1. in November 1999 complaining of weight loss, bulky stools, fatigue, abdominal distention, and anorexia. Review of those hospital records revealed an extensive evaluation that yielded a diagnosis of``protein losing enteropathy". She improved with total parenteral nutrition (TPN). Small bowel biopsy and serologies were not reported, nor was there mention of treatment with a gluten-free diet. In May 2000, the patient presented to our institution with similar complaints and worsening lower extremity edema and weight loss. Physical examination revealed an extremely cachectic woman with flat affect, hypotension, tachycardia, inspiratory crackles, hepatomegaly, and 2+ pitting lower extremity edema. Laboratory exam showed severe hypoalbuminemia, hyponatremia, and hypocalcemia, mildly elevated transaminases and alkaline phosphatase, and iron deficicency anemia. Antigliadin and antiendomysial antibodies were elevated. Histologic examination of biopsies obtained from the proximal small bowel was consistent with collagenous sprue. Due to her severe presentation, short-term corticosteroids and TPN were initiated. She improved and was discharged with instructions to continue a gluten-free diet. DISCUSSION: Adult patients with celiac sprue may present with a variety of gastrointestinal as well as extraintestinal symptoms, many of which were present in our patient. The diagnosis is usually made by histological evidence of villous atrophy in the small intestine along with symptomatic improvement on a gluten free diet. Serological tests (antiendomysial and antigliadin antibodies) further aid in diagnosis and screening of celiac sprue. Collagenous sprue was first described (in 1970) as continued malabsorption, failure of a gluten-free diet, and a subepithelial collagen layer on small bowel biopsies in a patient previously diagnosed with celiac sprue. Most published case reports of collagenous sprue have not detected these serological markers typical in celiac sprue. Recently, a relationship was postulated when serological markers were present in a patient with collagenous sprue. Our patient exhibited biopsy proven collagenous sprue, but also demonstrated positive serology for adult celiac sprue, supporting the notion that collagenous and adult sprue may be related. Whether this simply reflects an improvement of antibody assays remains to be established as more cases are evaluated. American female presented with abdominal pain, nausea and emesis for two days, and 10 lb. weight loss over a month. Physical examination revealed a cachectic female in moderate distress, hypotension, tachycardia, and diffuse abdominal pain with rebound tenderness. Laboratory exam showed an anion gap metabolic acidosis with a mild lactic acidosis, acute renal failure due to acute tubular necrosis, hyponatremia, leukocytosis with bandemia, and elevated Troponin associated with anteriorlateral ischemic EKG changes. Swan-Ganz readings indicated cardiogenic shock. Emergent cardiac catherization revealed diffuse``beading'' of small and medium coronary vessels consistent with vasculitis. Renal angiography revealed a similar picture. A primary vasculitis workup was negative. Hepatitis studies were consistent with acute HBV: + Hb SAg, À Hb SAb, + Hb Core IgM. Quantitative HBV-DNA was 6290 pg/ml. Hepatitis A, C, and D studies were negative. Initially, high-dose parenteral steroids were started for suspected PAN, but when the HBV serologies became known steroids were discontinued and Lamivudine initiated. Hemodialysis was required. Clinically, the patient improved and was discharged home. Three months later the patient' condition deteriorated acutely, and an acute cardiorespiratory arrest lead to her death. Histological examination revealed a multisystem, segmental, necrotizing vasculitis of medium and small-size arteries (most notably the coronary and renal vasculature) in various phases of progression consistent with classic PAN. DISCUSSION: HBV-related PAN is most commonly described with chronic HBV infections. In our case, laboratory evidence indicated acute HBV infection. Cardiopulmonary involvement of PAN is fairly common, but rarely associated with cardiogenic shock. Traditional treatment of PAN cannot be utilized when PAN is associated with an acute HBV infection. Good therapeutic outcomes have been reported with immunosuppressive agents along with plasma exchanges, or treatment with two weeks of high-dose steroids followed by immnuosuppresives and plasma exchanges. 