2.1 Case history / examination
A 70-year-old Japanese woman with a medical history of bronchial asthma,
rheumatoid arthritis, and hypertension had been prescribed a
fluticasone-vilanterol combination inhaler for asthma and tacrolimus,
iguratimod, and golimumab for rheumatoid arthritis. She had not
experienced asthma exacerbation during the previous decade. She was a
never-smoker with pollen allergy and had no history of drug allergies.
Although she had a slight cough and dyspnea for a few days, she received
the second dose of the mRNA-based COVID-19 vaccine BNT162b2
(Pfizer-BioNTech) and took acetaminophen to prevent fever. Approximately
12 h after vaccination, her respiratory symptoms worsened, and the
patient was transported to our emergency room by ambulance. The
percutaneous oxygen saturation (SpO2) was 86%
(reservoir mask O2, 15 L/min). Physical examination
revealed decreased respiratory sounds and a silent chest. Wheezing
emerged after nebulization with the SABA procaterol. The patient had no
edema, rash, or aggravation of joint symptoms.
The initial blood test showed an
increased white blood cell count with eosinophilia, a negative
C-reactive protein test, and increased total immunoglobulin (Ig)E.
Arterial blood gas analysis before intubation revealed acute hypercapnic
respiratory failure (Table 1). A 12-lead electrocardiogram
demonstrated sinus rhythm with ST elevation (V2-V5, Figure 1 ),
but the creatine kinase MB and
troponin I levels were not elevated. Chest radiography and
thoracoabdominal contrast-enhanced computed tomography revealed no acute
pulmonary abnormalities. Bronchial wall thickening and a calcified
nodule were detected in the lower lobe of the right lung.
Severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2) nucleic acid test results were negative. In
the emergency department, she had a depressed level of consciousness;
therefore, endotracheal intubation was performed, and intravenous
corticosteroids were administered. To rule out cardiogenic disease,
coronary angiography was performed, which revealed no significant
coronary artery disease. However,
left ventriculography and
ultrasonic cardiography revealed apical akinetic expansion (apical
ballooning) and severe hypokinesia of the mid-ventricular segments, with
slightly reduced systolic function (ejection fraction, 47%,Figure 2,3 ).