BACKGROUND:Long-term follow-up data on the travel-associated burden of vector-borne diseases (VBDs) are scarce. A prospective multi-site observational study was conducted to delineate the longitudinal course, symptom patterns, physical and mental burden and factors associated with prolonged illness in travellers after four VBDs. METHODS:Patients with confirmed travel-associated acute chikungunya, dengue, Zika or falciparum malaria were recruited at 15 GeoSentinel sites from 2016 to 2021. Persistent signs and symptoms were evaluated at 1, 3, 6, 12 and 18 months (M) post-diagnosis, using a multi-modular study questionnaire with quality of life (QOL) evaluated by 12-item short-form health survey (SF-12). Demographic, premorbid and acute disease characteristics were tested in multivariate analyses to determine factors associated with persistence of symptoms at M3. Missing data were imputed by rules and statistical methods. RESULTS:Among 273 patients enrolled, 35 (13%) had chikungunya, 110 (40%) dengue, 19 (7%) Zika and 109 (40%) falciparum malaria. Median age was 38 years (interquartile range 30-49), 148/273 (54%) were men. At M3, 24/35 (69%) of chikungunya, 27/110 (25%) of dengue, 8/19 (42%) of Zika and 12/109 (11%) of malaria patients had persistent symptoms. The proportion of symptomatic chikungunya patients was 18/35 (51%) at M6, mainly due to musculoskeletal symptoms including arthritis and stiffness. In dengue patients, fatigue and musculoskeletal symptoms without arthritis persisted until 1 year. Zika patients reported persisting headaches, musculoskeletal symptoms including arthritis and fatigue. One month after malaria, fatigue was the main persisting symptom, which resolved almost completely at M3. At M12, 6/35 (17%) of chikungunya, 5/110 (5%) dengue, 3/19 (16%) Zika and only 1/109 (1%) of malaria patients were still symptomatic.Impaired QOL was noted at M3 by 23/35 (66%) of patients with chikungunya, 20/110 (18%) with dengue and 6/19 (32%) with Zika but only 4/109 (4%) with malaria. Female sex, Zika, chikungunya and musculoskeletal symptoms during acute infection were associated with persistent M3 symptoms. CONCLUSIONS:Post-arboviral symptoms and impaired QOL persisted beyond 6 months after chikungunya, dengue and Zika. In contrast, post-malaria fatigue syndrome resolved within 3 months.

Anti-trypanosomal therapy is generally recommended for individuals under age 50 with the indeterminate form of Chagas disease to prevent disease progression. However, benznidazole and nifurtimox are associated with adverse drug reactions. We performed a retrospective review of treatment tolerability among patients with Chagas disease referred to Boston Medical Center from June 2016 to June 2024. There were 125 individuals evaluated, of whom 32 (25.6%) had contraindications to and 2 (1.6%) declined antiparasitic treatment. Ninety-one started therapy (83 with benznidazole, 8 with nifurtimox) with monitoring co-managed by infectious diseases physicians and pharmacists. Following benznidazole initiation, 70 (84.3%) had at least one adverse event, of which allergic (39/83, 47.0%), gastrointestinal (38/83, 45.8%), and neuropsychiatric (33/83, 39.8%) reactions were most common. Rash led to treatment discontinuation in 19 patients (22.9%) and met criteria for grade 3 severity in 13 (15.7%). Adjunctive therapies for rash included topical and systemic steroids and systemic antihistamines. Peripheral neuropathy led to treatment cessation for 13 patients (15.7%). Gastrointestinal adverse effects occurred in 38 patients (45.8%), were relatively mild, and managed with H2 blockers or proton pump inhibitors. Thirty (36.1%) patients were unable to complete 60 days of benznidazole, of whom 15 switched to nifurtimox. Eight patients started with nifurtimox during a benznidazole shortage. Nifurtimox was more frequently associated with gastrointestinal side effects (21/23, 91.3%) compared to benznidazole. Ultimately, 83 patients (91.2%) received at least 30 days, and 68 patients (74.7%) completed at least 60 days of benznidazole or nifurtimox. Multiple strategies were used to prevent and alleviate adverse events; multi-disciplinary team management was essential. These findings underscore the support needed for individuals with Chagas disease to tolerate and complete therapy and highlight the need for safer and more effective options to facilitate access to treatment.

