Age: 65.0
Sex: M
Vaccine: COVID19-2
Symptoms: Fungal disease carrier, Fungal test negative, Hypogammaglobulinaemia, Hypoxia, Immunoglobulin therapy
Clinical narrative: Patient is a 66 y.o. male with history of mantle cell lymphoma (s/p chemo/XRT in remission), NICM, recent COVID infection (end of December) who presented from home on 1/25/2023 with worsening shortness of breath, fatigue, hypoxia and cough. CT Chest reveals bibasilar patchy opacities on admit. He continues to have symptoms related to COVID-19 infection and superimposed bacterial pneumonia. He is undergoing treatment with antimicrobials as well as COVID specific therapies. He had significant improvement and is discharged home in stable condition on 1/31/2023.     Acute Hypoxemic Respiratory Failure Abnormal CT chest - Most likely etiology COVID; recent COVID (sx began 12/31) and cycle threshold elevated this admit still suggesting active virus  - Consider also superimposed bacterial pneumonia and fungal etiologies less likely. SLP performed MBS and was negative for aspiration.  - CTPA on admit with bibasilar patchy opacities, no PE.  - Blood cx NGTD (though obtained after abx started) Strep and Legionella urine Ag negative. MRSA probe negative. Fungitell and Aspergillus negative. Histo and blasto pending.  - Sputum Culture with heavy growth yeast; however patient without evidence of invasive fungal infection; will hold off additional fungal therapy, suspect this is colonization - Required 2 L NC on admit and has since been weaned to room air.  - Pulmonology and ID followed- Cefepime completed treatment with total 5 day course of abx for CAP (stop 1/30). Dexamethasone 10 day course planned for COVID. Remdesivir started 1/27 for total 5 days.  -Repeat CT chest in 4-6 weeks for resolution per pulm   COVID-19 Infection - Tested positive for COVID end of Dec 2022 and received paxlovid. Previously received Evusheld in Oct 2022. - ID following, cycle threshold consistent with active viral infection so started remdesivir and dexamethasone.  - The patient completed 5 days of Remdesivir.  He will complete 4 more days of dexamethasone on discharge for total 10 days of treatment   Laryngitis Cough - Secondary to COVID - CT soft tissue neck w/contrast negative for lymphadenopathy or soft tissue mass - Slowly improving with scheduled hycodan syrup and robitussin-DM, hypertonic saline nebs, prn magic mouthwash.    Hypogammaglobulinemia - Rechecked IG levels here which were low- IgG 407, IgM 19, IgA 80. No history of frequent infections in the past.  - Heme/Onc consulted for evaluation for benefit of immune globulin therapy due to refractory sinupulmonary infection. Oncologist here evaluated and patient discussed with his prior oncologist who was in favor of IVIG,  confirmed with Dr and low dose 400 mg/kg x 1 administered on 1/30 History of Mantle Cell Lymphoma - Follows with Dr., treated with chemo and XRT in mid 2000s and most recently CAR-T cell therapy in 2020.  - Follow up outpatient with Dr.   Mild leukopenia and anemia - Likely secondary to acute infection above - no evidence of active infection - Monitor CBC   Chemotherapy Induced Nonischemic Cardiomyopathy  - Per history, secondary to chemotherapy. Euvolemic on exam  - TTE 03/2021 with LVEF 55-60% and mild diastolic dysfunction  - Restarted home Coreg at lower dose (discussed with patient and his BP is usually in 90s systolic). Continue to hold ramipril while hospitalized, okay to resume on discharge and patient instructed to monitor BP and hold if SBP under 100   Chemotherapy Induced Cognitive Impairment  - Currently alert, oriented, able to discuss medical condition and history.  - Continue home memantine and wellbutrin   CAD - Continue ASA   HLD - Continue home statin    GERD - Continue home nexium    BPH - alfuzosin initially held due to soft pressures, resumed on discharge