Clinical history
The case concerns a 29 years old woman (57 Kg, 1.65 m, BMI 20,95)
working as MD in a covid department of a regional hospital in Mexico
city. She had no personal or familial antecedents, excepted her father
who displays high blood pressure and her deceased grandmother who
presented a diabetes mellitus. She received an anti-influenza vaccine
(Vaxigrip®, trivalent for A/B types, Sanofi Pasteur,
Val de Reuil, France) on October, 16, 2020.
On December 18, 2020, she noted pulsatile headaches (of 7/10 intensity),
coughing fit without dyspnea and displayed a 38.2°C fever with a CF at
120 bpm (blood pressure: 100/70 mm Hg; SpO2: 97%). On the same day,
positive results were obtained for SARS-CoV-2 RT-PCR (Logix Smart®
Covid-K-001, Co-Diagnosis, Salt Lake City, UT, USA) and antigen
detection (Panbio® Covid-19 Ag rapid test device,
Abbott, Jena, Germany), whereas RT-PCR testing for A and B influenza
viruses remained negative (SD Bioline® Influenza Ag
A/B/A-H1N1- Pandemic, Standard diagnostics, Inc, Kyonggi-do, Korea). She
reported also nocturnal diaphoresis and sleeping troubles and other
biological testing were performed the following day. The inflammatory
status was marked with a CRP at 5.6 mg/L, and D-Dimer at 1120 µg FEU/L,
while the standard hematological and chemical parameters remained in the
normal ranges. From this day (December 19, 2020), she was treated with
paracetamol (1 to 3g/day), dexamethasone IM (6 mg/day), cefixine (400
mg/day), during 5-7 days, and acetylcysteine (600 mg/day), rivaroxaban
(10 mg/day) and inhalation of budesonide/formoterol (x2/day) during
10-15 days. Fever persisted for 5 days fluctuating between 37.5 and
38.2°C. On December 24, a chest CT highlighted bilateral changes in
pulmonary parenchyma, particularly in both bases, confirming the
diagnosis of covid-19 (evaluation CO-RADS: 5; 4). The patient was
confined at home for 3 weeks and the symptoms slowly decreased with the
exception of bout of dry cough.
The hospital employing her initiated its campaign of anti-covid-19
vaccination for all the medical staff, insisting on this opportunity
which can hardly be repeated. On January 20, 2021, i.e. 33 days after
the beginning of her covid-19 pneumonia, the patient accepted to receive
the first dose of the BNT162b2 (Pfizer BioNTech) vaccine. Three hours
after the vaccine inoculation (IM into the deltoid portion of the left
arm), she perceived a sensation of fever (37.7°C), which quickly
disappeared with a single take of paracetamol (1g), without any local
reaction at the inoculation site. On the following day (January 21,
2021), she perceived a thoracic pain, mainly at the left thoracic base
(of 4/10 intensity) without other symptoms or signs. A first thoracic X
ray did not show significant pulmonary alterations. She kept taking
paracetamol (3 g/day). However, on January 22, the thoracic pain became
bilateral and stronger with a predominance at the left base (7/10 of
intensity), increasing with inspiration and associated to polypnea and
rales at both pulmonary bases. She also reported generalized arthralgias
and myalgias, as well as dry cough and dyspnea at moderate exertion,
diaphoresis and insomnia. A thorax CT showed a bilateral pneumonia with
the covid-19-typical frosted glass look of pulmonary parenchyma with
peripheral intersticial thickening of posterior segments. Biological
analyzes performed on the same day, mainly showed again an increase of
inflammatory markers with CRP at 11 mg/L, D-dimer at 1660 µg FEU/L.
Investigations of SARS-CoV-2 antigens and specific IgM and IgG
antibodies gave positive results. The patient was again confined at home
for 15 days with the following treatment: paracetamol/tramadol (325
mg/37.5 mg x3/day), etoricoxid (2x90 mg/day), dexamethasone IM (8
mg/day), levofloxacin (500 mg/day), enoxaparin(SC, 40 mg/day) during 7
days and inhalation of budesonide (x1/day) during 30 days. The thoracic
pain persisted for 24h (6/10 intensity) and progressively decreased to
3/10 and 2/10 respectively on days 3 and 5 after vaccination. The
biological testing on January 24 showed a decrease of the D-dimer
inflammatory marker (800 µg FEU/L), whereas CRP level remained high (11
mg/L), and the others parameters in the normal limits. In front of the
persistence of thoracic pain, an EKG was performed on January 26, but
reported normal parameters. On February 02, the biological
investigations indicated a D-dimer at 7060 µgFEU/L, a CRP at 2.3 mg/L
with normal results for the other standard parameters. A chest control
CT did not show interstitial anomalies. On February 13, D-Dimer and CRP
dropped to 1400 µg FEU/L, and 0.5 mg/L, respectively, with an ESR at 14
mm/hr. On February 19, 2021, the patient only presented a residual
dyspnea at moderate exertion, treated by pulmonary physiotherapy.