Background Dengue is a leading cause of febrile illness among international travellers. We aimed to describe the epidemiology and clinical characteristics of imported dengue in returning travellers evaluated at GeoSentinel sites from 2007 to 2022. Methods We retrieved GeoSentinel records of dengue among travellers residing in non-endemic countries. We considered dengue confirmed when diagnosed by a positive dengue virus (DENV)-specific reverse-transcriptase polymerase chain reaction, positive NS-1 antigen and/or anti-DENV IgG seroconversion, and probable when diagnosed by single anti-DENV IgM or high-titre anti-DENV IgG detection. Severe dengue was defined as evidence of clinically significant plasma leakage or bleeding, organ failure, or shock, according to the 2009 World Health Organization guidance. Complicated dengue was defined as either severe dengue or dengue with presence of any warning sign. Analyses were descriptive. Results This analysis included 5958 travellers with confirmed (n = 4859; 81.6%) or probable (n = 1099; 18.4%) dengue. The median age was 33 years (range: <1-91); 3007 (50.5%) travellers were female. The median travel duration was 21 days (interquartile range [IQR]: 15-32). The median time between illness onset and GeoSentinel site visit was 7 days (IQR: 4-15). The most frequent reasons for travel were tourism (67.3%), visiting friends or relatives (12.2%) and business (11.0%). The most frequent regions of acquisition were South East Asia (50.4%), South Central Asia (14.9%), the Caribbean (10.9%) and South America (9.2%). Ninety-five (1.6%) travellers had complicated dengue, of whom 27 (0.5%) had severe dengue and one died. Of 2710 travellers with data available, 724 (26.7%) were hospitalized. The largest number of cases (n = 835) was reported in 2019. Conclusions A broad range of international travellers should be aware of the risk of acquiring dengue and receive appropriate pre-travel counselling regarding preventive measures. Prospective cohort studies are needed to further elucidate dengue risk by destination and over time, as well as severe outcomes and prolonged morbidity (long dengue) due to travel-related dengue.

BackgroundLimited data exist regarding cardiac manifestations of Chagas disease in migrants living in non-endemic regions.MethodsA retrospective cohort analysis of 109 patients with Chagas disease seen at Boston Medical Center (BMC) between January 2016 and January 2023 was performed. Patients were identified by screening and testing migrants from endemic regions at a community health center and BMC. Demographic, laboratory, and cardiac evaluation data were collected.ResultsMean age of the 109 patients was 43 years (range 19-76); 61% were female. 79% (86/109) were diagnosed with Chagas disease via screening and 21% (23/109) were tested given symptoms or electrocardiogram abnormalities. Common symptoms included palpitations (25%, 27/109) and chest pain (17%, 18/109); 52% (57/109) were asymptomatic. Right bundle branch block (19%, 19/102), T-wave changes (18%, 18/102), and left anterior fascicular block (11%, 11/102) were the most common electrocardiogram abnormalities; 51% (52/102) had normal electrocardiograms. Cardiomyopathy stage was ascertained in 94 of 109 patients: 51% (48/94) were indeterminate stage A and 49% (46/94) had cardiac structural disease (stages B1-D). Clinical findings that required clinical intervention or change in management were found in 23% (25/109), and included cardiomyopathy, apical hypokinesis/aneurysm, stroke, atrial or ventricular arrhythmias, and apical thrombus.ConclusionsThese data show high rates of cardiac complications in a cohort of migrants living with Chagas disease in a non-endemic setting. We demonstrate that Chagas disease diagnosis prompts cardiac evaluation which often identifies actionable cardiac disease and provides opportunities for prevention and treatment.

