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A 24-year-old Caucasian woman with a history of intravenous drug abuse and multiple hospital admissions for substance abuse related medical problems presented with pneumonia and was discharged home on oral antibiotics. Three days later, her blood culture grew acid fast bacilli, which was subsequently identified as M. abscessus subspecies abscessus. Transthoracic and transesophageal echocardiogram (TTE and TEE respectively) was suggestive of tricuspid valve (TV) endocarditis. CT scan of the chest showed evidence of septic pulmonary emboli, pneumonic consolidation and pleural effusion requiring chest tube placement. BAL and blood cultures grew Mycobacterium abscessus while pleural fluid cultures remained sterile. She was treated with a combination antibiotic therapy and completed a six-week course with resolution of her symptoms and microbiological cure. We present this rare case of M. abscessus native tricuspid valve endocarditis associated with lung infection treated with a short course of combination antibiotic therapy.

BackgroundHepatitis C virus (HCV) is an important cause of chronic hepatitis resulting in end stage liver disease and hepatocellular carcinoma. Direct acting antivirals (DAAs) interfere with the HCV lifecycle and result in high rates of sustained virologic response (SVR). We hypothesized that treatment with DAAs in a real world setting is as successful in HCV/HIV coinfected patients as it is in HCV monoinfected patients, and that some degree of fibrosis regression can be observed after completion of therapy in both groups.MethodsWe retrospectively reviewed data from patients who received treatment for HCV from 2014 to 2016 at the Infectious Diseases clinic and collected demographic characteristics, HCV genotype and viral load, DAA regimen, SVR rates, and whether or not fibrosis improved at 12 or 24 weeks after treatment completion defined as one METAVIR stage improvement in FibroSURE™ score to estimate fibrosis. In those with HIV, HIV viral load, CD4 count and HIV antiretroviral regimen were examined.ResultsOut of 41 patients in each group, 24 had completed therapy in the monoinfected group and 26 in the coinfected group. In the monoinfected group, 22 (92%) achieved SVR. In the coinfected group, 26 (100%) achieved SVR. The SVR rates of the monoinfected group and coinfected group did not differ significantly (P = .956). In the monoinfected group, 10/17 (59%) had an improvement in FibroSURE™ score, and 7/17 (41%) had no change. In the coinfected group, 2/9 (22.2%) patients demonstrated an improvement in FibroSURE™ score, 4/9 (44.4%) had no change, and 3/9 (33%) had an increase in FibroSURE™ score. There was no significant difference in the change in FibroSURE™ score before and after SVR between the two groups (P = .100).ConclusionIn this small study, although not statistically significant, coinfected patients treated with DAAs had higher SVR rates than monoinfected patients. Treatment failure in the monoinfected group was linked to nonadherence, whereas, success of the coinfected patients was likely related to engagement in routine HIV care. Although not statistically significant, there were more patients in the monoinfected group that had an improvement in FibroSURE™ score, however the small sample size precludes any definitive conclusions.Disclosures P. P. Cook, Merck: Speaker’s Bureau, Grant recipient; Pfizer: Shareholder, Grant recipient; Gilead: Clinical Trials, Grant recipient; D. Siraj, Gilead: Speaker’s Bureau, Grant recipient

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Background: Hepatitis C virus (HCV) is an important cause of chronic hepatitis with necroinflammation and fibrosis resulting in end stage liver disease and hepatocellular carcinoma. Direct acting antivirals (DAAs) are newer agents that directly interfere with the HCV lifecycle and result in high rates of sustained virologic response (SVR). We evaluated if treatment with DAAs in a real-world setting is as successful in HCV/HIV coinfected patients as it is in HCV monoinfected patients, and if some degree of fibrosis regression can be observed after completion of therapy in both groups. Methods: We retrospectively reviewed data from HCV monoinfected and HCV/HIV coinfected patients who received treatment from 2014-2016 at the East Carolina University Infectious Diseases clinic. The primary outcome was to compare completion and sustained virologic response (SVR) rate at either 12 or 24 weeks between HCV monoinfected patients and HCV/HIV coinfected patients. The secondary outcome was to assess regression of fibrosis at either 12 or 24 weeks after completion of therapy, defined as one METAVIR stage improvement in their FibroSure™, a noninvasive biochemical test to estimate the stage of fibrosis. Results: There were 41 patients in each group. Compared to the coinfected group, patient no show rate was higher in the monoinfected group (p=0.0346). In the HCV monoinfected group, 25 (93%) achieved either SVR 12 or 24. Two patients were non-compliant and had detectable viral load on evaluation at week 12. In the HCV/HIV coinfected group, 37 patients achieved SVR (p=0.0039). One patient in the coinfected group did not complete therapy but achieved SVR. In terms of fibrosis, 12/18 (67%) in the monoinfected group demonstrated improvement in at least 1 Metavir stage and 6/18 (33%) had no change. In the coinfected group, 8/16 (50%) patients demonstrated an improvement in FibroSure™ stage, 5/16 (31%) had no change, and 3/16 (19%) had worsening fibrosis according to FibroSure™ stage, (p=0.4867). Conclusions: In this small, real-world cohort, HCV/HIV coinfected patients treated with DAAs had higher completion and SVR rates than HCV monoinfected patients. Treatment failures in the monoinfected group were all linked to non-adherence, whereas, more coinfected patients achieved SVR, likely related to the fact that they were regularly engaged in routine HIV care. Fibrosis regression based on FibroSure™ was observed more in monoinfected patients than those with coinfection. Although not statistically significant, at least 50% of the patients in each group had regression of fibrosis.

