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Strongyloides stercoralis is a soil transmitted helminth endemic to tropical and subtropical areas that can persist for decades in immunocompetent human hosts as a chronic asymptomatic infection. The use of corticosteroids, a mainstay of treatment for patients hospitalized with severe coronavirus disease (COVID-19), can trigger a life-threatening Strongyloides hyperinfection syndrome and disseminated disease. We identified 22 previously published cases of strongyloidiasis occurring in individuals with COVID-19, with one death reported among the seven patients who had Strongyloides hyperinfection syndrome. A total of seventeen patients had previously received corticosteroids, and of the five with no prior corticosteroid use, one presented with hyperinfection syndrome. We identify the key challenges in the diagnosis and treatment of Strongyloides within the context of COVID-19, including our imprecise knowledge of the global distribution of Strongyloides, the overlapping symptoms and signs of COVID-19 and Strongyloides hyperinfection syndrome, the limited utility of eosinophilia as a clinical marker for strongyloidiasis in this setting, the lack of validated algorithms to screen for Strongyloides prior to corticosteroid use, and the paucity of treatment options for critically ill patients with COVID-19 who cannot take oral ivermectin. Future research should focus on improved diagnostic methods and population prevalence estimates, optimizing the approaches for Strongyloides screening in persons with COVID-19 (including clinical trial participants and strategies for resource-limited settings) and better defining the role of pre-emptive treatment.

Using the incidence of bacterial sexually transmitted infection (STI) as a surrogate for condomless sexual behavior, we assessed the association between STI and uncontrolled HIV replication among in-care persons with HIV (PWH) enrolled in a longitudinal HIV cohort study in the District of Columbia (the DC Cohort). Although STI occurrence initially correlated with higher HIV viral load (VL), this difference became more attenuated over time (2012-2016). This was true overall and among those with the greatest number of STIs [age 18-34, men who have sex with men (MSM)]. This likely reflects gains in population-wide virologic control through improved antiretroviral therapy and access to care, which helps mitigate the risk of HIV transmission.

OBJECTIVES: To describe the demographics, clinical characteristics, and outcomes of hospitalized adults with coronavirus disease 2019 (COVID-19) in an academic medical center in the southern United States. METHODS: Retrospective, observational cohort study of all adult patients (18 years and older) consecutively admitted with laboratory-confirmed severe acute respiratory syndrome-coronavirus-2 infection between March 13 and April 25, 2020 at the University of Mississippi Medical Center. All of the patients either survived to hospital discharge or died during hospitalization. Demographics, body mass index, comorbidities, clinical manifestations, and laboratory findings were collected. Patient outcomes (need for invasive mechanical ventilation and in-hospital death) were analyzed. RESULTS: One hundred patients were included, 53% of whom were women. Median age was 59 years (interquartile range 44-70) and 66% were younger than 65. Seventy-five percent identified themselves as Black, despite representing 58% of hospitalized patients at our institution in 2019. Common comorbid conditions included hypertension (68%), obesity (65%), and diabetes mellitus (31%). Frequent clinical manifestations included shortness of breath (76%), cough (75%), and fever (64%). Symptoms were present for a median of 7 days (interquartile range 4-7) on presentation. Twenty-four percent of patients required mechanical ventilation and, overall, 19% died (67% of those requiring mechanical ventilation). Eighty-four percent of those who died were Black. On multivariate analysis, ever smoking (odds ratio [OR] 5.9, 95% confidence interval [CI] 1.2-28.6) and history of diabetes mellitus (OR 5.9, 95% CI 1.5-24.3) were associated with mortality, and those admitted from home were less likely to die (vs outside facility, OR 0.2, 95% CI 0.0-0.7). Neither age, sex, race, body mass index, insurance status, nor rural residence was independently associated with mortality. CONCLUSIONS: Our study adds evidence that Black patients appear to be overrepresented in those hospitalized with and those who die from COVID-19, likely a manifestation of adverse social determinants of health. These findings should help guide preventive interventions targeting groups at higher risk of acquiring and developing severe COVID-19 disease.

