Submitted by: Nico Herrera, MD & Peter Pappas, MD 

Institution: UAB 


Date: 02/16/2021 


 Chief Complaint: 78 yo male, COVID+, worsening SOB. 

Recent hx: Transferred from OSH for worsening SOB, +CoVID 8 days prior to transfer. 

Medical HXSocial HXSurgical HX
Coronary artery diseaseSmoked 50 yrs prior; 1.5-2 ppd x 15 yrsCABG 10 yrs prior to admission
Scalp MelanomaNo illicit drug use, drinks wine sociallyWide local excision (WLE) 4 yrs prior (for scalp melanoma)
DepressionPrior engineer, living in central ALRe-excision and split thickness skin graft 2 yrs prior
Hiatal HerniaDeep brain stimulator in left subthalamic nucleus (STN) 6 months prior
BPH s/p Turp
Pleural Plaques: Occult aspiration vs asbestosis
Parkinson’s Disease
No known allergies

 CT Chest 17 months prior to admission (because of history of melanoma) 

 -Bilateral calcified pleural plaques are noted without associated effusion 

-Subpleural reticulations and patchy ground glass parenchymal opacities especially in the lower lobes and to a lesser degree, right middle lobe and lingual persistent. 

Review of Symptoms:


Tachypnea, Shortness of Breath 

MEDICATIONS – at admission 

Ropinirole 12mg oral daily 

Citalopram 20mg daily 

Simvastatin 40mg daily 

Amantadine 100mg BID 

Carbidopa Levodopa 25-100mg 0.5 tabs 4 times daily, 50-200mg nightly 

Ubiquinone 600mg AM, 300mg PM 

Physical Examination:

Vital signs: 

Temp: 96.9 F, HR: 84 bpm, RR: 28 breaths/min, BP: 113/70 mmHg, Weight: 250 lb 

General : Alert and in moderate respiratory distress. Skin dry 

HEENT: Dry mucous membranes, no pharyngeal erythema 

Respiratory: Tachypneic, increased WOB, no wheezing, moving air well 

CVS: Difficult to auscultate; NR, RR, no murmurs 

GI: Soft, non-tender 

Neurology: Oriented, responsive to questions appropriately 

Admission Labs:


Na – 134 mmol/L 

K – 3.9 mmol/L 

Cl – 100 mmol/L 

HCO3 – 26 mmol/L 

BUN – 21 mg/dl 

Creatinine – 0.5 mg/dl 

Glucose – 116 mg/dl 

Ca – 7.6 mg/dl 

Total Protein –4.9 gm/dl 

Albumin – 2.7 gm/dl 

Total Bilirubin – 0.8 mg/dl 

AST – 49 units/L 

ALT – 14 units/L 

ALP – 69 units/L 


WBC – 9.77 x 103/cmm 

Hb – 11.4 gm/dl 

Platelets – 145 x 103/cmm 

%PMNLs – 93 

%Lymphocytes – 3 

%Eosinophils – 0 

Other labs 

ABG: pH: 7.39; pCO2: 38.5; pO2: 121; FiO2: 80% 

High-sensitive troponin – 2651 

Viral Respiratory Panel – Negative 

MRSA Nasopharyngeal Screen – Negative 

Admission Chest X-Ray 

Admission CTA Chest 

-Borderline enlarged main pulmonary artery measuring 3.1 cm in diameter. 

-Diffuse bilateral ground glass opacities throughout both lungs, most pronounced in the lower lungs. Scattered calcified pleural plaques, unchanged. 

-Multiple prominent mediastinal nodes, nonspecific but likely reactive. Stimulator device noted in the anterior upper left chest wall. 

-Prominent multilevel bridging, anterior osteophytes of the thoracic spine. 

Timeline of Hospital Course / Images

Day 1: Sputum Cultures, imaging 

Endotracheal intubation, transferred to MICU 

Day 3: Sputum Culture result: Aspergillus fumigatus complex 

1-2 Beta D Glucan: < 31 

Serum Aspergillus Galactomannan: 2.577 

Dexamethasone, Remdesivir, Vancomycin, Cefepime and Azithromycin started 

Day 4: Voriconazole started 

Day 5: Tracheal Aspirate: Acinetobacter baumannii (ceftazidime sensitive) 

Near minimal ventilator settings, failing spontaneous breathing trial 

Starts meropenem and minocycline (Day 6-8) 

Starts Ceftazidime (Day 9) 

Day 10: Tracheal Aspirate: Acinetobacter baumannii; fever 101 

Day 13: Alkaline phosphatase 51, AST 332, ALT 46. Due to elevated AST, 

Voriconazole discontinued and Isavuconazole initiated 

Day 14: Kidney injury (acute tubular necrosis and COVID) 

Requires Vasopressors 

Day 21: Tracheal aspirate: A. baumannii (resistant to ceftazidime) 

Raoultella ornitholytica 

Persistent encephalopathy, Neurology consult 

Day 16: Fever 101.7 

Day 21 – CT Chest 

Small bilateral pleural effusions, right greater than left. Significant improvement and crazy paving pattern of opacities scattered throughout the lungs with interval development of multifocal areas of cavitation in the posterior right upper lobe and left lower lobe. Dense, consolidation in both lower lobes. Small amount of endotracheal and endobronchial secretions present. 

Pneumomediastinum which is new from prior and of uncertain etiology. 

Constellation of findings suggestive of volume overload including small volume ascites and anasarca. 

Day 11- Chest Xray 

Day 29: Acalculosis cholecystitis; IR guide cholecystostomy 

Cultures: C. albicans (fluconazole and micafungin sensitive) 

Tracheostomy placed 

Day 30: Cardiac Arrest (Pulseless electrical activity (PEA) 

Day 35: Transitioned to comfort care 

Day 35: Died 

Day 29- Chest CT 

• Consolidation in both lower lobes is similar. Patchy peripheral regions of consolidation in the upper lobes represents a worsening. Peripheral cavities near the right lung apex and in the right upper lobe posterior segment appear to be parenchymal and have a similar distribution compared to the previous. 

• A few shotty and mildly enlarged mediastinal lymph nodes are slightly larger compared to the previous, possibly reactive. 

• Pneumomediastinum is decreased. 

• Small bilateral pleural effusions are slightly increase 

Day 29- Chest X-Ray