SARS-CoV-2 Persistence in Immunocompromised Patients Requiring Treatment With Convalescent Plasma: A Case Report

Severe acute respiratory syndrome-2 (SARS-CoV-2) infection in immunocompromised patients presents a challenge, as patients with such conditions may have severe courses. Identifying modalities to shorten the course or lessen the severity of infection could be potentially beneficial. A 76-year-old male with follicular lymphoma on rituximab and lenalidomide presented with COVID-19 pneumonia requiring intensive care unit (ICU) level care for persistent hypoxemia. He was treated with an extended course of remdesivir, as recommended by the Infectious Diseases service, but he maintained a persistently high viral load, necessitating a delay of his cancer treatment until he had recovered from his infection. On hospital day 31, he was given one dose of convalescent plasma with improvement in his SARS-CoV-2 viral load. He was able to be discharged and resumed cancer treatment soon thereafter. Convalescent plasma is a potential therapeutic option for immunocompromised patients with SARS-CoV-2 infection and should be considered early in the hospital course. Additionally, cycle threshold monitoring may be beneficial in certain scenarios: for instance to guide consideration of alternative therapies in patients with severe COVID-19 who have persistent symptoms and viremia while on guideline-directed therapy.

1135. Monoclonal Antibody Therapeutics in US Veterans against Delta and Omicron SARS-CoV-2 Variants

Background

Anti-SARS-CoV-2 monoclonal antibodies (mABs) target the viral spike protein and have been shown to have clinical benefit in treating COVID-19. The FDA had given emergency use authorization to mAB products: bamlanivimab+etesevinab (BAM), casirivimab+imdevimab (CAS), sotrovimab (SOT). However, due to reduced activity against the omicron variant the FDA recommended against use of BAM and CAS. SOT has retained efficacy against omicron. We reviewed the utilization of mABS in our institution during the pandemic as delta variant was replaced by omicron.

Methods

Retrospective chart review of US Veterans (USV) with confirmed SARS-CoV-2 infection who received mABs from 9/1/2021 to 2/28/22 at Northport Veterans Affairs Medical Center. Demographic data, comorbidities, choice of mAB, history of COVID-19 vaccination, SARS-CoV-2 sequencing, and IgG levels to the receptor-biding domain (RBD) of the spike protein in vaccinated USV were reviewed.

Results

66 USV received mAB therapy, tolerated well. 30 got CAS, 29 BAM, 7 SOT. 52 doses were given from Dec 2021 to Jan 2022, none were given in Feb. The median age of the cohort was 72.5 (range 32 to 97 years). 97% were men. 85% White, 12% Black, 3% Hispanic. 22 USV were not vaccinated. The vaccine recipients were: 3 Janssen, Moderna-2 shots (MOD-2): 6; MOD-3: 3; Pfizer 2 (PFZ-2) shots: 22; PFZ-3:10 The median days of COVID diagnosis from last dose of vaccine: Janssen 211 days (104 to 257); MOD-2 291 (205-322); MOD-3 56 (16-61), PFZ-2 222 (96-302) PFZ-3 78 (8-112). 62% had cough, dyspnea 24%, malaise 50%, diarrhea 11%, anosmia 11%, sore throat 17%, nasal congestion 41%, fever 32% Median BMI 30.8 (16.6 - 47.3). 36% had Diabetes, HTN 67%. COPD 23%, Asthma 11%, CAD 32%, HLD 67%; one woman was 28 weeks pregnant. Two coinfections with rhinovirus, 1 with RSV. 20 vaccine recipients had anti-SARS-CoV-2 RBD titers at presentation, median 2.60 (0.06-48.08). 11 USV were hospitalized but only 4 got steroids/remdesivir. 3 USV died but not directly due to COVID. 15 USV with omicron who received CAS (8) and BAM (7) survived. See tables for further data.

Demographic Data of US Veterans after receiving monoclonal antibody therapy

Data on hospitalized US Veterans after receiving monoclonal antibody therapy

Conclusion

As the pandemic transitioned from Delta to Omicron variants, mAB treatments in USV remained successful even in those USV who received therapies not active for omicron. Delta and omicron infections were seen in vaccinated and boosted USV.

Disclosures

All Authors: No reported disclosures.