BackgroundInfective endocarditis of the native heart valves due to M. abscessus has been reported in individuals who inject drugs. Only one case thus far has been reported with survival beyond 4 months after completion of antibiotic therapy. 24-year-old Caucasian woman with a history of intravenous drug use presented with intermittent fevers for 3–4 months. She was having chills, night sweats, and productive cough. She acknowledged using intravenous cocaine and heroin every few days after being discharged from our hospital 6 months previously when she was treated for tricuspid valve endocarditis. Chest radiograph demonstrated right lower lobe airspace disease suggestive of pneumonia. Three days later her blood cultures grew acid-fast bacilli, later identified as M. abscessus.MethodsShe was empirically treated with azithromycin, amikacin, and imipenem. Transthoracic and transesophageal echocardiograms were suggestive of tricuspid valve endocarditis. CT angiogram of the chest showed filling defects within several large right lower lobe pulmonary arteries and dense right lower lobe consolidation with pleural effusion. The patient underwent bronchoscopy with bronchoalveolar lavage (BAL) and therapeutic thoracoscopy with drainage and thoracostomy tube placement. BAL cultures also grew AFB. Multiple sets of blood cultures drawn after commencement of antibiotic therapy during the hospital course were negative. Drug susceptibilities were available 3 weeks later. The isolate was susceptible to amikacin. Linezolid, imipenem, and cefoxitin exhibited intermediate activity, and TMP/SMX, ciprofloxacin, moxifloxacin, doxycycline, minocycline, and clarithromycin were reported resistant. Inducible erm gene was present. Azithromycin and linezolid were discontinued and tigecycline was added.ResultsPatient completed 6 weeks of antibiotics from the day of the first negative blood culture. Repeat TTE 1 month after completion of therapy revealed a decrease in tricuspid valve vegetation. Blood culture done 3 months later was sterile. AFB blood cultures done a year later did not report any growth.ConclusionThis case opens a debate, if in a selected group of patients, a short course of combination antibiotic therapy is enough to obtain cure. This will require further analysis. Disclosures All authors: No reported disclosures.

Background With HIV therapy, the life expectancy of persons with HIV (PWH) has improved and complications associated with long-standing HIV and antiretroviral drugs have become more apparent. Low bone mineral density (BMD) (defined by T score < -1) and osteoporosis (defined by T-score < -2.5) are common in PWH. In a meta-analysis of 884 HIV-infected patients, 67% had reduced BMD, of whom 15% had osteoporosis which is 3 times greater than HIV uninfected controls. IDSA guidelines recommend routine screening for osteoporosis in PWH aged ≥ 50 years, yet the rate of screening for osteoporosis in these patients remains low (7.4%-17%). This QI project aimed to estimate the frequency of and identify the barriers to screening for osteoporosis in eligible HIV patients. Methods This prospective observational study was conducted in the HIV clinic at East Carolina University from 2018-2019. A sample of 104 HIV patients, ≥ 50 years were selected randomly. Data regarding referral for DXA (dual X-ray absorptiometry) scan, its results, and their insurance provider was collected. The plan was to analyze the barriers associated with guideline-recommended BMD screening and implement it in eligible patients. Results From a total of 104, 89 patients (85.6%) were referred for a DXA scan. The reasons for lack of referral were obesity, insurance barrier, wheelchair-bound, and test ordered by another provider. Of the 89 patients referred for DXA, only 49 (47% of total) underwent the scan. In terms of barriers, insurance limitation was the most common reason. Out of the patients that had DXA scans, 19 (39%) were found to have low bone density and 1 had osteoporosis. Low BMD was more common in men (63%) as compared to women (37%) in this group. Percentage of patients who underwent a DXA scan and the barriers in those who didn’t Frequency of BMD screening Incidence of Low BMD BMD results Conclusion In our study, 47% of patients had a BMD assessment. This is better than what has been reported in other single-center studies, however, it is not ideal. About 34% of the patients had insurance coverage as the major barrier for routine screening, as has been mentioned in other similar studies. Of the patients who underwent the DXA scan, 41 % had a low BMD. Other studies have reported variable prevalence of abnormal BMD, from 47-93%. Interestingly, the prevalence of low BMD in our cohort was close to the national average in non-HIV patients. Disclosures All Authors: No reported disclosures