Use of Advanced Diagnostics for Timely Identification of Travel-associated Leptospira santarosai Infection in Four Adolescents Through Plasma Microbial Cell-free DNA Sequencing With the Karius Test

BACKGROUND

Leptospirosis is an important zoonotic infection worldwide. Diagnosis of leptospirosis is challenging given its nonspecific clinical symptoms that overlap with other acute febrile illnesses and limitations with conventional diagnostic testing. Alternative advanced diagnostics, such as microbial cell-free DNA (mcfDNA), are increasingly being used to aid in the diagnosis of infections and can be applied to pathogens with public health importance such as Leptospira , a nationally notifiable disease.

METHODS

The Karius Test uses plasma mcfDNA sequencing to detect and quantify DNA-based pathogens. This test offered through the Karius lab detected 4 cases of Leptospira santarosai during a 5-month period across the United States in 2021 and were clinically reviewed.

RESULTS

In our case series, 4 adolescents with recent travel to Central America (Costa Rica, n = 3 and Belize, n = 1) from April to August 2021 were diagnosed with leptospirosis. While a large workup was performed in all cases, mcfDNA testing was the first test to detect L. santarosai as the microbiological diagnosis in all cases.

CONCLUSIONS

Results of the Karius Test enabled rapid, noninvasive diagnosis of leptospirosis allowing for targeted therapy. Use of mcfDNA can be utilized for diagnosis of pathogens where conventional testing is challenging or limited. This in turn can enable quick diagnosis for targeted treatment and potentially aid in supporting case definitions of reportable diseases of public health concern.

Multisystem Inflammatory Syndrome in Children and Cardiac Involvement: A Quaternary Center Experience

We prospectively analyzed clinical and laboratory characteristics associated with cardiac involvement and severe presentation in multisystem inflammatory syndrome in children. Of 146 patients, 66 (45.2%) had cardiac dysfunction and 26 (17.8%) had coronary artery abnormalities. Lower serum albumin levels, absolute lymphocyte and platelet counts, and elevated ferritin, fibrinogen, d-dimer and interleukin-6 levels were associated with cardiac dysfunction. Possible treatment complications were identified.

Multisystem inflammatory syndrome in children associated with COVID-19: from pathophysiology to clinical management and outcomes

Multisystem inflammatory syndrome in children (MIS-C), also known as pediatric inflammatory multisystem syndrome (PIMS), is a new postinfectious illness associated with COVID-19, affecting children after SARS-CoV-2 exposure. The hallmarks of this disorder are hyperinflammation and multisystem involvement, with gastrointestinal, cardiac, mucocutaneous, and hematologic disturbances seen most commonly. Cardiovascular involvement includes cardiogenic shock, ventricular dysfunction, coronary artery abnormalities, and myocarditis. Now entering the fourth year of the pandemic, clinicians have gained some familiarity with the clinical presentation, initial diagnosis, cardiac evaluation, and treatment of MIS-C. This has led to an updated definition from the Centers for Disease Control and Prevention in the USA driven by increased experience and clinical expertise. Furthermore, the available evidence established expert consensus treatment recommendations supporting a combination of immunoglobulin and steroids. However, the pathophysiology of the disorder and answers to what causes this remain under investigation. Fortunately, long-term outcomes continue to look promising, although continued follow-up is still needed. Recently, COVID-19 mRNA vaccination is reported to be associated with reduced risk of MIS-C, while further studies are warranted to understand the impact of COVID-19 vaccines on MIS-C. We review the findings and current literature on MIS-C, including pathophysiology, clinical features, evaluation, management, and medium- to long-term follow-up outcomes.

Direct Admission Program Implementation: A Qualitative Analysis of Variation Across Health Systems

OBJECTIVES

Direct admission (DA) to the hospital has the potential to improve family satisfaction and timeliness of care by bypassing the emergency department. Using the RE-AIM implementation framework, we sought to characterize variation across health systems in the reach, effectiveness, adoption, and implementation of a DA program from the perspectives of parents and multidisciplinary clinicians.

METHODS

As part of a stepped-wedge cluster randomized trial to compare the effectiveness of DA to admission through the emergency department, we evaluated DA rates across 69 clinics and 3 health systems and conducted semi-structured interviews with parents and clinicians. We used thematic analysis to identify themes related to the reach, effectiveness, adoption, and implementation of the DA program and applied axial coding to characterize thematic differences across sites.

RESULTS

Of 2599 hospitalizations, 171 (6.6%) occurred via DA, with DA rates varying 10-fold across health systems from 0.9% to 9.3%. Through the analysis of 137 interviews, including 84 with clinicians and 53 with parents, we identified similarities across health systems in themes related to perceived program effectiveness and patient and family engagement. Thematic differences across sites in the domains of program implementation and clinician adoption included variation in transfer center efficiency, trust between referring and accepting clinicians, and the culture of change within the health system.

CONCLUSIONS

The DA program was adopted variably, highlighting unique challenges and opportunities for implementation in different hospital systems. These findings can inform future quality improvement efforts to improve transitions to the hospital.

Update on nonpolio enterovirus and parechovirus infections in neonates and young infants

PURPOSE OF REVIEW

To review the epidemiology, clinical manifestations, and treatment strategies of nonpolio enterovirus and parechovirus (PeV) infections, and identify research gaps.

RECENT FINDINGS

There is currently no approved antiviral agent for enterovirus or PeV infections, although pocapavir may be provided on a compassionate basis. Elucidation of the structure and functional features of enterovirus and PeV may lead to novel therapeutic strategies, including vaccine development.

SUMMARY

Nonpolio human enterovirus and PeV are common childhood infections that are most severe among neonates and young infants. Although most infections are asymptomatic, severe disease resulting in substantial morbidity and mortality occurs worldwide and has been associated with local outbreaks. Long-term sequelae are not well understood but have been reported following neonatal infection of the central nervous system. The lack of antiviral treatment and effective vaccines highlight important knowledge gaps. Active surveillance ultimately may inform preventive strategies.

Asymptomatic COVID-19 Reinfection in a Pediatric Patient with Heterotaxy Syndrome

We report an asymptomatic child with heterotaxy syndrome who had recurrent positive SARS-CoV-2 polymerase chain reaction testing. An aberrant lymphocyte population expressing CD19, CD16, and CD56 was identified; its phenotyping revealing atypical NK cells. This subset's role in protection from severe disease or in reinfection cannot be ascertained.

