2) Realize its occurrence in males and nonmenstrual females. CASE INFORMATION: MZ was an 18 y.o. caucasian female with a PMH of depression and PTSD who presented to the ER with complaints of fever, rash and abdominal pain. Outpatient medications included only quetiapine. The patient was currently living in a women's shelter b/c of reported sexual abuse and she denied tobacco, alcohol, and drugs. Initial PE was significant for fever, hypotension, conjunctival injection, rash, diffuse abdominal tenderness, and a negative pelvic exam. Labs revealed an elevated WBC count, a renal panel with elevated AG, mild LFT abnormalities, negative CSF tap, negative tox. screen, and a contaminated U/A with ketones. The patient was initially treated with ceftriaxone and aggressive fluid management. She did develop anemia and mild pulmonary edema. Her illness gradually improved. She was discharged home and follow up in the office 5 days later revealed desquamation of her hands. Her infectious w/u was negative except for a stool cx growing S. aureus. Toxic Shock Staphylococcal Toxin-1 was negative, but Staph aureus B toxin was positive. IMPLICATIONS/DISCUSSION: The initial cases of staphylococcal TSS were described in young menstruating females in the late 1970's. Much was learned about this disease in a short time. Soon an association was found between highly absorbent tampons and TSS. These tampons were removed from the market in the early 1980's. Since then the number of cases of TSS has declined greatly. Today, however the number of reported cases is relatively stable. These cases can be found in the menstruating and nonmenstruating female, the young and old, and the male and female patient. There are very few cases of Staph TSS secondary to colitis in the literature. Overall disease mortality has also improved throughout the years but remains as high as 15% in some studies (although more likely 2±5% by most accounts). It is therefore important to think of this disease in the differential diagnosis and treat it appropriately. The patient was started on a diltiazem drip for rate control and advanced to metoprolol for long term management. She was also started on aspirin for thrombus prophylaxis. No underlying etiology for her arrhythmia was identified. However, an extensive review of the patient's family history revealed that her father had been diagnosed with heart failure secondary to Chagas' disease back in El Salvador. A sample of the patient's blood was sent for serology for Chagas' disease and returned positive with a titer of 1:512. The patient was placed on nifurtimox. Although it was believed that she may have been in the subacute phase of her illness, treatment was initiated as a means of preventing advancement of her disease to chronic illness. IMPLICATIONS/DISCUSSION: Chagas' disease is a protozoan infection due to Trypanosoma cruzi and is primarily related to three problems: megaesophagus; megacolon; and cardiac disease. Chagas' myocarditis is the most common form of cardiomyopathy in Latin-American countries and therefore has become a considerable public health problem for many areas. It is estimated that over 750,000 years of productive life are lost annually because of premature deaths due to this disorder. The presentation of Chagas' disease consists of an acute and chronic phase, separated by an indeterminate phase. The latter describes a patient who has positive se-rology, but no symptoms, physical signs, or laboratory evidence of organ involvement. Biopsy was consistent with candida without evidence of aspergilus. IMPLICATIONS/DISCUSSION: Aspergillosis encompasses a variety of manifestations of infection. The major entities include invasive disease, acute bronchopulmonary aspergillosis (ABPA) and pulmonary aspergilloma. Disease due to aspergillus organisms is uncommon and usually occurs in the setting of immunosuppression for which neutropenia (ANC < 1500 TH/ MM3) and corticosteroids are the most common predisposing factors. The most common manifestation of invasive aspergillosis involve the lung and contiguous structures. The central nervous system and gastrointestinal system (especially esophagus and bowel) are the first and second most common target of dissemination respectively. Symptoms of aspergillus esophagitis are usually consistent with severe odynophagia similar to those of candidiasis. Isolated esophageal aspergillosis is very rare. There are two case reports published describing this unusual presentation, one involving a patient with acute leukemia and another occurred in a patient 25 days post bone marrow transplantation. This case is of interest because though our patient was steroid dependent she was not neutropenic prior to and at the time of presentation (ANC > 1500 TH/MM3). Further she was asymptomatic in regards to her fungal infection and did not have evidence of aspergillus involvement at other sites. In addition esophageal involvement usually occurs as a secondary complication of severe invasive lung disease. To our knowledge, this is the first case to describe isolated esophageal aspergillosis in a patient without the overt risk factors for invasive aspergillosis. Health is now moving forward in fostering high quality language programs that will help eliminate racial and ethnic disparities in healthcare and will promote access to optimal healthcare for all. Legislation has been introduced into the State legislature regarding cultural competency training and additional recommendations to the State are being drafted to expand this model program. Our