Herpes zoster involving all three divisions of the trigeminal nerve is extremely rare and may pose a diagnostic challenge, especially in young and immunocompetent patients. We present a unique case of herpes zoster involving all three divisions of the trigeminal nerve and illustrate that this uncommon eruption can be a presenting sign of varicella zoster aseptic meningitis. This case emphasizes the importance of fundamental morphology recognition, particularly its ability to aid in clinical diagnosis and its potential to decrease patient morbidity and mortality by expediting the initiation of appropriate treatment.

Background COVID-19 associated pulmonary aspergillosis (CAPA) is a known complication of COVID-19 which carries a high mortality rate. While there are proposed diagnostic criteria, CAPA remains likely underdiagnosed. Our objectives are to evaluate markers of disease severity, bacterial coinfections, and outcome measures in order to assess the clinical impact of CAPA in patients admitted with COVID-19. Methods A retrospective chart review was performed on all adult patients admitted to a single-center, tertiary hospital from March 1, 2020 to May 1, 2022 with a positive COVID-19 PCR and probable or proven CAPA based on ECMM/ISHAM consensus criteria. Admission data, ICU status, time to CAPA diagnosis, respiratory cultures, and 90-day mortality were identified. Results 14 patients met criteria for probable CAPA. 10 of 14 patients (71.4%) were immediately admitted to the ICU. By day 14, 13 patients (92.9%) were intubated. The average time from admission to CAPA diagnosis was 31.3 days. 12 patients were diagnosed by BAL galactomannan, while 2 patients were diagnosed by growth on respiratory culture. 12 patients (85.7%) also had bacterial growth on respiratory cultures. The most common pathogen was Staphylococcus aureus, which was seen in 6 patients. All-cause mortality was 42.8%, or 6 of 14 patients, at day 90. In patients with a CAPA diagnosis, the average length of ICU stay was 36.4 days and average total hospital length of stay was 43.6 days, compared to 6.3 and 12.5 days, respectively, for all patients admitted with COVID-19 disease. Conclusion CAPA is a rare complication of COVID-19 but had substantial negative impacts on affected patients. The late onset of CAPA may be a result from longer hospitalizations and increased healthcare-associated infections. The association of CAPA with bacterial coinfections is consistent with literature on other viral infections such as influenza predisposing to secondary pneumonias. As the majority of cases were diagnosed by galactomannan rather than culture, providers should have a low threshold for testing in patients with protracted hospitalization for COVID-19. This case series emphasizes the poor outcomes associated with CAPA and its burden on already strained hospital resources, highlighting the need for improved disease awareness and further study. Disclosures All Authors: No reported disclosures.

Background Department of Health and Human Services (DHHS) guidelines recommend integrase strand transfer inhibitors (INSTIs) as the backbone of preferred initial antiretroviral (ART) regimens (1). Baseline mutation rates for the INSTI class is 0.8% compared with an overall rate of 19% for all ART classes, based on Centers for Disease Control and Prevention (CDC) U.S. data from 2013-16 (2). First-generation INSTIs (raltegravir and elvitegravir) have a lower genetic barrier to resistance compared with newer, second generation INSTIs (bictegravir and dolutegravir) (3, 4). DHHS guidelines do not currently recommend routine HIV genotypic resistance testing to INSTIs prior to ART initiation (1). Our study seeks to determine the current prevalence of transmitted INSTI and overall resistance in a large southeastern U.S. Ryan White clinic. Methods This was a single-center, retrospective analysis of treatment naïve PLWH presenting for care from January 1, 2017 to December 31, 2020. Of these, 164 had a baseline genotype performed by one of two commercially available assays – Vela Genomics or ViroSeq. Subsequent interpretations were based on Stanford HIV Drug Resistance Database. Results 65 patients (39.6%) had at least one transmitted resistance associated mutation (RAMs). Of these, 24 (36.9%) had an INSTI RAM. Baseline PI, NRTI, and NNRTI RAMs declined during the four-year interval (2017-2020), while the rate of INSTI RAMs increased from 11.1% to 19%; all conferred resistance to the first generation INSTIs with one also conferring resistance to second generation INSTIs. INSTI Resistance Associated Mutation Prevalence 2017-2020 Frequency of Antiretroviral Therapy Class Mutations Per Year Trend of INSTI Mutations and Resistance Associated Mutations 2017-2020 Conclusion Unlike the CDC data which showed the overall prevalence of INSTI RAM transmission rates during 2013-2016 to be 0.8%, our data suggests a higher rate of INSTI RAMs (14.6%) with overall ART RAM transmission of 39.6%. This increase in baseline resistance to the INSTI class, which occurred over time, mimics the historical development of RAMs seen in the earlier ART classes. Though suboptimal adherence in the population promotes development of RAMs, increased frequency of INSTI RAMs may be due to a lower barrier to resistance of first generation INSTIs. Should our observed trend continue, routine baseline INSTI resistance testing may need to be considered prior to ART initiation. Disclosures Cheryl Newman, MD, Gilead (Scientific Research Study Investigator)GSK/ViiV (Scientific Research Study Investigator, Advisor or Review Panel member, Speaker’s Bureau)Janssen (Scientific Research Study Investigator)Merck (Scientific Research Study Investigator)

Cytomegalovirus (CMV) is one of the most frequent microbes linked with kidney transplant recipients. CMV infection is typically classified as CMV virus isolation in any body fluid or specimen. We present a 43-yearold man who underwent a deceased donor kidney transplant with CMV donor-seronegative and recipientseronegative (CMV D-/R-) status and completed three months of CMV prophylaxis with high-dose acyclovir given his low-risk status. He was admitted for complaints of profuse watery diarrhea and persistent fevers lasting one week in duration. His infectious workup led to a CMV quantitative nucleic acid amplification test (QNAT) polymerase chain reaction (PCR) of 239,977 IU/mL with a biopsy-proven diagnosis of invasive CMV colitis. He was treated inpatient with intravenous ganciclovir for two weeks and then de-escalated to oral valganciclovir until achieving viremia resolution with undetectable CMV QNAT PCR as an outpatient. This case illustrates the importance of the changing epidemiology and clinical presentation of CMV disease in solid organ transplant (SOT) recipients in an era of new immunosuppression regimens and improved CMV disease detection in the early post-transplant period.