275. Evaluating the COVID-19 Pandemic in US Veterans: Transitioning from Delta to Omicron Variants

Background

During the COVID-19 pandemic many new variants of the SARS-CoV-2 virus have evolved. The omicron variant is the latest of concern and has numerous mutations in the spike protein (SP) which may alter COVID19 vaccine and therapeutic efficacy. We assessed whether COVID19 vaccination status would be protective among US Veterans (USV) who were diagnosed with SARS-CoV2 infection and performed an epidemiological analysis of this cohort.

Methods

A retrospective chart review was performed of USV with PCR confirmed SARS-CoV-2 infection who presented to Northport Veterans Affairs Medical Center between 11/1/2021 and 4/15/2022. Demographic information, vaccine status, medical comorbidities, SARS-CoV2 infection history, medical therapy receipt, need for hospitalization, SARS-COV-2 sequencing, and SP receptor-biding domain (RBD) IgG levels were reviewed. Two sample t-test and Chi-square analyses were performed.

Results

605 USV were diagnosed with SARS-CoV2, median age was 62 years, 559 (92.4%) were male, 474 (78.3%) Caucasian and 77 (12.7%) Hispanic. 426 (70.4%) received at least one COVID19 vaccine dose, largely mRNA (n=400, 66.1%). Median time from vaccine dose to SARS-CoV2 diagnosis was 211 days (1-468). 26 (4.3%) USV had a previous history of SARS-CoV2 infection and 38 vaccinated USV had RBD-SP IgG titers (positive > 1 S/CO) at time of presentation, median 6.8 S/CO (0.06 to 71.21). Unvaccinated USV had a higher mean body mass index (31.0 vs. 30.0, p=0.04), and more commonly carried a diagnosis of COPD or asthma (20.0 vs. 11.8%, p=0.0005). A greater number of vaccinated USV utilized tobacco (44.2 vs 6.1%, p< 0.0001) or opioids (6.8 vs 1.1%, p< 0.0001). Unvaccinated USV more often required remdesivir (RDV) or dexamethasone (DEX) therapy (10.6 vs 6.6%, p=0.04). There was no difference in hospitalizations, monoclonal antibody use, or all-cause mortality between groups. Omicron BA.1 was first found on December 13, BA.2 on March 9 and final Delta variant on January 12.

Demographic characteristics of the entire cohort, as well as by vaccination status

Monthly SARS-CoV2 infections among US Veterans

Monthly infections with delta and omicron SARS-CoV2 variants among vaccinated and unvaccinated US Veterans between 11/1/21 and 4/15/22

Daily SARS-CoV2 infections among US Veterans

Daily infections with delta and omicron SARS-CoV2 variants among vaccinated and unvaccinated US Veterans between 11/1/21 and 4/15/22

Conclusion

Omicron and Delta SARS-CoV-2 infections occurred in both vaccinated and unvaccinated USV, including among vaccinated persons with detectable neutralizing IgG titers. Unvaccinated USV were more likely to utilize RDV and DEX, suggesting severe infection was more common in this group.

Disclosures

All Authors: No reported disclosures.

1409. Infectious Complications in People Who Inject Drugs (PWID): A Retrospective Review and Recommendations for Improved Care

Background

Suffolk County, NY is home to 1.5. million people and has a higher drug related deaths per capita rate compared to NY state average (19.9 vs 14.9/100,000). Injection drug use (IDU) is associated with complicated infections and inadequate treatment of substance use disorder (SUD) leads to relapse of infection and treatment failure. Unfortunately, access to SUD treatment services is not optimized in Suffolk County. We aimed to characterize the incidence and outcome of admissions for PWID and identify modifiable risk factors which can contribute to suboptimal care for PWID.

Methods

A retrospective review of SBUH electronic medical record was conducted from Jan 1, 2015 to June 1, 2021. Length of stay, discharge disposition, 6-month hospital readmission, insurance, employment and housing status, SUD history plus infection type and antimicrobial receipt were assessed.

Results

Of 425 patients (pts) admitted between Jan 1, 2015 to June 1, 2021, the median age was 34 years, 93% were white, and 59% male. Most pts. (89%) reported stable housing and had government insurance. The average length of stay was 13.6 days with 1/3 of pts. requiring ICU admission. Notably, 34% of pts left prematurely against medical advice and 34% were readmitted within 6 months. Formal ID (63%) and Psychiatry (62.5%) consults were not requested on all pts. Only 18% and 25% of pts. were treated with methadone or suboxone. 60% of screened pts. had HCV but 50% were not screened for co-infections. Complicated skin and soft tissue represented 70%, sepsis/bacteremia 11%, osteomyelitis/arthritis 10% and endocarditis 12% of the cases. 14.8% of pts. with endocarditis died, 48% had recurrent endocarditis, 52% needed surgery including 12% of repeat valve replacements. Staphylococcus species caused 42% of infections. About 2/3 of pts required continued antibiotic therapy at time of discharge, leading to delayed discharge for IV catheter placement.

