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.