Patient is a very pleasant 38-year-old male with no significant past medical history other than a BMI of 37 and a past history of COVID-19 infection in February 2021 which was asymptomatic with  no sequela after he was required to test after his wife tested positive .he is on no medications prior to arrival, he smokes an occasional cigar and drinks alcohol only occasionally who presented to the emergency room on 6/6/21 With a chief complaint of difficulty breathing,  fever, malaise and significant left-sided chest pain that have been ongoing since May 23 slowly worsening.  He denied any recent travel any recent illness any recent sick contacts.  He denied any illicit drug use over-the-counter supplement use .patient reported he received his first Pfizer Covid vaccine on 5/17/2021 and a few days after began to feel congestion with mild coughing which progressed.  He initially thought he may be having  allergies and took some Claritin without relief.  As the week went on he developed increasing shortness of breath and cough and also developed a fever.  He went to the well now urgent care on June 3 and was told he may have pulled a muscle and was sent home.  He returned back to our emergency room in the early morning of 6/4 complaining of again of left-sided chest pain radiating into his ribs with associated shortness of breath worse with inspiration associated with coughing but no hemoptysis.  At that time he had no complaints of fever or chills.  He works at a hardware store and thought perhaps he may have strained himself lifting heavy boxes of flooring.  During that ER visit he was hypotensive and tachycardic with respirations of 30.  CTA of the chest did not show any pulmonary emboli but showed inflammatory changes in the left side in the lingula consistent with possible acute community-acquired pneumonia.  He was given Toradol and morphine and was discharged home on oral antibiotics.  His EKG at that time showed sinus tachycardia the ST segments were normal.  He was afebrile.  He returned back to the emergency room the morning of 6/5 with complaints of worsening left-sided chest pain worsening shortness of breath and worsening fatigue.  He reported any movement he develops a cough and he cannot lie flat as he develops significant chest pain which is relieved with sitting up.  He had been taking some ibuprofen with minimal improvement.  He also reported some nausea and fatigue.  He had a fever at home of 102 °F just before coming to the hospital but arrived afebrile.  Patient admitted to having COVID-19 infection in February when his wife tested positive.  He was asymptomatic other than a headache for 1 day and recovered without any incident.  In the ER he was again tachycardic but was afebrile.  His blood pressure was 137/81 his O2 sat was 97% on room air.  He however was quite tachypneic with respirations of 35 at times at rest.  Lab work revealed a white blood cell count of 13.2 with significant elevations of his erythrocyte sedimentation rate and CRP at 75 and 20.8 respectively.  Covid testing was negative.  Repeat chest imaging reveals a large left pleural effusion and atelectasis with no pulmonary edema.  CT scan of the chest revealed no pulmonary emboli but now reveals right middle lobe and bibasilar infiltrates suspicious for an infectious or inflammatory process.    EKG revealed sinus tachycardia but no ST changes were apparent.  Was clinically dehydrated with an elevated specific gravity positive nitrites but 0-9 white blood cells on urinalysis.  Troponin at 0-hour was low -3 1 hour was -3 with no change in his delta.  BNP was normal at 14 lactic acid was normal at 1.1.  Procalcitonin was normal at 0.60 and lipase was normal at 21 with a normal CMP.  He was subsequently admitted to the hospitalist service.  In the emergency room he was given Rocephin and azithromycin. The following day his condition worsened with continued fever and increasing shortness of breath. . ESR was worsened from 75 to 82 and cardiac crp now >200. A stat echo was ordered and his case was reviewed with the cardiologist. there was concern for possible myo/pericarditis so pt was started on colchicine and ibuprofen tid and the decision was made to transfer the patient to a larger tertiary care facility. stat echo showed normal ef and no sign pericardial effusion. He was transferred to another hospital where he was followed by cardiology and pulmonology. He ultimately underwent thorocentesis but the fluid reaccumulated so a chest tube/drain was placed. He was treated for a peripneumonic effusion. cultures and cytology were ultimately negative. acid fast bacilli was negative, blood cultures were negative. covid 19 pcr testing was negative x 2. He was discharged home on 6/11/2021 with instructions to continue augmentin bid for 4 more weeks with close follow up with pulmonary and repeat chest x ray in 1 month,