Conclusion

Managing infectious complications in PWID is a multi-faceted endeavor extending beyond inpatient care. This study highlights the need for standardized treatment plans involving specialized case managers to reduce LOS and AMA discharges, improve screening for infections and integrate SUD treatment for PWID.

Disclosures

All Authors: No reported disclosures.

Evaluation of the Impact of HIV Serostatus on the Hepatitis C Virus Care Cascade and Injection Drug Use Among Persons Initiating Medication Treatment for Opioid Use Disorder

Background

Persons who inject drugs are at increased risk for acquiring hepatitis C virus (HCV). Medications for opioid use disorder (MOUD) are associated with reduced injection drug use (IDU) frequency among persons with opioid use disorder (OUD). However, whether HCV treatment uptake or changes in IDU frequency differ by HIV serostatus among persons receiving MOUD is incompletely understood.

Methods

A secondary analysis was performed of data collected from 2 prospective cohort studies of participants with (PWH) or without HIV with Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition-diagnosed OUD who were initiated on methadone, buprenorphine, or naltrexone.

Results

Of 129 participants, 78 (60.5%) were HCV antibody positive. PWH underwent increased HCV viral load testing (76.7% vs 43.3%; P = .028), but HCV treatment rates did not differ (17.6% vs 10.0%; P = .45) by HIV status. Participants without HIV reported a greater reduction in mean opioid IDU at 90 days (10.7 vs 2.0 fewer days out of 30; P < .001), but there were no group differences at 90 days. Stimulant use did not differ between groups. Urine opioid positivity declined from baseline to 90 days among the entire cohort (61.4% to 38.0%; P < .001) but did not differ by HIV serostatus.

Conclusions

PWH who received MOUD underwent higher rates of follow-up HCV testing, but HCV treatment rates did not significantly differ by HIV serostatus. Participants without HIV on MOUD reported a greater reduction in opioid IDU. Improved integration of concomitant OUD with HCV and HIV screening, linkage to care, and treatment are needed for persons without HIV.

Maintenance on extended-release naltrexone is associated with reduced injection opioid use among justice-involved persons with opioid use disorder

INTRODUCTION

Opioid use disorder (OUD) and injection drug use (IDU) place justice-involved individuals at increased risk for acquiring or transmitting HIV or hepatitis C virus (HCV). Methadone and buprenorphine have been associated with reduced opioid IDU; however, the effect of extended-release naltrexone (XR-NTX) on this behavior is incompletely studied.

METHODS

This study examined injection opioid use and shared injection equipment behavior from a completed double-blind placebo-controlled trial of XR-NTX among 88 justice-involved participants with HIV and OUD. Changes in participants' self-reported daily injection opioid use and shared injection equipment was evaluated pre-incarceration, during incarceration, and monthly post-release for 6 months. The study also assessed differences in time to first opioid injection post-release. The research team performed intention to treat and "as treated" (high treatment versus low treatment) analyses.

RESULTS

Fifty-eight of 88 participants (69.5 %) endorsed IDU and 26 (29.5 %) reported sharing injection equipment in the 30 days pre-incarceration; 2 participants (2.2 %) reported IDU during incarceration; 19 (21.6 %) reported IDU one month post-release from prison or jail. Fifty-four (61.4 %) participants had an HIV RNA below 200 copies/mL and 62 (70.5 %) were baseline HCV antibody positive. The 6-month follow-up rate was 49.5 % and 50.5 % for those who received XR-NTX and placebo, respectively, which was not significantly different (p = 0.822). Participants in the XR-NTX and placebo groups had similar low mean opioid injection use post-release and time to first injection opioid use in the Intention-to-treat analysis. In the as-treated analysis, participants in the high treatment group had significantly lower mean proportion of days injecting opioids (13.8 % high treatment versus 22.8 % low treatment, p = 0.02) by month 1, which persisted up to 5 months post-release (0 % high treatment vs 24.3 % low treatment, p < 0.001) and experienced a longer time to first opioid injection post-release (143.8 days high treatment vs 67.4 days low treatment, p < 0.001).

