Occurs when tablets are pulverized and injected. The most common fillers used in tablets are talc, cornstarch, cellulose. These fillers cause an initial arteritis which is associated with rapid influx of neutrophils around the intravascular foreign body. The influx of neutrophils is followed shortly thereafter by granuloma formation as talc particles migrate through the vessel wall to the surrounding perivascular and interstitial tissue. The most common radiographic finding is widespread, 2-3mm well defined nodules typically in the mid lung. The clinical presentation is typically non-specific and may mimic URI with: cough, dyspnea, increased sputum. Sequelae of talcosis includes: panlobular emphysema, acute pulmonary hypertension, ARDS, and spontaneous pneumothorax. Treatment options are limited but include: Dexamethasone and D-penicillamine. Steroids appear to have a limited (if any) role. Vasodilatation with hydralazine may help those with pulmonary hypertension. FACTITIOUS DISORDER-A form of feigned illness which differs from malingering (which has a external incentive-avoiding work, financial gain) in that it has no other incentive other than to be a patient and experience the sick role. Both factitious disorder and malingering differ from somatoform disorders in that they are voluntarily produced. Munchausen's Syndrome is the most extreme (and highly publicized) form of factitious disorder. Patients with factitious disorder often appear more comfortable than their condition would warrant. They may be pleasant, cooperative and receptive to ANY intervention-even if painful and risky. Nurses often note that they often have no visitors/phone calls suggesting anti-social or isolating behaviors. They may also give a medical history that is unbelievable or``too good to be true''. Be suspicious when pt's deny you the right to access old records or speak with previous providers. Yesterday she had been seen in the clinic and diagnosed with trichomonas vaginitis. The resident had dutifully told her that this was a sexually transmitted disease and that both she and her husband needed to be treated simultaneously. Unfortunately, because of her husband's health they had not had sex in over ten years. Now her husband was accusing her of infidelity, a fact she denied vehemently. The Case: The patient is a 59 year old white woman with a 1 week history of burning on urination and a mild vaginal discharge, described as thin and clear. She denied fever or flank pain. Her social history was significant for part-time work as a housekeeper which took her out of the house periodically. Her husband had been disabled for 10 years with a back injury and there had been no sexual activity since the injury. The pelvic examination was remarkable only for a thin watery discharge with a mild odor. Cervix and adnexa were benign. A wet prep revealed numerous trichomonads. IMPLICATIONS/DISCUSSION: Trichomonas vaginalis infection classically presents as a vaginitis/cervicitis with a thin, yellow, frothy, foul smelling discharge often times associated with dysuria. Nevertheless, up to 40% of infections are asymptomatic. The association with sexual activity is well documented. As an illustration of this, the incidence of infection in the general population has been reported as high as 5-10%, while in venereal disease clinics the incidence jumps to 25% and up to 70% among prostitutes. However, unlike other sexually transmitted diseases, the age distribution of of trichomonas infection is bimodal. For example, most women with gonorrhea are in their early 20's, with less than 2% over the age of 40. Trichomonas infections also peak during years of maximal sexual activity but there appears to be a second peak around the time of menopause. Indeed, >30% of patients are over the age of 40. It has been hypothesized that this represents women infected at an early age who harbored the trichomonas asymptomatically but present with symptoms at a time when the vaginal milieu changes (eg. menopause) allowing the trichomonas to propagate. There are several reported cases of newborns and apparent virgins with trichomonas. These likely represent either transmission from infected mothers at the time of birth or a nonsexual source. Studies from the British literature (Burgess,1963; Whittington 1957) establish that trichomonas can survive for up to 45 minutes on a toilet seat, although transmission by this route has never been proven. Has she been faithful? Clearly there is valid justification to believe that she is telling the truth. year-old man presented with a five weeks of bowel and bladder incontinence and parethesias of the lower extremities. He had a history of diabetes mellitus and HIV. Two weeks prior he had presented for evaluation of urinary hesitancy and paresthesias of the lower extremities. He was diagnosed with diabetic peripheral neuropathy and released. On this admission, his neurological examination revealed decreased sensation in the lower extremities, absent ankle reflexes, an ataxic gait, saddle anesthesia, and decreased anal sphincter tone. An MRI of the spine revealed an extradural mass extending from L4 to S4. Biopsy confirmed the neoplasm to be Burkitt's lymphoma. IMPLICATIONS/DISCUSSION: Although spinal cord compression is a medical emergency, access to an MRI may be limited. The physical examination is instrumental in establishing the diagnosis and expediting appropriate therapy. Although diabetes and HIV are common causes of peripheral neuropathy, they are not causes of the cauda equine syndrome (CES). A methodical physical examination detected saddle anesthesia and sphincter impairment, establishing the diagnosis of CES. Compression of the roots can be caused by a ruptured disk, infection, fracture, or tumor. HIV patients are at increased risk for tumors associated with co-sexually transmited viral infections such as HHV6 and HHV8. CES is a neurosurgical emergency, requiring immediately operative decompression of the spinal canal. A timely diagnosis of this syndrome is essential, as patients with paraneoplastic impingement may not regain function beyond the deficit at presentation.