Chagas disease is an underrecognized, chronic, and potentially life-threatening disease caused by the parasite Trypanosoma cruzi. We aimed to improve awareness and screening for Chagas disease among patients from endemic areas using a large safety-net academic hospital system in the United States. We developed an educational intervention consisting of a case-based didactic session presented to physicians, trainees, and other healthcare providers at conferences across different departments. Performance on a knowledge assessment administered before and after the presentation was analyzed with paired Student's t-test for within-subject difference testing. Institutional testing rates for T. cruzi were evaluated for an equal time period (29 months) before and after the start of the intervention. Testing rates were compared by a Welch's unequal variances t-test and by interrupted time series based on multivariate linear regression. Eleven educational sessions were held over the intervention period, and 103 participants completed the pre- and post-presentation surveys. The mean survey scores were 59.2% before the presentation and 96.6% after presentation (P <0.001). Trypanosoma cruzi testing during the postintervention period was significantly higher than testing during the pre-intervention period (171 patients pre-intervention versus 378 patients postintervention [P = 0.015]). Notable increases in testing from the pre-intervention to postintervention periods occurred among midwives (1-68 patients tested) and trainees (57-133 patients tested). Overall, 56/537 (10.4%) nonduplicate T. cruzi commercial screening tests were positive. Testing increased over time, both at an institutional level and within targeted departments. In addition to the educational program, other factors likely influenced expanded testing.

Trypanosoma cruzi, the parasite that causes Chagas disease, affects as many as 300,000 individuals in the United States. Screening individuals of childbearing age can prevent congenital transmission, and diagnosing infants and children can prevent long-term sequelae of Chagas disease. Current methods to diagnose Chagas have limations, including relying on identification of at-risk individuals and requiring at least 2 separate tests to confirm infection.

Migration routes determine exposure to endemic infections. We present a case of complex cutaneous leishmaniasis in a man with HIV infection who migrated to the United States from Haiti, where Leishmania is uncommon, acquiring leishmaniasis while on his journey via South America and Central America. His presentation included hyperpigmented, nonulcerated plaques and nodules on his extremities, chest, back, face, palms, and soles; initially he had no mucosal lesions. Infection with Leishmania panamensis was confirmed via polymerase chain reaction. He was prescribed bictegravir/tenofovir alafenamide/emtricitabine with rapid suppression of HIV and liposomal amphotericin B for diffuse cutaneous leishmaniasis with a limited initial response. He subsequently developed mucosal lesions in the setting of immune reconstitution and was retreated with amphotericin dosed for mucocutaneous disease. A thorough migration history was critical to diagnosis. This case highlights the different presentations of leishmaniasis in people with HIV and the elevated risk for treatment failure.

