WEIGHT fatigue, and night sweats. He denied using tobacco or intravenous drugs. On physical examination, he had orthostatic hypotension and a new 2/6 systolic ejection murmur. He did not demonstrate peripheral stigmata associated with endocarditis (Osler's nodes, Janeway lesions, or splinter hemorrhages). Pertinent labs for the hospitalization included a hemoglobin of 10.2 g/dL, hematocrit of 30.1%, and mean corpuscular volume of 81.9 fL (further labs confimed iron deficiency). An erythrocyte sedimentation rate (ESR) was 35; C-reactive protein was 12.5 and albumin was 2.0. WBC, BUN, creatinine, liver function tests, chest radiograph, and EKG were normal. PSA, TSH, and morning cortisol levels were normal. PPD and HIV screening were negative. Esophagogastroduodenoscopy and colonoscopy did not show any abnormal pathology. CT scans of the head, neck, chest, abdomen, and pelvis were unremarkable except for a small pericardial effusion and an old ischemic left cerebellar infarct. On day six of his hospital stay, the patient had a fever with a Tmax of 39.0 and a bandemia of 14% with a normal WBC count. Two sets of blood cultures were drawn and diphtheroids, identified as species other than Corynebacterium jeikeium, grew in all specimens. A transthoracic echocardiogram revealed an aortic valve vegetation, moderate aortic regurgitation, and an ejection fraction of 60 to 65%. A diagnosis of subacute bacterial endocarditis was made and the patient was treated with a four week course of intravenous ampicillin. Surveillance cultures drawn five days after starting antibiotics were negative and the patient remained afebrile for the rest of his hospital stay. IMPLICATIONS/DISCUSSION: Bacterial endocarditis is a common entity encountered in the hospital setting. The diagnosis may be missed as it can mimick a variety of conditions due its protean clinical manifestations and the diversity of pathogens associated with it. Recognition of these signs and symptoms can enable the clinician to make an early diagnosis and pave the way for intervention and further reduction in morbidity and mortality. These include constitutional symptoms such as fever, fatigue, and weight loss; new and/or changing murmurs; embolic phenomenon such as Janeway lesions, mycotic aneurysms, and peripheral emboli to multiple organs; and immune complex mediated phenomena such as glomerulonephritis, Osler's nodes, and arthritis. Elevated ESR and C-reactive protein, and a positive rheumatoid factor often accompany these presentations. Anemia is present in 70 to 90% of cases. Weight loss is found in up to 25% of cases and often leads to an exhaustive work up for malignancy, tuberculosis, and other chronic diseases. If there is a high index of suspicion, diagnosis can be made by positive serial blood cultures or the presence of valvular vegetations on echocardiogram. Streptococci, enterococci, and staphylococci are isolated in the vast majority of cases. Other pathogens are rather uncommon and include the HACEK group (Hemophilus, Actinobacilus, Cardiobacterium, Eikenella, and Kingella), Coxiella, Neisseria, Pseudomonas, Salmonella, Streptobacillus, Bacteroides, Corynebacterium and other anaerobic gram-negative bacilli. There are case reports of native and prosthetic valve endocarditis caused by diptheroids including C. jeikeium, C. urealyticum and C. striatum. Of the nondiphtheriae corynebacteria, C. jeikeium is the most worrisome as it is resistant to multiple antibiotics and warrants treatment with vancomycin. Diagnosis of the causative organism is imperative for initiation of therapy with appropriate antibiotics and possible surgical intervention. LEARNING OBJECTIVES: After listening to this vignette presentation the leaner will: 1. Recognize the importance of NSAID-induced adverse effects in the lower GI tract. 2. Add NSAIDs (including the selective COX-2 inhibitors) to the differential diagnosis of rectal bleeding and intestinal strictures. CASE INFORMATION: A 58 year old female with a history of GERD treated with a proton pump inhibitor, hypertension, hyperlipidemia, and hypothyroidism was prescribed celecoxib 200mg/day for mechanical low back pain. After approximately a month of therapy she presented with bloody diarrhea. She denied fever or chills. There was only minor abdominal cramping. The patient has a strong family history of colon cancer and had undergone a surveillance colonoscopy 2 years ago. This was normal except for a few small diverticula.