A case of transfusion-transmission Anaplasma phagocytophilum from leukoreduced red blood cells

BACKGROUND

Anaplasma phagocytophilum is a tick-borne bacterium and the cause of human granulocytic anaplasmosis (HGA). Here, we report a case of transfusion-transmitted (TT)-HGA involving a leukoreduced (LR) red blood cell (RBC) unit.

CASE REPORT

A 64-year-old woman with gastric adenocarcinoma and multiple myeloma who received weekly blood transfusions developed persistent fevers, hypotension, and shortness of breath 1 week after receiving an RBC transfusion. Persistent fevers, new thrombocytopenia, and transaminitis suggested a tick-borne infection.

RESULTS

The absence of blood parasites on thick and thin blood smears suggested that malaria and Babesia infection were not present, and the recipient tested negative for antibodies to Borrelia burgdorferi. Blood testing by polymerase chain reaction (PCR) for Ehrlichia and Anaplasma species identified A. phagocytophilum. Treatment with doxycycline resolved the infection; however, the recipient expired due to complications of her known malignancies. The recipient lived in a nursing home and did not have pets or spend time outdoors. The donor was a female in her 70s from Maine who was diagnosed with HGA 3 weeks after donating blood and whose LR-RBCs from the donation were transfused to the recipient 9 days following collection.

CONCLUSION

This is a confirmed case of TT-HGA. Although rare, TT-HGA has been reported with LR-RBCs and platelets. In endemic areas, testing for tick-borne associated infections should be considered when investigating post-transfusion complications.

Seroprevalence of Chagas Disease among People of Latin American Descent Living in Suffolk County, Long Island, New York

This cross-sectional study estimated a one-time point seroprevalence rate of Chagas disease among people of Latin American descent in Suffolk County, Long Island, New York. Subjects who met the inclusion criteria were screened using the Chagas Detect Plus Rapid Test (InBios, Seattle, WA) with confirmation via Trypanosoma cruzi enzyme immunoassay and T. cruzi immunoblot assay. Administration of a questionnaire regarding demographics and risk factors followed. A seroprevalence rate of 10.74% was found. Identified risk factors included prior residence in a palm leaf house (odds ratio [OR], 10.42; P = 0.003; 95% CI, 2.18-49.76), residence in a house with triatomines (OR, 9.03; P = 0.006; 95% CI, 1.90-42.88), and history of triatomine bite (OR, 9.52; P = 0.009; 95% CI, 1.75-51.77). Our findings emphasize the importance of this frequently underdiagnosed disease and help highlight the importance of early screening among high-risk populations.

Relapsing Babesiosis With Molecular Evidence of Resistance to Certain Antimicrobials Commonly Used to Treat Babesia microti Infections

Human babesiosis cases are emerging with an increased incidence and a wider geographic range worldwide. Relapsing babesiosis cases are becoming more frequently encountered in clinical practice associated with the use of immunosuppressive medications. The 2020 Infectious Diseases Society of America babesiosis guideline recommends at least 6 weeks of antimicrobial treatment for highly immunocompromised patients with Babesia microti infection. Nevertheless, cases have relapsed even after 6 weeks of treatment. Genetic mutations regarded as the potential cause of antimicrobial resistance in B microti have been identified in certain relapsing cases. A few alternative antimicrobial regimens have been used successfully to achieve cure for some of these cases, but other cases have had fatal outcomes. In this review, we discuss the molecular evidence of genetic resistance to certain antimicrobials commonly used to treat B microti infections based on an evaluation of 9 patients with relapsing infection.

Feasibility of Training Community Health Workers to Use Smartphone-Attached Microscopy for Point-of-Care Visualization of Soil-Transmitted Helminths in the Peruvian Amazon

The prevalence of soil-transmitted helminths (STH) is high in communities within the Peruvian Amazon despite repeated mass-drug administration, demanding alternative strategies of control. Smartphone-attached microscopy (SAM) permits visualization of STH from a small portable microscope through a smartphone screen, potentially providing an inexpensive and rapid method of STH visualization in communities where diagnostic laboratories with microscopes are inaccessible. In this study, a total of 45 community health workers who work within the health systems of Loreto, Peru, attended a 1-day training session with lectures and practicums on STH and SAM. Participants received a pre- and post-intervention questionnaire. Post-intervention, participants were significantly more confident using SAM and identifying parasite images, symptoms, transmission, and treatment (P ≤ 0.0045). Post-intervention, participants correctly labeled a median of five of seven SAM apparatus components and five of eight steps of Kato-Katz technique, were less likely to choose taking medicine to prevent parasite infection (P = 0.0075), and were more likely to select Kato-Katz technique as a type of diagnostic test (P < 0.0001). Most participants felt ready to use SAM in their communities and stated that it could help rural communities far from health centers or laboratories (24%); provide faster identification, results, diagnosis (19%); permit at-home or on-the-spot visualization (14%); and save money (14%). Results show that community health workers show a high level of willingness and competency to learn about both STH and SAM and may be a yet-unexplored practical method of augmenting STH visualization, bringing healthcare to communities in Loreto with poor access to diagnostic laboratories and clinics.

Reduced Cholesterol Levels during Acute Human Babesiosis

BACKGROUND

Babesiosis, an intra-erythrocytic protozoan disease, is an emerging zoonotic parasitic disease worldwide. Cholesterol levels are correlated with severe infections, such as sepsis and COVID-19, and anecdotal reports suggest that high-density lipoprotein (HDL) cholesterol declines during acute babesiosis. Our aim was to describe the cholesterol levels in patients with acute babesiosis diagnosed in an endemic area in New York, hypothesizing that HDL levels correlate with the severity of infection.

METHODS

We reviewed the medical records of adult patients with babesiosis diagnosed by identification of Babesia parasites on a thin blood smear and confirmed by polymerase chain reaction from 2013 to 2018, who also had available a lipid profile drawn at the time of clinical presentation. Additional lipid profile levels were considered as "baseline" if they were drawn within 2 months before or after the infection as part of routine care.

RESULTS

A total of 39 patients with babesiosis had a lipid profile drawn on presentation. The patients were divided into two groups for comparison based on the treating physician's clinical decision: 33 patients who were admitted to the hospital and 8 patients who were evaluated as outpatients. A history of hypertension was more common in admitted patients (37% vs. 17%, p = 0.02). The median levels of low-density lipoprotein (LDL) and HDL were significantly reduced in admitted patients compared to non-admitted patients (46 vs. 76 mg/dL, p = 0.04; and 9 vs. 28.5 mg/dL, p = 0.03, respectively). In addition, LDL and HDL levels returned to baseline values following resolution of acute babesiosis.

CONCLUSION

LDL and HDL levels are significantly reduced during acute babesiosis, suggesting that cholesterol depletion may predict disease severity. Pathogen and host factors may contribute to a reduction in serum cholesterol levels during acute babesiosis.

False-Positive Serology for Rocky Mountain Spotted Fever in Long Island, New York, during 2011-2021

Cases of rocky mountain spotted fever (RMSF) are increasingly reported every year in Long Island, New York. In clinical practice, an uncommonly high number of referrals with a positive RMSF IgG test result have been seen in our tick-borne disease clinic. The aim of this study is to describe the clinical-epidemiological characteristics and outcomes of hospitalized patients with positive serologies for RMSF in our academic center in Long Island, NY. We found that out of twenty-four patients with a positive serology for RMSF, only one case met the case definition per CDC criteria, two had suspected RMSF, and the other twenty-one did not have a clinical picture consistent with RMSF. A high number of false-positive RMSF serology may be due to other spotted fever rickettsioses in Long Island. Further studies are needed to investigate the presence of another Rickettsia spp. (such as Rickettsia amblyommatis) in this area that may affect humans.

The global prevalence of human fascioliasis: a systematic review and meta-analysis

Background

Fascioliasis is a parasitic zoonosis that can infect humans and be a source of significant morbidity. The World Health Organization lists human fascioliasis as a neglected tropical disease, but the worldwide prevalence of fascioliasis data is unknown.

Objective

We aimed to estimate the global prevalence of human fascioliasis.

