3) Appreciate the wide and unusual manifestations of Vitamin B12 deficiency. CASE INFORMATION: A 56 year-old black male with history of hypertension presented to the outpatient clinic with six month history of intermittent low grade fever. On review of systems, he denied cough, chest pain or shortness of breath, palpitations, gastrointestinal bleed, urinary or bowel symptoms, arthritis, weight loss, numbness or weakness. Vital signs revealed temp 100.5, pulse 116, blood pressure 158/96, respirations 18. Physical exam was significant for pale conjunctiva, guaiac negative stool, and slight decreased sensation to light touch, pinprick, and vibration in the lower extremities. Labs showed Hgb 6.7, MCV 87 with normal WBC and platelet with blood smear displaying nucleated rbcs, anisocytosis, poikilocytosis, and isolated macrocytes. A work up including chemistries, cultures of blood and urine, ANA, ESR, and TSH was unremarkable. A vitamin B12 level was 108 pg/mL (normal 180±914 pg/mL) and hemoglobin electrophoresis showed beta thallasemia. With Vitamin B12 supplementation, the patient's fever resolved. IMPLICATIONS/DISCUSSION: The differential diagnosis of normocytic anemia includes chronic diseases, inflammation, endocrinopathies and renal diseases. In some cases, the simultaneous processes of microcytic and macrocytic anemia should also be in the differential diagnosis of normocytic anemia. The abnormal blood smear with size variation of erythrocytes and neuropathy led to the work up and concomitant diagnosis of beta thallasemia and Vitamin B12 deficiency. The clinical manifestations of Vitamin B12 deficiency include fatigue, glossitis, vomiting, diarrhea, dementia, and neuropathies, but fever is not considered a typical feature. From the literature, fever was found in approximately 40% of patients with megaloblastic anemia caused by folate and Vitamin B12 deficiencies in two case studies. The mechanism of the fever is uncertain, but one proposed theory is the increased activity and ineffective erythropoiesis in the bone marrow. Fever resolves rapidly with treatment and failure to do so should prompt a search for other causes. In summary, normocytic anemia can be caused by dual processes of microcytic and macrocytic anemia and fever should be recognized as an atypical feature of Vitamin B12 deficiency.`D LEARNING OBJECTIVES: 1) Differentiate between gynecomastia and breast cancer 2) Recognize the causes and treatment of gynecomastia. CASE INFORMATION: The patient is a 67 year-old male with alcoholic cirrhosis who presented with a painful lump in his right breast. Medications included spironolactone. Social history was significant for one year of sobriety and current tri-weekly use of marijuana. On physical exam, a 3 by 3 centimeter subareolar, tender, mobile, rubbery right breast mass was palpated. A smaller, similiar mass was palpated on the left. There was no nipple discharge or retraction, overlying skin changes, or lymphadenopathy. His testosterone was normal. A diagnosis of bilateral gynecomastia was made, felt to be due to his cirrhosis, compounded by his use of spironolactone and marijuana. The patient stopped both drugs. Two months later, the patient had significant improvement in his pain and decrease in breast tissue. IMPLICATIONS/DISCUSSION: Gynecomastia is common in adult males. The highest prevalence is between 50 to 80 years, with an incidence of 24 to 65 percent. Patients present with a unilateral or bilateral breast mass that may be painful. The most important differentiation is between gynecomastia and breast carcinoma. Carcinoma is less common, usually unilateral, and eccentric rather than symmetric to the nipple/areola. It is firm, fixed and may be associated with skin dimpling, nipple retraction or discharge, and lymphadenopathy. The conditions associated with gynecomastia are felt to represent an imbalance between estrogens and androgens. The most common causes in the adult male are as follows: idiopathic, drugs, cirrhosis, malnutrition, primary hypogonadism, testicular tumors, secondary hypogonadism, hyperthyroidism, and chronic renal insufficiency. Causal drugs include antiandrogens, antibiotics, antiulcers, chemotherapeutics, cardiovascular drugs, and drugs of abuse. The history, physical, and certain diagnostic tests can identify the cause in the majority of patients. Patients with a pain, acute onset, or without an obvious etiology should be evaluated with serum hCG, luteinizing hormone, testosterone, and estradiol levels. An asymptomatic patient found to have gynecomastia incidentally, deemed to be idiopathic, does not require further tests and should be reevaluated in six months. Otherwise, treatment should be directed at removing the underlying cause. Active treatment with androgens, antiestrogens, and aromatase inhibitors is indicated in persistent gynecomastia associated with severe pain, tenderness, or embarrassment. Surgical therapy, including liposuction or excision, is considered in patients who do not respond to medical therapy.