COVID Vaccine Breakthrough Case  Moderna Dose 1 1/20/21 (041L20A Moderna Dose 2 2/17/21 (011M20A) COVID Positive 11/17/21  11/17/21: Patient is a 64 year-old man with past medical history of T2DM and HTN who presented to the ED after taking a positive COVID test, wanting to get a PCR test so he could receive the outpatient monoclonal antibody infusion. He states that he began having upper respiratory symptoms on Friday which prompted him to take a home test. He felt well over the weekend but on Monday began having increased fatigue and cough. His appetite is decreased but he still has his taste and smell. He has been using tylenol prn but has taken his temperature at home and did not note any fevers. No other concerns.   He has not taken his home medications in several months. He states he can control his sugars with his diet.  Surgeries: Noncontributory  Allergies: NKDA  Social hx: Smokes cigars once per month. Drinks 1-2 beers twice per week. No other drugs.  Family hx: Noncontributory.   ED course: Presented with COVID. Tachycardic to 120s but saturating well on room air. Temp 100.3F. PCR confirmed COVID. CXR left lung pneumonia consistent w virus. CTA negative for PE. VBG showed pH 7.17 with pCO2 26. No leukocytosis. Troponin negative. Rocephin and azithromycin given in ED. Na 123, glucose 331, lactate 3.1->2.4. 1L LR given. Admitted to observation for COVID, tachycardia, and hyponatremia.  11/26/21: 64 year-old man with past medical history of T2DM and HTN who presented to the ED after taking a positive COVID test, wanting to get a PCR test so he could receive the outpatient monoclonal antibody infusion. He began having upper respiratory symptoms which prompted him to take a home test. He felt well over the weekend but later began having increased fatigue and cough. His appetite was decreased but he still had his taste and smell. He has been using tylenol prn but had taken his temperature at home and did not note any fevers. No other concerns.   ED course: Presented with COVID. Tachycardic to 120s but saturating well on room air. Temp 100.3F. PCR confirmed COVID. CXR left lung pneumonia consistent w virus. CTA negative for PE. VBG showed pH 7.17 with pCO2 26. No leukocytosis. Troponin negative. Rocephin and azithromycin given in ED. Na 123, glucose 331, lactate 3.1->2.4. 1L LR given. Admitted to observation for COVID, tachycardia, and hyponatremia.   During admission, he was not hypoxic initially, however had a decline in respiratory status with tachypnea to the 40s and hypoxia at 85%.  He was placed on OptiFlow, which improved his O2 saturations.  He was then given Decadron, though was still in distress, so was started on AVAPS. Pulmonology was consulted and he was escalated to ICU.  He was continued on treatment with remdesivir and Decadron, and then received Actemra given his significantly elevated CRP.  D-dimer was also elevated, though CT angiogram was negative for pulmonary embolism.  Troponin was elevated, so Cardiology was consulted, who started him on metoprolol tartrate 12.5 mg b.i.d. and baby aspirin once daily. Believed that COVID or possible viral myocarditis could have been the cause of elevation.  Blood sugars remained under control on GlucoStabilizer.  Patient was intubated due to decline in respiratory status.  Echo was done on 11/18, showing EF of 30-35% with moderately dilated left ventricle and moderate global hypokinesis.  Fortunately, his respiratory status did improve and became stable, so he was extubated on 11/23.  He completed his 7 day course of Rocephin 2 g daily on 11/24.  Oxygenation and overall respiratory function continued to improve, and he was moved to the general floor on 11/25.  Today, he is in good spirits, and is looking forward to going home.  He denies any current shortness of breath, chest pains, fevers, chills.  He had an O2 walk for determination of necessity for O2 use at home, and was found to require no supplemental oxygen.  D-dimer and CRP were repeated. D-dimer again elevated, though was stable.  Per IMPROVE-VTE score of 3 in combination with D-dimer greater than 2 times upper limit of normal, he qualifies for outpatient Xarelto 10 mg x 45 days.  Outpatient sleep study has also been ordered.  He was started on Lantus 10 units q.h.s. for further management of his blood sugars at home.  At this time, he is safe and stable for discharge home.  He will follow-up with his PCP within 1 week of discharge.  Return to ER precautions were given to patient, who verbalized understanding and agreed with plan.