546. Resolution of a Cluster of Travel-Associated Leptospira santarosai Infection in Four Adolescents by Plasma Microbial Cell-Free DNA Detection with the Karius Test®

Background

Leptospira can cause severe infections but their diagnosis can be challenging. Diagnosis is limited by nonspecific, protean clinical symptoms; the fastidious nature of Leptospira; and poor specificity, sensitivity, and long turnaround times of serologic testing. Given these limitations, identifying epidemiological clusters of leptospirosis can be challenging. Rapid, non-invasive diagnosis of leptospirosis by microbial cell-free DNA (mcfDNA) next-generation sequencing (NGS) of plasma offers a means to overcome these limitations in individual diagnosis and public health epidemiological surveillance.

Methods

The Karius Test® (KT) detects and quantifies mcfDNA in molecules/µL (MPM) in plasma from a curated genomic database of >20,000 organisms reporting on >1000 pathogens through the Karius CLIA certified/CAP accredited lab (Redwood City, CA). Four KT detections of Leptospira santarosai were identified April - August 2021 across four independent United States institutions. Clinical review was performed by pediatric infectious diseases consultants.

Results

KT detected L. santarosai in four adolescents with travel to Costa Rica or Belize (Table). A broad work-up was performed in all patients. McfDNA NGS was the first test to identify L. santarosai as the diagnosis in all cases with an average time to diagnosis of 2.5+/- 0.58 days from sample collection, enabling narrowed, targeted antibiotic treatment. L. santarosai mcfDNA was positive in three patients despite pretreatment; average L. santarosai mcfDNA concentration was 173.5+/- 186.1 MPM. Leptospira serologies were confirmatory in three patients, potential epidemiological exposures were identified in all patients, and all recovered.

Conclusion

KT enabled rapid, non-invasive diagnosis of diverse manifestations of L. santarosai against a competing broad differential in four adolescent travelers returning from Costa Rica or Belize. The resolution of the etiology of this cluster of patients with leptospirosis demonstrates the potential utility of mcfDNA to quickly diagnose and support case definitions of reportable diseases and the potential importance of plasma mcfDNA NGS in public health and epidemiological surveillance.

Disclosures

Asim A. Ahmed, MD, Karius: Employee|Karius: Stocks/Bonds Sara Saporta-Keating, MS, MD, Pfizer: Co-investigator in investigator-driven study sponsored by Pfizer.

Association of Models of Care for Kawasaki Disease With Utilization and Cardiac Outcomes

OBJECTIVES

Describe the prevalence of different care models for children with Kawasaki disease (KD) and evaluate utilization and cardiac outcomes by care model.

METHODS

Multicenter, retrospective cohort study of children aged 0 to 18 hospitalized with KD in US children's hospitals from 2017 to 2018. We classified hospital model of care via survey: hospitalist primary service with as-needed consultation (Model 1), hospitalist primary service with automatic consultation (Model 2), or subspecialist primary service (Model 3). Additional data sources included administrative data from the Pediatric Health Information System database supplemented by a 6-site chart review. Utilization outcomes included laboratory, medication and imaging usage, length of stay, and readmission rates. We measured the frequency of coronary artery aneurysms (CAAs) in the full cohort and new CAAs within 12 weeks in the 6-site chart review subset.

RESULTS

We included 2080 children from 44 children's hospitals; 21 hospitals (48%) identified as Model 1, 19 (43%) as Model 2, and 4 (9%) as Model 3. Model 1 institutions obtained more laboratory tests and had lower overall costs (P < .001), whereas echocardiogram (P < .001) and immune modulator use (P < .001) were more frequent in Model 3. Secondary outcomes, including length of stay, readmission rates, emergency department revisits, CAA frequency, receipt of anticoagulation, and postdischarge CAA development, did not differ among models.

CONCLUSIONS

Modest cost and utilization differences exist among different models of care for KD without significant differences in outcomes. Further research is needed to investigate primary service and consultation practices for KD to optimize health care value and outcomes.

Quality improvement methodology can reduce hospitalisation for abscess management

BACKGROUND

Abscesses are a common reason for ED visits. While many are drained in the ED, some require drainage in the operating room (OR). We observed that a higher percentage of patients at our institution in Columbus, Ohio, were admitted to the hospital with abscesses for incision and drainage (I&D) in the OR than other institutions, including paediatric institutions. Our aim was to decrease hospitalisations for abscess management.

METHODS

A multidisciplinary team convened to decrease hospitalisation for patients with abscesses and completed multiple 'Plan-Do-Study-Act' cycles, including increasing I&Ds performed in the ED. Other interventions included implementation of a clinical pathway, training of procedure technicians (PT), updating the electronic medical record (EMR), credentialing advanced practice nurses in sedation and individual follow-up with providers for admitted patients. Data were analysed using statistical process control charts. Gross average charges were assessed.

RESULTS

Admissions for I&D decreased from 26.3% to 13.7%. Abscess drainage in the ED improved from 79.3% to 96.5%. Mean length of stay decreased from 19.5 to 11.5 hours for all patients. Patients sedated increased from 3.3% to 18.2%. The number of repeat I&Ds within 30 days decreased from 4.3% to 1.7%.

CONCLUSION

We decreased hospitalisations for abscess I&D by using quality improvement methodology. The most influential intervention was an initiative to increase I&Ds performed in the ED. Additional interventions included expanded training of PTs, implementation of a clinical pathway, updating the EMR, improving interdepartmental communication and increasing sedation providers.

EVALI versus MIS-C, one more overlapping diagnosis to consider

We describe six teenagers presenting with fever and severe abdominal symptoms admitted with concerns for multisystem inflammatory syndrome in children (MIS-C). Laboratory evaluation revealed elevated markers of inflammation, lymphopenia, and increased D-dimers. Imaging studies revealed multifocal airspace disease and ground-glass opacities. SARS-CoV-2 polymerase chain reaction and serologies were negative. All patients reported a history of vaping, prompting E-cigarette, or vaping, product use-associated lung injury (EVALI) diagnosis. MIS-C has overlapping clinical and laboratory features highlighting the added challenge of diagnosing EVALI during the COVID-19 pandemic. Keywords COVID-19 pandemic, EVALI, MIS-C.

