Patient: Male, 28 Final Diagnosis: Bartonella endocarditis Symptoms: Abdominal pain • cough • weight loss Medication: — Clinical Procedure: — Specialty: Infectious Diseases Objective: Rare co-existance of disease or pathology Background: Culture-negative Bartonella quintana endocarditis is challenging to diagnose and is associated with high mortality rates. Diagnostic confirmation of Bartonella quintana infection requires specialized assays, as identifying Bartonella henselae endocarditis by serology can be difficult due to the high rate of serological cross-reactivity. This is a case report of culture-negative Bartonella quintana endocarditis that was diagnosed with epidemio-logic data, histology, and nucleic acid amplification testing. Case Report: A 28-year-old man with a history of homelessness was admitted to hospital with worsening productive cough, weight loss, and abdominal pain. A transthoracic echocardiogram (TTE) showed pulmonary valve vegetation and several aortic valve vegetations. His hospital course was complicated by cardiogenic shock and septic shock requiring transfer to a tertiary care medical intensive care unit. Although blood cultures remained negative for bacterial infection, serology testing was positive for Bartonella henselae and Bartonella quintana IgM and IgG. Nucleic acid amplification testing for 16S ribosomal RNA (rRNA) using valve tissue was diagnostic for Bartonella quintana . Conclusions: This case of culture-negative Bartonella quintana endocarditis demonstrates the use of diagnostic nucleic acid amplification methods to confirm the diagnosis.

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BackgroundApproximately 730,000 Americans are estimated to have chronic hepatitis B (HBV) infection, but recent studies have identified gaps in HBV care. Our aim is to characterize the HBV care cascade at the Veterans Affairs Maryland Health Care System (VAMHCS).MethodsWe used administrative VA data sources to identify patients enrolled at VAMHCS with a positive hepatitis B surface antigen (HBsAg) result within the VA from October 1, 1999 through February 7, 2018. Non-Veteran employees, Veterans who had died, or those with confirmed resolution of HBV infection were excluded. Chronic HBV infection was defined as a second positive HBsAg result or detectable HBV DNA >6 months later, or if included in the medical record. Resolved HBV infection was defined as undetectable HBsAg in someone with previously positive HBsAg.ResultsWe identified 159 patients with a history of detectable HBsAg; only 68 (43%) had confirmatory testing to verify chronic HBV infection. Most patients with confirmed HBV (90%) were male, Black (75%; 18% Caucasian, 5% Asian), with a mean age of 62 years (with standard deviation of ±12 years). Among patients with confirmed chronic HBV, 91% were seen by a provider at least once after diagnosis where HBV was addressed in the assessment and plan, 93% had e-Antigen testing, 41% had fibrosis staging (via transient elastography, liver biopsy, or FibroSure), 85% had at least one time screening for hepatocellular carcinoma (HCC), 100% had ALT testing at least once, 84% had ALT > upper limit of normal (men 30 U/L, women 19 U/L), 62% had HBV treatment at some point.ConclusionThis analysis reveals that within the Veteran population followed at the VAMHCS, less than half of those with initial detectable HBsAg have had confirmatory testing, and while the majority of patients with confirmed chronic HBV were by providers for HBV, less than half of patients received recommended fibrosis staging. More than half (62%) received treatment and the majority (84%) have had liver imaging at least once. The cascade of HBV care highlights multiple areas for targeted improvement of the care of Veterans with chronic HBV.Disclosures All authors: No reported disclosures.