Data sources and methods

We performed a systematic review and prevalence meta-analysis. We used the following inclusion criteria: articles published in the English, Portuguese, or Spanish languages from December 1985 to October 2022 and studies assessing the prevalence of Fasciola in the general population with an appropriate diagnostic methodology, including longitudinal studies, prospective and retrospective cohorts, case series, and randomized clinical trials (RCTs). We excluded animal studies. Two reviewers independently reviewed the selected studies for methodological quality, performing critical standard measures from JBI SUMARI. A random-effects model was conducted of the summary extracted data on the prevalence proportions. We reported the estimates according to the GATHER statement.

Results

In all, 5617 studies were screened for eligibility. Fifty-five studies from 15 countries were selected, including 154,697 patients and 3987 cases. The meta-analysis revealed a pooled prevalence of 4.5% [95% confidence interval (CI): 3.1-6.1; I² = 99.4%; T² = 0.07]. The prevalence in South America, Africa, and Asia was 9.0%, 4.8%, and 2.0%, respectively. The highest prevalence was found in Bolivia (21%), Peru (11%), and Egypt (6%). Subgroup analysis showed higher prevalence estimates in children, in studies from South America, and when Fas2-enzyme-linked immunosorbent assay (ELISA) was used as a diagnostic method. A larger study sample size (p = 0.027) and an increase in female percentage (p = 0.043) correlated with a decrease in prevalence. Multiple meta-regression showed a higher prevalence for hyperendemic than hypoendemic (p = 0.002) or mesoendemic (p = 0.013) regions.

Conclusion

The estimated prevalence and projected disease burden of human fascioliasis are high. Study findings support that fascioliasis continues to be a globally neglected tropical disease. Strengthening epidemiological surveillance and implementing measures to control and treat fascioliasis is imperative in the most affected areas.

507. Peripheral blood RNA signatures associated with human babesiosis, quality of life and neurological symptoms

Background

Human babesiosis is an emerging tick-borne disease in the US that is primarily caused by the protozoan Babesia microti (Bm). Although Babesiosis can cause life-threatening infections, the pathophysiology including host and parasite determinants associated with disease severity are largely unknown. The aim of this study is to identify parasite and host signatures of human babesiosis and correlate these with disease severity and long-term symptoms.

Methods

We enrolled prospectively patients with acute babesiosis (microcopy positive blood smear for Bm, confirmed by PCR) at Stony Brook University Hospital during 2020-2021. Blood samples and surveys were completed at initial diagnosis (Visit=1;V1) and at months 1, 6 and 12 (V2,V3,V4). Total RNA from whole peripheral blood was isolated using the PAXgene Blood RNA Kit from individuals infected with Bm and healthy controls. Quality of life (QOL) surveys were administered to patients.

Results

Peripheral blood transcriptome analysis of 17 patients (median age: 63 years, range 42-78; 24% female) who presented with babesiosis were distinctly different from uninfected individuals (n=9). Babesiosis was associated with a peripheral blood Type I and Type II Interferon transcriptional signature. Other dominant transcriptional signatures included those involved in activation of mononuclear cells, oxidative phosphorylation, inducible nitric oxide synthase and regulation of homeostasis as well as inducible nitric oxide synthase. Ingenuity Pathway Analysis for clinical chemistry and hematology also highlight changes associated with cardiotoxicity, hepatotoxicity, and nephrotoxicity as well as increased levels of red blood cells. Patients with babesiosis showed a persistent deterioration of QOL in cognition [mean V1=33.1; V3=36.3] and satisfaction [mean V1=28.4; V3=34]. Also a decrease in QOL over time despite effective treatment [mean at V1 82 (SD: 5.9), V2 80 (8.1), V3 76 (4.7) (p &gt;0.05).

Heat Map Summary.

Volcano Plot

Gene Pathways Analysis

Conclusion

Babesiosis is associated with a marked alteration in the peripheral blood transcriptome of patients that may also provide insight into both the pathophysiology of the disease including severity and complications. Furthermore, even after successful treatment, babesiosis may result in long-term impacts on quality of life indicators.

Disclosures

All Authors: No reported disclosures.

367. Procalcitonin as a Potential Biomarker in the Study of Human Babesiosis

Background

Procalcitonin (Pct) has been gaining momentum as a potential biomarker during parasitic infections as studies have demonstrated that Pct levels are significantly elevated during certain forms of protozoal sepsis. Given this, the goal of this pilot study is to determine the relationship between Pct levels and parasitemia (Par) during infection with Babesia microti and to elucidate the potential for Pct to be used as a biomarker in the study of babesiosis.

Methods

Babesia cases were collected from Stony Brook University Hospital (SBUH) and South Hampton Hospital (SHH) from 2012 to 2019. Median values of maximum Par and Pct throughout hospitalization were recorded and cases were referenced for admission to the intensive care unit (ICU).

Correlation between maximum Par and Pct values were examined with the nonparametric Spearman rank correlation and fractional polynomials were used to assess the functional form of the correlation. Receiver-operator characteristic (ROC) curve analyses were used to identify cutoff points for Pct and maximum Par as markers for prediction of ICU admission.

Results

A total of 33 patients met the inclusion criteria for acute babesiosis. In fractional polynomial analysis, log-transformed Pct levels had a linear correlation with log-transformed maximum Par, r=0.556 (P=0.001, Fig 1A). In ROC curve analysis, a cut off level of ≥ 1.2 ng/mL for Pct had optimal prediction characteristics for ICU admission (sensitivity 62.5%, specificity 88%; correct classification 82%) with a relevant AUC of 0.77 (95% CI: 0.58–0.89; P=0.005, Fig 1B). A cut off level of ≥ 3.6% for maximum Par had optimal prediction characteristics for ICU admission (sensitivity 75%, specificity 92%, correct classification 88%) with a relevant AUC of 0.75 (95% CI 0.58—0.89; P= 0.005, Fig 1B). Comparison of AUC for Pct and Par yielded no significant difference (P=0.8).

Figure 1A. Linear correlation between log10-parasitemia and log10- procalcitonin levels. The linear correlation of the log-transformed variables was r=0.556 (P=0.001), similar to the nonparametric (Spearman) correlation coefficient (ρ=0.567). The red dots represent patients who were admitted to the intensive care unit.

Figure 1B. Receiver-operator characteristic curve of parasitemia for prediction of intensive care unit admission (0.75; 95%CI: 0.58—0.89; P=0.005); optimal cut-off is 3.6%. Receiver-operator characteristic curve of procalcitonin for prediction of intensive care unit admission (C=0.77; 95%CI: 0.58–0.89; P=0.005); optimal cut-off is 1.2 ng/mL.

Conclusion

Our analysis demonstrated a positive linear correlation between Pct and maximum Par, which is the current standard marker for severe disease. Also, our ROC analyses estimate that Pct values ≥ 1.2 ng/mL and Par ≥ 3.6% suggests severe disease and need for ICU admission (Fig 1A, 1B). Given this, our findings suggest that Pct may have potential for predicting severe disease during babesiosis.

Disclosures

All Authors: No reported disclosures.

Procalcitonin as a Potential Biomarker in the Study of Babesiosis Caused by B. microti

Procalcitonin is gaining momentum in the study of protozoal sepsis, but its utility as a biomarker has yet to be fully discovered in human babesiosis. A total of 33 cases of acute babesiosis dating between 2012 and 2019 were retrospectively collected from Stony Brook University Hospital (SBUH) and Stony Brook South Hampton Hospital (SHH), both of which are located on Long Island, NY. Cases were cross-referenced for the need for ICU admission, and the procalcitonin levels were measured by the use of BRAHMS Elecsys assay at SBUH and BRAHMS Architect assay at SHH. Our study demonstrated that the log-transformed procalcitonin levels had a linear correlation with log-transformed maximum parasitemia, which suggests that procalcitonin directly correlates with parasitemia values. Furthermore, when comparing values that predict ICU admission, our ROC analysis of procalcitonin demonstrated similar AUC values to the percentage of parasitemia, suggesting that procalcitonin may assist in determining the severity of disease. We demonstrate that procalcitonin may directly correlate with the parasitemia percentage and have prognostic capabilities, which suggests that procalcitonin may have biomarker potential in human babesiosis.

