COVID Breakthrough Case  Moderna Dose 1 5/18/21  COVID Positive 10/16/21  10/16/21: A 45-year-old male with no significant past medical history is transferred from ED for COVID-19 pneumonia with hypoxia and acute kidney injury.  Patient complains of feeling sick for almost 1 week, was having body aches and fatigue.  Last couple of days he has been having cough with a dark brown mucoid sputum, nonbloody.  Complains of feeling short of breath.  Denies chest pain or abdominal pain.  Feels nauseous but no vomiting.  No constipation or diarrhea or dysuria or flank pain.  Patient states that 2 weeks back he visited last week as, flew back.  Denies leg swelling or calf pain. Denies sick contacts.   Patient had 1 dose of COVID-19 vaccine on June 15th, and he missed a the 2nd dose.  Lives with his daughter, and daughter has no symptoms.  Current smoker, smokes about 1 pack cigarettes per day.  Takes alcohol socially and admits to meth use.   On arrival to the ED, he was afebrile, blood pressures were soft, responded to fluid bolus 1 L normal saline. Initially his oxygenation was in 90s, but noted to be hypoxic in the ED, started on oxygen by nasal cannula now on 4 L, saturating 93%.  COVID-19 rapid test is positive.  Blood work is significant for elevated BUN and creatinine 52/4.3, potassium of 5.4 and lactic acid of 3.7.  CBC negative for leukocytosis, but shows lymphocytopenia.  D-dimer is elevated 2.14.  Patient is given IV ceftriaxone and Zithromax, and started on heparin drip for anticoagulation.   Patient is seen by me on medical floor, complains of cough but no chest pain, says he feels weak and tired.  10/23/21: This 45-year-old male had received 1 dose of COVID-19 vaccine a week before developing increasing shortness of breath, hypoxemia, and acute kidney injury.  He tested positive for COVID-19.  Chest x-ray showed bilateral infiltrates.  He was started on IV antibiotics for possible community-acquired pneumonia, transferred.  He had required 6 L of oxygen much of the time, had some shortness of breath with any activity.  We tried to reduce some of the oxygen, and the patient was eager to return home. He had some financial dealings he had to deal with, but the one positive MRSA blood culture had suggested we should continue IV vancomycin for a full 10 days.  A PICC line was placed; however, the patient was needing to leave the hospital on Saturday.  We are unable to get home oxygen or other arrangement for outpatient IV antibiotics.  The PICC lines were pulled and switched to oral doxycycline and he was actually discharged home without any supplemental oxygen.  Last oxygenation 92% on room air.  He was seen the day of discharge, blood pressure 130/54, pulse 100 regular, temperature is 99.2.  Lungs are coarse, but improved.  We warned the patient that he has potential Staph pneumonia or bacteremia, and the doxycycline may not be adequate coverage.  He should be prepared to return to his family physician or the emergency room if symptoms worsen.  We will try to arrange home oxygen, but he seems to actually be doing quite well at the time of discharge from the oxygenation standpoint. We tried to get him to stay for another few days, but he has some financial problems and needs to leave today without question.  The patient was polite and cooperative, and we will try to work with him on getting him treatment if he has any further symptoms.  The patient is seen the day of discharge and actually doing quite well.