COVID Vaccine Breakthrough Case  Pfizer Dose 1 2/22/21 (EN5318) Pfizer Dose 2 3/17/21 (EN6204) Pfizer Dose 3 10/13/21 (30145ba) COVID Positive 12/20/21  12/20/21: Patient is a 90-year-old male who presented to the emergency department with complaints of shortness of breath, cough, and loss of taste and smell times all0 "several days."  He reports that his wife recently passed away and he thinks he may have been exposed to COVID at her funeral.  He was vaccinated against COVID with the Pfizer vaccine.  He had his booster 6 weeks ago.   In the ED, his SpO2 was 82% on room air.  He has been requiring up to 5 L of supplemental oxygen.  He was tachycardic on arrival. He also had a fever of 100.5° F. His vitals are otherwise stable.  Labs were significant for BUN 45, creatinine 2.87, proBNP 4006, troponin 0.03, WBC 25.42, ESR 57, D-dimer 1.52, CRP 28.59.  In the ED the patient received 1.5 g vancomycin, 1 L normal saline, IV Zosyn, 40 mg Lasix, 6 mg dexamethasone, DuoNeb, and 1 g of Tylenol.   I discussed the case with Dr. as I feel the patient is a good candidate for Actemra.  He completed a chart review and agreed with my assessment.  He will call the pharmacy for Actemra orders.  1/18/22: Patient is a 91-year-old male with history of hypertension, hyperlipidemia, obesity, obstructive sleep apnea, type 2 diabetes mellitus, stage 3-4 chronic kidney disease, anemia of chronic disease has presented to the emergency room on 12/20/2021 with the shortness of breath, cough, loss of smell and taste.  Patient's wife apparently passed away a few weeks ago and was exposed to COVID-19 at her funeral.  Patient did receive his vaccine for COVID including booster of Pfizer.  Patient was at 82% on room air in the emergency room and was needing 5 L supplemental oxygen.  He was tachycardic.  Chest CT showed airspace disease involving all 5 lobes consistent with viral pneumonitis and multilobar pneumonia and traces of bilateral pleural effusions right greater than left. Traces to small pericardial effusion, mediastinal lymphadenopathy possibly reactive.  CT of the abdomen and pelvis showed trace of right pleural effusion and bibasilar infiltrates. Cystic pancreatic body lesion stable compared to prior MRI. Stable scattered areas of focal dilatation of the left ureter with adjacent fat stranding in the retroperitoneum. No obstructing stone or lesion is visualized. Nephrology and Pulmonary Services were consulted in view of acute kidney injury on chronic and respiratory failure.  Patient was needing OptiFlow after failing 15 L of OxyMask. Patient received Actemra.  He also completed remdesivir and dexamethasone.  He was also treated with IV antibiotics Zosyn and vancomycin. Patient had a prolonged hospitalization with OptiFlow during the daytime and CPAP at night.  Patient had an echocardiogram which showed an EF of 60-65%. He had worsening of kidney function which has finally stabilized.  Unfortunately he was unable to be placed in LTAC.  Patient was gradually weaned to high-flow O2 nasal cannula.  His renal function remained stable. Patient was also on insulin for his diabetes.  Within the last few days the patient was able to wean oxygen to 10 L high-flow O2 nasal cannula and occasionally needing higher oxygen.  Unfortunately, none of the local skilled nursing facilities would accept him at 10 L high-flow nasal cannula.  He was wanting to go home on high-flow.  Patient today was weaned to 7 L high-flow and was saturating well. On home O2 walk test patient was noted to need 2 L of O2 nasal cannula with rest and 5 L of oxygen with activity. Patient is being discharged home today.