Specific and Sensitive Diagnosis of Babesia microti Active Infection Using Monoclonal Antibodies to the Immunodominant Antigen BmGPI12

The apicomplexan pathogen Babesia microti is responsible for most cases of human babesiosis worldwide. The disease, which presents as a malaria-like illness, is potentially fatal in immunocompromised or elderly patients, making the need for its accurate and early diagnosis an urgent public health concern. B. microti is transmitted primarily by Ixodes ticks but can also be transmitted via blood transfusion. The parasite completes its asexual reproduction in the host red blood cell, where each invading merozoite develops and multiplies to produce four daughter parasites. While various techniques, such as microscopy, PCR, and indirect fluorescence, have been used over the years for babesiosis diagnosis, detection of the secreted B. microti immunodominant antigen BmGPI12 using specific polyclonal antibodies was found to be the most effective method for the diagnosis of active infection and for evaluation of clearance following drug treatment. Here, we report the development of a panel of 16 monoclonal antibodies against BmGPI12. These antibodies detected secreted BmGPI12 in the plasma of infected humans. Antigen capture assays identified a combination of two monoclonal antibodies, 4C8 and 1E11, as a basis for a monoclonal antibody-based BmGPI12 capture assay (mGPAC) to detect active B. microti infection. Using a collection of 105 previously characterized human plasma samples, the mGPAC assay showed 97.1% correlation with RNA-based PCR (transcription-mediated amplification [TMA]) for positive and negative samples. The mGPAC assay also detected BmGPI12 in the plasma of six babesiosis patients at the time of diagnosis but not in three matched posttreatment samples. The mGPAC assay could thus be used alone or in combination with other assays for accurate detection of active B. microti infection.

Neurocysticercosis control for primary epilepsy prevention: a systematic review

Neurocysticercosis (NCC) is a leading cause of preventable epilepsy in lower- and upper- middle-income countries (LMICs/UMICs). NCC is a human-to-human transmitted disease caused by ingestion of Taenia solium eggs from a Taenia carrier. T. solium infection control is the key to reduce NCC incidence. This systematic review aims to identify T. solium control programs that can provide frameworks for endemic areas to prevent NCC-related epilepsy. A systematic search was conducted in PubMed/Medline, Embase, Web of Science, and Cochrane Library databases in March 2021. After title and abstract review, full texts were screened for qualitative analysis. Additional articles were identified via citation search. Of 1322 total results, 34 unique studies were included. Six major intervention types were identified: national policy (8.8%), community sanitation improvement (8.8%), health education (8.8%), mass drug administration (29.4%), pig vaccination and treatment (32.4%), and combined human and pig treatment (11.8%). Overall, 28 (82.4%) studies reported decreased cysticercosis prevalence following the intervention. Only health education and combined human and pig treatment were effective in all selected studies. NCC causes preventable epilepsy in LMICs/UMICs and its incidence can be reduced through T. solium control. Most interventions that disrupt the T. solium transmission cycle are effective. Long-term sustained results require comprehensive programs, ongoing surveillance, and collaborative effort among multisectoral agencies.

A Short Series of Case Reports of COVID-19 in Immunocompromised Patients

Immunocompromised individuals are at risk of prolonged SARS-CoV-2 infection due to weaker immunity, co-morbidities, and lowered vaccine effectiveness, which may evolve highly mutated variants of SARS-CoV-2. Nonetheless, limited data are available on the immune responses elicited by SARS-CoV-2 infection, reinfections, and vaccinations with emerging variants in immunocompromised patients. We analyzed clinical samples that were opportunistically collected from eight immunocompromised individuals for mutations in SARS-CoV-2 genomes, neutralizing antibody (NAb) titers against different SARS-CoV-2 variants, and the identification of immunoreactive epitopes using a high-throughput coronavirus peptide array. The viral genome analysis revealed two SARS-CoV-2 variants (20A from a deceased patient and an Alpha variant from a recovered patient) with an eight amino-acid (aa) deletion within the N-terminal domain (NTD) of the surface glycoprotein. A higher NAb titer was present against the prototypic USA/WA1/2020 strain in vaccinated immunocompromised patients. NAb titer was absent against the Omicron variant and the cultured virus of the 20A variant with eight aa deletions in non-vaccinated patients. Our data suggest that fatal SARS-CoV-2 infections may occur in immunocompromised individuals even with high titers of NAb post-vaccination. Moreover, persistent SARS-CoV-2 infection may lead to the emergence of newer variants with additional mutations favoring the survival and fitness of the pathogen that include deletions in NAb binding sites in the SARS-CoV-2 surface glycoprotein.

Prevalence and factors associated with human Taenia solium taeniosis and cysticercosis in twelve remote villages of Ranomafana rainforest, Madagascar

Background

Infections with the tapeworm Taenia solium (taeniosis and cysticercosis) are Neglected Tropical Diseases (NTD) highly endemic in Madagascar. These infections are however underdiagnosed, underreported and their burden at the community level remains unknown especially in rural remote settings. This study aims at assessing the prevalence of T. solium infections and associated risk factors in twelve remote villages surrounding Ranomafana National Park (RNP), Ifanadiana District, Madagascar.

Methodology

A community based cross-sectional survey was conducted in June 2016. Stool and serum samples were collected from participants. Tapeworm carriers were identified by stool examination. Taenia species and T. solium genotypes were characterised by PCR and sequencing of the mitochondrial cytochrome c oxidase subunit 1 (cox1) gene. Detection of specific anti-cysticercal antibodies (IgG) or circulating cysticercal antigens was performed by ELISA or EITB/Western blot assays.

Principal findings

Of the 459 participants with paired stool and blood samples included ten participants from seven distinct villages harbored Taenia spp. eggs in their stools samples DNA sequencing of the cox1 gene revealed a majority of T. solium Asian genotype (9/10) carriage. The overall seroprevalences of anti-cysticercal IgGs detected by ELISA and EITB were quite similar (27.5% and 29.8% respectively). A prevalence rate of 12.4% of circulating cysticercal antigens was observed reflecting cysticercosis with viable cysts. Open defecation (Odds Ratio, OR = 1.5, 95% CI: 1.0–2.3) and promiscuity with households of more than 4 people (OR = 1.9, 95% CI: 1.1–3.1) seem to be the main risk factors associated with anticysticercal antibodies detection. Being over 15 years of age would be a risk factor associated with an active cysticercosis (OR = 1.6, 95% CI: 1.0–2.7). Females (OR = 0.5, 95% CI: 0.3–0.9) and use of river as house water source (OR = 0.3, 95% CI: 0.1–1.5) were less likely to have cysticercosis with viable cysts.

Conclusions/Significance

This study indicates a high exposure of the investigated population to T. solium infections with a high prevalence of cysticercosis with viable cysts. These data can be useful to strengthen public health interventions in these remote settings.

Taenia solium infections in humans (taeniosis and neurocysticercosis) and in pigs (cysticercosis) are endemic in Madagascar presenting a significant public health burden. Neurocysticercosis with localization of the parasite in the Central Nervous System is the most severe and frequent form of parasitic brain diseases in humans and responsible of thousands of worldwide deaths per year. Madagascar is a T. solium endemic country where poor sanitation, free roaming pigs and outdoor defecation are common, and maintain the parasite transmission cycle. Little information is available regarding taeniosis/cysticercosis epidemiology in Madagascar. We carried out a community-based study to investigate the prevalence of human taeniosis/cysticercosis and associated risk factors in 12 rural remote villages of Ranomafana and Kelilalina townships (Ifanadiana district, Madagascar). Our results reveal that in 7/12 villages investigated, a high number of participants had teaniosis. Moreover, a high number of active cysticercosis cases were detected. Open defecation and promiscuity were seemed to be the main risk factors associated to T. solium infections. The results of this study will be useful to guide interventions in these remote settings surrounding the Ranomafana National Park.

U.S. bound journey of migrant peoples InTransit across Dante's Inferno and Purgatory in the Americas

Rapid rise of population migration is a defining feature of the 21st century due to the impact of climate change, political instability, and socioeconomic downturn. Over the last decade, an increasing number of migrant peoples travel across the Americas to reach the United States seeking asylum or cross the border undocumented in search of economic opportunities. In this journey, migrant people experience violations of their human rights, hunger, illness, violence and have limited access to medical care. In the 'Divine Comedy', the Italian poet Dante Alighieri depicts his allegorical pilgrimage across Hell and Purgatory to reach Paradise. More than 700 years after its publication, Dante's poem speaks to the present time and the perilious journey of migrant peoples to reach safehavens. By exploring the depths and heights of the human condition, Dante's struggles resonate with the multiple barriers and the unfathomable experiences faced by migrant peoples in transit across South, Central, and North America to reach the United States. Ensuring the safety of migrant peoples across the Americas and elsewhere, and attending to their health needs during their migratory paths represent modern priorities to reduce social injustices and achieving health equity.

