobe pulmonary nodule.   Pulmonology consulted and patient underwent bronchoscopy.  BAL returned positive for Pneumocystis cm the and HSV.  Patient was continued on Bactrim Decadron was transition to prednisone with plan to complete a 21 day course.  Per ID patient was started on Biktarvy after CD4 count returned 8 viral load >7 million.  Patient complained of blurry vision ophthalmology was consulted to ensure no CMV retinitis.  Left eye clear however right eye has significant cataract limiting examination.     Patient noted to have waxing and waning mental status.  MRI of the brain was obtained which showed diffuse white matter changes hence neurology consultation was obtained.  EEG was negative.  LP was negative for infection.  Repeat MRI with and without contrast also reiterated above findings.  Neurology suggested brain biopsy given her HIV status.  Patient with several intervals of lucidity, was able to identify her husband be her decision maker if needed.  Care management requested for DPOA paperwork.  After further discussion with Neurology and Infectious Disease it was felt that patients encephalopathy was likely secondary to the HIV itself.  Patient will need periodic reassessment regarding improvement of encephalopathy while on the Biktarvy.  Id considered possible involvement of HSV meningitis/encephalitis.  Patient had already been started on valganciclovir for positive CMV. This will be continued and for now is considered to provide coverage.  If patient does not continue to improve could consider repeat LP for additional CSF to test for HSV.  Id will continue to monitor this and follow up after discharge.  Pharmacy is recommending cbc again in one week for monitoring and ID states weekly CMV titers.   She had outpatient follow-up with Hematology for ongoing pancytopenia, hematology consultation was requested .  Patient was noted to be HIV positive, test done on 06/21 however  not noticed until 6/28.  History was not available at admit however after further including, patient was previously diagnosed to have HIV, was on anti-retroviral but stop taking more than 10 years ago.   Previous workup elevated inflammatory markers serum free light chains elevation but normal ratio, negative ANA negative rheumatoid factor , iron level 9 iron binding capacity 136 saturation 7% ferritin 623 folate/B12 normal normal methylmalonic acid and homocystine Per Hematology no plans to pursue bone marrow biopsy at this time Patient has received 4 doses of Venofer recently.   Patient was previously noted to have a porta hepatis mass 28 mm and this was evaluated with an ultrasound on MRI of the abdomen.  NO MASS. Patient with obvious failure to thrive with a significant amount of weight loss 25- 30 lb this year.  Patient presented with cachexia and anorexia and discontinued during the hospital stay.  Corpak was placed for tube feeds.  On the day of discharge KUB showed Corpak was in the proximal gastric body.  Discussed with MD Nutrition Service who stated if patient has been tolerating gastric feeds okay to continue to use tube with current placement however if patient pulled out further will likely need to readvance/replaced.