Problem/Condition: During 2012-2021, the volume of international travel reached record highs and lows. This period also was marked by the emergence or large outbreaks of multiple infectious diseases (e.g., Zika virus, yellow fever, and COVID-19). Over time, the growing ease and increased frequency of travel has resulted in the unprecedented global spread of infectious diseases. Detecting infectious diseases and other diagnoses among travelers can serve as sentinel surveillance for new or emerging pathogens and provide information to improve case identification, clinical management, and public health prevention and response.Reporting Period: 2012-2021.Description of System: Established in 1995, the GeoSentinel Network (GeoSentinel), a collaboration between CDC and the International Society of Travel Medicine, is a global, clinical-care-based surveillance and research network of travel and tropical medicine sites that monitors infectious diseases and other adverse health events that affect international travelers. GeoSentinel comprises 71 sites in 29 countries where clinicians diagnose illnesses and collect demographic, clinical, and travel-related information about diseases and illnesses acquired during travel using a standardized report form. Data are collected electronically via a secure CDC database, and daily reports are generated for assistance in detecting sentinel events (i.e., unusual patterns or clusters of disease). GeoSentinel sites collaborate to report disease or population-specific findings through retrospective database analyses and the collection of supplemental data to fill specific knowledge gaps. GeoSentinel also serves as a communications network by using internal notifications, ProMed alerts, and peer-reviewed publications to alert clinicians and public health professionals about global outbreaks and events that might affect travelers. This report summarizes data from 20 U.S. GeoSentinel sites and reports on the detection of three worldwide events that demonstrate GeoSentinel's notification capability.Results: During 2012-2021, data were collected by all GeoSentinel sites on approximately 200,000 patients who had approximately 244,000 confirmed or probable travel-related diagnoses. Twenty GeoSentinel sites from the United States contributed records during the 10-year surveillance period, submitting data on 18,336 patients, of which 17,389 lived in the United States and were evaluated by a clinician at a U.S. site after travel. Of those patients, 7,530 (43.3%) were recent migrants to the United States, and 9,859 (56.7%) were returning nonmigrant travelers.Among the recent migrants to the United States, the median age was 28.5 years (range = <19 years to 93 years); 47.3% were female, and 6.0% were U.S. citizens. A majority (89.8%) were seen as outpatients, and among 4,672 migrants with information available, 4,148 (88.8%) did not receive pretravel health information. Of 13,986 diagnoses among migrants, the most frequent were vitamin D deficiency (20.2%), Blastocystis (10.9%), and latent tuberculosis (10.3%). Malaria was diagnosed in 54 (<1%) migrants. Of the 26 migrants diagnosed with malaria for whom pretravel information was known, 88.5% did not receive pretravel health information. Before November 16, 2018, patients' reasons for travel, exposure country, and and latent tuberculosis (10.3%). Malaria was diagnosed in 54 (<1%) migrants. Of the 26 migrants diagnosed with malaria for whom pretravel information was known, 88.5% did not receive pretravel health information. Before November 16, 2018, patients' reasons for travel, exposure country, and exposure region were not linked to an individual diagnosis. Thus, results of these data from January 1, 2012, to November 15, 2018 (early period), and from November 16, 2018, to December 31, 2021 (later period), are reported separately. During the early and later periods, the most frequent regions of exposure were Sub-Saharan Africa (22.7% and 26.2%, respectively), the Caribbean (21.3% and 8.4%, respectively), Central America (13.4% and 27.6%, respectively), and South East Asia (13.1% and 16.9%, respectively). Migrants with diagnosed malaria were most frequently exposed in Sub-Saharan Africa (89.3% and 100%, respectively). Among nonmigrant travelers returning to the United States, the median age was 37 years (range = <19 years to 96 years); 55.7% were female, 75.3% were born in the United States, and 89.4% were U.S. citizens. A majority (90.6%) were seen as outpatients, and of 8,967 nonmigrant travelers with available information, 5,878 (65.6%) did not receive pretravel health information. Of 11,987 diagnoses, the most frequent were related to the gastrointestinal system (5,173; 43.2%). The most frequent diagnoses among nonmigrant travelers were acute diarrhea (16.9%), viral syndrome (4.9%), and irritable bowel syndrome (4.1%). Malaria was diagnosed in 421 (3.5%) nonmigrant travelers. During the early (January 1, 2012, to November 15, 2018) and later (November 16, 2018, to December 31, 2021) periods, the most frequent reasons for travel among nonmigrant travelers were tourism (44.8% and 53.6%, respectively), travelers visiting friends and relatives (VFRs) (22.0% and 21.4%, respectively), business (13.4% and 12.3%, respectively), and missionary or humanitarian aid (13.1% and 6.2%, respectively). The most frequent regions of exposure for any diagnosis among nonmigrant travelers during the early and later period were Central America (19.2% and 17.3%, respectively), Sub-Saharan Africa (17.7% and 25.5%, respectively), the Caribbean (13.0% and 10.9%, respectively), and South East Asia (10.4% and 11.2%, respectively).Nonmigrant travelers who had malaria diagnosed were most frequently exposed in Sub-Saharan Africa (88.6% and 95.9% during the early and later period, respectively) and VFRs (70.3% and 57.9%, respectively). Among VFRs with malaria, a majority did not receive pretravel health information (70.2% and 83.3%, respectively) or take malaria chemoprophylaxis (88.3% and 100%, respectively).Interpretation: Among ill U.S. travelers evaluated at U.S. GeoSentinel sites after travel, the majority were nonmigrant travelers who most frequently received a gastrointestinal disease diagnosis, implying that persons from the United States traveling internationally might be exposed to contaminated food and water. Migrants most frequently received diagnoses of conditions such as vitamin D deficiency and latent tuberculosis, which might result from adverse circumstances before and during migration (e.g., malnutrition and food insecurity, limited access to adequate sanitation and hygiene, and crowded housing,). Malaria was diagnosed in both migrants and nonmigrant travelers, and only a limited number reported taking malaria chemoprophylaxis, which might be attributed to both barriers to acquiring pretravel health care (especially for VFRs) and lack of prevention practices (e.g., insect repellant use) during travel. The number of ill travelers evaluated by U.S. GeoSentinel sites after travel decreased in 2020 and 2021 compared with previous years because of the COVID-19 pandemic and associated travel restrictions. GeoSentinel detected limited cases of COVID-19 and did not detect any sentinel cases early in the pandemic because of the lack of global diagnostic testing capacity.Public Health Action: The findings in this report describe the scope of health-related conditions that migrants and returning nonmigrant travelers to the United States acquired, illustrating risk for acquiring illnesses during travel. In addition, certain travelers do not seek pretravel health care, even when traveling to areas in which high-risk, preventable diseases are endemic. Health care professionals can aid international travelers by providing evaluations and destination-specific advice. Health care professionals should both foster trust and enhance pretravel prevention messaging for VFRs, a group known to have a higher incidence of serious diseases after travel (e.g., malaria and enteric fever). Health care professionals should continue to advocate for medical care in underserved populations (e.g., VFRs and migrants) to prevent disease progression, reactivation, and potential spread to and within vulnerable populations. Because both travel and infectious diseases evolve, public health professionals should explore ways to enhance the detection of emerging diseases that might not be captured by current surveillance systems that are not site based.

