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A 59-year-old woman presented to the hospital with acute, hypoactive altered mental status. Her symptoms had begun 3 days prior when she developed hallucinations, urinary and faecal incontinence, and somnolence. She also exhibited confabulations, amnesia, motor memory loss and a wide-based gait. Medical, psychiatric and neurological evaluations including imaging and laboratory workup were unrevealing. Treatment for possible Wernicke encephalopathy and psychosis with high-dose intravenous thiamine and antipsychotic medications did not lead to improvement. After discharge, a send-out cerebrospinal fluid autoimmune encephalitis panel resulted positive for the newly identified neuronal inositol triphosphate receptor one (ITPR1) antibody. This prompted readmission for intravenous steroids, plasmapheresis and intravenous immunoglobulin, which yielded mild clinical improvement. Here, we describe confabulations and psychiatric symptoms as novel manifestations of the primary presentation of anti-ITPR1 encephalitis in an effort to promote faster recognition of this disease and early initiation of treatment in suspected cases.

Background Pre-exposure prophylaxis (PrEP) is a highly effective biomedical strategy to decrease Human Immunodeficiency Virus (HIV) acquisition. Effectiveness of oral PrEP is linked to medication adherence. In 2018, Grady Health System (GHS) launched a PrEP program to increase PrEP access among un- and underinsured individuals living in metro Atlanta, Georgia. The purpose of this study is to determine PrEP medication adherence, PrEP discontinuation rates, and associated individual factors of patients enrolled during the first 18 months of the program’s implementation. Methods A single-center, retrospective chart review was conducted on patients enrolled in the GHS PrEP program between June 1, 2018 and February 29, 2020 who received more than one monthly PrEP prescription. Adherence was estimated using the medication possession ratio (MPR). The primary outcome was mean adherence to PrEP. Secondary outcomes include rate of high percent adherence (MPR > 80%), median time of engagement in care, PrEP discontinuation rates, rates of PrEP re-engagement, and individual factors associated with PrEP discontinuation and low adherence. Results This study included 154 patients, 70.8% of them were Black, 62.3% were cisgender men, 59.1% were uninsured, and the mean age was 34. The majority of patients identified as men who have sex with men (51.9%). Mean PrEP adherence was 89.2%; 77.3% of patients demonstrated a high rate of adherence. No individual or social factors were associated with low adherence, but younger age was associated with higher rates of PrEP discontinuation (p< 0.0061). At the end of the follow up period on October 30, 2020, 53.8% of patients were active in the program and 12.7% of those who discontinued had re-engaged with the program. The average length of program engagement was 9.8 months. Table 1. Baseline socio-demographic characteristics (N=154) Table 2. PrEP Adherence and Discontinuation at the GHS PrEP Program from 2018 to 2020 (N=154) Table 4. Multivariate analysis of individual factors associated with PrEP discontinuation and low adherence Conclusion Mean PrEP adherence at a safety net PrEP program in Atlanta was high and PrEP discontinuation rates were comparable to other PrEP clinics nationwide. We found no association with individual factors previously linked to lower adherence, including Black race, younger age, and insurance status. Program-related factors that may have impacted these findings need to be investigated. Other future areas of research include strategies to optimize engagement in care in younger patients. Disclosures Bradley L. Smith, Pharm.D., AAHIVP, Gilead Sciences, Inc (Advisor or Review Panel member)

Background Since reaching its nadir in 2000, syphilis has re-emerged as a public health threat in the U.S. The incidence of syphilis is disproportionately high in Atlanta, the epicenter of the HIV epidemic in the U.S. South. Given that syphilis infection is a strong predictor of HIV infection, identifying patients with syphilis is an important and underutilized method for connecting patients to HIV prevention and care services. Emergency departments (EDs) act as a critical access point to care in safety net health systems. We describe the recognition and empiric treatment of syphilis in the ED of Grady Healthcare System, a safety net hospital serving Atlanta. Methods We performed a retrospective chart review on all reactive rapid plasma reagin (RPR) tests collected from patients 18 years and older at the Grady ED from 5/1/20 to 10/31/20. We abstracted reported reason for testing, diagnosis, treatment administered, and location of treatment from the electronic health record. Results From 5/1/20 to 10/31/20, 148 patients with reactive RPR tests were identified. Reasons for testing were broad and included the evaluation of neurologic symptoms (47), genital/anal lesions (31), and a history of syphilis (18) (Table 1). 74 patients had presumed active syphilis (50%), 34 had previously treated syphilis (23%), 12 had false positives (8%), and 28 had an unclear diagnosis (19%) (Table 2). Of those with presumed primary syphilis who were discharged from the ED, 53% (8/15) received empiric treatment in the ED; 59% (10/17) of those with secondary syphilis received empiric treatment prior to discharge. Of the patients discharged from the ED, clinical follow up was indicated for 52% (31/59) given lack of empiric treatment or of confirmed prior treatment. Contact was attempted for 39% (12/31), but only 29% (9/31) were ultimately treated at Grady. Table 1: Abstracted Reasons for Testing for Syphilis in the ED For ED patients from 5/1/20-10/31/20 who had reactive RPRs, reasons for syphilis testing were taken from the chief complaint, history, or medical decision making documentation of ED providers, admitting providers, or consultants. Table 2: Syphilis Diagnoses of ED patients with reactive RPRs ED patients with a positive RPR from 5/1/20-10/31/20 were chart reviewed to determine their diagnosis. Previous RPR, treponemal antibodies, CSF results, media images, progress notes, and descriptions by medical staff were reviewed to attempt to retroactively determine the most likely syphilis diagnosis. Conclusion Reactive RPRs were common in this acute care setting and most represented active syphilis infection. Empiric treatment was most likely to be provided for patients with clear syphilis syndromes. However, a majority of patients who were discharged without empiric treatment did not receive follow up. Institutional protocols for following up reactive tests after discharge represent an opportunity to connect patients with syphilis treatment and HIV prevention services. Disclosures All Authors: No reported disclosures