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TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Coronavirus Disease 2019 (COVID-19) has affected over 140 million with over 3 million deaths worldwide. As the virus continues, we face a new challenge;to discern between post COVID syndromes or COVID reinfection. We present a case with this medical dilemma. CASE PRESENTATION: 64 y/o F with Diabetes, Hypertension & history of asymptomatic COVID infection eight weeks prior to presentation with follow-up negative testing, presented with fever & SOB. She initially developed progressive dyspnea on exertion for which bronchodilators were initiated as an outpatient. She then presented to our hospital with fevers & progressive SOB. Her initial workup revealed normal blood work & inflammatory markers, however her COVID RNA test was positive with seronegative COVID antibodies. Imaging revealed increased bilateral ground-glass opacities & inter-septal thickening when compared to imaging one month prior. Her positive COVID tests were attributed to viral shedding & COVID therapy was not initiated. On hospital day 6 she began to decompensate requiring rapid escalation of oxygen supplementation to high flow nasal cannula. At this time high dose steroids were initiated as post COVID syndrome was thought to be the disease pathology. On hospital day 12 retesting revealed seroconversion of COVID antibodies. Her hospital course was complicated by severe hypoxia requiring prolonged steroid taper & oxygen supplementation. She was ultimately discharged on home oxygen with outpatient management. DISCUSSION: Complications of COVID-19 disease include reinfection & post-COVID syndrome. Reinfection was considered in this patient due to repeated negative tests & an asymptomatic period. This remains a rare phenomenon. There are only 5 reported known cases thus far. It was ruled out according to WHO guidelines, since there were <90 days between her 1st & 2nd positive tests. There was no genomic sequencing of both samples to confirm different genetic lineages. Her course was attributed to prolonged shedding of virus which can occur >3 months after infection & despite neutralizing antibodies. We believe she developed severe ARDS due to COVID pneumonitis with possible progression to ILD. Typical disease course is still unclear. There is increasing evidence of fibrotic-like changes in the lung in high rate of patients for up to 6 months. Reversibility of these findings is unknown. Post-mortem evaluation of lung tissue reveals diffuse alveolar damage from chronic inflammation. Obesity, ARDS, prolonged hospitalization & NIMV are reported risk factors. CONCLUSIONS: This case shows the importance of considering COVID reinfection in patients with atypical presentation. It is imperative that we differentiate between viral shedding & reinfection in patients with post-acute COVID symptoms. Both presentations may be similar, therefore it is pivotal that we continue to investigate these two-potentially fatal COVID related processes. REFERENCE #1: Pan American Health Organization / World Health Organization. Interim guidelines for detecting cases of reinfection by SARS-CoV-2. 29 October 2020, Washington, D.C.: PAHO/WHO;2020 REFERENCE #2: Qian Li, Xiao-Shuang Zheng, Xu-Rui Shen, Hao-Rui Si, Xi Wang, Qi Wang, Bei Li, Wei Zhang, Yan Zhu, Ren-Di Jiang, Kai Zhao, Hui Wang, Zheng-Li Shi, HuiLan Zhang, Rong-Hui Du & Peng Zhou (2020): Prolonged shedding of severe acute respiratory syndrome coronavirus 2 in patients with COVID-19, Emerging Microbes & Infections, DOI: 10.1080/22221751.2020.1852058 REFERENCE #3: Han X, Fan Y, Alwalid O, et al. Six-month Follow-up Chest CT Findings after Severe COVID-19 Pneumonia. Radiology. 2021;299(1):E177-E186. doi:10.1148/radiol.2021203153 DISCLOSURES: No relevant relationships by Angelica Medina-Pena, source=Web Response No relevant relationships by Anna-Belle Robertson, source=Web Response No relevant relationships by Noura Semreen, source=Web Response no disclosure on file for David Shiu;No relevant relationships by Ro-Kaye Simmonds, source=Web Re ponse No relevant relationships by Jodi-Ann Smith, source=Web Response