Abstract Background Professional soccer athletes are at risk of acquiring severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). United States Major League Soccer (MLS) uses protocol-based SARS-CoV-2 testing for identification of individuals with coronavirus disease 2019. Methods Per MLS protocol, fully vaccinated players underwent SARS-CoV-2 real-time polymerase chain reaction testing weekly; unvaccinated players were tested every other day. Demographic and epidemiologic data were collected from individuals who tested positive, and contact tracing was performed. Whole genome sequencing (WGS) was performed on positive specimens, and phylogenetic analyses were used to identify potential transmission patterns. Results In the fall of 2021, all 30 players from 1 MLS team underwent SARS-CoV-2 testing per protocol; 27 (90%) were vaccinated. One player who had recently traveled to Africa tested positive for SARS-CoV-2; within the following 2 weeks, 10 additional players and 1 staff member tested positive. WGS yielded full genome sequences for 10 samples, including 1 from the traveler. The traveler's sample was Delta sublineage AY.36 and was closely related to a sequence from Africa. Nine samples yielded other Delta sublineages including AY.4 (n = 7), AY.39 (n = 1), and B.1.617.2 (n = 1). The 7 AY.4 sequences clustered together; suggesting a common source of infection. Transmission from a family member visiting from England to an MLS player was identified as the potential index case. The other 2 AY.4 sequences differed from this group by 1–3 nucleotides, as did a partial genome sequence from an additional team member. Conclusions WGS is a useful tool for understanding SARS-CoV-2 transmission dynamics in professional sports teams.

