Sequential Treatment Failure With Aztreonam-Ceftazidime-Avibactam Followed by Cefiderocol Due to Preexisting and Acquired Mechanisms in a New Delhi Metallo-β-lactamase-Producing Escherichia coli Causing Fatal Bloodstream Infection

We report a fatal case of New Delhi metallo-β-lactamase (NDM)-producing Escherichia coli in a bacteremic patient with sequential failure of aztreonam plus ceftazidime-avibactam followed by cefiderocol. Acquired resistance was documented phenotypically and mediated through preexisting and acquired mutations. This case highlights the need to rethink optimal treatment for NDM-producing organisms.

Pediatric solid organ transplant recipients demonstrate robust cell-mediated and humoral responses to three doses of mRNA SARS-CoV-2 vaccine

Pediatric solid organ transplant recipients (pSOTR) often demonstrate suboptimal vaccine responses and are not included in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine efficacy trials. This population has shown variable humoral immunity following SARS-CoV-2 vaccination, and no studies have assessed cell-mediated responses after SARS-CoV-2 vaccination in pSOTR. SARS-CoV-2-specific interferon-gamma release assay (IGRA), immunoglobulin G (IgG), and receptor-binding domain (RBD)-angiotensin-converting enzyme 2 (ACE2) blocking antibody (Ab) were measured in pSOTR aged 5-17 years after 2-3 doses of SARS-CoV-2 mRNA vaccine. In all, 33 subjects were included, with 25 tested after the second dose of mRNA vaccine (V2) and 21 tested after the third dose of mRNA vaccine (V3). Of the 19 subjects who had IgG testing after V3, 100.0% (19/19) had a positive IgG response. Of the 17 subjects who had IGRA testing after V3, 94.1% (16/17) had a positive IGRA response. RBD-ACE2 blocking antibody increased significantly from V2 to V3 (p = .007). Subjects <1 year from transplant demonstrated a significantly larger increase in RBD-ACE2 blocking Ab from V2 to V3 than did those >1 year from transplant (p = .05). SARS-CoV-2 vaccination induces humoral and cell-mediated responses in the majority of pSOTR, with improved quantitative humoral response after three doses.

Cellular and humoral immune response to SARS-CoV-2 vaccination and booster dose in immunosuppressed patients: An observational cohort study

BACKGROUND

Humoral and cellular immune responses to SARS-CoV-2 vaccination among immunosuppressed patients remain poorly defined, as well as variables associated with poor response.

METHODS

We performed a retrospective observational cohort study at a large Northern California healthcare system of infection-naïve individuals fully vaccinated against SARS-CoV-2 (mRNA-1273, BNT162b2, or Ad26.COV2.S) with clinical SARS-CoV-2 interferon gamma release assay (IGRA) ordered between January through November 2021. Humoral and cellular immune responses were measured by anti-SARS-CoV-2 S1 IgG ELISA (anti-S1 IgG) and IGRA, respectively, following primary and/or booster vaccination.

RESULTS

496 immunosuppressed patients (54% female; median age 50 years) were included. 62% (261/419) of patients had positive anti-S1 IgG and 71% (277/389) had positive IGRA after primary vaccination, with 20% of patients having a positive IGRA only. Following booster, 69% (81/118) had positive anti-S1 IgG and 73% (91/124) had positive IGRA. Factors associated with low humoral response rates after primary vaccination included anti-CD20 monoclonal antibodies (P < 0.001), sphingosine 1-phsophate (S1P) receptor modulators (P < 0.001), mycophenolate (P = 0.002), and B cell lymphoma (P = 0.004); those associated with low cellular response rates included S1P receptor modulators (P < 0.001) and mycophenolate (P < 0.001). Of patients who had poor humoral response to primary vaccination, 35% (18/52) developed a significantly higher response after the booster. Only 5% (2/42) of patients developed a significantly higher cellular response to the booster dose compared to primary vaccination.

CONCLUSIONS

Humoral and cellular response rates to primary and booster SARS-CoV-2 vaccination differ among immunosuppressed patient groups. Clinical testing of cellular immunity is important in monitoring vaccine response in vulnerable populations.

