COVID Vaccine Breakthrough Case  Pfizer Dose 1 2/12/21 (en6201) Pfizer Dose 2 3/8/21 (EN6199) Pfizer Dose 3 10/18/21 (301308A) COVID Negative 10/30/21 COVID Negative 10/30/21 COVID Positive 11/11/21  10/30/21: Patient is a 81 year old female with past history of multiple myeloma, breast cancer status post right partial mastectomy, JAK2 positive myeloproliferative disorder requiring frequent transfusions, and peripheral arterial disease who was admitted with increased weakness and fever.  History is obtained from chart review as well as discussion with the patient, her husband at bedside, and the ED provider.  Patient has a history of breast cancer in 2011 which required a partial right mastectomy.  She then was diagnosed with multiple myeloma approximately 5 years ago per she completed a course of chemotherapy and had good results without evidence of monoclonal protein on follow-up 24 urine in 2020. She developed essential thrombocytosis and was diagnosed with a right lower extremity arterial occlusion in 2018 requiring right superficial femoral thrombectomy.  Her platelet count at that time was greater than 1 million and has been on hydroxyurea since that time. She is also on Plavix at baby aspirin daily.  She has had frequent blood transfusions for ongoing anemia.  She did develop hemochromatosis secondary to the frequent transfusions and was placed on a chelating agent in the last couple of months.  She states she has been having quite a bit of diarrhea after starting that medication. Also had increasing weakness along with shortness of breath.  Her last transfusion of PRBCs was on the 15th. She was seen in urgent care earlier this week and diagnosed with a UTI given nitrofurantoin.  Continued to have increasing weakness and really unable to even stand at this time.  At baseline she does not require any assistive device to walk.  In the ER she was found to have a continued urinary tract infection along with fever. Hemoglobin also less than 7 and receiving 1 unit PRBCs. She does admit to having fevers and chills along with decreased appetite.  Not having abdominal pain.  She has noticed increasing lower extremity swelling which is unusual for her.  11/12/21: Patient is an 81-year-old female with past medical history of multiple myeloma, breast cancer status post right partial mastectomy, JAK2 positive myeloproliferative disorder requiring frequent transfusions, essential thrombocytosis, hemochromatosis secondary to multiple transfusions, diabetes, GERD, hypertension, hyperlipidemia, and peripheral artery disease who presented on 10/29/2021 with chief complaint of weakness and fever.  She had been diagnosed with the UTI at the urgent care prior to presenting to the ER.  Patient was placed on Rocephin.  She was also anemic and was transfused 1 unit of PRBCs and administered vitamin K as her INR was 2.0.  The cause of her elevated INR was unknown.  Patient was placed on broad-spectrum antibiotics with Rocephin and Zosyn.  Patient's CBC was also notable for blasts concerning for new onset of acute leukemia.  Oncology was consulted.  Patient continued to worsen and her WBC continued to rise.  Patient's fever continued and her mentation became altered.  She later tested positive for COVID-19 and had evidence of pneumonia on her chest CT. The case was once again discussed with Oncology.  Oncology met with the family on 11/12/2021 in the decision was made to transition towards hospice care given her frail state and multiple cor morbidities .  The patient passed away in the hospital this morning at 10:52 a.m..