It is unknown whether COVID-19 can trigger malaria recrudescence or relapse. Although Plasmodium falciparum recrudescence occurring years after infection is extremely rare, delayed Plasmodium vivax and Plasmodium ovale relapse from the latent hypnozoite stage is well described. We report a case of acute P falciparum and P ovale co-infection that occurred 2 weeks after COVID-19 in an otherwise immunocompetent patient living in a malaria nonendemic country and without exposure to malaria in the preceding 5 years. This case highlights a potential mechanism by which COVID-19–associated immune depletion and/or dysregulation may trigger a delayed presentation of malaria.

Background International travellers frequently acquire infectious diseases whilst travelling, yet relatively little is known about the impact and economic burden of these illnesses on travellers. We conducted a prospective exploratory costing study on adult returning travellers with falciparum malaria, dengue, chikungunya or Zika virus. Methods Patients were recruited in eight Travel and Tropical Medicine clinics between June 2016 and March 2020 upon travellers' first contact with the health system in their country of residence. The patients were presented with a structured 52-question self-administered questionnaire after full recovery to collect information on patients' healthcare utilization and out-of-pocket costs both in the destination and home country, and about income and other financial losses due to the illness. Results A total of 134 patients participated in the study (malaria, 66; dengue, 51; chikungunya, 8; Zika virus, 9; all fully recovered; median age 40; range 18-72 years). Prior to travelling, 42% of patients reported procuring medical evacuation insurance. Across the four illnesses, only 7% of patients were hospitalized abroad compared with 61% at home. Similarly, 15% sought ambulatory services whilst abroad compared with 61% at home. The average direct out-of-pocket hospitalization cost in the destination country (USD $2236; range: $108-$5160) was higher than the direct out-of-pocket ambulatory cost in the destination country (USD $327; range: $0-$1560), the direct out-of-pocket hospitalization cost at home (USD $35; range: $0-$120) and the direct out-of-pocket ambulatory costs at home (US$45; range: $0-$192). Respondents with dengue or malaria lost a median of USD $570 (Interquartile range [IQR] 240-1140) and USD $240 (IQR 0-600), respectively, due to their illness, whilst those with chikungunya and Zika virus lost a median of USD $2400 (IQR 1200-3600) and USD $1500 (IQR 510-2625), respectively. Conclusion Travellers often incur significant costs due to travel-acquired diseases. Further research into the economic impact of these diseases on travellers should be conducted.

Abstract Background In 2020–2022, U.S. Major League Soccer (MLS) used SARS-CoV-2 mitigation protocols that included masking, social distancing, avoiding contact with others outside of training and games, testing, quarantine, and isolation. In addition to isolation for those who tested positive, a SARS-CoV-2 genomic sequencing strategy was developed to identify whether infections were associated with intra-league transmission. Methods Nasopharyngeal swabs were collected by MLS club medical staff from players and staff from February 2021 through September 2022. During this time, surveillance testing changed from daily to weekly to testing only symptomatic players and staff. SARS-CoV-2 positive samples were analyzed using amplicon-based whole genome sequencing. A phylogenetic tree was constructed using Nextstrain to visualize genomes from infected players and staff in the context of genomes available on GISAID circulating in the United States during corresponding time periods. To identify transmission links, all genomes were compared in a pairwise fashion. Genomes that were 0–2 nucleotides different were considered part of direct transmission clusters. Results Of 250 samples that were rtPCR positive for SARS-CoV-2, 215 (86%) were sequenced. Phylogenetic analysis showed a broad diversity of lineages, including some predominant overseas (e.g., AY.98.1). Pairwise comparison revealed SARS-CoV-2 sequences from 7 individuals appeared to be linked. These individuals were on 2 different MLS teams; there was an off-field exposure (dinner). Five (71%) had identical SARS-CoV-2 sequences; 2 had sequences that were 1 nucleotide different at the consensus level. Subconsensus genome analysis revealed that differences of 1 nucleotide were due to subconsensus mutations fluctuating below and above 50%, suggesting all 7 individuals were part of a transmission cluster. Phylogenetic analysis revealed that the sequences from the cluster were distinct from reference sequences and were likely a unique transmission chain. Conclusion SARS-CoV-2 transmission may occur within, and even between, professional sports teams. Pairwise comparison of individual genomes can provide improved granularity to identify clusters and understand SARS-CoV-2 transmission. Disclosures Davidson H. Hamer, MD, Kephera Diagnostics: Grant/Research Support|Takeda: Advisor/Consultant|Takeda: Grant/Research Support|Trinity Biotech, LLC: Advisor/Consultant|Valneva: Advisor/Consultant|Valneva: Grant/Research Support Daniel Bourque, MD, Kephera Diagnostics: Grant/Research Support

