Age: 71.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Acute respiratory failure, Angiogram pulmonary abnormal, Aspiration pleural cavity, Bacterial test negative, Blood culture positive
Clinical narrative: Patient with history of COVID vaccines who admitted to hospital with COVID detected PCR.  Provider d/c note:  "72-year-old divorced male with past medical history significant for longstanding type 1 diabetes complicated by blindness in the setting of proliferative retinopathy, pancreatic insufficiency, hypothyroidism, primary hypertension, Gilbert's disease and hyperlipidemia with recent upper respiratory illness due to influenza A in December 2022 presented with acute onset of cough, worsening shortness of breath and fevers or chills at home found to have sepsis and acute respiratory failure with hypoxia in the setting of a right lower lobe pneumonia with associated right pleural effusion.  Of note COVID-19 virus was also detected at time of admission.  Procalcitonin was markedly elevated at 26.26.  Patient also had marked hyperglycemia in the mid 300s.   Brief Summary of Hospital Stay: (Include Significant Findings and Invasive Procedures)  Patient's sepsis in the setting of pneumonia was treated with IV fluid bolus and then maintenance IV fluids as well as starting antibiotics with IV ceftriaxone and azithromycin.  CRP was markedly elevated to 19.3 and D-dimer elevated to 2170.  In the setting of COVID 19 CT angiogram of chest was obtained to rule out pulmonary emboli which was ruled out.  However a large right pleural effusion was noted associated with near complete consolidation of the right lower lobe and some consolidation in the lateral segment of the right middle lobe and inferior right upper lobe.  There was also some characteristics consistent with possible pulmonary necrosis.  Patient's ceftriaxone was brought to Unasyn to cover for oral anaerobes.  MRSA nares swab was negative.  Urine strep pneumoniae and urine Legionella antigens were negative.  Interventional Radiology was consulted and performed a right-sided thoracentesis draining 1.2 L of transudative fluid.  Pleural fluid cultures were no growth to date.  With hypoxia being attributed to bacterial pneumonia it was decided to not treat COVID-19 viral infection.  Patient's hypoxia resolved over several days as did his sepsis.  Notably patient had 2 sets of blood cultures that both grew staph epidermidis, pansensitive.  Collaborated informally with Infectious Diseases and they felt that it would be impossible to rule out this bacteria as a pathogen although it still would be most likely contaminant.  Infectious diseases felt treatment for 7 days with Unasyn transition to Augmentin to cover the bacterial pneumonia would be adequate to also treat the staph epidermidis in the blood which cleared quickly with surveillance cultures.  Echocardiogram was obtained which showed normal structural heart with no signs of vegetations.  Plan was to complete course of antibiotics and then weight 1 additional week and then rechecked 2 sets of blood cultures to confirm no residual signs of bacteremia.  Patient was discharged on Augmentin in stable condition.  On separate note he was also started on vitamin-D supplementation for vitamin-D deficiency.  Patient was also noted to have renal insufficiency which developed some time after October 2022.  There was evidence only of minimal left hydronephrosis on imaging with no stones or other obvious pathology.  Patient's renal function remained stable which suggested a somewhat chronic component to the kidney disease versus a component of acute tubular necrosis which has delayed renal recovery.  Urinalysis was noninflammatory so there was felt to be no need to consult Nephrology. Of note patient was very particular about managing his diabetes because of history of hypoglycemia and so he was allowed to decide how much long and short-acting insulin he took during his hospitalization.  He preferred no changes to his outpatient diabetic regimen on discharge       Issues Requiring Follow Up: (Who, what, when, and how communicated?)  Follow-up resolution of bacterial pneumonia with plan to repeat 2 sets of blood cultures 1 week after completing antibiotics, discussed this with primary care provider who agreed to follow-up with repeat blood cultures; follow-up renal insufficiency, mild left hydronephrosis and other medical issues with primary care provider; follow-up diabetes mellitus with endocrinology; recommend repeat CT of chest in 6-8 weeks to assess resolution of pneumonia with possible component of pulmonary necrosis."