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Introduction Isolated sleep paralysis (ISP) occurs when rapid eye movement (REM)-based atonia intrudes into wakefulness, outside the context of narcolepsy, substance abuse, mental disorder or other medical conditions. No “gold standard” assessment and diagnostic instrument currently exists. Report of Case A 63-year old female with hypersomnia and positive airway pressure (PAP)-controlled obstructive sleep apnea was referred for recurrent episodes of paralysis during sleep-wake transitions, lasting 15-20 seconds, occurring every 2-3 years since the age of 15, and associated with fear and anxiety. Episodes were more frequent in the last 2 years after significant sleep deprivation and starting a weight loss supplement, BIO-X4, which contains green tea and probiotics. No cataplexy, or history of traumatic brain injury and stroke were identified. Epworth Sleepiness Scale score was 14 on armodafinil. Reported sleep amounts were regularly scheduled 6-7-hour periods, with no suggestion of circadian dysfunction. In 2016, polysomnogram showed Apnea-Hypopnea index of 2.6/hour, Respiratory Disturbance Index of 13.8/hour with oxygen nadir of 92% in the setting of hypersomnia. Continuous PAP of 11 cmH20 was initiated after a successful titration with controlled residual AHI during follow-ups. Multiple Sleep Latency Test during the same time revealed mean sleep latency of 5.5 minutes and no sleep-onset REM with 5 naps. Brain imaging and electroencephalogram were both normal as well as drug panel, blood counts, metabolic profile and thyroid function. Decreased episodes and severity of recurrent ISP were reported after discontinuation of the supplement. Apart from anxiety related to the episodes, the patient denied any interference with daytime function. Conclusion Isolated sleep paralysis is an important sleep disorder that requires proper evaluation to rule out competing diagnoses and consideration of therapeutic interventions. Likely associated with a lack of understanding and available literature, the prevalence in the general population is likely higher than what is currently perceived.

Introduction Children with Down syndrome (DS) are at risk for obstructive sleep apnea (OSA) and related health consequences. Adherence to treatment plans, especially positive airway pressure (PAP), can be difficult for people with DS. We present a case of a pediatric patient with DS who developed pulmonary arterial hypertension (PAH) due to poor adherence of OSA therapy. Report of Case A 4-year-old male with a past medical history of DS was diagnosed with severe OSA and hypoventilation at 18 months of age – AHI 27, (oAHI 27), CO2 above 50 mmHg for 53.2% of total sleep time (TST)). A titration study showed that on a bi-level pressure (BPAP) of 11/6 cm H2O his OSA was improved – AHI 5.9 (oAHI 3.7), O2 nadir of 93%. The family attempted PAP at home but discontinued after 2 weeks. He underwent an adenoidectomy at 22 months of age and tonsillectomy and repeat adenoidectomy at 40 months of age. Patient presents to the emergency center with respiratory distress. Chest films showed cardiomegaly. Echocardiogram revealed evidence of worsening PAH (tricuspid regurgitation of 3.5-3.8 m/s and flattening of the interventricular septum). He was admitted to the pediatric intensive care unit for further management of his PAH attributed to his underlying uncorrected OSA and hypoventilation. Repeat polysomnogram showed continue severe OSA and hypoventilation – AHI 30.3 (oAHI 30.3) CO2 above 50 mmHg for 89% of TST. Repeat titration study showed that a pressure of 11/7 cm H2O improved his OSA– AHI 6.4 (oAHI 6.4) CO2 max of 52 mmHg. Treatment with BPAP was initiated prior to discharge. Repeat echocardiogram 2 months after admission showed improvement of the PAH while on BPAP without additional vasoactive drug therapy. Conclusion Children with DS are at high risk for OSA. Although treatment can be difficult, proper management of the OSA essential to preventing potential serious health consequences.

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Background Streptococcus pneumoniae remains an important cause of bacteremia in the United States with high morbidity and mortality despite readily available treatment and vaccines. Increased incidence of bacteremia observed during 2017–2018 season.MethodsRetrospective chart review of patients admitted with pneumococcal bacteremia over the last two winter seasons. Demographics, laboratory data, ICU stay, need for ventilation or pressor, comorbidities, and mortality were collected.ResultsFifty-three patients enrolled. 62% admitted during 2017–2018. Sixty-six percent white, 60% male, mean BMI 27 (38% had normal BMI). Mean age was 55 years (1–93) (57% > 61). Mean hospital length of stay was 7.8 days (1–30). More than 40% required ICU stay. The use of NPPV, vasopressors, and mechanical ventilation were 6%, 15%, and 17%, respectively. Most common presentation: dyspnea 30% and fever 18%. Smoking history (55%). Eighty percent of these patients had pneumonia. Resistance to penicillin 9% and intermediate susceptibility 6%. Resistance to erythromycin 44% and trimethoprim-sulfamethoxazole 12% which increased during winter 2017 (52% and 12%) compared with winter 2016 (30% and 10%). Only 2% of patients with pneumonia had positive sputum culture for pneumococcus and 62% had positive serum pneumococcal antigen with bacteremia. Positive co-detection of bacterial or viral targets in sputum using Multiplex PCR did not correlate with mortality and hospital stay but they were more likely needed ICU stay, use of vasopressor and mechanical ventilation. 43% of empiric therapy was as recommended by IDSA guidelines. Comparing 2016 vs. 2017 seasons, mortality (15% vs. 6%), hospital stay (9 days vs. 7 days), use of NPPV (5% vs. 6%) mechanical ventilation (15% vs. 18%) and vasopressor (5% vs. 21%). No correlation between influenza infection and bacteremia. Overall 6-month mortality and re-admission rate was 9% and 2%, respectively. Mortality was higher in overweight patients (60% vs. 20%), non-smokers (40% vs. 20%), coronary artery disease (40%) and congestive heart failure (40%).ConclusionPneumococcal bacteremia cause significant morbidity and mortality, we observed less mortality and hospital stay, but more use of NPPV, mechanical ventilation, and vasopressor during 2017–2018 season which had widespread influenza like activity. Disclosures All authors: No reported disclosures.