Abstract Background Chagas disease is under-recognized in the United States (US) and little is known about how time spent living in endemic versus non-endemic settings affects features of the disease. Methods We performed a cross-sectional, retrospective analysis of 108 individuals with Chagas disease. Presence of cardiac disease was defined according to the American Heart Association classification of Chagas cardiomyopathy. We performed a multivariate logistic regression adjusting for country of birth (COB, analyzed as El Salvador vs. other) and age at confirmatory diagnosis to evaluate whether proportion of lifetime in COB was associated with cardiac disease. We also performed an exploratory analysis of semi-quantitative Trypanosoma cruzi ELISA optical density (OD) values to assess for association with proportion of lifetime in COB, including the same covariates in a multivariate linear regression. Results This patient cohort was predominantly from El Salvador (92/108, 85%) and other countries in Central America (11/108, 10%), with a median age at diagnosis of 44 years (interquartile range [IQR] 18). Most individuals originated from rural areas (84/90, 93%) and immigrated to the US in adulthood (median 26 years, IQR 13) after having lived a median of 70% (IQR 25) of their life in their COB. Age at migration and age at confirmatory diagnosis were highly correlated (Pearson’s correlation coefficient [CC]= 0.69, p< 0.001). Confirmatory diagnosis occurred a median of 13 years (IQR 14) after arrival in the US. Cardiac disease was present in 47/108 (44%). Adjusting for age at diagnosis and COB, the proportion of lifetime in COB was not significantly associated with cardiac disease (odds ratio 5.6, [95% CI 0.355 - 87.1], p=0.22), nor was it associated with higher OD values (CC = –0.2, 95% CI –1.2-0.9, p=0.74). Cohort demographics and time to Chagas disease diagnosis after arrival in the U.S. Features of migration history and Chagas cardiac disease status Conclusion In this cohort of individuals with Chagas disease, there was a substantial delay in diagnosis after arrival to the US, which may have been longer if not for local screening efforts. Cardiac disease was prevalent but not associated with higher proportion of time spent in COB. Exploratory analysis of serology titers was not associated with proportion of lifetime spent in COB, contrary to our expectation. Disclosures Davidson H. Hamer, MD, Kephera Diagnostics: Grant/Research Support|Takeda: Advisor/Consultant|Takeda: Grant/Research Support|Trinity Biotech, LLC: Advisor/Consultant|Valneva: Advisor/Consultant|Valneva: Grant/Research Support Natasha Hochberg, MD, MPH, Novartis Institute for Biomedical Research: Full-time employment|Novartis Institute for Biomedical Research: Stocks/Bonds Daniel Bourque, MD, Kephera Diagnostics: Grant/Research Support

