A WOMAN FROM CAMEROON WITH FEVER, ABDOMINAL PAIN AND EOSINOPHILIA. K. Dendrinos 1 ; 1 Boston University, Boston, MA (Tracking ID #75960) LEARNING OBJECTIVES: Review the Differential Diagnosis of Eosinophilia, Evaluate Fever of Unknown Origin. CASE INFORMATION: A 70 year old woman, recently emigrated to the U.S., presents to this hospital complaining of fever and chills for the past 3 months. She also complained of right and left upper quadrant pain. These complaints originally began in her home country of Cameroon, she came to the U.S. one week prior to her initial admission. During her first admission, she was febrile daily to 101 degrees Fahrenheit. Her exam was notable for right upper quadrant abdominal tenderness. Her laboratory examinations were significant for a CBC with an eosinophilia of 43%, that would peak later that month at 60%. Suspicion was high for a parasitic infection. Serologies would later be positive for multiple parasites endemic to Cameroon. She was treated with a wide array of antibiotics, including anti-tuberculosis medications, anti-fungals, and anti-helminthics. Her clinical course deteriorated and she died in the intensive care unit. On autopsy, she was found to have widely disseminated lymphoma involving nearly every organ system. IMPLICATIONS/DISCUSSION: This case initially appeared to be a classic presentation of a parasitic infection: a patient with fever and eosinophilia from an endemic area with positive serologies. It presents a chance to review the differential diagnosis of eosinophilia, and to again rethink the work-up of a fever of unknown origin. This case again demonstrates that``common things occur commonly'' (even when the patient comes from an unfamiliar part of the world). It also demonstrates the importance of keeping the differential diagnosis open, especially when the therapy instituted according to the initial dianosis fails.`L OCKING'' IN THE CASE FOR PREVENTIVE IMMUNIZATIONS. J. Derby 1 , C. Manhart 1 , C. Murphy 1 ; 1 Creighton University, Omaha, NE (Tracking ID #74723) LEARNING OBJECTIVES: Recognize that there are many patients at risk who have not received a primary series in tetanus. Distinguish a differential diagnosis of tetany. Manage a tetanus infection. CASE INFORMATION: A 71 year old female with no significant past medicial history and on no medications presented to the ER complaining of waking up in the middle of the night and being unable to move for the last 24 hours due to muscle stiffness. On initial exam she had marked neck stiffness with muscle spasms triggered by light touch and deliberate speech. A CT scan was unremarkable. A trial of IV diphenhydramine was administered to rule out a dystonic reaction. Stychnine levels and tetanus antibodies were drawn ( both later reported as negative). Over the next few hours obvious trismus developed. Her muscle spasms spread inferiorly to involve her abdominal wall, and her upper and lower extremities demonstrated lead pipe rigidity. The patient was intubated prophylactically and IV diazepam was begun. The patient was given tetanus immunoglobulin as well as a Td vaccination (since the illness is not protective). Metronidazole was administered IV. IMPLICATIONS/DISCUSSION: The majority of reported cases of tetanus in the US are in patients over the age of 60 years old. Currently, nearly 50% of elderly patients in the United States have non-protective titers. This is attributed to waning immunity in patients who have not received booster shots. Additionally, many elderly never received the primary series as children (which was not available until the 1950's). This patient had received one booster without a primary series which did not protect her,but may have prevented her mortality. Many immigrants as well, may have never received the primary tetanus series. Physicians must be diligent in immunizing at-risk groups and ensure that all patients whos tetanus immunization status is unknown receive a primary series. LEARNING OBJECTIVES: To analyze an interesting presentation of rhinocerebral mucormycosis and review current diagnostic and treatment modalities. CASE INFORMATION: The patient is a 26 yo African American male with a past medical history significant for Type I Diabetes Mellitus who presented with a chief complaint of leftsided facial swelling for nine days. He stated that the onset of facial swelling occurred over few hours and that the progression was rapid. Pt reported subjective fevers and chills. He denied upper respiratory or sinus-related symptoms. He initially presented to an outside hospital after two days of facial swelling. There he underwent a sinus CT that revealed mucosal thickening involving the left ethmoid, maxillary and ethmoid sinuses. He was treated with a seven day course of Rocephin and Cleocin. The patient was in DKA at the time of presentation and was treated for two days per hospital DKA protocol. On the day of discharge from this outside hospital the patient presented to our institution reporting that the facial swelling had not improved with prior therapies. Additionally, he complained of bilateral blurry vision with increased sensitivity to light. On physical examination the patient was afebrile. HEENT examination was significant for left-sided facial swelling with infraorbital involvement, a greenish-yellow discharge from the left medial canthus and left nares, photophobia and a necrotic plaque of the hard palate. The patient was unable to medially deviate his left