COVID Breakthrough Case  Moderna Dose 1 3/17/21 (002B21A) Moderna Dose 2 4/9/21 (025B21A) Pfizer Dose 3 10/27/21 (lot not listed in immunization registry)  11/2/21: This is a 62 yo male  with medical history of atrial fibrillation s/p ablation therapy and obstructive sleep apnea who presented to the emergency department on 10/31/21 with complaint of neck stiffness and fever. The patient received a COVID-19 booster vaccine on Wednesday and started having symptoms on Friday. He reportedly received  Pfizer vaccine and previously got Moderna vaccine *2 . On Friday he started noticing neck stiffness but did not think anything of it and thought it was a "kink" .  He also notice a little bit of right sinus pressure.  On Saturday the neck stiffness was worse but he was still able to do yard work.  He wears gloves when he works on the yard.  Saturday night he had to take some Tylenol for the pain.  He noticed a large bruise on his left shoulder where he had his COVID shot.  On Sunday morning at 5 he woke up with shaking chills, temperature of a 100.8° and with severe neck stiffness.  He could not move his neck at all due to pain.  He called his PCP and was to instructed to go to emergency room.  He denies any history of herpes infection or any shingles infection.  He recently visited his parents. No recent camping, hiking, swimming in lake or arthropod bites that he could recall.  In the emergency department he underwent CT and MRI of the brain and cervical spine which were unremarkable.   Lumbar puncture was performed and preliminary CSF analysis showed glucose 72, protein 31, TNC 1, RBC 1. His white blood cell count was 7.03, lactate was normal.   He was afebrile with stable vital signs. Blood cultures were drawn and he was empirically started on vancomycin,  acyclovir ,  ceftriaxone and  dexamethasone. Neurology was consulted and it was recommended to continue Flexeril and pain reliever for neck stiffness. Meningitis was ruled out. Subsequently his blood cultures came back positive for staph aureus. He is currently on vancomycin. Today his pain is better but he needs to take Flexeril and Lortab.  He feels constipated.  He denies cough shortness of breath, no cough, no nausea no vomiting, no dysuria urgency or frequency.  Sinus pressure is improved.  11/9/21: PCP NOTE -  62 yo   male  with medical history of atrial fibrillation s/p ablation therapy and obstructive sleep apnea who presented to the ER on 10/31/21 with c/o neck stiffness and fever. The patient received a COVID-19 booster vaccine on Wednesday and started having symptoms on Friday with  neck stiffness. He also notice a little bit of right sinus pressure.  On Saturday the neck stiffness was worse but he was still able to do yard work.  Saturday night he had to take some Tylenol for the pain.  On Sunday morning at 5am he woke up with shaking chills, temperature of a 100.8° and with severe neck stiffness.  He noticed a large bruise where he had his COVID shot.  He could not move his neck at all due to pain and came to the ER to be evaluated.  He underwent CT and MRI of the brain and cervical spine which were unremarkable.   Lumbar puncture was performed and  CSF analysis showed glucose 72, protein 31, TNC  1, RBC 1. His WBC was 7.03, lactate was normal. He was afebrile with stable vital signs. Blood cultures were drawn and he was empirically started on vancomycin, acyclovir ,  ceftriaxone and  dexamethasone. Neurology was consulted and it was recommended to continue Flexeril and pain reliever for neck stiffness. Meningitis was ruled out. Subsequently, his blood cultures came back positive for staph aureus. He  has been on vancomycin. Repeat blood cultures done on November 1st. Neck pain persists. PLAN: Afebrile, on room air, BP stable Bacteremia, etiology unclear. Port of entry may have been COVID vaccine injection Has 4 positive blood cultures with staph. Blood cultures 11/06/21  no growth Ancef for 4 weeks (until December 4th) Follow up with PCP in 1 and 4 weeks Place midline repeat blood cultures 2 weeks after off antibiotic Waiting for antibiotic to be set up before discharge  11/10/21: MSSA bacteremia, cleared Neck pain and stiffness, improved  Atrial fibrillation status post ablation  Obstructive sleep apnea  Attenuation lesion over the lower pole of left kidney, non emergent renal ultrasound to be arranged  by PCP.