A man fully mRNA-vaccinated against COVID-19 presented to our hospital with an acute febrile illness, respiratory symptoms and a positive test for SARS-CoV-2. He was later found early into hospitalisation to have two morbid bacterial co-infections: Legionella pneumophila serogroup 1 and methicillin-resistant Staphylococcus aureus (MRSA). Although this patient was initially admitted for COVID-19 management, his initial presentation was remarkable for lobar pneumonia, hyponatraemia and rhabdomyolysis more compatible with Legionnaire’s disease than severe COVID-19. On discovery of MRSA pneumonia as a second bacterial infection, immunosuppressive COVID-19 therapies were discontinued and targeted antibiotics towards both bacterial co-infections were initiated. The patient’s successful recovery highlighted the need to have high suspicion for bacterial co-infections in patients presenting with community-acquired pneumonia and a positive SARS-CoV-2 test, as patients with serious bacterial co-infections may have worse outcomes with use of immunosuppressive COVID-19 therapies.

A man in his 80s with metastatic melanoma presented with progressive dyspnea on exertion and dry cough after 7 cycles of pembrolizumab monotherapy. He was initially treated with antibiotics for community acquired pneumonia; however, his symptoms recurred after 2 weeks, and he developed hydropneumothorax. Pleural fluid, bronchoalveolar lavage fluid, and transbronchial biopsy results were all negative for infection, and he was diagnosed with unilateral immune checkpoint inhibitor pneumonitis, highlighting that the radiographic findings of immune checkpoint inhibitor pneumonitis can be unpredictable and include hydropneumothorax.