Patient is 36 years old male with no significant chronic medical condition who is reported to be in his usual state of health about 3 weeks ago when he started having a cough for which she was tested for COVID-19 and this was negative, patient having continued cough was re-evaluated at the urgent care about 10 days ago and was prescribed Zithromax at he finished couple days ago no presented to the hospital as was noticed to be having rash in the hand , under the chin and also anterior chest for which patient was evaluated in the emergency room where he was found to be in AFib with RVR with heart rate of over 200 for which he was started on diltiazem infusion, he is also noted to be in pleural effusion on the CT scan therefore he has noticed her to be hospitalized for further evaluation management. Patient is denying to any hemoptysis, patient denied any fever chills, patient denied any trauma to the chest, patient denied any dizziness or lightheadedness, he is feeling a little better and the chest after the heart rate is controlled now and emergency room, cough is also getting better, patient is reporting that he probably noticed some of these lesion or rash 3 days ago though the family just noticed it today, this is not itchy, mild discomfort at the site of the rash otherwise I have reviewed all other systems with him and they were negative.   While in ED patient developed acute onset of left sided weakness, hemineglect, and slurred speech at 0330 hours. TPA was not given due to concern that patient may have septic emboli. Non-invasive imaging demonstrated right MCA occlusion with sizeable penumbra. Consulted for mechanical thrombectomy.   CTH showed loss of gray-white differentiation in the right insula and hyperdense right MCA but no other acute pathology. CTA revealed an occlusive thrombus in the right M1 with a favorable perfusion mismatch. TPA was not given due to suspicion for septic emboli. Mechanical thrombectomy was performed and achieved TICI 3 reperfusion.. After the thrombectomy patient became hypoxic and hypotensive. Pressors were started. Perioperative tee was performed and, per report, did not reveal any intracardiac thrombus or vegetations. Later over read by Cardiology reported significant left ventricular thrombus burden. Body IR formed a pulmonary arteriogram and did not identify a PE. NIR performed a cerebral angiogram and identified reocclusion of the right M2 inferior division. A 2nd thrombectomy was performed and achieved TICI 2b revascularization. Postprocedure CTH demonstrated hyperdensity in the right hemisphere subarachnoid space. MRI brain revealed no GRE changes. DWI did reveal right MCA ischemic stroke and a right MCA/PCA watershed territory stroke. Post thrombectomy MRA did not show signs of intracranial artery dissection. ID consult: Acute respiratory failure, cardiomyopathy/ shock, CNS thromboemboli,  Rash - clustered over chin (petechial), single over chest (pustular), L index finger singular deroofed - send ET aspirate for COVID PCR -- > low suspicion for active infection - suspect possible VITT associated myocarditis/ cardiomyopathy-- > ? pulm edema/ effusions; cerebral thrombosis vs atypical pneumonia related cardiomyopathy/ CNS thromboemboli though unusual for latter - cardiogenic shock vs septic shock (cool extremities)-- > await BC, stool studies             (prolonged prodrome of lingering cough)               - follow BC; get HIV/ RPR for screening (though low risk), send atypical pneumonia serologies, stool studies             - send PF4 antibodies -- > d/w lab to have test expedited              - get Heme consult -- > ? IVIG / ?exchange             - report to regulatory authority             - add fibrinogen/ D Dimers             - agree with Vanc/ Cefepine and Doxy             - noted patient is on Doxy at this time (? Mycoplasma; Chlamydophila; Legionella; Doubt tick borne - no recent travels/exposures; home bound) but given prolonged cough > 5-6 wks may continue             - recent intermittent diarrhea mom/sister/ dad x 60 days (suspected irritable) -- > send stools for cultures, viral cultures, O/P