CONCLUSIONS

Injection opioid use was low during incarceration and remained low post-release in this justice-involved population. Retention on XR-NTX was associated with reduced intravenous opioid use, which has important implications for reducing transmission of HIV and HCV.

Four Human Cases of Eastern Equine Encephalitis in Connecticut, USA, during a Larger Regional Outbreak, 2019

Incidence increased among human and equine hosts after primary and bridge mosquito virus vectors more than doubled over normal levels 1 month earlier in the season than usual.

During 3 weeks in 2019, 4 human cases of Eastern equine encephalitis (EEE) were diagnosed at a single hospital in Connecticut, USA. The cases coincided with notable shifts in vector–host infection patterns in the northeastern United States and signified a striking change in EEE incidence. All 4 cases were geographically clustered, rapidly progressive, and neurologically devastating. Diagnostic tests conducted by a national commercial reference laboratory revealed initial granulocytic cerebrospinal fluid pleocytosis and false-negative antibody results. EEE virus infection was diagnosed only after patient samples were retested by the arbovirus laboratory of the Centers for Disease Control and Prevention in Fort Collins, Colorado, USA. The crucial diagnostic challenges, clinical findings, and epidemiologic patterns revealed in this outbreak can inform future public health and clinical practice.

Unilateral leg pain caused by cryptococcal myositis: An unusual presentation of disseminated cryptococcosis in a kidney transplant recipient

Cryptococcal disease is a rare but often serious infection in solid organ transplant recipients, commonly presenting as meningitis and pneumonia but can rarely cause myositis. We report the case of a 43-year-old female kidney transplant recipient with two previous graft failures requiring re-transplantations who presented with a 1-month duration of worsening unilateral leg pain, swelling, and shortness of breath. Blood cultures isolated Cryptococcus neoformans. A calf biopsy was performed and histopathology revealed myonecrosis with yeast forms consistent with Cryptococcus spp. Liposomal amphotericin B (LamB) was administered. Her course was complicated by hypoxemic respiratory failure with development of ground glass opacities on chest imaging. Work-up revealed bacterial and C neoformans pneumonia and probable Pneumocystis jirovecii pneumonia (PJP) She received trimethoprim-sulfamethoxazole and LamB and was discharged on fluconazole. Shortly thereafter she was re-admitted with confusion, septic shock, and multi-organ failure. Work-up revealed PJP with subsequent development of cryptococcal meningitis. Despite aggressive management, she expired. Disseminated cryptococcal infection may manifest as myositis. Presence of cryptococcal infection is a marker of severe net state of immunosuppression (IS), hence, presence of other opportunistic infections is likely. Early recognition of cryptococcal infection, institution of targeted therapy, and IS reduction are important to improve overall survival.

Case Report: Disseminated Strongyloidiasis in a Patient with COVID-19

The SARS-CoV-2 virus has emerged and rapidly evolved into a current global pandemic. Although bacterial and fungal coinfections have been associated with COVID-19, little is known about parasitic infection. We report a case of a COVID-19 patient who developed disseminated strongyloidiasis following treatment with high-dose corticosteroids and tocilizumab. Screening for Strongyloides infection should be pursued in individuals with COVID-19 who originate from endemic regions before initiating immunosuppressive therapy.

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.

Human Myo19 is a novel myosin that associates with mitochondria

Mitochondria are pleomorphic organelles that have central roles in cell physiology. Defects in their localization and dynamics lead to human disease. Myosins are actin-based motors that power processes such as muscle contraction, cytokinesis, and organelle transport. Here we report the initial characterization of myosin-XIX (Myo19), the founding member of a novel class of myosin that associates with mitochondria. The 970 aa heavy chain consists of a motor domain, three IQ motifs, and a short tail. Myo19 mRNA is expressed in multiple tissues, and antibodies to human Myo19 detect an approximately 109 kDa band in multiple cell lines. Both endogenous Myo19 and GFP-Myo19 exhibit striking localization to mitochondria. Deletion analysis reveals that the Myo19 tail is necessary and sufficient for mitochondrial localization. Expressing full-length GFP-Myo19 in A549 cells reveals a remarkable gain of function where the majority of the mitochondria move continuously. Moving mitochondria travel for many micrometers with an obvious leading end and distorted shape. The motility and shape change are sensitive to latrunculin B, indicating that both are actin dependent. Expressing the GFP-Myo19 tail in CAD cells resulted in decreased mitochondrial run lengths in neurites. These results suggest that this novel myosin functions as an actin-based motor for mitochondrial movement in vertebrate cells.