Use of tafenoquine to treat a patient with relapsing babesiosis with clinical and molecular evidence of resistance to azithromycin and atovaquone

Tafenoquine is a highly effective treatment for Babesia microti infections in animal models. An immunocompromised patient infected by a strain of B. microti that was at least partially resistant to both azithromycin and atovaquone was treated with tafenoquine. Systematic clinical studies using tafenoquine for treating other patients with babesiosis should be considered.

Persistent Clostridium difficile Colitis Mimicking A Fatal Case Of Strongyloides Hyperinfection Syndrome

Strongyloidiasis, a disease caused by the helminth Strongyloides stercoralis, has been identified as a life-threatening parasitic infection among immunocompromised patients. In the most severe of cases, which include hyperinfection syndrome and dissemination of larvae throughout multiple organ sites, there is typically a history of immunosuppression amongst the afflicted. Herein, we describe an immigrant from rural Ecuador with a fatal case of S. stercoralis hyperinfection presenting with diarrhea along with a Clostridium difficile colitis following the use of a prolonged course of steroids. Despite the appropriate administration of ivermectin, living Strongyloides larvae were discovered in a tracheal lavage. The patient ultimately developed a multiorgan failure requiring life-supporting measures in the intensive care unit and later succumbed to his condition. This case of S. stercoralis hyperinfection emphasizes the importance of screening for this parasite in the appropriate clinical scenarios. The diagnosis of S. stercoralis can be made more accessible to practitioners through the utilization of methods such as the Modified Baermann technique, agar plate culture, and serologic antibody testing.

Hemagophagocytic lymphohistiocytosis associated with recurrent Babesiosis with Lyme disease co-infection in an immunocompromised host on anti-CD20 monoclonal antibody therapy: A case report

In the Northeastern United States, a nationally notifiable emerging infectious disease caused by a protozoan infecting erythrocytes is endemic. Transmitted by a deer tick, Ixodes scapularis, this protozoan, Babesia microti, has a complex life cycle including multiple mammalian hosts with humans affected as a dead end reservoir. Although humans are not necessary for the survival of this protozoan, if human erythrocytes are infected by it, especially in a host that is immunocompromised, devastating clinical illness with a significant risk of mortality occurs. Erythrocytic infection of the human host causes many pathogenic changes within the human body, leading to red blood cell destruction and release of pro inflammatory cytokines (3). This pro-inflammatory cascade can very rarely lead to a cycle of further erythrocytic destruction through development of a rare syndrome with high mortality, hemagophagocytic lymphohistocytosis (HLH), which requires early recognition and diagnosis for treatment. This case discusses infection in an immunocompromised host with Babesiosis with complications of HLH and co-infection with Lyme disease requiring multiple diagnostic and therapeutic decisions.

•

Human Babesiosis is an emerging infectious disease in the Northeastern United States, particularly in Long Island, NY.

•

Babesiosis can lead to a rare syndrome (pro-inflammatory cascade) with high mortality, Hemagophagocytic lymphohistiocytosis.

•

HLH may present as a management challenge in Babesiosis, as it requires addition of steroids to anti parasitic therapy.

[Clinicopathological profile of patients with hepatobiliary cancers at two main referral hospitals in Lima, Peru]

OBJECTIVE

The aim of the study was to describe the clinicopathological profile of patients diagnosed with liver, bile ducts or gallbladder cancer.

MATERIALS AND METHODS

Between 2006 and 2017, 89 patients (57% female; mean age: 62 years-old) with these cancers were diagnosed at two national hospitals in Lima, Peru.

RESULTS

Most patients (64%) had advanced stages of disease. Anemia was more frequent in patients with bile duct and liver cancer and in advanced stages. Hypertension (HTN) was frequent among liver cancer patients (32%). The analysis by age showed that HTN was more frequent in patients over 50 years. Likewise, people under 50 years had more frequent history of previous infections (50%), Hepatitis B (HBV) being the most common.

CONCLUSIONS

This study describes the baseline clinicopathological characteristics of a malignancy poorly studied in Peru.

734. Abnormal Lipid Profiles in Human Babesiosis

Background

Babesiosis has gained attention as an emerging protozoal zoonotic disease with an expanding known incidence and geographical range in the US. The infection is caused by Babesia microti in the US and is transmitted by the bite of Ixodes ticks, and occasionally by blood transfusion. The diagnosis is usually established by microscopic examination of a stained blood smear to see intraerythrocytic organisms. The level of parasitemia is only loosely correlated with clinical severity. Anecdotal reports suggest that HDL cholesterol levels decline during acute babesiosis. In this study, we report cholesterol levels in a series of patients with acute babesiosis with the hypothesis that HDL levels may be a potential biomarker for more severe infections.

Methods

A retrospective chart review was performed at Stony Brook University Hospital and Stony Brook Southampton Hospital between 2013 and 2018. Inclusion criteria was defined as a case of acute Babesia infection proven by peripheral blood smear microscopy and who had a lipid profile drawn during presentation to the emergency department. Cholesterol levels that were measured either before or after the infection (at least 1 month apart) were also recorded to compare to the levels reported during acute infection.

Results

A total of 40 patients (27.5% female) met criteria for acute Babesia infection. Fifteen (37.5%) had a history of splenectomy. The patients were divided into two groups for comparisons based on the treating physician’s clinical decision: 32 patients who were admitted to the hospital and 8 patients who were not-admitted. History of hypertension was more common in admitted than non-admitted patients (37% vs. 17%, Chi-square test p=0.02); the median levels of LDL and HDL were more reduced in admitted than non-admitted patients (46 vs 76 mg/dL, p=0.04 and 9 vs 28.5 mg/dL, p=0.03, based on t-test respectively)

Conclusion

LDL and HDL levels are significantly reduced in acute babesiosis, and LDL levels are inversely proportional to the parasitemia, suggesting that low levels of LDL may predict worsening disease in babesiosis. The mechanism of this phenomenon is unknown. Further prospective studies are needed.

Disclosures

All Authors: No reported disclosures

Association of Serum Ferritin Levels and Methylprednisolone Treatment With Outcomes in Nonintubated Patients With Severe COVID-19 Pneumonia

IMPORTANCE

Serum ferritin, an acute phase marker of inflammation, has several physiologic functions, including limiting intracellular oxidative stress. Whether the effectiveness of corticosteroids differs according to serum ferritin level in COVID-19 has not been reported.

OBJECTIVE

To examine the association between admission serum ferritin level and methylprednisolone treatment outcomes in nonintubated patients with severe COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study included patients with severe COVID-19 admitted to an academic referral center in Stony Brook, New York, from March 1 to April 15, 2020, receiving high-flow oxygen therapy (fraction of inspired oxygen, ≥50%). The outcomes of treatment with methylprednisolone were estimated using inverse probability of treatment weights, based on a propensity score comprised of clinical and laboratory variables. Patients were followed up for 28 days. Data were analyzed from December 19, 2020, to July 22, 2021.

EXPOSURES

Systemic methylprednisolone administered per the discretion of the treating physician.

MAIN OUTCOMES AND MEASURES

The primary outcome was mortality, and the secondary outcome was a composite of death or mechanical ventilation at 28 days.

RESULTS

Among 380 patients with available ferritin data (median [IQR] age, 60 years [49-72] years; 130 [34.2%] women; 250 [65.8%] men; 310 White patients [81.6%]; 47 Black patients [12.4%]; 23 Asian patients [6.1%]), 142 patients (37.4%) received methylprednisolone (median [IQR] daily dose, 160 [120-240] mg). Ferritin levels were similar in patients who received methylprednisolone vs those who did not (median [IQR], 992 [509-1610] ng/mL vs 893 [474-1467] ng/mL; P = .32). In weighted analyses using tertiles of ferritin values (lower: 29-619 ng/mL; middle: 623-1316 ng/mL; upper: 1322-13 418 ng/mL), methylprednisolone was associated with lower mortality in patients with ferritin in the upper tertile (HR, 0.16; 95% CI, 0.06-0.45) and higher mortality in those with ferritin in the middle (HR, 2.46; 95% CI, 1.15-5.28) and lower (HR, 2.43; 95% CI, 1.13-5.22) tertiles (P for interaction < .001). Composite end point rates were lower with methylprednisolone in patients with ferritin in the upper tertile (HR, 0.45; 95% CI, 0.25-0.80) but not in those with ferritin in the middle (HR, 0.83; 95% CI, 0.50-1.39) and lower (HR, 0.89; 95% CI, 0.51-1.55) tertiles (P for interaction = .11).