690. Oka-Strain Varicella-Zoster Virus Meningitis in a Healthy Adolescent

Background

Routine vaccination with varicella-zoster (VZV) vaccine has resulted in significant declines in the incidence of VZV cases, hospitalizations, and deaths across pediatric age. This vaccine is safe and effective and adverse events are monitored closely.

Methods

We describe a case of vOka meningoencephalitis in a twelve-year-old vaccinated boy who presented with altered mental status and a vesicular facial rash.

Results

A twelve-year-old healthy, fully-vaccinated boy presented to urgent care clnic with left-sided frontotemporal headache, left-sided eye pain, and photosensitivity. Over several days, a left-sided facial rash progressed to include papular and vesicular lesions over the cheek, as well as over the left side of the chin and at the midline of the lower lip. He was somnolent, sleeping 18- 20 hours a day. The child was evaluated by a pediatric neurologist who noted a left-sided ptosis and left lateral rectus palsy; he was admitted for further workup. Cerebrospinal fluid (CSF) analysis showed WBC of 33 cells/ml³ with 92% lymphocytes; glucose of 44mg/dL (serum glucose 84mg/dL), and protein of 50mg/dL (range: 15-45). Nasopharyngeal multiplex polymerase chain reaction (PCR) (BioFire Diagnostics, Salt Lake City, Utah) was positive for rhinovirus/enterovirus. Testing of facial vesicles for varicella-zoster virus (VZV) and herpes simplex virus (HSV) was negative by DFA and culture, and enteroviral throat and rectal PCRs were negative. However, CSF PCR for VZV was found to be positive. In light of this finding, the viral isolate was sent to Dr. Anne Gershon’s research lab at Columbia University Medical Center for typing and was determined to be vOka. Quantitative and functional immune studies were performed, and were normal. The patient initially received 7 days of intravenous acyclovir, during which time his rash resolved and mental status returned to baseline. He completed a total of 14 days of acyclovir and has had no recurrences.

Conclusion

This case represents only the tenth case of Oka-strain meningitis in an immunocompetent child reported to date, and one of very few cases in immunocompetent adolescents. While rare, vOka meningitis is an entity of which primary care pediatricians and infectious diseases specialists should be aware, even in older children.

Disclosures

All Authors: No reported disclosures

Improving case finding of invasive aspergillosis in children using string searches

Surveillance for invasive Aspergillus (IA) in children is complex. We performed a retrospective study (2004-2013) using string searches of relevant terms within histopathology and radiology reports in efforts to improve detection of IA. Overall, 22 children met IA criteria, of whom 5 (23%) were only identified by string searches.

Congenital Parvovirus B19 Infection: Persistent Viremia and Red Blood Cell Aplasia

We describe a case of fetal parvovirus B19 infection resulting in preterm birth and leading to hydrops fetalis requiring multiple in utero transfusions. The infant developed chronic postnatal anemia responsive to intravenous immunoglobulin therapy. Serum viral load decreased after immunoglobulin treatment but remained detectable for over 1 year.

Biological risk factors in pediatric bipolar disorder

BACKGROUND

The current study attempted to determine whether neurodevelopmental and acquired brain abnormalities are more common in pediatric bipolar disorder (PBD).

METHODS

The study sample consisted of 98 subjects with a mean age of 11.5 +/- 3.3 years comprising three demographically matched groups: healthy controls (HC, n = 28), subjects with bipolar disorder - Type I (PBD, n = 37), and bipolar disorder - Type I combined with attention deficit hyperactivity disorder (PBD+ADHD, n = 33). Family history of PBD was determined using the Family History Screen. Additional measures were administered to assess the history on perinatal risk, development milestones, serious physical illnesses, and head injury.

RESULTS

Logistic regression showed that that family history and perinatal risk factors predicted the diagnosis of PBD. PBD diagnosis was 15 times higher among those with a family history of BD. Second, for every additional perinatal risk factor such as prenatal exposure to drugs or birth complications, the risk of having a PBD diagnosis increased more than six-fold.

CONCLUSIONS

Having a positive familial history of BD in a first degree relative and perinatal insults may elevate the risk for developing PBD. Presence of these risk factors, especially in the context of clinical signs of affect dysregulation, should alert clinicians to screen for PBD.