Manifestations of Toxic Shock Syndrome in Children, Columbus, Ohio, USA, 2010-20171

Data are limited on the incidence and management of streptococcal toxic shock syndrome (TSS) and nonstreptococcal TSS in children. We aimed to define the clinical patterns of TSS at Nationwide Children's Hospital in Ohio as they relate to published criteria, diagnostic decisions, and treatment options. Through retrospective chart reviews, we identified 58 patients with TSS (27 streptococcal, 31 nonstreptococcal) during January 2010-September 2017. We observed clinical and laboratory findings that are not part of TSS criteria, such as pyuria in streptococcal TSS (50% of patients) and pulmonary involvement (85%) and coagulopathy (92%) in nonstreptococcal TSS patients. Recommended treatment with clindamycin and intravenous immunoglobulin was delayed in streptococcal TSS patients without rash (3.37 days vs. 0.87 days in patients with rash), leading to prolonged hospitalization and complications. Incorporation of additional TSS signs and symptoms would be helpful in TSS diagnosis and management.

Cerebrospinal Fluid Analysis for Viruses by Metagenomic Next-Generation Sequencing in Pediatric Encephalitis: Not Yet Ready for Prime Time?

BACKGROUND

Metagenomic next-generation sequencing offers an unbiased approach to identifying viral pathogens in cerebrospinal fluid of patients with meningoencephalitis of unknown etiology.

METHODS

In an 11-month case series, we investigated the use of cerebrospinal fluid metagenomic next-generation sequencing to diagnose viral infections among pediatric hospitalized patients presenting with encephalitis or meningoencephalitis of unknown etiology. Cerebrospinal fluid from patients with known enterovirus meningitis were included as positive controls. Cerebrospinal fluid from patients with primary intracranial hypertension were included to serve as controls without known infections.

RESULTS

Cerebrospinal fluid metagenomic next-generation sequencing was performed for 37 patients. Among 27 patients with encephalitis or meningoencephalitis, 4 were later diagnosed with viral encephalitis, 6 had non-central nervous system infections with central nervous system manifestations, 6 had no positive diagnostic tests, and 11 were found to have a noninfectious diagnosis. Metagenomic next-generation sequencing identified West Nile virus (WNV) in the cerebrospinal fluid of 1 immunocompromised patient. Among the 4 patients with known enterovirus meningitis, metagenomic next-generation sequencing correctly identified enteroviruses and characterized the viral genotype. No viral sequences were detected in the cerebrospinal fluid of patients with primary intracranial hypertension. Metagenomic next-generation sequencing also identified sequences of nonpathogenic torque Teno virus in cerebrospinal fluid specimens from 13 patients.

CONCLUSIONS

Our results showed viral detection by cerebrospinal fluid metagenomic next-generation sequencing only in 1 immunocompromised patient and did not offer a diagnostic advantage over conventional testing. Viral phylogenetic characterization by metagenomic next-generation sequencing could be used in epidemiologic investigations of some viral pathogens, such as enteroviruses. The finding of torque Teno viruses in cerebrospinal fluid by metagenomic next-generation sequencing is of unknown significance but may merit further exploration for a possible association with noninfectious central nervous system disorders.

Tinea faciei caused by Trichophyton benhamiae in a child

Tinea faciei is a common pediatric skin disease, most often caused by fungi of the genus Trichophyton. T benhamiae has been recently reclassified as a distinct species and is recognized as an emerging zoonotic dermatophyte with a wide range of possible infectious reservoirs worldwide. We present a previously healthy 7-year-old child presenting with unusual inflammatory facial plaques due to T benhamiae, confirmed by mass spectroscopy.

Year-Round, Routine Testing of Multiple Body Site Specimens for Human Parechovirus in Young Febrile Infants

OBJECTIVES

To test our hypothesis that routine year-round testing of specimens from multiple body sites and genotyping of detected virus would describe seasonal changes, increase diagnostic yield, and provide a better definition of clinical manifestations of human parechovirus (PeV-A) infections in young febrile infants.

STUDY DESIGN

PeV-A reverse-transcriptase polymerase chain reaction (RT-PCR) analysis was incorporated in routine evaluation of infants aged ≤60 days hospitalized at Nationwide Children's Hospital for fever and/or suspected sepsis-like syndrome beginning in July 2013. We reviewed electronic medical records of infants who tested positive for PeV-A between July 2013 and September 2016. Genotyping was performed with specific type 3 RT-PCR and sequencing.

RESULTS

Of 1475 infants evaluated, 130 (9%) tested positive for PeV-A in 1 or more sites: 100 (77%) in blood, 84 (65%) in a nonsterile site, and 53 (41%) in cerebrospinal fluid (CSF). Five infants (4%) were CSF-only positive, 31 (24%) were blood-only positive, and 20 (15%) were nonsterile site-only positive. PeV-A3 was the most common type (85%) and the only type detected in CSF. Although the majority (79%) of infections were diagnosed between July and December, PeV-A was detected year-round. The median age at detection was 29 days. Fever (96%), fussiness (75%), and lymphopenia (56%) were common. Among infants with PeV-A-positive CSF, 77% had no CSF pleocytosis. The median duration of hospitalization was 41 hours. Four infants had bacterial coinfections diagnosed within 24 hours of admission; 40 infants had viral coinfections.

CONCLUSIONS

Although most frequent in summer and fall, PeV-A infections were encountered in every calendar month within the 3-year period of study. More than one-half of patients had PeV-A detected at more than 1 body site. Coinfections were common. PeV-A3 was the most common type identified and the only type detected in the CSF.

1331. Reducing Inpatient Antimicrobial Treatment Duration for Febrile Infants through Implementation of Rapid Diagnostic Testing and Clinical Risk Definition

Background

The management approach to febrile infants remain challenging. Despite new advances in rapid diagnostic testing, febrile infants with a viral infection could receive prolonged antimicrobial treatment due to concerns for co-existing serious bacterial infection (SBI). We sought to decrease the duration of antibiotic treatment in febrile infants less than 8 weeks of age hospitalized on inpatient infectious disease service following sepsis evaluation, who have enterovirus, parechovirus, or respiratory viruses detected, from average 30 hours to 24 hours and sustain for six months.

