COVID Vaccine Breakthrough Case  Pfizer Dose 1 4/1/21 (EN6198) Pfizer Dose 2 7/31/21 (ew0179) COVID Positive 11/29/21  11/29/21: Patient is a 69-year-old male with past medical history of alcoholic cirrhosis with recurrent ascites, chronic atrial fibrillation, HFrEF, hypothyroidism,  and chronic hyponatremia.  He also had a recent hospitalization from 11/15/21-11/19/21 with 1/2 blood cultures positive for MSSA.  He also had peritoneal fluid grow Staph epi.  He was prescribed a 14 day course of Keflex in regards to this. This is scheduled to finish 12/01/2021. The patient presented to the emergency department on 11/28/2021 with chief complaint of altered mental status and weakness.  His wife stated that he was fairly altered for the last 2 days and was slumped over in his chair today.  She was concerned about a stroke and therefore had him transferred to the emergency department.  The patient was diagnosed with septic shock on arrival as his rectal temperature was low and his blood pressures were low as well.  He was administered appropriate fluids and was still hypotensive. He therefore received Levophed in the ED overnight.  He was also administered midodrine, Zosyn, vancomycin.  A chest x-ray was negative.  A UA is pending.  Blood cultures were drawn.  Patient came back positive for COVID-19.  It was later felt that his hypotension may in fact be chronic in nature as he struggled with this during his last hospitalization and was discharged on midodrine and fludrocortisone.  He was nonetheless admitted for rule out sepsis/septic shock/weakness secondary to COVID-19 infection.  The patient confirms the above story.  He believes that he is currently back to his baseline health. He has no acute complaints.  Review of systems is negative. He denies any recent alcohol use and states that he quit drinking several years ago.  Family history is noncontributory.  12/9/21: Patient is a 69-year-old male with past medical history of alcoholic cirrhosis with recurrent ascites, chronic atrial fibrillation, HFrEF, hypothyroidism,  and chronic hyponatremia.  He also had a recent hospitalization from 11/15/21-11/19/21 with 1/2 blood cultures positive for MSSA.  He also had peritoneal fluid grow Staph epi.  He was prescribed a 14 day course of Keflex in regards to this. This is scheduled to finish 12/01/2021. The patient presented to the emergency department on 11/28/2021 with chief complaint of altered mental status and weakness. Patient was then admitted with Septic shock verses chronic hypotension with acute COVID-19 infection  Chronic hyponatremia  Lactic acidosis  Recent MSSA bacteremia, finishing course of antibiotics  Peritoneal fluid culture positive for MSSA  Chronic Alcoholic cirrhosis with recurrent ascites  Chronic Atrial fibrillation  Chronic HFrEF  Chronic Hypothyroidism   Patient was then started with started with IV antibiotics.  Ascites has been evaluated and there is increase WBC suggesting a possible SBP.  IV antibiotics have been started.  The patient is on both midodrine and Florinef for his hypotension, but diuretic for his fluid overload have been discontinued.  He unexpectedly tested positive for COVID-19 infection but has no hypoxemia or respiratory symptoms.  Patient had repeated paracentesis and did not show any sign of infection and was discharged to SNF to follow-up as outpatient