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A patient in Pennsylvania, USA, with common variable immunodeficiency sought care for fever, cough, and abdominal pain. Imaging revealed lesions involving multiple organs. Liver resection demonstrated necrotizing granulomas, recognizable tegument, and calcareous corpuscles indicative of an invasive cestode infection. Sequencing revealed 98% identity to a Versteria species of cestode found in mink.

Background Herpes simplex virus (HSV) is the most common cause of infectious encephalitis in the United States. While early treatment with acyclovir has improved acute management, long-term morbidity and mortality remain high and warrant further characterization. Methods We retrospectively identified adult patients (≥18 years) with HSE admitted to the Cleveland Clinic Main Campus and affiliated regional hospitals from April 2006 to June 2016. HSE diagnosis was concordant with Infectious Disease Society of America Encephalitis Guidelines. HSE diagnosis was confirmed in that HSV-1 DNA was detected in cerebrospinal fluid (CSF) by polymerase chain reaction (PCR) assay for all patients included in this study. Patients for which HSV-2 was detected in the CSF were excluded to avoid inclusion of HSV meningitis. Clinical information was collected in a REDCap database and analyzed by descriptive statistics. Patients were indexed at the date of admission, and Kaplan–Meier analysis was used to estimate overall survival. Results We identified 32 patients with confirmed HSE. The median patient age was 62 years (interquartile range [IQR] 45–72). All patients received treatment with intravenous (IV) acyclovir, with a median treatment duration of 24 days (IQR 19–30). The median time from initial symptom onset to IV acyclovir treatment was 5 days (IQR 3–8). Three patients (9%) died during the hospitalization course, 16 (50%) were discharged to a nursing facility, 11 (35%) returned home, and two (6%) transitioned to an acute care facility (Figure 1). Within three months of discharge, 15 (47%) patients were readmitted, six (19%) of which readmitted for HSE relapse. The overall survival rate at one month was 84% and 74% at 12 months (Figure 2). At outpatient follow-up, cognitive deficits were self-reported by 19 (66%) patients, followed in frequency by motor (31%) and sensory deficits (7%). Conclusion Despite appropriate treatment with IV acyclovir, HSE survivors frequently experienced severe morbidities after initial hospitalization, including HSE relapse, discharge to long-term care facilities, and neurocognitive impairment. Risk of death was highest within one month of admission. Further investigation is needed to optimize treatment of HSE to improve mortality and to reduce permanent neurologic deficits. Disclosures All Authors: No reported Disclosures.

Background A 68-year-old woman with hypogammaglobulinemia and prior treated lymphoma presented with fever and abdominal pain. Evaluation revealed numerous nodules in the lung, eye, brain, and liver (Figure 1). Initial lung and liver biopsies showed necrotizing granulomas with no organisms and negative serology and cultures. After progression while on broad-spectrum antibiotics for 4 months, an open liver biopsy revealed numerous nodular lesions and a mass made up of multifocal coalescing cystic lesions. The mass consisted of a degenerating 3-layered membrane without scoleces characterized by a wavy protuberant ciliated eosinophilic outer layer, subjacent degenerating cells with pyknotic nuclei, and loose connective tissue suggestive of a bladder wall and calcareous corpuscles in a matrix of granulomatous inflammation with areas of necrosis (Figure 2). This was diagnostic of disseminated metacestodes (larval stage) of a cestode (tapeworm). Treatment with praziquantel and albendazole led to improvement of symptoms and lesions. Disseminated cestode infections other than due to Echinococcus species are rare in humans. Sequencing was pursued due to the unusual findings. Methods DNA was extracted from liver tissue followed by targeted amplification of the cestode COX1 gene. PCR products confirmed to be 134 bp, as expected for a cestode COX1 gene, then inserted into a 2.1 Topo vector and cloned. Five separate isolates were sequenced, and 4 were interpretable. The 129-bp consensus sequence is shown in Figure 3. Basic Local Alignment Search Tool (NCBI BLAST) was used to find highly similar sequences. Results The sequence matched to Versteria sp. (T. mustelae) COX1 gene from a mink in Oregon (accession KT223034) with 98% identity. Conclusion Metacestodes have the propensity to proliferate and rarely disseminate. There is one reported case of Versteria sp. causing a lethal disseminated infection of an orangutan. This is the first report of a Versteria sp. disseminated infection in a human and is singular because the patient survived. The patient likely accidentally ingested ova shed from a tapeworm in a mink or similar mammalian host. Histopathologic assessment is crucial in diagnosing cestode infection. COX1 gene sequencing is useful for cestode identification. Disclosures All authors: No reported disclosures.

Aminoglycosides are a mainstay of treatment for enterococcal infective endocarditis. However, the benefit of adding aminoglycosides to cell wall-active agents after surgery is unclear. The aim of this study was to determine if adjunctive aminoglycoside treatment after surgery for enterococcal endocarditis leads to better outcomes. We included patients who underwent surgery for enterococcal endocarditis at our institution between July 2007 and July 2014. Treatment was defined as at least 1 dose of an aminoglycoside after surgery. Propensity to receive aminoglycosides was calculated in a model that included age, native vs prosthetic valve endocarditis, chronic kidney disease, high-level aminoglycoside resistance, metastatic infection, invasive disease, positive valve culture, and creatinine on the day of surgery. A multivariable Cox proportional hazards model was used to compare the primary outcome of death, adjusted for propensity to receive aminoglycosides, among patients who did and did not receive aminoglycosides. A total of 108 patients were identified of whom 37 (34%) received at least 1 dose of an aminoglycoside after surgery, with a median duration of 5 days (interquartile range: 2.5-10). In the multivariable model, patients treated with adjunctive aminoglycoside therapy had better survival than those treated with a cell wall-active agent alone, although the difference did not reach statistical significance (hazard ratio = 0.65, 95% CI: 0.32-1.33). The survival difference was consistently present in subgroups stratified by all-purpose refined diagnosis-related group mortality risk, and with varying definitions of aminoglycoside therapy. In conclusion, antibiotic monotherapy with a cell wall-active agent after surgery for enterococcal endocarditis may be inferior to combination therapy including an aminoglycoside.