THE USUAL SUSPECT IN AN UNUSUAL SPOT. J.T. Tseng 1 , P.P. Balingit 1 ; 1 UCLA San Fernando Valley Program, Sylmar, CA (Tracking ID #76488) LEARNING OBJECTIVES: 1. Recognize the clinical presentation of liver abscess. 2. Consider mycobacterial and other atypical organisms as etiologies of liver abscess in the immunocompromised host. CASE INFORMATION: A 41 year old Mexican male with no significant past medical history presented to an urgent care clinic with 1 month of gradually worsening right upper quadrant abdominal pain associated with fevers and night sweats. He described the pain as a dull, constant discomfort without radiation, exacerbated with movement and without change with food intake. Several episodes of nausea and vomiting occurred in the last two days. Intermittent watery diarrhea was present over the past two weeks. He sought medical attention for his abdominal pain one week ago and was prescribed levofloxacin and metronidazole without relief of symptoms. The patient reported frequently visiting Mexico, his last trip being 2 months prior. He denied HIV risk factors including homosexual or promiscuous sexual behaviors, IV drug use, or transfusions. Exam was significant for temperature of 38.8 C and heart rate of 106. Tenderness was elicited upon palpation of the right upper abdominal quadrant. No hepatomegaly was apparent, and a Murphy's sign was not present. CBC was remarkable for lymphopenia. Liver transaminases were within normal limits. No organisms were identified from blood cultures, stool cultures, and studies for ova and parasites. HIV antibody test was positive. Abdominal CT scan revealed a 2 Â 2 cm low-density irregular lesion consistent an with abscess within the right hepatic lobe. Tissue obtained from percutaneous drainage of the liver lesion revealed necrosis and granulomatoid inflammation. AFB stain was positive, and TB was identified in culture. TB was also isolated from the patient's sputum, despite the absence of cough, dyspnea, or other pulmonary symptoms. Four-drug antitubercular therapy was initiated with resolution of the patient's presenting symptoms. IMPLICATIONS/DISCUSSION: Liver abscesses of varying etiologies tend to have similar clinical presentations. Patients typically present with fever, night sweats, and right upper quadrant abdominal pain. Identification of the causative agent becomes critical when patients fail to respond to empiric therapy against pyogenic or amebic abscesses. Serologies are often not helpful in identifying an organism as assays often lack sufficient sensitivity or specificity and blood cultures may not reveal the offending agent. While CT, MRI, or ultrasonography may help differentiate liver abscesses from neoplastic processes, they are unable to identify a specific organism. Drainage of the abscess remains the mainstay of diagnosis. For immunocompromised patients, laboratory analysis of drainage fluid should include evaluation for atypical organisms as well as Gram stain, culture, and ova and parasites. In these patients, mycobacterial and fungal organisms may form abscesses in addition to typical granulomatous lesions when they invade the liver. LEARNING OBJECTIVES: 1. Acromegaly can present in younger patients 2. The role of insulin-like growth factor 1 in diagnosis and therapy 3. The importance of early diagnosis CASE INFORMATION: 22 y/o latino male presented to our urgent care clinic with a history of headache for over 2 years. The headache was intermittent in nature, mostly frontal and without exacerbating, relieving factors or associated symptoms and with minimal relief from analgesics. On systems review he admitted to an increase in the size of his hands and feet. His family also reported a gradual change in his appearance. On examination, the patient was normotensive. He had prominent supraorbital ridges and a large lower jaw with poor occlusion of teeth and lower teeth overbite. His facial wrinkles were exaggerated and lips full. The nose tongue and ears were enlarged, the hands were large, doughy spade like and the skin over them thickened. Neurological exam showed grossly intact bitemporal visual fields. His appearance was consistant with the diagnosis of acromegaly. A work up consisting of growth hormone (GH), insulin-like growth factor 1 (IGF-1), TSH and random glucose was initiated with MRI imaging of the brain. The patient was also referred to ophthomology for visual field testing. IMPLICATIONS/DISCUSSION: Acromegaly is a disease caused by secretion of excessive amounts of growth hormone, almost always occurring as a result of a benign adenoma of the anterior pituitary gland. The disease occurs most frequently in middle age with an incidence of 3±4 per million. Somatotroph adenomas of the pituitary may be large enough to cause visual impairment or headaches as in our patient. Acromegaly leads to decreased life expectancy with a 2±3 fold increase in mortality from cardiovascular causes, cancer and all causes. The diagnosis is made clinically and confirmed by finding a high levels of GH and IGF-1. Growth hormone binds to receptors resulting in the stimulation of production of IGF-1 which mediates most of the actions of GH. Growth hormone release is pulsitile with concentrations varying throughout the day. Random GH is therefore not a reliable diagnostic marker and is only useful when correlated with the glucose tolerance test. IGF-I is present at more steady concentrations and is a reliable marker of disease and its control. Most patients are treated with transphenoidal surgery which usually results in clinical improvement with decreased GH and serum IGF-I concentrations. Other options include radiation therapy, medical therapy with dopamine agonists or somatostatin analogues. Pegvisomant is a newly developed GH receptor antagonist that leads to decreased IGF-I levels and clinical improvement. Reducing growth hormone levels improves symptoms and complications of the disease and increases life expectancy.