eye. Laboratory work revealed a normal white cell count and differential, and a normal chemistry panel with the exception of an elevated serum glucose of 256. The differential diagnosis at this point included among other conditions fungal sinusitis, bacterial sinusitis, lymphoma and Wegener's granulomatosis. MRI of brain revealed extensive paranasal sinus opacification with abnormal dural enhancement extending from the left sphenoid sinus to involve the left cavernous sinus, left middle cranial fossa and left fifth cranial nerve with no intracranial, parenchymal or orbital involvement. The patient underwent a nasal biopsy that revealed multiple hyphal elements consistent with Mucormycosis. The patient was started on Amphotericin B at 1.5/mg/kg/day and underwent extensive surgical debridement. Although no orbital involvement was confirmed on MRI, the patient's cranial nerve palsy and opthalmoplegia were understood to be a manifestation of rhino-orbital mucormycosis. The hospital course was complicated by acute renal failure, septic shock, diabetic ketoacidosis and cardiac arrest. While serial MRIs showed no regression of disease, the patient was medically stabilized, and showed clinical improvement over an eight week hospital course. However, the patient's vision loss and opthalmoplegia did not improve with treatment. IMPLICATIONS/DISCUSSION: Rhizopus oryzae accounts for 90% of rhinocerebral mucormycosis. Patients in DKA are highly susceptible because the acidic, glucose rich environment provides a perfect medium for growth. The clinical presentation includes classic sinusitis symptoms and signs along with nasal necrosis (38%) and palatal or gingival necrosis (14%) as in the case of our patient. The diagnosis of mucormycosis is histologic, and it is the only fungus that can be seen with H & E stain. The mainstays of treatment are surgical debridement and reversal of predisposing factors. While lipid containing formulations allow for higher doses to be given due to reduced toxicity there may be problems with delivering the complex to infarcted tissue and obtaining effective concentrations. Administration of intravenous Amphotericin B along with alternative routes such as aerosolized and CSF perfusion pathways is an aggressive treatment modality. Hyperbaric oxygen is an accepted, but not commonly utilized adjuvant to treatment. Even with early detection and treatment the overall mortality rate in patients with rhinocerebral mucormycois remains high. A 59 year old homosexual Caucasian male presented with complaints of b/l hearing loss, tinnitus and vertigo for several months prior to presentation. Patient had an audiogram performed which showed moderate to severe symetrical sensorineural hearing loss. Patient did not have a history of recent aminoglycoside use and was not a diabetic. He was worked up with thyroid stimulating hormone, sedimentation rate, coagulation tests, rheumatoid factor and anti-nuclear antibody titers which were all within normal limits. PPR was positive at 1:16 and MHA-TP was positive at 4+. He refused an HIV test. Patient subsequently received a lumbar puncture which was positive for VDRL . He was thus diagnosed with neurosyphilis and admitted to the inpatient medicine wards where he received a 14 day course of IV Penicillin. Hearing loss improved with treatment of the neurosyphilis. IMPLICATIONS/DISCUSSION: Neurological manifestations of syphilis can occur during any phase of this disease as the central nervous system is seeded during spirochetemia. Up to forty percent of patients infected with Treponema pallidum will have cns involvement. Although neurosyphilis can be aymptomatic, symptomatic neurosyphilis can present earlier as syphilitic meningitis or later in the infection, can have a meningovascular or parenchymatous pesentation. Cranial nerve involvement, especially of cranial nerves II±VIII, can be seen. Syphilitic otitis is a form of neurosyphilis that can present as deafness, vertigo and/or tinnitus and should considered in patients who present sensorineural hearing loss. If treated early, syphilitic otitis may be curable, but can lead to irreversible damage if untreated. CASE INFORMATION: 78 years old man with coronary artery disease, emphysema and alcoholism presents with short of breath and palpitations. He had clear chest film, but was found to be in rapid atrial fibrillation and controlled with diltiazem. On day 3 of hospital stay, his mental status deteriorated and rapidly went into delirium tremens. He subsequently had temperature spike to 103.0(F) with associated leukocytosis. His oxygen saturation became very unstable and eventually requiring mechanical ventilation. He repeat chest X-ray showed right lower lobe consolidation. His sputum gram stain showed 4+ small gram negative rods which was identified to be Pasteurella Multocida. He had been a long time avid deer hunter and has three dogs which he is in close contact with. He was treated with a third generation cephalosporin and his condition slowly improved. His subsequent CT of chest revealed left lung nodule. The biopsy of the nodule was consistent with squamous cell carcinoma of the lung. IMPLICATIONS/DISCUSSION: Pasteurella Multocida is common organism in many domestic and wild animals. Human Pasteurella is a major pathogen in wound infections due to animal bites. Greater than 70% of the reported cases of Pasteurella Multocida pneumonia occurred in patients with non-traumatic exposure to colonized animals.