SHOULD WE SCREEN YOUNG HYPERTENSIVE PATIENTS WITH ACUTE ISCHEMIC STROKES FOR HYPERHOMOCYSTEINEMIA? L. Vaidyanathan 1 , K. Barnard 1 ; 1 University of Pittsburgh Medical Center Shadyside, Pittsburgh, PA LEARNING OBJECTIVES: There is data suggesting that increased plasma homocysteine confers an independent risk for vascular disease (cardiac, cerebral and peripheral). It also (powerfully) increases the risk associated with smoking and hypertension. Therefore, consider obtaining homocysteine levels in young patients with strokes despite the presence of other risk factors. CASE INFORMATION: A 40 year old hypertensive African American male was admitted to the hospital with sudden onset right sided weakness and slurred speech of 8 hours duration. Past medical history includes hypertension (diagnosed at 24 years). Patient is a nonsmoker. Initial evaluation revealed a blood pressure of 200/110 mmHg, right upper and lower extremity weakness with an upgoing right plantar reflex and dysarthria. MRI of the brain showed small vessel ischemia in the lenticulostriate distribution in the posterior limb of the left internal capsule extending into the anterior aspect of the thalamus and corona radiata. EKG showed normal sinus rhythm and there were no arrhythmais on the monitor. Transthoracic echocardiogram only showed left ventricular ejection fraction of 50%. Carotid and transcranial Dopplers were normal. Fasting homocysteine level was increased at 14.4 Umoles/liter (reference < 9Umoles/liter). DISCUSSION: More data is required to determine if hypertensives and smokers under 60 years with acute ischemic stokes, should be screened for hyperhomocysteinemia and if treating these patients with folate and vitamin B6 will decrease their risk of a recurrent cerebrovascular event. We treated our patient with asprin, folate and Vitamin B6 for secondary stroke prevention. LEARNING OBJECTIVES: 1. Recognize the increasing prevalence of Tuberculosis (TB) in the U.S. due to the immigration of high-tech workers. 2. Highlight the diagnostic dilemma a physician can face when the traditional work-up for TB is negative. 3. Highlight the Adenosine Deaminase Test (ADA) as a quick and highly sensitive and specific test to aid in the diagnosis of TB. CASE INFORMATION: A 26-year-old high-tech worker from Madras, India presented with new, severe headache. He denied cough or constitutional symptoms. The patient had a history of``Intestinal TB'' two years prior, with 16 months of medical therapy, the details of which were not known at the time of admission. His physical exam was completely normal, his chest X-ray showed a diffuse miliary pattern, and a head CT showed multiple ring-enhancing lesions. An extensive work-up for TB was undertaken, all of which was negative. Additionally, tests for fungi, HIV, bacteria, viruses and malignancy were negative. The patient's headache continued to worsen, so anti-tubercular therapy was started along with prednisone to cover for possible neurosarcoidosis. The patient did quite well and was discharged home soon thereafter. One week later, the patient returned with altered mental status. A new CT scan showed massive hydrocephalus. A ventriculostomy was placed and the CSF was analyzed for TB; the AFB smears and PCR were once again negative. An Adenosine Deaminase Test of the CSF was positive. Treatment was initiated to cover for multi-drug resistent TB. An open lung biopsy was performed to harvest tissue for culture and a few AFB were identified by smear. The original sputum culture finally turned positive for TB eight weeks after the patient's initial presentation. The patient improved slowly over the next several weeks and was eventually discharged in stable but neurologically impaired condition. DISCUSSION: CNS TB is uncommon, but is in the differential diagnosis of ring-enhancing lesions. It occurs in only 10% of immunocompetent patients and is highly lethal with mortality exceeding 25%. Even if a patient has widespread TB, the diagnosis of TB can be very difficult and require an extensive, invasive investigation. The ADA test is highly sensitive (100%) and specific (99%) for TB when compared to culture-proven disease in the CNS and lungs. It is an excellent test to aid in the diagnosis of TB and should be considered in the routine work-up whenever CSF or pleural fluid are analyzed.