Figure 1. Antibiotic Treatment Duration of Infants Underfoing Evaluation for Sepsis

Figure 2. Length of Stay in Infants Underfoing Sepsis Evaluation

Methods

A new management guideline that defined “low-risk” infants, as well as inclusion and exclusion criteria, was created to monitor the accurate duration of parenteral treatment and length of hospitalization. Respiratory viruses were detected by a multiplex PCR assay. We created a QlikSense App for further clinical characterization of patients and follow-up. This management guideline was adapted as a quality improvement division initiative. Control charts were used to assess the impact of the interventions.

Figure 3. Readmissions in Infants Underfoing Sepsis Evaluation

Results

The management guideline was developed and implemented by pediatric infectious disease faculty. Febrile infants < 8 weeks of age were included if they had both documented viral infections and sepsis evaluation. 178 infants were admitted with fevers in 2018 and 148 infants were admitted in 2019. The mean inpatient antibiotic treatment duration decreased from 27.7 hours in 2018 to 24.9 hours in 2019 (P > 0.05) (Figure 1). There was no significant difference in length of hospitalization or 30-day readmission rates (Figure 2 and 3). There was no reported readmission for SBI.

Conclusion

Antibiotic treatment could be discontinued in clinically stable infants with a documented viral infection after 24 hours of negative blood, CSF, and urine bacterial culture incubation so as not to receive unnecessary prolonged inpatient treatment that may increase side effects. In addition to possible decreased treatment side effects our protocol led to decreased patient care costs with no documented changes in readmission rates.

Disclosures

Octavio Ramilo, MD, Bill & Melinda Gates Foundation (Grant/Research Support)Janssen (Grant/Research Support, Advisor or Review Panel member)Medimmune (Grant/Research Support)Merck (Advisor or Review Panel member)NIH/NIAID (Grant/Research Support)Pfizer (Consultant, Advisor or Review Panel member)Sanofi/Medimmune (Consultant, Advisor or Review Panel member)

Pediatric Inpatient Problem List Review and Accuracy Improvement

BACKGROUND AND OBJECTIVES

The problem list (PL) is a meaningful use-incentivized criterion for electronic health record documentation. Inconsistent use or inaccuracy of the PL can create communication gaps among providers, potentially leading to diagnostic delays and serious safety events. The objective of the study was to increase the rate of PL review by attending physicians for inpatients discharged from hospital pediatrics and infectious disease services from a baseline of 70% to 80% by June 2018 and to sustain the rate for 6 months. The secondary aim was to improve PL accuracy by decreasing the rate of duplicate codes and red code diagnoses that should resolve before discharge from a baseline of 12% and 11%, respectively, to 5% and sustaining the rate for 6 months.

METHODS

A quality improvement team used the Institute for Healthcare Improvement Model for Improvement. We tracked duplicate codes and red codes as surrogate markers of PL quality. Rates of PL review and PL quality were analyzed monthly via statistical process control charts (p-charts) with 3-σ control limits to identify special cause variation.

RESULTS

PL review improved from a baseline of 70% to 90%, and the change was sustained for 1 year. PL quality improved as duplicate codes at the time of discharge decreased from 12% to 6% and as red codes decreased from a baseline of 11% to 6%.

CONCLUSIONS

The PL is an important communication tool that is underused. By engaging and educating stakeholders, incentivizing compliance, standardizing PL management, leveraging electronic health record enhancements, and providing physician feedback, we improved PL meaningful use and quality.

Eosinophilic Pneumonia and Lymphadenopathy Associated With Vaping and Tetrahydrocannabinol Use

Idiopathic acute eosinophilic pneumonia is a rare and potentially life-threatening condition that is defined by bilateral pulmonary infiltrates and fever in the presence of pulmonary eosinophilia. It often presents acutely in previously healthy individuals and can be difficult to distinguish from infectious pneumonia. Although the exact etiology of idiopathic acute eosinophilic pneumonia remains unknown, an acute hypersensitivity reaction to an inhaled antigen is suggested, which is further supported by recent public health risks of vaping (electronic cigarette) use and the development of lung disease. In this case, a patient with a year-long history of vaping in conjunction with tetrahydrocannabinol cartridge use who was diagnosed with idiopathic acute eosinophilic pneumonia with associated bilateral hilar lymphadenopathy is described.

Irbesartan in Marfan syndrome (AIMS): a double-blind, placebo-controlled randomised trial

BACKGROUND

Irbesartan, a long acting selective angiotensin-1 receptor inhibitor, in Marfan syndrome might reduce aortic dilatation, which is associated with dissection and rupture. We aimed to determine the effects of irbesartan on the rate of aortic dilatation in children and adults with Marfan syndrome.

METHODS

We did a placebo-controlled, double-blind randomised trial at 22 centres in the UK. Individuals aged 6-40 years with clinically confirmed Marfan syndrome were eligible for inclusion. Study participants were all given 75 mg open label irbesartan once daily, then randomly assigned to 150 mg of irbesartan (increased to 300 mg as tolerated) or matching placebo. Aortic diameter was measured by echocardiography at baseline and then annually. All images were analysed by a core laboratory blinded to treatment allocation. The primary endpoint was the rate of aortic root dilatation. This trial is registered with ISRCTN, number ISRCTN90011794.

FINDINGS

Between March 14, 2012, and May 1, 2015, 192 participants were recruited and randomly assigned to irbesartan (n=104) or placebo (n=88), and all were followed for up to 5 years. Median age at recruitment was 18 years (IQR 12-28), 99 (52%) were female, mean blood pressure was 110/65 mm Hg (SDs 16 and 12), and 108 (56%) were taking β blockers. Mean baseline aortic root diameter was 34·4 mm in the irbesartan group (SD 5·8) and placebo group (5·5). The mean rate of aortic root dilatation was 0·53 mm per year (95% CI 0·39 to 0·67) in the irbesartan group compared with 0·74 mm per year (0·60 to 0·89) in the placebo group, with a difference in means of -0·22 mm per year (-0·41 to -0·02, p=0·030). The rate of change in aortic Z score was also reduced by irbesartan (difference in means -0·10 per year, 95% CI -0·19 to -0·01, p=0·035). Irbesartan was well tolerated with no observed differences in rates of serious adverse events.

INTERPRETATION

Irbesartan is associated with a reduction in the rate of aortic dilatation in children and young adults with Marfan syndrome and could reduce the incidence of aortic complications.

