Respiratory infection caused by Pasteurella Multocida can range from asymptomatic colonization to otitis media, sinusitis, epiglottitis, pneumonia, empyema and lung abscess. The degree of pulmonary infection depends on the immunity state of the host and can carry a very high mortality. Treatment of choice for Pasteurella Multocida infection is either penicillin, second or third generation cephalosporins, or doxycline. Prolonged antibiotic treatment is warranted in immnocompromised host. 2) To consider macrophagic myofasciitis in patients presenting with proximal muscle weakness and myalgias. CASE INFORMATION: Macrophagic myofasciitis is a syndrome of proximal muscle weakness, pain and fatigue. Clinical presentation is very similar to polymyositis, with proximal muscle pain, weakness, fatigue, fever and ternderness. Macrophagic myofasciitis is distinguished from polymyositis microscopically, with infiltration of the fascia with macrophages in MM. Cardiac involvement is found in over 70% of patients with polymyositis. We report a case of macrophagic myofasciitis presenting with proximal muscle weakness and ventricular tachycardia. A 49 year-old African American female with several months of progressive muscle weakness presents with palpitations and dizziness. Physical examination demonstrated significant proximal muscle weakness with no evidence of a skin rash. Laboratory data revealed a creatinine kinase of 1301 u/liter (normal <2oo), a CK-MB of 41.7 (normal 0± 60) and an aldolase of 40.2 (normal 1.5±8.1). An EKG showed a wide complex tachycardia with a rate of 220. A coronary angiogram was normal and electrophysiologic studies failed to induce ventricular tachycardia. Electromyopathy was consistent with a myopathy and her muscle biopsy revealed macrophagic infiltration of fascia, consistent with a diagnosis of macrophagic myofasciitis. Her ventricular tachycardia was postulated to have arisen from a myofasciitis. After initiation of high dose steroids, her muscle enzymes normalized and no further episodes of tachyarrhythmia occurred. IMPLICATIONS/DISCUSSION: MM is a relatively new muscle disease, with a first case report in 1993 in France. In several ways, it is similar to polymyositis, with bilateral muscle weakness and pain. Both are associated with an altered immune system. Cardiac arrhythmia in polymyositis is fairly common, occurring in over 70% of patients. These arrhythmias are due to an increase in spontaneous and disorganized myopathic contraction. There are no previous reports of cardiac disrhythmias in macrophagic myofasciitis. Most patients respond well to treatment with steroids and/or antibiotics in a few weeks. LEARNING OBJECTIVES: To recognize rare presentations of severe hypothyroidism. CASE INFORMATION: 18 year old African American female presented to the teen pregnancy center secondary to increased abdominal girth and amenorrhea. She also reported fatigue, hair loss, dyspnea on exertion, and sadness. Physical exam was significant for alopecia, a large goiter, markedly distended abdomen with fluid wave, tense edema of the hands, and delayed deep tendon reflexes. Labs were remarkable for a TSH of 240 with undetectable T4 and T3, marked microcytic anemia and an erythrocyte sedimentation rate of 140. CXR revealed a globular pericardial silhouette and ultrasound of the abdomen showed a large amount of ascites. Echocardiogram was unremarkable except for a moderate pericardial effusion. Pelvic ultrasound showed enlarged cystic ovaries, consistent with Van Wky Grumbach syndrome. Peritoneal fluid studies were consistent with myxedematous ascites. Upon further questioning, the patient stated that she had been treated for hypothyroidism as a young teen and had been lost to follow-up for two years. She also had a history of prior suicide attempts and depression. IMPLICATIONS/DISCUSSION: The manifestations of thyroid disorders are many, myxedematous ascites are a well-known but not often seen presentation. Serositis from hypothyroidism may be caused by several things: a capillary leak syndrome resulting from the dearth of thyroid hormones, an SIADH-like picture causing body cavity fluid accumulation, or high hyaluronate concentrations in the body fluid acting as an osmotic attractant. The anemia of hypothyroidism is thought to be caused by either direct bone marrow toxicity, lack of stimulation of erythropoiesis, decreased RBC survival time, and increased 2,3-DPG concentration. Van Wky Grumbach syndrome is a rare condition in which the