ObjectiveA rise in incidence of STIs has been noted in the USA and in the District of Columbia (DC). We aim to describe changes in incident STIs among persons in care for HIV in Washington, DC as well as trends in HIV viral load among those with incident STIs.MethodsWe conducted a retrospective DC Cohort analysis (n=7810) measuring STI incidence (syphilis, gonorrhoea and chlamydia) as well as incare viral load (ICVL) and percentage with all viral loads less than the limit of detection (%ResultsFrom 2012 to 2016, the incidence of STIs increased: chlamydia from 2.1 to 3.4 cases/100 person-years (p=0.0006), gonorrhoea from 2.1 to 4.0 (pConclusionsRates of incident STIs rose among persons in care for HIV in Washington, DC, with improved but not optimal measures of HIV viral suppression. These findings inform focused interventions towards preventing STI transmission and ending the HIV epidemic.

Background The Undetectable = Untransmittable (U = U) campaign advances the goal of ending the HIV epidemic by promoting durable viral suppression and therefore reducing sexual transmission. We used geospatial analysis to assess the potential for sexual HIV transmission by ZIP code of residence in the District of Columbia (DC) using data from the DC Cohort Longitudinal HIV Study (DC Cohort), a city-wide cohort of persons with HIV (PWH). Methods DC Cohort participants aged ≥13 years were included in the study period between April 1, 2016, and March 31, 2018. Potential for sexual HIV transmission was defined as the proportion of participants with incident sexually transmitted infection (STI; gonorrhea, chlamydia, syphilis) and with HIV RNA ≥200 copies/mL from 9 months before to 3 months after STI diagnosis. We performed geographic information system (GIS) analysis to determine the ZIP codes with the highest potential for sexual HIV transmission. Results Of 3467 participants, 367 (10.6%) had at least 1 incident STI, with 89.4% residing in 11 of the 20 residential ZIP codes in DC. Of the 367 participants with an incident STI, at least 1 HIV RNA was available for 348 (94.8%). Ninety-seven (27.9%) individuals with an incident STI had HIV RNA ≥200 copies/mL in the defined time window. Of these 97, 66 (68.0%) resided in 5 of the 20 DC ZIP codes. Conclusions In DC, 5 ZIP codes of residence accounted for the majority of the estimated potential for HIV transmission among participants in the DC Cohort. These results support focused neighborhood-level interventions to help end the HIV epidemic.

We observed a higher rate of blood-culture contamination during the COVID-19 pandemic at our institution compared to a prepandemic period. Given the potential implications of blood contamination in antibiotic and diagnostic test utilization as well as added cost, it is imperative to continue efforts to minimize these episodes during the pandemic.

Highlights • There is ongoing concern about airborne transmission of Coronavirus disease 2019 • Transmission from infected individuals without symptoms has been reported • Healthcare workers were exposed to an asymptomatic patient during prolonged surgery • None developed COVID-19 despite not wearing respirator masks • Additional research needed to better understand perioperative transmission risk, There is ongoing debate regarding the role of aerosols in the transmission of SARS-CoV2 in the healthcare environment. Here we report a case in which multiple operating room healthcare providers were exposed to a patient with asymptomatic SARS-CoV2 infection during a prolonged orthopedic surgical intervention and had no evidence of COVID-19 during the 14-day post-exposure period.