FUNDING

British Heart Foundation, the UK Marfan Trust, the UK Marfan Association.

P1790TAVI is associated with less patient-prosthesis-mismatch than surgical aortic valve repair of severe aortic stenosis: A systematic review and meta-analysis

Background

TAVI has shown to be non-inferior to surgical aortic valve replacement (sAVR) in terms of mortality for the treatment of intermediate and high-risk patients with severe aortic stenosis (AS).

Purpose

We sought to assess whether there is a difference on echocardiographic parameters up to 2 years after TAVI and sAVR

Methods

We conducted a systematic review and a random-effect model meta-analysis of randomized controlled trials that compared TAVI and sAVR. The primary outcome was post-proceduralpatient-prosthesis-mismatch (PPM). Secondary outcomes were post-procedural and 2-year effective orifice area (EOA), paravalvular gradient (PVG) and moderate/severe paravalvular leak (PVL).

Results

We identified 5 trials with a total of 5552 participants with AS, including 2777 patients randomized to TAVI and 2775 randomized to sAVR (Figure 1). TAVI was associated with a significant 35% relative risk reduction (95% CI [0.50–0.8), p=0.005) in moderate/severe post-procedural PPM. The effect was more evident in self- than balloon-expandable valves (p=0.029). Similar results were found in terms of post procedural EOA (RR=0.53, 95% CI [0.43–0.62]), and residual gradients (RR=0.54, 95% CI [0.32–0.76]). As expected, TAVI demonstrated higher rates of moderate/severe PVL (RR=9.41, 95% CI [5.22–16.96]). The results were sustainable at 2 years as seen in pooled increased EOA (pooled mean difference 0.48, 95% CI [0.24–0.72]), and the pooled decreased residual gradients of 0.58 (95% CI [0.77–0.25]) in favor of TAVI. The incidence of moderate/severe PVL remained also lower in sAVR patients (RR=10.39, 95% CI [4.80–22.46]).

Figure 1. PRISMA flow diagram

Conclusions

Our meta-analysis suggests that TAVI is associated with a lower risk of PPM, as well as higher EOA and lower residual gradients through 2 years of follow-up. This was accompanied by a higher incidence of moderate/severe PVL compared to sAVR. Future research should focus on the effect of these echocardiographic differences on clinical outcomes.

The Kawasaki Disease Comparative Effectiveness (KIDCARE) trial: A phase III, randomized trial of second intravenous immunoglobulin versus infliximab for resistant Kawasaki disease

BACKGROUND

Although intravenous immunoglobulin (IVIG) is effective therapy for Kawasaki disease (KD), the most common cause of acquired heart disease in children, 10-20% of patients are IVIG-resistant and require additional therapy. This group has an increased risk of coronary artery aneurysms (CAA) and there has been no adequately powered, randomized clinical trial in a multi-ethnic population to determine the optimal therapy for IVIG-resistant patients.

OBJECTIVES

The primary outcome is duration of fever in IVIG-resistant patients randomized to treatment with either infliximab or a second IVIG infusion. Secondary outcomes include comparison of inflammatory markers, duration of hospitalization, and coronary artery outcome. An exploratory aim records parent-reported outcomes including signs, symptoms and treatment experience.

METHODS

The KIDCARE trial is a 30-site randomized Phase III comparative effectiveness trial in KD patients with fever ≥36 h after the completion of their first IVIG treatment. Eligible patients will be randomized to receive either a second dose of IVIG (2 g/kg) or infliximab (10 mg/kg). Subjects with persistent or recrudescent fever at 24 h following completion of the first study treatment will cross-over to the other treatment arm. Subjects will exit the study after their first outpatient visit (5-18 days following last study treatment). The parent-reported outcomes, collected daily during hospitalization and at home, will be compared by study arm.

CONCLUSION

This trial will contribute to the management of IVIG-resistant patients by establishing the relative efficacy of a second dose of IVIG compared to infliximab and will provide data regarding the patient/parent experience of these treatments.

2323. Unexpected Pediatric Presentation Patterns of Toxic Shock Syndrome

Background

A subcategory of severe septic shock, toxic shock syndrome (TSS) represents up to 20% of pediatric septic shock in the United States. Diagnostic criteria for streptococcal TSS (STSS) and non-streptococcal TSS (NSTSS) were first published by the CDC in the early 1990s, with updates, respectively, in 2010 and 2011.

Methods

The Nationwide Children’s Hospital electronic medical record was queried for inpatient hospitalizations with ICD-9/10 codes of interest between 1/1/2010 and 8/31/2017. The query returned 579 hospitalizations which were assessed for adherence to STSS and NSTSS criteria published by the CDC. 61 cases of TSS were identified: 27 STSS, 32 NSTSS. The prevalence of organ system involvement was quantified, and organ system involvement unanticipated by CDC criteria was examined for prevalence, quality and chronology.

Results

TSS patients were predominately female (62%) with an average age of 12. The most common presentation of TSS was with hypotension (93%), fever (82%) and rash (72%). Findings unanticipated by CDC criteria include: pyuria in STSS (41%), pulmonary involvement in NSTSS (66%) and coagulation abnormalities in NSTSS (92%). Pyuria in STSS was commonly accompanied by protein (73%) and leukocyte esterase (55%) on urinalysis. Pyuria also commonly presented with hematuria (45%). Radiographic evidence of pulmonary involvement in NSTSS was typically described as bilateral/diffuse airspace disease, presenting simultaneously with pulmonary edema and pleural effusions. Abnormalities in PT/PTT associated with NSTSS were commonly found within the first few hours of admission and began normalizing by the next day; d-dimer assays were abnormal in the six instances in which they were assessed.

Conclusion

This study suggests that early signs and symptoms of pediatric TSS may exist beyond those described by existing guidelines. The organ systems found to be involved in this review are often found early in the clinical course and can be assessed by noninvasive methods. Contextualization of these findings within the narrative of TSS might help clinicians better detect and diagnose a disease associated with significant patient morbidity and mortality. They may also aid in understanding the results of toxic shock surveillance efforts.

Disclosures

All authors: No reported disclosures.

