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An otherwise healthy 84-year-old male tested positive for
SARS-CoV-2 with a reverse transcription-polymerase chain reaction (RT-PCR) about
2 months after getting a COVID-19 vaccine. He was a participant in an ongoing
COVID-19 vaccines long-term safety study NCT04832932. He had no
known past medical problems or allergies and was not on any
medications except daily topical beta-blocker eye drops prescribed after
vaccination. His social history was negative for tobacco or drug use. He led
a physically active lifestyle and was always compliant about wearing a face
mask in public.
Approximately 24 hours after receiving the first dose of the
Vaxzevria - AstraZeneca COVID-19 (AZD1222 also known as ChAdOx1 nCov-19 or
C19VAZ) vaccine, the patient had a near fall experience because of a sudden
bilateral lower extremity stiffness. Besides swelling
and skin redness at the injection site, he also developed extreme fatigue, muscular weakness,
respiratory distress with tachypnea (over 30 breaths per minute that
decreased to 25 breath per minute for the next few hours after rest) and
tachycardia (resting heart rate of 100-110 beats per minute for the next 15
hours). He had walking difficulties and
his gait appeared stiff (spastic/ataxic). Acute symptoms resolved within 24
hours without treatment and with no significant sequelae, although he experienced increased hunching or leaning forward while walking. About 4
weeks later he developed delayed localized cutaneous reaction, possibly as a
result of reactivated latent skin infection.
6.5 weeks after receiving the vaccine, the gentleman
experienced acute nighttime cough and a few days later had an episode of
gastrointestinal distress. Next week he presented with sudden onset of
low-grade fever and fatigue. Oropharyngeal and nasal swab sampling for COVID-19 was
performed on day 2. By the time PCR test results were returned as positive,
the patient had 2 fall incidents. When the ambulance arrived, early morning of day 4, he was not able to
lift his arms nor even index fingers for a basic neurological exam. He was
hospitalized with asthenia and mild dyspnea.
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Patient’s status on admission was classified as moderate based
on normal blood values and chest computed tomography (CT) score of 12. This
score comprised the sum of scores for each of the 5 lung lobes, with each
lobe awarded 0 to 5 points, depending on the percentage of the involvement,
including ground-glass opacity, interstitial opacity, and air trapping on
thin-section: 0 (0%), 1 (<5%), 2 (5-25%), 3 (26-49%), 3 (50-75%), or 5
(76-100%). The scoring system was an adaptation of a method
previously established to describe idiopathic pulmonary fibrosis and severe
acute respiratory syndrome (SARS). |
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During the hospital stay, the patient
received low molecular weight heparin (LMWE) for thromboprophylaxis, ventilator
support, broad-spectrum antibiotics and antipyretics along with other
supportive treatments. In view of rapidly progressing COVID-19 pneumonia he also
received dexamethasone.
On the first day of admission, supplemental oxygen was
administered with a low-flow system via nasal cannula. This helped to achieve
peripheral oxygen saturation (SpO2) range of 96% to 97%. LMWE was started on
admission. On the evening of the second day, the patient was found to be in
respiratory distress. He was tachypneic and in severe pain since that morning.
His laboratory evaluation revealed elevated levels of C-Reactive Protein
(CRP) and Alanine Aminotransferase (ALT). The hospital was not equipped with
electromyography machines and could not reliably distinguish rapidly
progressing weakness from myopathy, neuropathy, fatigue or asthenia.
On the third day of admission (day #6 of symptoms) the patient
developed higher fever (axillary temperature,100.5oF) that
continued to increase reaching 101oF 24 hours later. Fever
was unresponsive to usual measures and required intravenous Metamizole
administration. Dexamethasone was prescribed, but CRP levels kept increasing
exponentially (from 3 mg/L on the day of admission to 11 mg/L on day #3, to
72 and 134 mg/L on days #5 and 6 in the hospital) indicative of acute
inflammation and a possible cytokine storm.
On the 5th day of admission (day #8 of symptoms), the patient
no longer had fever, but his oxygen levels kept dropping. A Continuous
Positive Airway Pressure (CPAP) was initiated, but less than 24 hours later (day
#9 of symptom onset), the patient was found unresponsive with SpO2 at 60%. He
was intubated and moved to ICU. Levels of positive end-expiratory pressure
(PEEP) were maximally increased to provide acceptable oxygenation, but
pulmonary indices continued to deteriorate. On the 5th day in ICU (day #12) patient
progressed to septic shock. Despite ongoing antibiotic treatment, ventilatory
and vasopressor support, he developed cardiac arrest and died on the 12th
day in ICU (day #17 of hospitalization, day # 20 of symptom onset).
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REFERENCE
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