COVID Vaccine Breakthrough Case  Pfizer Dose 1 2/18/21 (EN6200) Pfizer Doze 2 3/12/21 (EN6204) COVID Positive 11/7/21  11/13/21: This is a 67-year-old male with history of hypertension, coronary artery disease status post stenting in the past, hyperlipidemia and obesity who presented with worsening shortness of breath. Patient reports that he has been having worsening shortness of breath, cough, fatigue and dizziness for the past week. Patient had a COVID-19 test on 11/07/2021 which was positive. Patient states that at home he has been noticing that his oxygen saturation has been falling to the 80s and 70s. He denies associated fever, chest pain, abdominal pain, nausea, vomiting, diarrhea or constipation. He states that multiple family members are currently sick with COVID-19. He received full vaccination for COVID-19 earlier this year.   In the emergency department, patient was found to be hypoxic and he was put on 5 L of O2 via nasal cannula. He was found to have a temperature of 100.1° F. His labs showed sodium of 127, creatinine of 1.33, ALT of 46, AST of 86, lactic acid of 5.2, proBNP of 918, troponin of 0.04, WBC count of 12.8. CT angiography of the chest showed extensive pulmonary embolism involving all 5 lobes of the lungs with right heart strain as well as extensive bilateral area of airspace disease consistent with viral pneumonitis. Patient received dose of p.o. Tylenol, IV Rocephin, Decadron and IV fluids.  Patient was started on IV heparin drip.  11/23/21: Patient is admitted to the hospital, placed on contact and droplet precautions and started on IV heparin drip.  Cardiology consulted, they recommended anteversion heparin drip, did not recommend EKOS, has the thought patient is high risk of massive bleeding.  Echocardiogram done showed LVEF of 45-50%.  Pulmonology is consulted for worsening respiratory failure, patient is seen and followed by pulmonary team.  Patient is treated with Actemra, IV remdesivir and empirical IV antibiotics ceftriaxone Zithromax.  Patient has earlier received monoclonal antibody on 11/09/2021.  Patient was already vaccinated with Pfizer x2 doses in February and March 2021. He is also treated with IV dexamethasone 6 mg daily, which is today converted to 4 mg p.o. daily.  He was also given Precedex drip in the ICU for claustrophobia.  Has been on IV Lasix initially 40 mg, now decreased to 20 mg for fluid volume overload.  Clinical condition continued to improve, oxygen requirements trending down. He was also placed on CPAP at bedtime.  Anticoagulation was switched from heparin to Lovenox 1 milligram/kilos subcu q.12 hours, later switched to DOAC Eliquis.  Patient is clinically improved, oxygen requirements are significantly down.  Patient is cleared for discharge from pulmonary standpoint.  Today prior to discharge oxygen walk test is done to determine the need for home oxygen therapy, patient qualifies for home oxygen, is on room air at rest, but requires 3 L oxygen by NC with activity.  Findings are discussed with the patient and he is agreeable to have home oxygen therapy.  Discussed the care coordination and arrangements are being made for delivery of oxygen cylinders at home, both stationary and portable as patient is mobile.   Patient is discharged to home on tapering dose of dexamethasone, Lasix along with supportive therapy.  He will follow up with pulmonology group in 2 weeks with CBC, ESR, CRP and chest x-ray.  Discharge plan is discussed the patient.