2311. Atypical Cat Scratch Disease Presentations

Background

Cat scratch disease (CSD) is caused by B henselae, a Gram-negative intracellular bacilli which is transmitted to humans via cat bite/scratch. Typical CSD presents as regional lymphadenopathy and fever. However, there are multiple atypical presentations of cat scratch disease that have been reported including prolonged fever, absence of lymphadenopathy and systemic complications such hepatosplenic disease, osteomyelitis, Parinaud oculoglandular syndrome, neuroretinitis, encephalitis, and bacillary angiomatosis among other rare presentations. The aim of this study was to review the frequency, presentation, and treatment outcomes of aytpical CSD presentations at Nationwide Children’s Hospital (Columbus OH).

Methods

This was a retrospective study performed at Nationwide Children’s Hospital, Columbus, OH. EMR of patients were reviewed between January 2010 and March 2017 using ICD9 or ICD 10 codes for CSD. Patients were identified on the basis of compatible clinical presentation and confirmatory serological test or PCR results for B. henselae. Clinical, radiological, and histopathological findings were collected

Results

A total of 204 patients were serologically diagnosed as having cat scratch disease between January 2010 and July 2017. Of the 204 cases, 166 (81%) had typical CSD and 38 (18.6%) had atypical CSD. Of the atypical manifestations, 20 (52%) patients had no lymphadenopathy, 12 (31%) had osteomyelitis, 12 (31%) patients had hepatic and/or splenic microabscesses, 4 (10.5%) had osteomyelitis and hepatic/splenic involvement, 3 (1.5%) had encephalitis, 2 (5.2%) had neuroretinitis, and there was one case each (2.6%) of Parinaud oculoglandular syndrome, uveitis, pulmonary cavitary lesion, myocarditis, and endocarditis. Fever of unknown origin was present in 28 (75.6%) of the atypical CSD cases. The median duration of antibiotic treatment was 25 days (IQR 31) and median duration of illness in patients with atypical CSD was 51 days (IQR 56). The majority of patients were treated with dual antibiotic therapy that included rifampin.

Conclusion

In children with fever of unknown origin, serologic testing for CSD should be performed even in the absence of lymphadenopathy and a search for underlying systemic complications is recommended for prompt diagnosis and appropriate treatment.

Disclosures

All authors: No reported disclosures.

Pneumococcal colonization among tracheostomy tube dependent children

Streptococcus pneumoniae colonization is a precursor to pneumococcal disease. Although children with a tracheostomy have an increased risk of pneumococcal pneumonia, the pneumococci colonizing their lower airways remain largely uncharacterized. We sought to compare lower respiratory tract isolates colonizing tracheostomy patients and a convenience sample of isolates from individuals intubated for acute conditions. We collected pneumococcal isolates from the lower respiratory tract of 27 patients with a tracheostomy and 42 patients intubated for acute conditions. We compared the penicillin susceptibility, rates of co-colonization, genetic background, and serotype of isolates colonizing these patient populations. Isolates from both groups showed high genetic diversity. Forty multi-locus sequence types and 20 serotypes were identified. There was no significant difference in serotype distribution, co-colonization rates, vaccine coverage, or non-susceptibility to penicillin among pneumococcal isolates from the two groups. Colonization of the lower airways with non-vaccine serotypes 15B/C, 23B and 35B was noted for the first time in patients with tracheostomies and supports recently observed increases in nasopharyngeal colonization and disease due to these serotypes.

Clinical and Radiologic Manifestations of Bone Infection in Children with Cat Scratch Disease

We identified 13 patients with cat scratch (Bartonella henselae) bone infection among those admitted to a large tertiary care children's hospital over a 12-year period. The median age was 7 years and the median time from onset of illness to diagnosis was 10 days. Multifocal osteomyelitis involving spine and pelvis was common; no patient had a lytic bone lesion. Median treatment duration was 28 days (IQR, 24.5 days). Despite significant variations in treatment duration and antimicrobial therapy choices, all patients showed improvement.

A Very Rare Case - Hairy Cell Leukemia in Patient with Sarcoidosis

Although the coexistence of hairy cell leukemia with sarcoidosis has been reported in a few cases in the literature, in our case the patient had been diagnosed and followed about 10 years with sarcoidosis and massive splenomegaly. It has been demonstrated that T helper 1 cells exist in organs influenced by sarcoidosis. These cells produce IL-2 and IFN-γ and induce a nonspecific inflammatory response and granuloma formation. Also these cytokines may play a role in the development of hairy cell leukemia.Key words: hairy cell leukemia -  sarcoidosis - massive splenomegaly.

Design and rationale of a prospective, collaborative meta-analysis of all randomized controlled trials of angiotensin receptor antagonists in Marfan syndrome, based on individual patient data: A report from the Marfan Treatment Trialists' Collaboration

Rationale

A number of randomized trials are underway, which will address the effects of angiotensin receptor blockers (ARBs) on aortic root enlargement and a range of other end points in patients with Marfan syndrome. If individual participant data from these trials were to be combined, a meta-analysis of the resulting data, totaling approximately 2,300 patients, would allow estimation across a number of trials of the treatment effects both of ARB therapy and of β-blockade.

Such an analysis would also allow estimation of treatment effects in particular subgroups of patients on a range of end points of interest and would allow a more powerful estimate of the effects of these treatments on a composite end point of several clinical outcomes than would be available from any individual trial.

Design

A prospective, collaborative meta-analysis based on individual patient data from all randomized trials in Marfan syndrome of (i) ARBs versus placebo (or open-label control) and (ii) ARBs versus β-blockers will be performed.

A prospective study design, in which the principal hypotheses, trial eligibility criteria, analyses, and methods are specified in advance of the unblinding of the component trials, will help to limit bias owing to data-dependent emphasis on the results of particular trials. The use of individual patient data will allow for analysis of the effects of ARBs in particular patient subgroups and for time-to-event analysis for clinical outcomes.

The meta-analysis protocol summarized in this report was written on behalf of the Marfan Treatment Trialists' Collaboration and finalized in late 2012, without foreknowledge of the results of any component trial, and will be made available online (http://www.ctsu.ox.ac.uk/research/meta-trials).

No Evidence of Human Leukocyte Antigen Gene Association With Rheumatic Fever Among Children in Samoa

Human leukocyte antigens (HLAs) have been implicated in rheumatic fever pathogenesis. This pilot whole genome association study compares genotypes of Samoan children with rheumatic fever to unaffected siblings and unrelated healthy controls. No risk-related genotypes were associated with HLA genes. Thirteen Regions of Interest were identified as candidates for further study.