hospital is now implementing an on-going training program for all interpreters and staff prior to enlisting their services, have hired bilingual greeters for the hospital, and a bilingual patient advocate. We have also initiated a cumulative and ongoing series of research projects in the field of cross-cultural -old Oriental man presented with complaints of cramping abdominal pain, tenesmus (immediately after eating) and constipation with pellet like stools of 3 weeks duration. His past history included Coronary Artery Disease and Radical Prostatectomy for Prostate Carcinoma 8 years ago with regular follow up. Physical examination was normal except for an irregular rectal mass partially occluding the lumen of the rectum. A preliminary clinical diagnosis of rectal carcinoma was made. Flexible sigmoidoscopy showed a cauliflower like ulcero-nodular mass occupying the lumen of the rectum. Biopsies of which were consistent with Adenocarcinoma. CT scan of the pelvis showed a mass adherent to the posterior wall of urinary bladder in the region of trigone, partially obstructing lumen of the rectum and also causing bilateral hydroureters and bilateral hydronephrosis. A subsequent serum PSA was 138 ng /ml, the previous value being 22 ng/ml. Based on this data a diagnosis of prostate carcinoma was made. Because of the extent of disease and underlying heart disease palliative measures were chosen for management including the stents in rectum and bladder to relieve obstruction. IMPLICATIONS/DISCUSSION: Finding a rectal mass on clinical examination is not uncommon. Our case is unusual in that the rectal mass was of prostatic origin, presenting 8 years after initial diagnosis. Though rectal involvement by prostatic carcinoma is present in 0.56% to 11.5% of cases on postmortem studies, the presence of Denonvillier's Fascia usually inhibits it. Commonest modes of involvement of rectum are a bulging prostate mass with intact rectal mucosa or an annular stricture, ulcerating masses being the rarest and accounting for less than 1% of these cases. Knowledge of this is important as it can avoid a misdiagnosis of primary rectal cancer, especially in patients who do not have a history of Prostate cancer or those with a history of prostate cancer who have received radiotherapy. LEARNING OBJECTIVES: 1. To recognise that superwarfarin causes prolonged coagulopathy needing high dose Vitamin K treatment for weeks to months 2. To suspect superwarfarin overdose as a cause of coagulopathy resistant to vitamin K and fresh frozen plasma treatment CASE INFORMATION: A 50 years old gentleman with a past medical history of depression and recurrent suicidal attempts presented to emergency room (ER) with history of hematuria, epistaxis and bruising of skin after suicidal attempt with anticoagulant ingestion. Physical examination revealed widespread ecchymosis of skin and heme positive stool but was otherwise unremarkable. Laboratory studies revealed hemoglobin (Hbg) 4.8 g/dl (13.7±16.5 g/dl), prothrombin time (PT) >50 sec (11.5±14.3 sec), INR too high to be reported, and activated partial thromboplastin time (APTT) >150 sec (21±37 sec). Patient was thought to have ingested warfarin, the most commonly available anticoagulant. His anemia was corrected with blood transfusion and coagulopathy treated by fresh frozen plasma (FFP) and Vitamin K. After 6 days of treatment his Hbg was12.2 g/dl, PT = 14.7sec, INR = 1.26, and APTT = 50 sec. Vitamin K was discontinued and he was discharged home after psychiatry consultation. His epistaxis and bruising of skin returned after 1 week resulting him to revisit ER. Patient denied any further intake of anticoagulant since discharge, however confirmed that the anticoagulant he had ingested 4 weeks ago with suicidal intent was infact superwarfarin (rodenticide) subsequently identified as brodifacoum. His blood studies revealed Hbg 7.9 g/dl, PT >200 sec, INR = 397.5 and APTT = 95.3 sec. He was again treated with FFP, blood transfusion and Vitamin K. This time he was discharged on long term high dose (100 mg/day) oral Vitamin K and out patient follow-up. IMPLICATIONS/DISCUSSION: Superwarfarins were developed in 1970's to overcome warfarin resistance in rats. They are long acting, fat-soluble anticoagulants, and 100 times more potent than warfarin. Their half-life varies from 16 to 69 days compared to 37 hours for warfarin. Brodifacoum is the most commonly used superwarfarin thus the commonest cause of superwarfarin poisoning. Its poisoning is mostly accidental however it can result from suicidal attempt, industrial exposure or deliberate self-poisoning with denial (Munchausen syndrome). Clinical features of brodifacoum poisoning are varied and include epistaxis, hematurea, gastrointestinal bleeding, ecchymosis, hemoptysis, spontaneous abortion and intracranial bleeding. PT, INR and PTT are usually severely prolonged but correct on mixing study. The diagnosis may be confirmed by detecting brodifacoum in blood however it is usually missed on the initial screening test for superwarfarin and may need a special assay. Physicians must have a high index of suspicion of superwarfarin exposure when patients have prolonged unexplained coagulopathy resistant to vitamin K replacement and FFP, along with undetectable warfarin levels and depletion of vitamin K dependent coagulation factors. After correction of initial life threatening coagulopathy by transfusion of blood products these patients should be placed on long-term high dose Vitamin K therapy and closely followed in outpatient clinic.