Rationale for review Giardiasis is one of the most common human protozoal infections worldwide. First-line therapy of giardiasis includes nitroimidazole antibiotics. However, treatment failure with nitroimidazoles is increasingly reported, with up to 45% of patients not responding to initial treatment. There is no clear consensus on the approach to the management of nitroimidazole-refractory giardiasis. This systematic review aims to summarize the literature on pharmacotherapy for nitroimidazole-refractory giardiasis. Methods We conducted a systematic review of the literature to determine the optimal management strategies for nitroimidazole-refractory giardiasis. We searched Pubmed/MEDLINE, Embase and Cochrane library using the following search terms ‘Giardia’ AND ‘treatment failure’ OR ‘refractory giardia’ OR ‘resistant giardia’ with date limits of 1 January 1970 to 30 June 2021. We included all reports on humans, which described clinical outcomes of individuals with treatment refractory giardiasis, including case series and case reports. A descriptive synthesis of the data was conducted with pooling of data for interventions. Key findings Included in this review were five prospective studies, three retrospective studies, seven case series and nine case reports. Across these reports, a wide heterogeneity of treatment regimens was employed, including retreatment with an alternative nitroimidazole, combination therapy with a nitroimidazole and another agent and monotherapy with non-nitroimidazole regimens, including quinacrine, paromomycin and nitazoxanide. Retreatment with a nitroimidazole was not an effective therapy for refractory giardiasis. However, treatment with a nitroimidazole in combination with albendazole had a cure rate of 66.9%. In the included studies, quinacrine monotherapy was administered to a total of 179 patients, with a clinical cure rate of 88.8%. Overall, quinacrine was fairly well tolerated. Conclusions Reports on the treatment of nitroimidazole-refractory giardiasis demonstrate a heterogeneous approach to treatment. Of these, quinacrine appeared to be highly effective, though more data on its safety are needed.

INTRODUCTION:West Nile Virus varies in presentation from asymptomatic to a febrile illness often associated with malaise, weakness and maculopapular rash. West Nile neuro-invasive disease often manifests as meningitis, encephalitis, and less commonly acute flaccid paralysis in a "polio-like" presentation. Acute transverse myelitis (ATM) is a rare manifestation. We present a case of neuro-invasive West Nile Virus infection with radiographic evidence of longitudinally extensive transverse myelitis (LETM), a subset of ATM.CASE NARRATION:A 42-year-old male from Massachusetts presented with progressive asymmetric paralysis of 4 days duration after developing a prodrome of fever, neck stiffness and urinary retention. Physical examination demonstrated asymmetric lower extremity weakness Lumbar puncture revealed lymphocytic pleocytosis with normal protein and glucose and a positive West Nile IgM in CSF (4.89, reference <0.90), and West Nile Virus detected by PCR in CSF. His West Nile serum IgM was 3.03 (reference range <0.90) and IgG was <1.30 (reference range <1.30). MRI of the lumbar spine showed findings consistent with the diagnosis of ATM.CONCLUSION:With our patient's presentation of acute onset asymmetrical weakness following a viral illness, we ruled out differentials including demyelinating syndrome such as GBS, inflammation of the meninges through meningitis or meningoencephalitis, or traumatic/ischemic involvement of the spinal cord directly. Due to the MRI findings, his motor weakness and urinary retention, supporting CSF findings and WNV positive serologies, ATM due to WNV infection was the main suspect for his presentation. Although ATM is an uncommon manifestation of WNV, it is imperative to consider this in the differential for patients presenting with acute onset flaccid paralysis in regions where WNV is endemic.

Morin, Scott J. MD; Jani, Chinmay MD; Rupal, Arashdeep MD; Singh, Harpreet MD; Bourque, Daniel MD; Colgrove, Robert C. MD Author Information

Enteric fever, caused by Salmonella enterica serovar Typhi ( S . Typhi) and S. enterica serovar Paratyphi ( S . Paratyphi), is a common travel-related illness. Limited data are available on the antimicrobial resistance (AMR) patterns of these serovars among travelers. Records of travelers with a culture-confirmed diagnosis seen during or after travel from January 2007 to December 2018 were obtained from GeoSentinel. Traveler demographics and antimicrobial susceptibility data were analyzed.