CONCLUSIONS AND RELEVANCE

In this cohort study of nonintubated patients with severe COVID-19, methylprednisolone was associated with improved clinical outcomes only among patients with admission ferritin in the upper tertile of values.

Admission NT-proBNP and outcomes in patients without history of heart failure hospitalized with COVID-19

Aims

We examined the value of N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP) in patients admitted for coronavirus disease 2019 (COVID‐19) without prior history of heart failure (HF) or cardiomyopathy.

Methods and results

Retrospective cohort of consecutive adults (N = 679; median age 59 years; 38.7% women; 87.5% White; 7.1% Black; 5.4% Asian; 34.3% Hispanic) admitted with documented COVID‐19 in an academic centre in Long Island, NY. Admission NT‐proBNP was categorized using the European Society of Cardiology Heart Failure Association age‐specific criteria for acute presentations. We examined (i) mortality and the composite of death or mechanical ventilation and (ii) out‐of‐hospital, intensive care unit (ICU)‐free, and ventilator‐free days at 28 days. Estimates were adjusted for confounders using a lasso selection process. Using age‐specific criteria, 417 patients (61.4%) had low, 141 (20.8%) borderline, and 121 (17.8%) high NT‐proBNP. Mortality was 5.8%, 20.6%, and 36.4% for patients with low, borderline, and high NT‐proBNP, respectively. In lasso‐adjusted models, high NT‐proBNP was associated with higher mortality [hazard ratio (HR) 2.15; 95% confidence interval (CI) 1.06–4.39; P = 0.034] and composite endpoint rates (HR 1.66; 95%CI 1.04–2.66; P = 0.035). Patients with high NT‐proBNP had 32%, 33%, and 33% fewer out‐of‐hospital, ICU‐free, and ventilator‐free days compared with low NT‐proBNP counterparts. Results were consistent across age, sex, and race, and regardless of coronary artery disease or hypertension, except for stronger mortality signal with high NT‐proBNP in women.

Conclusions

In patients with COVID‐19 and no HF history, high admission NT‐proBNP is associated with higher mortality and healthcare resources utilization. Preventive strategies may be required for these patients.

In silico prediction of secretory proteins of Opisthorchis viverrini, Clonorchis sinensis and Fasciola hepatica that target the host cell nucleus

Liver flukes Fasciola hepatica, Opisthorchis viverrini and Clonorchis sinensis are causing agents of liver and hepatobiliary diseases. A remarkable difference between such worms is the fact that O. viverrini and C. sinensis are carcinogenic organisms whereas F. hepatica is not carcinogenic. The release of secretory factors by carcinogenic flukes seems to contribute to cancer development however if some of these target the host cell nuclei is unknown. We investigated the existence of O. viverrini and C. sinensis secretory proteins that target the nucleus of host cells and compared these with the corresponding proteins predicted in F. hepatica. Here we applied an algorithm composed by in silico approaches that screened and analyzed the potential genes predicted from genomes of liver flukes. We found 31 and 22 secretory proteins that target the nucleus of host cells in O. viverrini and C. sinensis, respectively, and that have no homologs in F. hepatica. These polypeptides have enriched the transcription initiation process and nucleic acid binding in O. viverrini and C. sinensis, respectively. In addition, other 11 secretory proteins of O. viverrini and C. sinensis, that target the nucleus of host cells, had F. hepatica homologs, have enriched RNA processing function. In conclusion, O. viverrini and C. sinensis have 31 and 22 genes, respectively, that may be involved in their carcinogenic action through a direct targeting on the host cell nuclei.

High-dose methylprednisolone in nonintubated patients with severe COVID-19 pneumonia

BACKGROUND

Recent trials with dexamethasone and hydrocortisone have demonstrated benefit in patients with coronavirus disease 2019 (COVID-19). Data on methylprednisolone are limited.

METHODS

Retrospective cohort of consecutive adults with severe COVID-19 pneumonia on high-flow oxygen (FiO₂  ≥ 50%) admitted to an academic centre in New York, from 1 March to 15 April 2020. We used inverse probability of treatment weights to estimate the effect of methylprednisolone on clinical outcomes and intensive care resource utilization.

RESULTS

Of 447 patients, 153 (34.2%) received methylprednisolone and 294 (65.8%) received no corticosteroids. At 28 days, 102 patients (22.8%) had died and 115 (25.7%) received mechanical ventilation. In weighted analyses, risk for death or mechanical ventilation was 37% lower with methylprednisolone (hazard ratio 0.63; 95% CI 0.47-0.86; P = .003), driven by less frequent mechanical ventilation (subhazard ratio 0.56; 95% CI 0.40-0.79; P = .001); mortality did not differ between groups. The methylprednisolone group had 2.8 more ventilator-free days (95% CI 0.5-5.1; P = .017) and 2.6 more intensive care-free days (95% CI 0.2-4.9; P = .033) during the first 28 days. Complication rates were not higher with methylprednisolone.

CONCLUSIONS

In nonintubated patients with severe COVID-19 pneumonia, methylprednisolone was associated with reduced need for mechanical ventilation and less-intensive care resource utilization without excess complications.

Safety, tolerability, and outcomes of losartan use in patients hospitalized with SARS-CoV-2 infection: A feasibility study

BACKGROUND

Retrospective studies on the use of Renin-Angiotensin-Aldosterone System blockade in patients with Coronavirus Disease 2019 (COVID-19) have been informative but conflicting, and prospective studies are required to demonstrate the safety, tolerability, and outcomes of initiating these agents in hospitalized patients with COVID-19 and hypertension.

METHODS AND FINDINGS

This is a single center feasibility study encompassing two cohorts: (1) prospective cohort (April 21, 2020 to May 29, 2020) and (2) retrospective cohort (March 7, 2020 to April 1, 2020) of hospitalized patients with real-time polymerase chain reaction (PCR) positive SARS-CoV-2 by nasopharyngeal swab. Key inclusion criteria include BP > 130/80 and a requirement of supplemental oxygen with FiO2 of 25% or higher to maintain SpO2 > 92%. Key exclusion criteria included hyperkalemia and acute kidney injury (AKI) at the time of enrollment. Prospective cohort consisted of de novo initiation of losartan and continuation for a minimum of 7 days and assessed for adverse events (AKI, hyperkalemia, transaminitis, hypotension) and clinical outcomes (change in SpO2/FiO2 and inflammatory markers, need for ICU admission and mechanical ventilation). Retrospective cohort consisted of continuation of losartan (prior-to-hospitalization) and assessment of similar outcomes. In the prospective cohort, a total of 250 hospitalized patients were screened and inclusion/exclusion criteria were met in 16/250 patients and in the retrospective cohort, a total of 317 hospitalized patients were screened and inclusion/exclusion criteria were met in 14/317 patients. Most common adverse event was hypotension, leading to discontinuation in 3/16 (19%) and 2/14 (14%) patients in the prospective and retrospective cohort. No patients developed AKI in the prospective cohort as compared to 1/14 (7%) patients in the retrospective cohort, requiring discontinuation of losartan. Hyperkalemia occurred in 1/16 (6%) and 0/14 patients in the prospective and retrospective cohorts, respectively. In the prospective cohort, 3/16 (19%) and 2/16 (13%) patients required ICU admission and mechanical ventilation. In comparison, 3/14 (21%) required ICU admission and mechanical ventilation in the retrospective cohort. A majority of patients in both cohorts (14/16 (88%) and 13/14 (93%) patients from the prospective and retrospective cohort) were discharged alive from the hospital. A total of 9/16 (prospective) and 5/14 (retrospective) patients completed a minimum 7 days of losartan. In these 9 patients in the prospective cohort, a significant improvement in SpO2/FiO2 ratio was observed from day 1 to 7. No significant changes in inflammatory markers (initiation, peak, and day 7) were observed in either cohort.

