COVID Vaccine Breakthrough CAse  J&J Dose 4/12/21 (042A21A) COVID Positive 12/3/21  12/3/21: Patient is a 55-year-old male with a past medical history significant for HIV.  The patient presents to the ED today with complaints of slight cough, worsening shortness of breath.  Per the patient's medical documentation, his symptoms started 1 week ago. The patient's other accompanying symptoms include body aches, nausea, vomiting, diarrhea.  The patient denies any fever, chills, chest pain.  The patient had a known exposure to his family with COVID-19.  The patient is vaccinated against COVID-19.  The patient's oxygen saturation was 74% on room air upon arrival to the ED, the patient was placed on high-flow oxygen which improved patient's O2 saturations.  The patient subsequently had an episode of desaturation on oxygen with respiratory distress which required being placed on BiPAP.  The patient is currently at 40% FiO2 with a respiration rate of 26, the patient's oxygen saturation is 93%.   Upon arrival to ED patient's temperature is 99.6°, heart rate 99, respirations 24, pulse ox 78% on room air, blood pressure 116/87.  Chest x-ray revealed bibasilar airspace disease, suspicious for multifocal infection although volume overload can be a similar appearance.  Patient's laboratory findings are significant for glucose 122, BUN 27, creatinine 1.67, AST 55, proBNP 221, D-dimer 1.31. Patient received 500 mg IV azithromycin and 6 mg IV Decadron in ED.  12/9/21: Admission diagnosis:  Acute hypoxic respiratory failure secondary to COVID-19 pneumonia Rule out superimposed bacterial pneumonia, underlying immunosuppression, AIDS  Patient is 55-year-old male with past medical history of HIV/AIDA on HAART, and CKD.  He presented to the emergency room with complaint of cough and progressively worsening shortness of breath x 1 week. He had a known exposure to his family with COVID-19.  Patient is fully vaccinated for COVID-19.Upon arrival to ED patient's temperature is 99.6°, heart rate 99, respirations 24, pulse ox 78% on room air, blood pressure 116/87.  Chest x-ray revealed bibasilar airspace disease, suspicious for multifocal infection although volume overload can be a similar appearance. Patient's laboratory findings are significant for glucose 122, BUN 27, creatinine 1.67, AST 55, proBNP 221, D-dimer 1.31.  CT chest with IV contrast was obtained which was negative for pulmonary embolism but revealed bilateral infiltrates.  Patient was admitted for further management of acute hypoxic respiratory failure likely secondary to COVID-19 pneumonia with possible superimposed bacterial pneumonia.  Patient was started with empiric IV antibiotic treatment. He also started with IV dexamethasone. Initially, remdesivir was held because of elevated creatinine.  However, patient is on chronic prophylactic treatment with Bactrim which is known to increase creatinine without affecting kidney function.  Kidney function improved with IV hydration.  Later,he  was started with IV remdesivir.  Actemra was deferred as patient has severe M*Modal suppression from underlying AIDS with CD4 count of 78. Case was discussed with ID specialist Dr.  Patient's respiratory status progressively improved.  On day of discharge, he underwent home oxygen walk test and did require any supplemental oxygen.  He is being discharged home with 4 more days of dexamethasone 4 mg p.o. daily.  He will follow-up with his PMD in 1 week time.  He was instructed to self isolate at home for 7 more days.  He is being discharged home with COVID-19 home program.