Background Washington, DC, has one of the highest rates of HIV infection in the United States. Sexual intercourse is the leading mode of HIV transmission, and sexually transmitted infections (STIs) are a risk factor for HIV acquisition and transmission. Methods We evaluated the incidence and demographic factors associated with chlamydia, gonorrhea, and syphilis among HIV-infected persons enrolled at 13 DC Cohort sites from 2011 to 2015. Using Poisson regression, we assessed covariates of risk for incident STIs. We also examined HIV viral loads (VLs) at the time of STI diagnosis as a proxy for HIV transmission risk. Results Six point seven percent (451/6672) developed an incident STI during a median follow-up of 32.5 months (4% chlamydia, 3% gonorrhea, 2% syphilis); 30% of participants had 2 or more STI episodes. The incidence rate of any STIs was 3.8 cases per 100 person-years (95% confidence interval [CI], 3.5–4.1); age 18–34 years, 10.8 (95% CI, 9.7–12.0); transgender women, 9.9 (95% CI, 6.9–14.0); Hispanics, 9.2 (95% CI, 7.2–11.8); and men who have sex with men (MSM), 7.7 (95% CI, 7.1–8.4). Multivariate Poisson regression showed younger age, Hispanic ethnicity, MSM risk, and higher nadir CD4 counts to be strongly associated with STIs. Among those with an STI, 41.8% had a detectable VL within 1 month of STI diagnosis, and 14.6% had a VL ≥1500 copies/mL. Conclusions STIs are highly prevalent among HIV-infected persons receiving care in DC. HIV transmission risk is considerable at the time of STI diagnosis. Interventions toward risk reduction, antiretroviral therapy adherence, and HIV virologic suppression are critical at the time of STI evaluation.

Necrotizing fasciitis is a deep-seated subcutaneous tissue infection that is commonly associated with streptococcal toxic shock syndrome (TSS). Surgical debridement plus penicillin and clindamycin are the current standard of care. We report a case of necrotizing fasciitis and streptococcal TSS where linezolid was added after a failure to improve with standard therapy. Briefly after isolation of Streptococcus pyogenes from tissue cultures, the patient underwent two surgical debridement procedures and was changed to standard of care therapy. While the patient was hemodynamically stable, the patient’s wounds, leukocytosis, and thrombocytopenia all progressively worsened. After initiation of linezolid, the patient slowly improved clinically. The present report is the first to highlight the role of linezolid in streptococcal necrotizing fasciitis and TSS not improving with standard therapy.

The presentation of anaplastic lymphoma kinase protein (ALK)-negative anaplastic large cell lymphoma (ALCL) in bone is rare. We describe a patient with ALK-negative ALCL presenting with clinical and radiographic findings suggesting osteomyelitis 6 months after left rotator cuff repair surgery. A review of the characteristics of ALK-negative ALCL with primary bone involvement is presented. ALCL should be considered in patients not responding to therapies for osteomyelitis.

Background The District of Columbia (DC) has one of the highest HIV infection rates among metropolitan areas in the United States, as well as recent increases in the incidence of sexually transmitted infections (STI), particularly among men who have sex with men (MSM). A previous study of the DCCohort, (a longitudinal observational cohort of HIV-infected persons receiving care in DC, identified a disconcertingly high incidence of detectable HIV viral load (VL) close to the time of STI occurrence. Studies have identified time spent with HIV VL above 1,500 copies/mL as a proxy measure for risk of sexual transmission of HIV. The present study examines percentage of time with VL above 1,500 among persons living with HIV infection (PLWH) with incident STI. Methods We conducted a retrospective cohort analysis measuring STI incidence (including syphilis, gonorrhea, chlamydia) among all individuals enrolled in the DC Cohort from 2011 to 2015. We conducted descriptive analysis to estimate the number of days with HIV VL >1,500 copies/mL, relative to the total number of days of observation, among those with an incident STI during the same observation period. Results We analyzed data for 5,033 DC Cohort enrollees for whom STI data and at least two VL observations were available. During a median observation of 32.8 months, 4,610 individuals had no STI and 423 (8%) individuals had any incident STI; 293 had one and 130 had two or more. Of the 423 participants with an incident STI, 67.8% did not spend any time with a VL >1,500; 10.7% had VL >1,500 during > 0 to < 25% of the time; 7.3% had VL >1,500 during 25 to < 50% of the time; 5.0% had VL >1,500 during 50 to < 75% of the time; and 9.2% of participants with any incident STI had VL >1,500 during 75–100% of the time. Among participants with two or more STIs over the observation period, 17.7% spent greater than 50% of the time with a viral load >1,500. Conclusion Among PLWH with incident STIs, as many as one-third spent considerable time with a VL >1,500 copies/mL, placing them at increased risk of transmitting HIV to others. Public health interventions need to focus on mitigating the risk of HIV transmission in the highest-risk populations, while also seeking to reduce overall incidence of other STIs. Disclosures All authors: No reported disclosures.