CONCLUSION

In this pilot study we demonstrate that losartan was well-tolerated among hospitalized patients with COVID-19 and hypertension. We also demonstrate the feasibility of patient recruitment and the appropriate parameters to assess the outcomes and safety of losartan initiation or continuation, which provides a framework for future randomized clinical trials.

Outcomes Associated with the Use of Renin-Angiotensin-Aldosterone System Blockade in Hospitalized Patients with SARS-CoV-2 Infection

Background

Data regarding the benefits or harm associated with the continuation of Angiotensin Converting Enzyme Inhibitors (ACEIs) and Angiotensin II Receptor Blockers (ARBs), especially the impact on inflammation, in hypertensive, hospitalized patients with COVID-19 in the United States is unclear.

Methods

This is a single-center cohort study of sequentially hospitalized patients with COVID-19 at Stony Brook University Medical Center from March 7, 2020 to April 1, 2020, inclusive of these dates. Data collection included history of known comorbidities, medications, vital signs and laboratory values (admission and during the hospitalization). Outcomes include inflammatory burden (composite scores for multiple markers of inflammation), acute kidney injury (AKI), admission to the intensive care unit (ICU), need for invasive mechanical ventilation, and mortality.

Results

Of the 300 patients in the study cohort, 80 patients (26.7%) had history of ACEI or ARB use prior to admission, with 61.3% (49/80) of these patients continuing the medications during hospitalization. Multivariable analysis revealed that the history of ACEI or ARB use prior to hospitalization was not associated with worse outcomes. In addition, the continuation of these agents during hospitalization was not associated with an increase in adverse outcomes and predicted fewer ICU admissions (OR=0.25, 0.08-0.81) with a decrease in the severity of inflammatory burden (peak CRP (6.9±3.1mg/dl, p=0.03) and peak inflammation score (2.3±1.1unit reduction, p=0.04)).

Conclusion

Use of ACEI or ARBs prior to hospitalization was not associated with adverse outcomes in COVID-19 and the therapeutic benefits of continuing ACEI or ARB in hospitalized patients with COVID-19 was not offset by adverse outcomes.

Presence of Borrelia miyamotoi infection in a highly endemic area of Lyme disease

A series of cases in the Northeast of the US during 2013–2015 described a new Borrelia species, Borrelia miyamotoi, which is transmitted by the same tick species that transmits Lyme disease and causes a relapsing fever-like illness. The geographic expansion of B. miyamotoi in the US also extends to other Lyme endemic areas such as the Midwestern US. Co-infections with other tick borne diseases (TBD) may contribute to the severity of the disease. On Long Island, NY, 3–5% of ticks are infected by B. miyamotoi, but little is known about the frequency of B. miyamotoi infections in humans in this particular region. The aim of this study was to perform a chart review in all patients diagnosed with B. miyamotoi infection in Stony Brook Medicine (SBM) system to describe the clinical and epidemiological features of B. miyamotoi infection in Suffolk County, NY. In a 5 year time period (2013–2017), a total of 28 cases were positive for either IgG EIA (n = 19) or PCR (n = 9). All 9 PCR-positive cases (median age: 67; range: 22–90 years) had clinical findings suggestive of acute or relapsing infection. All these patients were thought to have a TBD, prompting the healthcare provider to order the TBD panel which includes a B. miyamotoi PCR test. In conclusion, B. miyamotoi infection should be considered in the differential diagnosis for flu-like syndromes during the summer after a deer tick bite and to prevent labeling a case with Lyme disease.

Soil-Transmitted Helminthiasis in Children from a Rural Community Taking Part in a Periodic Deworming Program in the Peruvian Amazon

Children in the Peruvian Amazon Basin are at risk of soil-transmitted helminths (STH) infections. This study aimed to determine the prevalence of STH infection in children from a rural Amazonian community of Peru and to elucidate epidemiological risk factors associated with its perpetuation while on a school-based deworming program with mebendazole. Stool samples of children aged 2–14 years and their mothers were analyzed through direct smear analysis, Kato–Katz, spontaneous sedimentation in tube, Baermann’s method, and agar plate culture. A questionnaire was administered to collect epidemiological information of interest. Among 124 children, 25.8% had one or more STH. Individual prevalence rates were as follows: Ascaris lumbricoides, 16.1%; Strongyloides stercoralis, 10.5%; hookworm, 1.6%; and Trichuris trichiura, (1.6%). The prevalence of common STH (A. lumbricoides, T. trichiura, and hookworm) was higher among children aged 2–5 years than older children (31.6% versus 12.8%; P = 0.01). In terms of sanitation deficits, walking barefoot was significantly associated with STH infection (OR = 3.28; CI 95% = 1.11–12.07). Furthermore, STH-infected children more frequently had a mother who was concomitantly infected by STH than the non-STH–infected counterpart (36.4% versus 14.1%, P = 0.02). In conclusion, STH infection is highly prevalent in children from this Amazonian community despite routine deworming. Institutional health policies may include hygiene and sanitation improvements and screening/deworming of mothers to limit the dissemination of STH. Further studies are needed to address the social and epidemiological mechanics perpetuating these infections.

Kankanet: An artificial neural network-based object detection smartphone application and mobile microscope as a point-of-care diagnostic aid for soil-transmitted helminthiases

Background

Endemic areas for soil-transmitted helminthiases often lack the tools and trained personnel necessary for point-of-care diagnosis. This study pilots the use of smartphone microscopy and an artificial neural network-based (ANN) object detection application named Kankanet to address those two needs.

Methodology/Principal findings

A smartphone was equipped with a USB Video Class (UVC) microscope attachment and Kankanet, which was trained to recognize eggs of Ascaris lumbricoides, Trichuris trichiura, and hookworm using a dataset of 2,078 images. It was evaluated for interpretive accuracy based on 185 new images. Fecal samples were processed using Kato-Katz (KK), spontaneous sedimentation technique in tube (SSTT), and Merthiolate-Iodine-Formaldehyde (MIF) techniques. UVC imaging and ANN interpretation of these slides was compared to parasitologist interpretation of standard microscopy.Relative to a gold standard defined as any positive result from parasitologist reading of KK, SSTT, and MIF preparations through standard microscopy, parasitologists reading UVC imaging of SSTT achieved a comparable sensitivity (82.9%) and specificity (97.1%) in A. lumbricoides to standard KK interpretation (97.0% sensitivity, 96.0% specificity). The UVC could not accurately image T. trichiura or hookworm. Though Kankanet interpretation was not quite as sensitive as parasitologist interpretation, it still achieved high sensitivity for A. lumbricoides and hookworm (69.6% and 71.4%, respectively). Kankanet showed high sensitivity for T. trichiura in microscope images (100.0%), but low in UVC images (50.0%).

Conclusions/Significance

The UVC achieved comparable sensitivity to standard microscopy with only A. lumbricoides. With further improvement of image resolution and magnification, UVC shows promise as a point-of-care imaging tool. In addition to smartphone microscopy, ANN-based object detection can be developed as a diagnostic aid. Though trained with a limited dataset, Kankanet accurately interprets both standard microscope and low-quality UVC images. Kankanet may achieve sensitivity comparable to parasitologists with continued expansion of the image database and improvement of machine learning technology.

For rainforest-enshrouded rural villages of Madagascar, soil-transmitted helminthiases are more the rule than the exception. However, the microscopy equipment and lab technicians needed for diagnosis are a distance of several days’ hike away. We piloted a solution for these communities by leveraging resources the villages already had: a traveling team of local health care workers, and their personal Android smartphones. We demonstrated that an inexpensive, commercially available microscope attachment for smartphones could rival the sensitivity and specificity of a regular microscope using standard field fecal sample processing techniques. We also developed an artificial neural network-based object detection Android application, called Kankanet, based on open-source programming libraries. Kankanet was used to detect eggs of the three most common soil-transmitted helminths: Ascaris lumbricoides, Trichuris trichiura, and hookworm. We found Kankanet to be moderately sensitive and highly specific for both standard microscope images and low-quality smartphone microscope images. This proof-of-concept study demonstrates the diagnostic capabilities of artificial neural network-based object detection systems. Since the programming frameworks used were all open-source and user-friendly even for computer science laymen, artificial neural network-based object detection shows strong potential for development of low-cost, high-impact diagnostic aids essential to health care and field research in resource-limited communities.