TSH at high levels acts as an FSH analogue to cause ovarian hyperstimulation/cyst formation. This should be considered when a patient with no known thyroid disease presents with cystic ovaries. year old Hispanic male with no significant past medical history presents to our clinic with a one year history of intermittent bright red blood per rectum and two week history of mild dyspnea on exertion. He has previously been evaluated for the rectal bleed at various clinics and treated with topical hemorrhoidal ointments without relief. Patient denies chest pain, orthopnea, paroxysmal nocturnal dyspnea, abdominal pain, bowel changes, fever, chills, and weight loss. He is a sexually active homosexual. Family history is negative for colon cancer and polyps. Vital signs show temperature 100.3, BP 138/76, HR 75, RR 14. Physical exam is significant for mildly decreased breath sounds in left upper lobe and guaiac positive stool but no palpable rectal mass. Lab results show hemoglobin 10.9, MCV 78.0, and WBC 6.4. HIV test is negative. Colonoscopy with biopsy shows squamous cell cancer. Staging studies including chest x ray and a CT scan of the thorax display a 3.5 cm mass in the left upper lobe and CT pelvis confirms anorectal mass. Biopsy of the lung mass is consistent with a metastatic lesion. He is treated with chemotherapy and undergoes resection of the solitary lung mass. IMPLICATIONS/DISCUSSION: Anal canal carcinoma can be overlooked in young otherwise healthy patients as rectal bleeding is often attributed to hemorrhoids. Squamous cell cancer of the anal canal has a high association with human papilloma virus (HPV) particularly HPV-16. HPV DNA is isolated in 88% of anal cell cancers. Other risk factors include chronic immunosuppressive therapy, HIV, and smoking. Past treatment for anal canal carcinoma involved abdominoperineal resection with permanent colostomy. Cure rates with surgical resection ranged between 40±70%. However, in recent studies, chemotherapy with 5-FU and mitomycin combined with radiotherapy offer a 66±70% cure rate and lower rate of complications. Prognosis is dependent on the size of tumor, distant metastases, and nodal involvement. In conclusion, recurrent rectal bleeding in young patients with associated risk factors warrants a more thorough investigation. year old male presented with ten days of progressive difficulty walking, stating he had weakness in the lower extremities and in his right hand. He also reported slurred speech. Pt had no known medical problems and denied the use of medications, illicit drugs, tobacco or alcohol. Physical examination was significant for 3/5 right lower extremity strength with absent reflexes of the right leg. Sensory exam was grossly intact. The patient had poor performance of finger to nose testing and difficulty with rapid alternating movements. There was severe gait instability. Babinski's sign was bilaterally equivocal. CBC, chemistry panel, ESR, TSH, RPR, EKG were normal. After an unremarkable head CT, an MRI of the head showed a demyelinating pattern involving the middle cerebellar peduncles. The CSF protein, gram stain, culture, cell count, and glucose were within normal limits. On hospital day 4, HIV serology was positive and thus confirmed the clinical diagnosis of PML. CSF testing for JC virus later returned positive. IMPLICATIONS/DISCUSSION: PML is a demyelinating disease associated with infection of the JC virus. An AIDS defining condition, PML may present with rapid or progressive focal neurological deficits, including aphasia, ataxia, hemiparesis, hyporeflexia, and impaired cognition. In AIDS, PML implies a very poor prognosis with a survival expectancy of about six months. The diagnosis of PML is made through a clinical constellation which includes HIV positivity, characteristic MRI findings, and positivity for JC virus in the CSF. MRI findings of PML are similar to those seen in Acute Disseminated Encephalomyelitis (ADEM), a demyelinating process associated with infections or vaccinations in children, but they differ from those seen in Multiple Sclerosis (MS). The MRI with MS typically shows plaques in the periventricular region, corpus callosum, centrum semiovale, and less commonly in the deep white matter structures. There is no specific therapy for PML, and improvement of symptoms relies on increasing CD4 count via antiretroviral therapy. There has also been suggestion of improved clinical response with the addition of Cidofovir, a drug typically used to treat CMV retinitis.