EVALUATION AND SIGNIFICANCE OF PERSISTENT ASYMPTOMATIC ELEVATED BONE ALKALINE PHOSPHATASE. K.S. Jorn 1 ; 1 Mayo Community Internal Medicine, Jacksonville, FL (Tracking ID #74454) LEARNING OBJECTIVES: 1. To review a series of cases in which asymptomatic elevated bone alkaline phosphatase was discovered, evaluated, and followed. 2. To propose an algorithm for evaluation of asymptomatic elevated bone alkaline phosphatase. 3. To suggest that additional study is needed to determine if this algorithm is cost-effective. CASE INFORMATION: Asymptomatic elevated liver enzymes are commonly encountered in primary care and are well documented in medical literature. Asymptomatic elevated alkaline phosphatase (bone subtype) also appears to be common in primary care but there is a lack of guidance in the literature for further evaluation of the abnormality once it is discovered. The cases presented provide examples of persistently elevated bone alkaline phosphatase and the outcome of the evaluation and followup over three to five years. Diagnoses revealed during evaluation of asymptomatic elevated bone alkaline phosphatase include metastatic lung cancer, male osteoporosis, and an apparently benign elevation of the enzyme. An algorithm for evaluation of an asymptomatic elevated bone alkaline phosphatase is proposed. IMPLICATIONS/DISCUSSION: The author hopes that this limited case series will help to focus additional attention on this relatively common clinical problem, ultimately providing more robust guidance to the clinician in its evaluation and management. -old female with a history of fibromyalgia and penicillin allergy presented several weeks after rectal abscess drainage with malaise, generalized myalgias and subjective low grade fever. On the first visit to her physician, the patient was sent home with the presumptive diagnosis of fibromyalgia exacerbation. Having continued to experience symptoms that she described as different from her usual``fibromyalgia pain'', she returned to the office to seek additional medical care. She was afebrile and her physical exam was notable for a diastolic murmur and generalized muscle tenderness. Pertinent labs included H/H of 11/ 39, WBC 14 and ESR 66. Blood cultures were drawn and returned 24±48 hours later, being positive for Enterococcus faecalis in 3 out of 3 bottles. TEE demonstrated an aortic valve vegetation with regurgitation. The diagnosis of IE was made and she was treated initially with vancomycin and gentamicin. She was successfully desensitized to penicillin and her treatment course with IV penicillin and gentamicin continued for 6 weeks. The patient had gradual resolution of her presenting symptoms during her treatment course. IMPLICATIONS/DISCUSSION: Patients with fibromyalgia or chronic pain syndrome can be challenging as they present frequently with multiple nonspecific complaints. It can be tempting to attribute all of their symptoms to these underlying disorders. However, physicians should objectively evaluate the patient and entertain other diagnoses when these patients present with new or worsening symptoms. In our case, this finally led to the diagnosis of IE.