Infection with New York Orthohantavirus and Associated Respiratory Failure and Multiple Cerebral Complications

We report a case of infection with New York orthohantavirus in a woman who showed renal impairment and hemorrhage, complicated by hydrocephalus, in Long Island, New York, USA. Phylogenetic analysis showed that this virus was genetically similar to a New York orthohantavirus isolated in the same region during 1993.

Risk Factors Associated with Linkage to Care among Suburban Hepatitis C-Positive Baby Boomers and Injection Drug Users

INTRODUCTION

Suffolk County, located in Eastern Long Island, has been an epicenter for the opioid epidemic in New York State, yet no studies have examined hepatitis C virus (HCV) prevalence in this population. Additionally, few studies have assessed barriers for linkage to care (LTC) to HCV treatment in people who inject drugs (PWID), a high-risk HCV cohort. We aimed to determine prevalence of HCV infection in a suburban medical center and to assess risk factors associated with LTC in HCV-positive baby boomers and young PWID.

METHODS

A retrospective chart review was carried out on adult patients with ICD-9/10 diagnostic codes for HCV from January 2016 to December 2018 at Stony Brook Medicine. Data collected included sociodemographics, RNA serostatus, LTC, health insurance, employment, past medical or psychiatric history, and substance or injection drug use.

RESULTS

Overall, 27,049 individuals were screened for HCV and 1017 were HCV seropositive (3.8%), 437 (42.9%) were HCV RNA-positive and 153 (40.6%) achieved LTC. In multivariate analysis, living with cirrhosis was associated with a positive LTC. Medicaid or Medicare insurance was associated with a negative LTC. Intravenous drug users were more likely to be young and have concomitant polysubstance use and psychiatric disease. A bimodal distribution of HCV-positives is present in our population.

CONCLUSION

Those with liver cirrhosis are more likely to achieve LTC, as are those with private insurance. Public health efforts to promote awareness of HCV and to facilitate access to treatment among PWID are needed.

Epidemiology of soil transmitted helminth and Strongyloides stercoralis infections in remote rural villages of Ranomafana National Park, Madagascar

Soil-transmitted helminth (STH) infections carry the highest number of disability adjusted life years among all neglected tropical diseases, disproportionately affecting low-income countries such as Madagascar.  This study describes the epidemiology of STH and S. stercoralis infections in twelve remote villages surrounding Ranomafana National Park (RNP), Ifanadiana, Madagascar. Questionnaires and stool samples were collected from 574 subjects from random households. The Kato-Katz method and spontaneous sedimentation technique were used to examine stool samples for evidence of infection. Infection prevalence rates were 71.4% for Ascaris lumbricoides (95% CI: 67.7-75.1), 74.7% for Trichuris trichiura (95% CI: 71.1-78.2), 33.1% for hookworm (95% CI: 29.2-36.9), and 3.3% for Strongyloides stercoralis (95% CI: 1.84-4.77). Participants who were older in age (OR = 0.96; 95% CI: 0.95-0.99) and who had a high school education (OR = 0.17; 95% CI: 0.04-0.77) were less likely to be infected with a STH. Females were less likely to be infected with A. lumbricoides (OR = 0.52; 95% CI: 0.33-0.82). Participants living in villages further from the main road were more likely to be infected with a STH (F = 4.00, p = 0.02). Overall, this study found that 92.5% (95% CI: 90.3-94.6) of the people living in rural regions near RNP have at least one STH infection. This calls into question the current preventative chemotherapy (PC) program in place and suggests that further medical, socioeconomic, and infrastructural deveopments are needed to reduce STH prevalence rates among this underserved population.

2202. The Hepatitis C Virus Cascade of Care at Stony Brook University Hospital: Risk Factors for Linkage to Care

Background

Huge efforts are being made to screen high-risk populations for Hepatitis C virus (HCV) infection, however linkage to care (LTC) rates remain low. The aim of this study was to assess the factors affecting LTC among HCV positives in a major tertiary academic medical center in eastern New York.

Methods

A retrospective chart review was performed on all patients with ICD-9 or 10 diagnostic codes for HCV positive antibody over a period of 2 years (2016–2017) at Stony Brook Medicine. Data were collected for HCV RNA, LTC, demographics, type of insurance, employment status, psychiatric diagnosis, comorbidities, HIV or HBV coinfections, substance use disorder, and level of fibrosis. Univariate and multivariate analyses were performed to find associated factors with LTC.

Results

A total of 600 cases (62.6% male; 74% White; median age: 59 years) had a positive HCV antibody, 264 (44.4%) had a positive follow-up HCV RNA test and 138 (52.2%) were LTC. The average time for LTC was 1.5 months (50 days; interquartile range 21–121). In the univariate analysis, the following factors were significantly associated with LTC: older age (OR 1.022), having medicaid (OR 0.421), people who inject drugs (PWID) (OR 0.216), cocaine and marijuana use (OR 0.457), polysubstance use (OR 0.311), having a primary care provider (OR 2.290) and being a baby boomer (OR 1.718). The vast majority of patients came from three zip codes within south central Suffolk County, coinciding with the highest prevalence of heroin use.

Conclusion

In this population insurance type, younger age and substance use (injection drugs, marijuana, cocaine, polysubstance) were associated with lower odds of LTC. Having a primary care provider and being a baby boomer were the only two independent risk factors associated with increased odds of LTC. Due to an increased number of HCV cases in younger populations, particularly PWID, further outreach efforts are urgently needed to spread HCV screening awareness and increase testing in high prevalence areas.

Disclosures

All authors: No reported disclosures.

450. Using Geographical Information Systems to Interpret the Efficacy of Mass Drug Administration for Soil-Transmitted Helminthiasis in Rural Madagascar

Background

In Madagascar, mass drug administration (MDA) of anti-parasitics is administered every 6 months to combat soil-transmitted helminthiasis (STH) in school-aged children, although little information exists as to its efficacy. In recent years, geographical information systems (GIS) have been used for visualization of patterns in disease epidemiology. This inexpensive technology may be leveraged to aid in education of local health workers toward a more integrated approach to control STH.

Methods

Baseline questionnaires and stool/blood samples were collected from participants of Mangevo, a rural village in southeast Madagascar. GPS coordinates and qualitative descriptions were collected from all village homes, common latrines, and animal pens. All children 5–15 years old were given MDA per WHO protocol. Stool was again collected from these children 2 weeks later and 3 months later. Parasitological examination of stool samples for STH eggs was performed using Spontaneous Sedimentation Technique. Results were overlaid onto GIS maps and used to further educate the local mobile health team.

Results

A total of 183 participants were eligible for the study. Analysis found 89% of adults >15 years old were infected with one or more parasite and 100% of children 5–15 were infected with one or more parasite at time 0. Trichuris trichuria prevalence fell 8% (P < 0.5) in 2 weeks and climbed 17% (P < 0.05) by 3 months follow-up. Ascaris lumbricoides prevalence fell 96% (P < 0.0001) in the 2 weeks and climbed 95% (P < 0.0001) by 3 months follow-up. Hookworm prevalence dropped 89% (P < 0.0001) in 2 weeks and climbed 5% (P < 0.5) by 3 months follow-up. Prevalence data, descriptive results, and GPS coordinates of village homes were integrated into a GIS maps pre- and post-MDA of children, and pre-MDA for adults.

Conclusion

While GIS has been used to yield insights into the ecology of infection, this study examined the efficacy of the current MDA through the lens of small scale GIS mapping. This may be an ideal and inexpensive technology to help in the implementation of future interventions of the government-mandated STH treatment protocol and work toward the strengthening of local health teams.

Disclosures

All authors: No reported disclosures.

665. Key Clinical and Laboratory Features in Early Diagnosis of Ehrlichiosis in an Endemic Area of Long Island, New York

Background

Human monocytic ehrlichiosis (HME) is a tick-borne disease caused by Ehrlichia chafeensis in the northeast United States. Suffolk County, New York has the highest amount of HME cases in NY (176 from 2010 to 2014). Our aim is to identify risk factors for HME and compare clinical presentation and laboratory findings of young vs. older adults.

Methods

A retrospective chart review from January 1, 2014 to December 31, 2017 was performed on all patients ≥18 years who presented to the ER at Stony Brook University Hospital (SBUH) or Stony Brook Southampton Hospital (SBSH) with (i) ICD-9 code 082.4 or ICD-10 code A77.40 and (ii) a positive E. Chafeensis PCR. Data were collected on demographics, clinical presentation, and laboratory results.