Anomalous origin and interarterial course of right coronary artery associated with angina and proven ischemia

Clinical significance of coronary arteries with anomalous origin and/or course is highly heterogeneous. Anomalies with the origin from the opposite sinus and interarterial course can be associated with angina, syncope, and sudden cardiac death. However, there are no clear guidelines for diagnosis and treatment of such cases. We present the case of a young lady who presented with typical angina, and later proved to have an anomalous right coronary artery (RCA) originating from the left sinus of Valsalva coursing between the aorta and pulmonary artery. This was associated with demonstrable stress ischemia with nuclear perfusion scan. The patient underwent surgery with a bypass graft to the anomalous RCA with complete relief of her angina.

A prospective, randomized, placebo-controlled, double-blind, multicenter study of the effects of irbesartan on aortic dilatation in Marfan syndrome (AIMS trial): study protocol

BACKGROUND

Cardiovascular complications are the leading cause of mortality and morbidity in Marfan syndrome (MFS), a dominantly inherited disorder caused by mutations in the gene that encodes fibrillin-1. There are approximately 18,000 patients in the UK with MFS. Current treatment includes careful follow-up, beta blockers, and prophylactic surgical intervention; however, there is no known treatment which effectively prevents the rate of aortic dilatation in MFS. Preclinical, neonatal, and pediatric studies have indicated that angiotensin receptor blockers (ARBs) may reduce the rate of aortic dilatation. This trial will investigate the effects of irbesartan on aortic dilatation in Marfan syndrome.

METHODS/DESIGN

The Aortic Irbesartan Marfan Study (AIMS) is an investigator-led, prospective, randomized, placebo-controlled, double-blind, phase III, multicenter trial. Currently, 26 centers in the UK will recruit 490 clinically confirmed MFS patients (aged ≥6 to ≤40 years) using the revised Ghent diagnostic criteria. Patients will be randomized to irbesartan or placebo. Aortic root dilatation will be measured by transthoracic echocardiography at baseline and annually thereafter. The primary outcome is the absolute change in aortic root diameter per year measured by echocardiography. The follow-up period will be a minimum of 36 months with an expected mean follow-up period of 48 months.

DISCUSSION

This is the first clinical trial to evaluate the ARB irbesartan versus placebo in reducing the rate of aortic root dilatation in MFS. Not only will this provide useful information on the safety and efficacy of ARBs in MFS, it will also provide a rationale basis for potentially lifesaving therapy for MFS patients.

TRIAL REGISTRATION

ISRCTN, 90011794.

Severe Hypokalemia Probably Associated With Sertraline Use

Objective: To report a case of ventricular fibrillation caused by severe hypokalemia probably associated with sertraline use. Case Summary: A 48-year-old male patient experienced ventricular fibrillation and cardiac arrest 2 hours after an uneventful coronary angiography procedure, which revealed normal, unobstructed coronary arteries. Blood chemistry was immediately obtained, revealing a very low potassium (K+) level of 2.44 mEq/L. Other blood electrolytes, including magnesium, ECG, and corrected QT intervals, were all within normal limits. A thorough search for an etiology of hypokalemia, including adrenal gland causes, herbal product consumption, and toxic exposure, did not reveal any identifiable cause. This led us to consider the only drug he was on—sertraline 50 mg per day—as the possible culprit. Discussion: There has been no clear identification of severe hypokalemia associated with sertraline use in the literature. However, there have been a considerable number of self-reported cases of hypokalemia in patients on sertraline therapy. Scoring according to the Naranjo adverse drug reaction scale revealed a probable relationship between severe hypokalemia and sertraline use in our patient. No clear pathogenic mechanism for the effect of sertraline on serum K equilibrium is known. However, considering the number of self-reported incidences and this case report, the effect of sertraline on serum K levels warrants consideration. Conclusions: This is the first documented case report of severe hypokalemia probably associated with sertraline use.

Individual patient data meta-analysis of beta-blockers in heart failure: rationale and design

The Beta-Blockers in Heart Failure Collaborative Group (BB-HF) was formed to obtain and analyze individual patient data from the major randomized controlled trials of beta-blockers in heart failure. Even though beta-blockers are an established treatment for heart failure, uptake is still sub-optimal. Further, the balance of efficacy and safety remains uncertain for common groups including older persons, women, those with impaired renal function and diabetes. Our aim is to provide clinicians with a thorough and definitive evidence-based assessment of these agents. We have identified 11 large randomized trials of beta-blockers versus placebo in heart failure and plan to meta-analyze the data on an individual patient level. In total, these trials have enrolled 18,630 patients. Uniquely, the BB-HF group has secured access to the individual data for all of these trials, with the participation of key investigators and pharmaceutical companies.Our principal objectives include deriving an overall estimate of efficacy for all-cause mortality and cardiovascular hospitalization. Importantly, we propose a statistically-robust sub-group assessment according to age, gender, diabetes and other key factors; analyses which are only achievable using an individual patient data meta-analysis. Further, we aim to provide an assessment of economic benefit and develop a risk model for the prognosis of patients with chronic heart failure.This paper outlines inclusion criteria, search strategies, outcome measures and planned statistical analyses.

CLINICAL TRIAL REGISTRATION INFORMATION

http://clinicaltrials.gov/ct2/show/NCT00832442.

Rates and causes of death from non-ST elevation acute coronary syndromes: ten year follow-up of the PRAIS-UK registry

BACKGROUND

Long term nationally representative mortality rates following acute coronary syndrome (ACS) admissions are lacking beyond 5 years. We report rates and causes of mortality at approximately 10 years from PRAIS-UK.

METHODS

PRAIS-UK was a prospective registry of 1046 non-ST-elevation ACS admissions to 56 UK hospitals between 1998 and 1999. 493 patients surviving to 6 months were consented to long term follow-up. We identified deaths and causes (ICD codes) via the UK central death register and examined the influence of baseline characteristics and early revascularisation procedures. A modified GRACE risk score was constructed to determine the association of baseline score with long term risk of death.

