COVID Vaccine Breakthrough CAse  Pfizer Dose 1 12/19/2020 (ek5730) Pfizer Dose 2 1/20/2021 (EL3248) COVID Positive 11/28/2021  12/2/21: Patient is a pleasant 58-year-old female with past medical history of rheumatoid arthritis, hypertension, COVID-19 vaccinated 2/2 comes in with chief complaint of cough, shortness of breath.  Clinical picture started approximately 6 days ago his been progressively getting worse patient had noted symptoms was tested for COVID this past Sunday and was positive.  Was being monitor home reportedly was on azithromycin and Tessalon however symptoms worsened she had pulse ox at home was saturating 80-83% on ambulation on room air so came into the emergency department for further evaluation.  In the ED chest x-ray noted bilateral infiltrates, CT PA was done negative for PE however extensive infiltrates noted.  Patient notes she has history of RA and has been holding her immunomodulators/meds since at least Thursday of last week at instruction of her rheumatologist.  Has not received a booster as she was receiving some steroids and was waiting to finish course as an outpatient.  Received IV fluids antibiotics in ED, was slightly tachypneic in ill-appearing request was made to admit to medical service for further evaluation and treatment.  Bedside patient is sitting up in bed currently denies any lightheadedness or dizziness however gets symptomatic with ambulation, no chest pain or palpitations does endorse subjective dyspnea worse with exertion no abdominal pain, paresthesia, nausea, vomiting, diarrhea, peripheral edema.  Only medication changes as noted were her rheumatoid medications which have been held since last Thursday, she was receiving azithromycin, Tessalon.  Denies tobacco, alcohol, marijuana/recreational drugs or over-the-counter medication use.  COVID-19 vaccinated 2/2 has not received booster, no recent travel outside the area.  On no known sick contacts however she is a hospice nurse.  Family history reviewed and noncontributory to presenting finding.  12/5/21: The patient is a 58 year but he pleasant lady who is a nurse by occupation.  She has had two COVID-19 vaccine but was supposed to hold immunosuppressants for two weeks before getting the booster.  However in the meantime she got sick.  Initially it started as a cough and she went to align I emergency room.  However her pulse ox was getting low due to which she was sent to the Emergency Room. Her pulse ox was in the 80s and she is having dyspnea on exertion.  In the emergency room she had chest x-ray showed worsening infiltrates and CT scan of chest showed no PE but there were extensive bilateral ground-glass infiltrates consistent with atypical pneumonia or viral pneumonitis. It was thought to be from COVID-19.  Her D-dimer was 1.9 and when she came.  CRP was 5.9 and was 1.5 on discharge. D-dimer also improved 0.65 by discharge.  She had blood cultures that are growing no organism till date.  She has had azithromycin before and she was started on IV Levaquin the hospital.  She was also given Decadron along with remdesivir.  She initially was needing oxygen at about 2 L but subsequently she was weaned off.  By discharge saturation on room air were 95%.  She got about three days of remdesivir and we talked about completing the course but she did not want.  He was feeling good and wanted to go home on oral antibiotics.  Steroids were also ordered.  She was ambulatory time of discharge without any assistance.