Results

Twenty-seven cases of HME were found and separated into Group 1 (G1, n = 10) or Group 2 (G2, n = 17) based on age (Table 1). G1 had a significantly higher chance of being Hispanic than G2. Twenty-four of the 27 patients (89%) were hospitalized with an average length of stay of 3.4 days (range 1–14 days).The only significant difference in clinical presentation was that G1 was more likely to have myalgia (P = 0.02). 40% or more of patients in both groups presented with an acute kidney injury and the average length of hospital stay in days was 4.0 ± 2.9 and 3.2 ± 3.1 for G1 and G2, respectively. The number of cases overall have increased 6.0% per year between 2014 and 2017. Thrombocytopenia presented in all cases.

Conclusion. HME is prevalent in Suffolk County. Clinical presentation and laboratory findings were largely similar between the two groups, except the younger population more often presented with myalgia. A risk factor in this study was to be young and Hispanic, likely due to occupational exposure.

Disclosures

All authors: No reported disclosures.

Mycobacterium orygis Lymphadenitis in New York, USA

We report a case of lymphadenitis caused by Mycobacterium orygis in an immunocompetent person in Stony Brook, New York, USA. Initial real-time PCR assay failed to provide a final subspecies identification within the M. tuberculosis complex, but whole-genome sequencing characterized the isolate as M. orygis.

Lyme Disease in Hispanics in Long Island, New York: A New Health Disparity in the U.S

Background

Lyme disease (LD) is the most commonly reported vector-borne illness in the U.S. A risk factor for acquiring LD is the exposure to outdoors. In Long Island, Hispanics compromise a large share of the outdoor occupational workforce.

Methods

A retrospective chart review was performed in all patients with ICD-9 or ICD-10 diagnostic codes for LD between 2011–2016 in SHH and 2010–2015 in SBUH. Inclusion criteria was defined as a clinical scenario compatible with LD (erythema migrans -EM, arthritis, central nervous system (CNS) involvement, carditis, meningitis) and serological confirmation by western blot according to CDC (SBUH) or Imugen® (SHH) criteria.

Results

Out of 1,026 cases (766 SBUH;260 SHH) that carried a diagnosis of LD, 284 cases (22% Hispanics) met inclusion criteria and were added to final analysis (241 SBUH: 43 SHH). The mean age was 48.8 (SD:17.8) and 48.3 (SD:17.5) years-old in H and NH, respectively (p &gt; 0.05). Most were male (H:62.2%; NH: 54.3%; P = 0.2). In the univariate analysis, headaches were more frequently present in H (42.6%) than in NH (26.6%) (P = 0.015). In the logistic regression analysis, the following symptoms were significantly different between H and NH: headaches (OR 1.17, 96% CI 1.60–6.59, &#x2028;P = 0.001) and peripheral neuropathy (OR 0.38, 95% CI: 0.15-0.96, P = 0.04). Among seasons, H were more frequently diagnosed with Lyme during spring months than NH (H: 26.3% vs. NH: 12.6%, P = 0.03)

Conclusion

Hispanics have a greater risk for presenting with headaches and less peripheral neuropathy than NH. Initiation of outdoor work among H may be the reason of this disproportionate presentation of LD symptoms during spring months. These findings may suggest the propensity for Hispanics to go underdiagnosed with LD, despite their high likelihood of exposure through their occupations in this region.

Disclosures

All authors: No reported disclosures.

Comparison of Fidaxomicin and Vancomycin for Recurrent Clostridium difficile Colitis

Background

Fidaxomicin is a narrow spectrum macrocyclic antibiotic used for the treatment of Clostridium difficileinfection (CDI). The objective of this study is to compare the recurrence and mortality rates of patients with CDI who received either vancomycin or fidaxomicin at Stony Brook University Hospital.

Methods

A retrospective chart review was performed to identify all hospitalized patients who received fidaxomicin and vancomycin for CDI for the period 2011–2015. Inclusion criteria included patient age ≥18 years, stool positive PCR test for C. difficile and being treated ≥10 days of either fidaxomicin or vancomycin orally. Clinical recurrence was defined as a return of diarrhea, a positive test for C. difficiletoxin B and a need for retreatment for CDI within 90 days of cessation of therapy.

Results

A total of 55 (52.7% male) and 74 (51.4% male) cases met inclusion criteria in the fidaxomicin (F) and vancomycin (V) groups, respectively. The mean age was 65.9 ± 1.88 and 63.7 ± 1.86 years in group F and V respectively (P = 0.4). Median length of hospitalization was 14 and 9 days for F and V respectively (P = 0.6). Both groups had similar proportions on the following variables: immunosuppression (V 36.5% vs. F 36.4%; P = 0.9), ≥ 1 prior episode of CDI (V 59.5% vs. F 61.8%; P = 0.8), sepsis on admission (V 29.7%, F 36.4%; P = 0.4), the use of any antibiotic during the last 30 days (V 74.3%, 71%, P = 0.7), and treatment with additional anti-CDI therapy (V 24.3%, F 29.1%; P = 0.5). CDI recurrence rate was 24% (V) and 40% (F, P = 0.057). The 90-day mortality rate was 4.1% in the vancomycin group and 10.9% in the fidaxomicin group (P = 0.13).

Conclusion

Fidaxomicin had a higher recurrent CDI than vancomycin in this tertiary medical center.

Disclosures

All authors: No reported disclosures.

A computational assessment of the predicted structures of Human Macrophage Migration Inhibitory Factor 1 orthologs in parasites and its affinity to human CD74 receptor

The human macrophage migration inhibitory factor 1 (Hu-MIF-1) is a protein involved in the inflammatory and immunology response to parasite infection. In the present study, the existence of Hu-MIF-1 from parasites have been explored by mining WormBase. A total of 35 helminths were found to have Hu-MIF-1 homologs, including some parasites of importance for public health. Physicochemical, structural, and biological properties of Hu-MIF-1 were compared with its orthologs in parasites showing that most of these are secretory proteins, with positive net charge and presence of the Cys-Xaa-Xaa-Cys motif that is critical for its oxidoreductase activity. The inhibitor-binding site present in Hu-MIF-1 is well conserved among parasite MIFs suggesting that Hu-MIF inhibitors may target orthologs in pathogens. The binding of Hu-MIF-1 to its cognate receptor CD74 was predicted by computer-assisted docking, and it resulted to be very similar to the predicted complexes formed by parasite MIFs and human CD74. More than 1 plausible conformation of MIFs in the extracellular loops of CD74 may be possible as demonstrated by the different predicted conformations of MIF orthologs in complex with CD74. Parasite MIFs in complex with CD74 resulted with some charged residues oriented to CD74, which was not observed in the Hu-MIF-1/CD74 complex. Our findings predict the binding mode of Hu-MIF-1 and orthologs with CD74, which can assist in the design of novel MIF inhibitors. Whether the parasite MIFs function specifically subvert host immune responses to suit the parasite is an open question that needs to be further investigated. Future research should lead to a better understanding of parasite MIF action in the parasite biology.

Babesiosis in Long Island: review of 62 cases focusing on treatment with azithromycin and atovaquone

BACKGROUND

Babesiosis is a potentially life-threatening, tick-borne infection endemic in New York. The purpose of this study was to review recent trends in babesiosis management and outcomes focusing on patients, who were treated with combination of azithromycin and atovaquone.

METHODS

A retrospective chart review of patients seen at Stony Brook University Hospital between 2008 and 2014 with peripheral blood smears positive for Babesia was performed. Clinical and epidemiological information was recorded and analyzed.

RESULTS

62 patients had confirmed babesiosis (presence of parasitemia). Forty six patients (74%) were treated exclusively with combination of azithromycin and atovaquone; 40 (87%) of these patients were hospitalized, 11 (28%) were admitted to Intensive Care Unit (ICU), 1 (2%) died. Majority of patients presented febrile with median temperature 38.5 °C. Median peak parasitemia among all patients was 1.3%, and median parasitemia among patients admitted to ICU was 5.0%. Six patients (15%) required exchange transfusion. Majority of patients (98%) improved and were discharged from hospital or clinic.

CONCLUSION

Symptomatic babesiosis is still rare even in endemic regions. Recommended treatment regimen is well tolerated and effective. Compared to historical controls we observed a lower overall mortality.