Dyspnoea

50-year-old male with a past medical history of coronary artery disease, non-ischaemic cardiomyopathy, type 2 diabetes mellitus, essential hypertension, and prior stroke who recently underwent kidney and heart transplant in February 2020. His post-transplant course was complicated with upper respiratory symptoms about one month after transplant, and his nasopharyngeal nucleic acid amplification test for SARS-CoV-2 returned positive. During that admission, he did not require supplemental oxygen, and was discharged home to complete a total five-day course of hydroxychloroquine. Three days after discharge, he presented to the emergency department for severe dyspnoea. While being evaluated in the emergency department, he experienced rapid and profound hypoxic respiratory decompensation requiring intubation and mechanical ventilation. Initial lab work was significant for IL-6 level of 45 pg/mL, ferritin of 648 ng/mL, LDH of 426 U/L, D-Dimer of 4.84 UG/mL, high-sensitivity CRP of 74.9 mg/L. Admission chest radiograph showed significant burden of bilateral airspace opacities. He was given 400 mg of tocilizumab on his first hospital day, approximately 5 hours after intubation. He was also started on broad spectrum antibiotics (vancomycin and cefepime), azithromycin 500 mg daily, and hydroxychloroquine 200 mg twice a day. His transplant immunosuppression with tacrolimus was continued, he was started on stress dose hydrocortisone 50mg every 6 hours and his mycophenolate was held