Strongyloides stercoralis is an intestinal nematode that can persist in the human host for decades after the initial infection and can progress to fulminant hyperinfection syndrome in immunocompromised hosts. We describe a patient who died of Strongyloides hyperinfection syndrome 2 months after orthotopic heart transplantation and discuss approaches to prevention, diagnosis, and treatment. Current practice guidelines recommend screening for and treatment of Strongyloides infection before transplantation, but physicians in the United States often miss opportunities to identify patients with chronic strongyloidiasis. Screening tests have limitations, and clinical suspicion remains an important component of the evaluation before transplantation. After immunocompromised patients develop hyperinfection syndrome, diagnosis is often delayed and mortality is high, so emphasis must be placed on screening and treatment before transplantation. We review current strategies for prevention, diagnosis, and treatment of chronic intestinal strongyloidiasis in patients who will undergo transplantation and discuss the clinical features and management of Strongyloides hyperinfection syndrome in transplant recipients.

IMPORTANCE Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused epidemic spread of coronavirus disease 2019 in the Seattle, Washington, metropolitan area, with morbidity and mortality concentrated among residents of skilled nursing facilities. The prevalence of COVID-19 among older adults in independent/assisted living is not understood.OBJECTIVES To conduct surveillance for SARS-CoV-2 and describe symptoms of COVID-19 among residents and staff of an independent/assisted living community. DESIGN, SETTING, AND PARTICIPANTSIn March 2020, public health surveillance of staff and residents was conducted on site at an assisted and independent living residence for older adults in Seattle, Washington, after exposure to 2 residents who were hospitalized with COVID-19.EXPOSURES Surveillance for SARS-CoV-2 infection in a congregate setting implementing social isolation and infection prevention protocols.MAIN OUTCOMES AND MEASURES SARS-CoV-2 real-time polymerase chain reaction was performed on nasopharyngeal swabs from residents and staff; a symptom questionnaire was completed assessing fever, cough, and other symptoms for the preceding 14 days. Residents were retested for SARS-CoV-2 7 days after initial screening. RESULTSTesting was performed on 80 residents; 62 were women (77%), with mean age of 86 (range, 69-102) years. SARS-CoV-2 was detected in 3 of 80 residents (3.8%); none felt ill, 1 male resident reported resolved cough and 1 loose stool during the preceding 14 days. Virus was also detected in 2 of 62 staff (3.2%); both were symptomatic. One week later, resident SARS-CoV-2 testing was repeated and 1 new infection detected (asymptomatic). All residents remained in isolation and were clinically stable 14 days after the second test.CONCLUSIONS AND RELEVANCE Detection of SARS-CoV-2 in asymptomatic residents highlights challenges in protecting older adults living in congregate settings. In this study, symptom screening failed to identify residents with infections and all 4 residents with SARS-CoV-2 remained asymptomatic after 14 days. Although 1 asymptomatic infection was found on retesting, a widespread facility outbreak was avoided. Compared with skilled nursing settings, in assisted/independent living communities, early surveillance to identify asymptomatic persons among residents and staff, in combination with adherence to recommended preventive strategies, may reduce viral spread.

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Breast milk CMV levels and maternal CD4 count are major determinants of CMV transmission in the setting of maternal HIV-1. Maternal immune reconstitution or lowering breast milk CMV levels may reduce vertical CMV transmission.

BackgroundStudies in HIV-1-infected infants and HIV-1-exposed, uninfected infants link early cytomegalovirus (CMV) acquisition with growth delay and cognitive impairment. We investigated maternal valacyclovir to delay infant acquisition of CMV.MethodsPregnant women with HIV-1, HSV-2 and CD4 count >250 cells/µl were randomized at 34 weeks gestation to 500 mg twice-daily valacyclovir or placebo for 12 months. Maternal CMV DNA was measured in plasma at 34 weeks gestation, in cervical secretions at 34 and 38 weeks gestation, and in breast milk at 7 postpartum timepoints; infant CMV DNA was measured in dried blood spots at 8 timepoints including birth.ResultsAmong 148 women, 141 infants were compared in intent-to-treat analyses. Maternal and infant characteristics were similar between study arms. Infant CMV acquisition did not differ between study arms, with 46/70 infants (66%) in placebo arm and 47/71 infants (66%) in the valacyclovir arm acquiring CMV; median time to CMV detection did not differ. CMV DNA was detected in 92% of 542 breast milk specimens with no difference in CMV level between study arms. Change in cervical shedding of CMV DNA between baseline and 38 weeks was 0.40-log greater in the placebo arm than the valacyclovir arm (p = 0.05).ConclusionsIn this cohort of HIV-1-seropositive mothers, two-thirds of infants acquired CMV by one year. Maternal valacyclovir had no effect on timing of infant CMV acquisition or breast milk CMV viral loads, although it modestly reduced cervical CMV shedding. Maternal prophylaxis to reduce infant CMV acquisition warrants further evaluation in trials with antiviral agents.Trials RegistrationClinicalTrials.gov NCT00530777

Background Depot-medroxyprogesterone acetate (DMPA) is associated with HIV acquisition. We studied changes in vaginal microbiota and inflammatory milieu after DMPA initiation. Methods In a cohort of HIV-negative Kenyan women, we collected monthly vaginal swabs over 1 year pre- and post-DMPA. Using quantitative PCR, we compared quantities of Lactobacillus crispatus, L. jensenii, L. iners, Gardnerella vaginalis, and total bacterial load (16S rRNA gene levels). Six vaginal immune mediators were measured with ELISA. Trends in detection and quantity of bacteria were estimated by logistic and linear mixed-effects regression. Results From 2010-2012, 15 HIV-seronegative women initiated DMPA, contributing 85 visits (median 6 visits/woman (range 3-8)). The median time of DMPA-exposed follow-up was 8.4 months (range 1.5-11.6). Seven women (46%) had bacterial vaginosis (BV) within 70 days before DMPA start. Lactobacillus iners was detected in 13 women (87%) prior to DMPA start, but other lactobacilli were rarely detected. Gardnerella vaginalis declined by 0.21 log10 copies/swab per month after DMPA exposure (p=0.01). Total bacterial load declined by 0.08 log10 copies/swab per month of DMPA (p=0.02). Sustained declines in interleukin (IL)-6 (p=0.03), IL-8 (p=0.04) and IL-1 receptor antagonist (p<0.001) were also noted. Nine women (60%) had L. crispatus detected post-DMPA; which was significantly correlated with reduced IL-6 (p=<0.01) and IL-8 (p=0.02). Conclusion Initiation of DMPA led to sustained shifts in vaginal bacterial concentrations and levels of inflammatory mediators. Further studies are warranted to outline components of the vaginal microbiota influenced by DMPA use, and impact on HIV susceptibility.

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We found a low prevalence of SARS-CoV-2 (2.7% [5/188]) among pregnant and postpartum patients after initiating universal testing. Prevalence among symptomatic patients (22.2% [4/18]) was similar to initial targeted screening approaches (19.1% [8/42]). Among 170 asymptomatic patients, two were positive or inconclusive, respectively; repeat testing at 24 hours was negative.