RESULTS

The mean age was 66 years and 40% were women. After a median follow-up of 11.6 years (IQR 6.3-11.9), 46% (225) of patients had died with 55% being classified as cardiovascular. In a multivariate analysis, the following variables were associated with higher mortality (hazard ratio [HR] and 95% confidence intervals [CI]): age (10 years increase) 2.14 (1.87 to 2.45), ST depression or bundle branch block (compared to normal ECG) 1.68 (1.06 to 2.67), and history of heart failure (compared to no HF) 1.81 (1.28 to 2.56). The HR for risk of death in patients who received a revascularisation procedure (versus those who did not) in the first 6 months was 0.41 (0.24 to 0.69). The mean adapted GRACE score was 99.3 ± 26.4, associated with approximately 50% mortality at 10 years.

CONCLUSIONS

Non-ST elevation ACS is associated with about 50% mortality over 10 years that may be improved by early revascularisation. Well designed long-term registries can provide key data to determine prognosis and burden of disease.

Calcineurin inhibitor treatment of intravenous immunoglobulin-resistant Kawasaki disease

OBJECTIVE

To describe the clinical course and outcome of 10 patients with Kawasaki disease (KD) treated with a calcineurin inhibitor after failing to respond to multiple therapies.

STUDY DESIGN

Demographic and clinical data were prospectively collected using standardized case report forms. T-cell phenotypes were determined by flow cytometry, and KD risk alleles in ITPKC (rs28493229), CASP3 (rs72689236), and FCGR2A (rs1801274) were genotyped.

RESULTS

Intravenous followed by oral therapy with cyclosporine (CSA) or oral tacrolimus was well tolerated and resulted in defervescence and resolution of inflammation in all 10 patients. There were no serious adverse events, and a standardized treatment protocol was developed based on our experiences with this patient population. Analysis of T-cell phenotype by flow cytometry in 2 subjects showed a decrease in circulating activated CD8(+) and CD4(+) T effector memory cells after treatment with CSA. However, suppression of regulatory T-cells was not seen, suggesting targeting of specific, proinflammatory T-cell compartments by CSA.

CONCLUSION

Treatment of refractory KD with a calcineurin inhibitor appears to be a safe and effective approach that achieves rapid control of inflammation associated with clinical improvement.

Plasminogen activator inhibitor-1 levels in patients with primary varicose vein

AIM

Plasmin is involved in extracellular matrix remodeling by activating some matrix metallo-proteinases and degrading extracellular matrix; therefore component of fibrinolytic system such as tissue plasminogen activator and plasminogen activators inhibitors (PAI-1) might have a role in the pathogenesis of vascular remodeling. In our study we aimed to investigate the levels of PAI-1 levels in patients with primary varicose veins (VV) and in their age and gender matched control group.

METHODS

Forty-one consecutive patients with peripheral varicose veins and 37 healthy age and gender-matched control subjects were included in the study from the outpatient cardiology and cardiovascular surgery clinic. Study population consisted of 41 consecutive patients who met the inclusion criteria and diagnosed as having class II primary VV according to CEAP classification. Routine biochemical and hematological analysis were performed in all patients and control subjects.

RESULTS

Plasma levels of PAI-1 were found to be lower in patients than those in control subjects (5.19±2.2 ng/mL vs. 6.47±2.6 ng/mL, P=0.025). Logistic regression analysis revealed that only the plasma levels of PAI-1 were found to be independently but inversely associated with the presence of primary VVs (Odds ratio: 0.80 CI: 0.64-0.99, P=0.04).

CONCLUSION

We have shown that PAI-1 levels are significantly decreased in patients with pVVs and it has an independent association with the presence of pVVs. However, its exact relation and role via matrix metlalloproteinases on the pathogenesis of the disease remains to be elucidated in further studies.

Motile ciliary microorganisms in peritoneal fluid

We report a patient with chronic renal failure and ciliocytophthoria or "detached ciliary tufts" identified from her peritoneal fluid. The recognition of these rare structures is critical to avoid misdiagnosing a presumed protozoan infection and embarking on further costly investigations and unnecessary treatments.

Radiological findings of community-acquired methicillin-resistant and methicillin-susceptible Staphylococcus aureus pediatric pneumonia in Hawaii

BACKGROUND

Community-acquired Staphylococcus aureus (CA-SA) infections are common among pediatric patients in Hawaii.

OBJECTIVE

We wanted to characterize the radiological features of methicillin-susceptible (CA-MSSA) and methicillin-resistant (CA-MRSA) staphylococcal pneumonia in Hawaiian children.

MATERIALS AND METHODS

We retrospectively reviewed medical records and imaging studies of children with SA pneumonia identified from 1996 through 2007.

RESULTS

Of 40 children, 26 (65%) had CA-MRSA pneumonia and 14 patients (35%) had CA-MSSA pneumonia. CA-MRSA patients were significantly younger than CA-MSSA patients (65% younger than 1 year vs. 36% older). In a majority (62%) of CA-MRSA patients, the consolidation was unilateral; in most of the CA-MSSA cases (79%), the consolidation was bilateral. Fifty percent of the patients with CA-MRSA and 21% of those with CA-MSSA had pneumatoceles (P = 0.1). CA-MRSA patients more commonly had pleural effusions (85% vs. 64% for CA-MSSA) and pleural thickening (50% vs. 36% for CA-MSSA).

CONCLUSION

This case series describes the radiologic characteristics of CA-MRSA and CA-MSSA pneumonia in children in a highly endemic area. We found that CA-MRSA pneumonias are unilateral in a majority of pediatric pneumonia cases, are more common in children 1 year or younger, and have higher rates of complications in comparison to CA-MSSA patients.

Priming the immune system for heart disease: a perspective on group A streptococci

Although immune responses against group A streptococci and the heart have been correlated with antibodies and T cell responses against cardiac myosin, there is no unifying hypothesis about carditis caused globally by many different serotypes. Our study identified disease-specific epitopes of human cardiac myosin in the development of rheumatic carditis in humans. We found that immune responses to cardiac myosin were similar in rheumatic carditis among a small sample of worldwide populations, in which immunoglobulin G targeted human cardiac myosin epitopes in the S2 subfragment hinge region within S2 peptides containing amino acid residues 842-992 and 1164-1272. An analysis of rheumatic carditis in a Pacific Islander family confirmed the presence of potential rheumatogenic epitopes in the S2 region of human cardiac myosin. Our report suggests that cardiac myosin epitopes in rheumatic carditis target the S2 region of cardiac myosin and are similar among populations with rheumatic carditis worldwide, regardless of the infecting group A streptococcal M serotype.