A 65-year-old female with a left ventricular assist device (LVAD) presents to the hospital with a productive cough, shortness of breath and increased oxygen requirements from her baseline.

The patient has an extensive medical history including breast cancer treated several years ago with a left mastectomy, radiation, and doxorubicin chemotherapy resulting in nonischemic cardiomyopathy and New York Heart Association (NYHA) Class III and Stage D heart failure (HF) necessitating a single chamber automatic implantable cardioverter-defibrillator (AICD) and LVAD; recurrent drive line infections requiring indefinite antibiotics; paroxysmal atrial fibrillation; chronic hypoxic respiratory failure from obstructive lung disease requiring supplemental oxygen; stage 3A chronic kidney disease; chronic normocytic anemia; hypothyroidism; and pulmonary coccidioidomycosis for which patient is receiving long-term antifungal therapy.

Her current home medications include alendronate, carvedilol, cholecalciferol, warfarin, doxycycline, enalapril, gabapentin, magnesium oxide, B complex with C20-folic acid, esomeprazole magnesium, posaconazole, albuterol sulfate, rosuvastatin, levothyroxine, torsemide, and fluticasone-umeclidin-vilanter.

Notably, the patient was discharged from the hospital just 2 days prior for similar respiratory symptoms, at which time they were attributed to COVID-19 pneumonia and treated with a short course of steroids and remdesivir.

Physical exam findings on current presentation reveal an acutely ill, alert, and oriented female in moderate respiratory distress with diffuse wheezing and poor airway entry throughout all lung fields, irregularly irregular tachycardia with stable blood pressure, pitting edema to bilateral lower extremities, and a benign abdomen. Oxygen saturations are low in the mid-80s on room air which improve with noninvasive positive pressure ventilation (BiPAP). Diagnostic work up is concerning for a new leukocytosis.

Remaining lab studies including hemoglobin and renal function are consistent with the patient's baseline.

Imaging of the chest reveals severe emphysema with diffuse infiltrates and ground glass opacities that have progressed from the previous hospitalization.

The patient is admitted for acute on chronic hypoxic respiratory failure secondary to a chronic obstructive pulmonary disease exacerbation that is presumed to be precipitated by a superimposed multifocal pneumonia.

Hospital Course
The patient's respiratory status improved with BiPAP, steroids, and intravenous antimicrobial therapy. Initial blood, sputum, and urine cultures were noted to be negative. Her hospitalization however was complicated by an acute gastrointestinal bleed caused by dieulafoy lesions which were managed with epinephrine injections and hemostasis clippings, as well as a pre-renal injury progressing to acute tubular necrosis requiring brief hemodialysis, intravenous fluids, and a temporary hold of lisinopril.

While her conditions eventually stabilized, her course was prolonged by persistent complaints of generalized weakness and fatigue. She was observed to have significant difficulty with independently getting out of bed and ambulating short distances from the bed to the chair, activities able to be performed at home prior to hospitalization.

Daily physical assessments were unremarkable for fevers, hemodynamic instability, overt infections, or focal neurologic deficits. Labs demonstrated a down-trending white count, and serial chest imaging revealed interval improvement in air space opacities. Kidney function and hemoglobin slowly returned to the patient's baseline, and electrolytes remained stable. Routine LVAD interrogations were unrevealing for functional abnormalities or new alarms.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Cardio-Oncology, Cardiovascular Care Team, COVID-19 Hub, Dyslipidemia, Heart Failure and Cardiomyopathies, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Lipid Metabolism, Novel Agents, Statins, Acute Heart Failure, Mechanical Circulatory Support, Geriatric Cardiology

Keywords: Alendronate, Antifungal Agents, Breast Neoplasms, Carvedilol, Doxycycline, Esomeprazole, Gabapentin, Lisinopril, Magnesium Oxide, Rosuvastatin Calcium, Thyroxine, Torsemide, Warfarin, Heart-Assist Devices, remdesivir, Atrial Fibrillation, Blood Culture, Blood Pressure, COVID-19, Coccidioidomycosis, Defibrillators, Implantable, Electromyography, Leukocytosis, Respiratory Sounds, Positive-Pressure Respiration, Mastectomy, Respiratory Insufficiency, Respiratory Distress Syndrome, Pulmonary Disease, Chronic Obstructive, Heart Failure, Renal Insufficiency, Chronic, Dyspnea, Lower Extremity, Cholecalciferol, Hypothyroidism, Cardiomyopathies, Electrolytes, Renal Dialysis, Tachycardia, Anti-Bacterial Agents, Doxorubicin, Epinephrine, Fluticasone, Hemoglobins, Hemostasis, Emphysema, Enalapril, Hospitals, Fatigue, Anemia, Edema

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