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280. Monitoring Serum Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP) in Correlation with (1–3)-β-d-Glucan Levels in Vascular Pythiosis: A Preliminary Study

Abstract Background Vascular pythiosis, caused by Pythium insidiosum, is a life-threatening disease despite aggressive treatment. Our recent study showed that serum β-d-glucan (BG) trends can be used to monitor disease activity after treatment initiation. A significant decline in BG by 0.5 month indicated complete resection without residual disease. However, BG assay is cost probihitive and available only at King Chulalongkorn Memorial Hospital in Thailand. This study was conducted to preliminarily evaluate erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) as monitoring tools. Methods A prospective study included proven vascular pythiosis patients receiving treatment with combination therapy from November 2018 to January 2019. Clinical information, BG, ESR, and CRP were collected at 0, 0.5, 1.5, and 3 months post diagnosis. Spearman’s correlation coefficient and analysis of response profiles were used. Results Six patients were enrolled. All had thalassemia. Four developed disease at popliteal artery, 1 at common iliac artery, and 1 at brachial artery. All underwent amputation with negative surgical margins achievement. All received itraconazole, azithromycin, and P. insidiosum immunotherapy. One received terbinafine and one received doxycycline additionally. All had positive BG > 500 pg/mL at diagnosis. After treatment initiation, means of ESR were significantly decreased at 0.5 months (P = 0.02). Means of CRP were not significantly changed until 1 month (P = 0.02) (Figure 1a and b). Correlation coefficients between BG and ESR vs. BG and CRP were 0.74 and 0.65, respectively. All survived without relapse at 3 months. Conclusion ESR and CRP are potentially valuable markers to monitor vascular pythiosis in resource-limited countries. However, ESR levels and trends seem to be correlated with BG better than CRP. Further studies are needed to enroll more patients, especially patients with incomplete resection or non-surgical candidates. Disclosures All authors: No reported disclosures.


Background.
Vascular pythiosis, caused by Pythium insidiosum, is a life-threatening disease despite aggressive treatment. Our recent study showed that serum β-d-glucan (BG) trends can be used to monitor disease activity after treatment initiation. A significant decline in BG by 0.5 month indicated complete resection without residual disease. However, BG assay is cost probihitive and available only at King Chulalongkorn Memorial Hospital in Thailand. This study was conducted to preliminarily evaluate erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) as monitoring tools.
Methods. A prospective study included proven vascular pythiosis patients receiving treatment with combination therapy from November 2018 to January 2019. Clinical information, BG, ESR, and CRP were collected at 0, 0.5, 1.5, and 3 months post diagnosis. Spearman's correlation coefficient and analysis of response profiles were used.
Results. Six patients were enrolled. All had thalassemia. Four developed disease at popliteal artery, 1 at common iliac artery, and 1 at brachial artery. All underwent amputation with negative surgical margins achievement. All received itraconazole, azithromycin, and P. insidiosum immunotherapy. One received terbinafine and one received doxycycline additionally. All had positive BG > 500 pg/mL at diagnosis. After treatment initiation, means of ESR were significantly decreased at 0.5 months (P = 0.02). Means of CRP were not significantly changed until 1 month (P = 0.02) (Figure 1a and b). Correlation coefficients between BG and ESR vs. BG and CRP were 0.74 and 0.65, respectively. All survived without relapse at 3 months.
Conclusion. ESR and CRP are potentially valuable markers to monitor vascular pythiosis in resource-limited countries. However, ESR levels and trends seem to be correlated with BG better than CRP. Further studies are needed to enroll more patients, especially patients with incomplete resection or non-surgical candidates.
Disclosures. All authors: No reported disclosures. Background. Battarrea puffball mushrooms are found extensively worldwide and contain spore-containing sacs. Inhalation of the spores of similar mushrooms, such as Lycoperdon, have been implicated in cases of lycoperdonosis-a syndrome of hypersensitivity pneumonitis. We report a case of hypersensitivity pneumonitis confirmed to be secondary to Battarrea spore exposure diagnosed by broad-range PCR.

Hypersensitivity Pneumonitis
Methods. A 23-year-old homeless man with a history of methamphetamine use presented to the emergency department with a 2-week history of fevers, chills, productive cough, and malaise. He reported his symptoms began soon after eating a long-stemmed mushroom he found growing next to a building. He reported inhaling particles from the mushroom when he picked it up prior to eating it. He vomited within 1 hour of ingestion, and then had a worsening progression of cough and malaise over the following 2 weeks. In the emergency department, he was noted to have leukocytosis and mild elevation of transaminases. He required supplemental oxygen due to hypoxemia. CT scan of his chest demonstrated extensive bilateral nodular pulmonary infiltrates. He was admitted and started on treatment for community-acquired pneumonia. Over the next several days, he had worsening respiratory failure, and routine work up for infectious etiologies was unrevealing. To further investigate, bronchoscopy and bronchoalveolar lavage (BAL) was performed and routine bacterial, fungal and mycobacterial cultures and cytology with Gomori Methanamine-silver and acid-fast stains were negative. BAL fluid was sent for broad range DNA testing by PCR. Antibiotic therapy was stopped, and he was started on steroids to treat presumed hypersensitivity pneumonitis. He recovered rapidly and was discharged on a course of oral corticosteroids.
Results. After the patient was discharged, molecular testing of BAL fluid resulted with detection of Battarrea species DNA using 28s and ITS primer sets. DNA from no other pathogens was detected.
Conclusion. Identified through broad range DNA PCR testing, exposure to Battarrea mushroom spores may be a previously unreported cause of hypersensitivity pneumonitis. PCR testing should be considered in the workup of hypersensitivity pneumonitis with known or suspected exposure to mushroom spores.