A 24-year-old female with Gravida 4 Para 3 pregnancy at 25 +- 2 weeks presented with a 5-day history of fever, bilateral chest pain pleuritic in nature, exertional shortness of breath, sweating, and palpitation starting 1 day after she received her second dose of the Pfizer-BioNTech COVID-19 vaccine. She had recovered from a mild COVID-19 infection (RT-PCR cycle threshold value: 25.7) requiring home isolation nine months prior to the current vaccination dose and was still on thyroxin 100 micrograms for hypothyroidism. In the emergency department, she was afebrile and hypotensive, with 80%-85% desaturating oxygen saturation (SPO2), bilateral bronchial breath sounds, and crepitations. A chest X-ray (Figure-1) revealed right lower lobe consolidation with extensive diffuse infiltrates. A computed tomography pulmonary angiogram scan (2) showed a dilated pulmonary trunk (3.35 cm), right lower lobe consolidation with an associated bilateral diffuse area of ground glass consolidation, a few enlarged mediastinal lymph nodes, and mild pleural effusion, with no major pulmonary embolism. Her white blood cell count was 22.09 x  109/L, with neutrophils 77%, lymphocytes 10%, monocytes 4%, band forms 8.0%, atypical lymphocytes 1.0%, and a C-reactive protein level of 344.66 mg/L. Her thyroid stimulating hormone, electrolytes, platelet count, coagulation profile, and liver and renal function tests were within normal limits.
On day 2 of admission to the intensive care unit, the echocardiogram showed normal left ventricular systolic function, an ejection fraction >55%, and normal valves with no evidence of raised pulmonary artery pressure or left ventricular clot or pericardial effusion. The cardiology referral team recommended initiation of a therapeutic dose of enoxaparin 80 mg twice a day for myocarditis in view of nonspecific ST-T changes and a mild rise in troponin-I (4.700 ng/mL). She was electively intubated on day 2 because of persistent tachypnea and a PaO2/FiO2 ratio of <= 100 (PEEP >= 5 cmH20) on a high-flow nasal cannula and noninvasive ventilation. Antibiotics were escalated to meropenem 1 g thrice daily and vancomycin 1 g twice daily in view of worsening desaturation, a white blood cell count of 22.09 x  109/L and C-reactive protein 356 mg/L. She was also started on prednisolone 1 mg/kg/day once daily. Three serial endotracheal tube secretion cultures (days 1, 3, and 5), two serial blood cultures (days 1 and 4) and a urine culture (day 1) were sterile. RT-PCR for Mycobacterium tuberculosis, an acid-fast bacilli smear, and pneumocystis jirovecii antigen from deep tracheal aspirate were negative. Four serial samples analyzed by COVID-19 RT-PCR (days 1, 2, 3, 5, and 7) and two COVID-19 antigen tests (days 1 and 2) were negative. She was seronegative for Legionella pneumophilia, Mycoplasma Pneumoniae, Coxiella Burnettii, Chlamydia Pneumoniae, Adenovirus, respiratory syncytial virus, Influenza A, Influenza B, Parainfluenza IgG, and IgM antibodies. A throat swab culture was negative for GROUP A, C, and G Streptococcus. A high vaginal swab was negative for Trichomonas vaginalis, Gardnerella Vaginalis, Candida Spp., and Group B Streptococcus. Serological tests for cytomegalovirus, Epstein-Barr virus, hepatitis B, hepatitis C, and human immunodeficiency virus were all negative. Screening tests for anti-nuclear antibody, complement, anti-cardiolipin, anti ss2-glycoprotein, anti-phospholipid antibody, and rheumatoid factor were all negative. Consecutive procalcitonin levels sent for 10 days (days 1-10) were negative. She was extubated on day 8. The patient's relatives refused consent for lung biopsy and bronchoalveolar lavage, which may aid in the diagnosis of drug-induced interstitial lung disease/hypersensitive pneumonitis, in view of her improving parameters. Prednisolone was tapered and stopped over two weeks from the day of initiation, with no relapse. She was discharged to the ward on day 11 on oxygen-nasal cannula 3L/min and discharged from the hospital on day 14 on room air with good fetal movements. She eventually gave birth to a healthy male baby through a normal vaginal delivery at term.