Post-operatively, the pt was emergently intubated for acute respiratory failure. Physical exam revealed Temp 39.2, HR 146 (reg), BP 107/38, slight RUQ tenderness, liver span 13 cm, no fluid wave or shifting dullness, and 2 vesicular lesions on the Rt upper inner thigh. DDx at this point included HELLP syndrome, acute fatty liver of pregnancy, acute viral hepatitis, pyelophlebitis, portal vein thrombosis, and acute hepatic failure secondary to sepsis. Antimicrobials were changed to ceftazidime, vancomycin, and acyclovir. On hospital day 11, PCR for HSV type 1 and 2 returned positive. In addition, cultures of the vesicular lesions on the patient's right thigh grew herpes simplex. Further questioning of the patient's partner revealed a hx of genital herpes. With the initiation of acyclovir, the pt defervesced and her transaminases decreased. However, she suffered multiple ICU complications, as well as herpes encephalitis. The newborn infant was in the NICU with herpes meningitis. IMPLICATIONS/DISCUSSION: Hepatitis due to herpes simplex virus (HSV) is an uncommon, but potentially fatal cause of hepatitis that is often not considered in the DDx of acute hepatitis during pregnancy. HSV can affect the liver during primary or recurrent infection, although hepatitis during recurrent infection has not been documented in immunocompetent hosts. Review of the literature suggests that HSV hepatitis can present with wide clinical spectrum from mild symptoms to fulminant hepatic failure. However, the initial symptoms are often nonspecific. Therefore, a high index of suspicion and early diagnostic tools, such as HSV DNA detection are essential. Unfortunately, serological tests have limited value for establishing an early diagnosis, though they may be used retrospectively to support the diagnosis. Definitive diagnosis is made with a liver biopsy, but this is frequently not possible because of severe coagulopathy.`J UST A MED REFILL''. S. Elad 1 , G. Applebaum 1 ; 1 University of California, Los Angeles, Sylmar, CA (Tracking ID #74705) LEARNING OBJECTIVES: 1. To recognize the impact the closing of community clinics has had on uninsured and indigent patients. 2. To raise the possibility that short term economic gains resulting from the closure of primary care clinics may result in preventable hospitalizations. CASE INFORMATION:`Maria' is a 56 -year old woman with a past medical history of diabetes, hypertension and hyperlipidemia that came to the hospital urgent care for a`med refill'. She ran out medications 2 months ago after her community clinic was closed secondary to`budget cuts'. Today Maria reports she has noticed increased urination and thirst for the past two weeks and a frontal headache with blurry vision for the past three days. She denies chest pain or shortness of breath. She has not been febrile. Maria had been on two medications for her blood pressure and diabetes, and a pill for high cholesterol. Presently she is completely out of her medications. When questioned why she waited two months to get her medications refilled Maria stated the two hour bus ride and 6 hour wait in the emergency room required her to take time off work she could not afford. On exam, Maria's blood pressure was 190/108 with a pulse of 83. The rest of her cardiac, pulmondary and nuerologic exam was unremarkable except for bilateral decreased visual acuity. Her blood sugar was 275 with sugar and protien in her urine but no ketones. Her anion gap was normal as was her blood count. Maria was given a dose of lisinopril and her headache resolved once her blood pressure decreased to 160/90. She was restarted on her oral diabetes medication. Her medications were refilled and she was instructed to return to urgent care in one week to have her blood pressure and blood sugar rechecked. IMPLICATIONS/DISCUSSION: The national health care crisis has been the topic of many news programs and newspaper articles for the past year. According to the Kaiser Family Foundation approximately 19% of Californians are uninsured. In California, which faces a multi-billion dollar deficit, politicians have been discussing ways to trim costs which have included proposals to close hosptials and clincs. The recent closure of several primary care clinics in Los Angeles County has left many patients like Maria without access to health care. By the time Maria was able to visit the hospitals' urgent care clinic she had run out of medications and both her diabetes and hypertension were poorly controlled. Had Maria required hospitalization at the time of her visit the cost would have been much higher. Maria's primary care visit to the emergency room was entirely avoidable had her clinic not been closed. Much of the short term economic gains obtained by closing county subsidized clinics may later be lost by patients utlizing our emergency rooms for primary care visits. Even in the context of our current financial situation steps need to be taken to ensure that uninsured patients have reasnable access to primary care services outside the hospital setting. LEARNING OBJECTIVES: 1-To recognize fungal vertebral osteomyelitis as an etiology for worsening back pain in patients with history of multiple back surgeries. 2-To consider secondary bacterial infection in patients who fail to respond to appropriate antifugal therapy. CASE INFORMATION: A 48-year-old male presented in January 2001 with worsening back pain, bilateral leg weakness and urinary incontinence. Condition started in 1993 after back injury during demolition job that required multiple back surgeries. Examination was remarkable for bilateral leg weakness and local tenderness over lumbar spine. MRI examination revealed disc space infection at the L3-4 level with adjacent vertebral osteomyelitis. CT guided aspiration of L3-4 space was performed and cultures grew Candida albicans. Treatment was instituted with IV Amphotericin B via Mediport. Therapy was switched to oral fluconazole 400 mg daily. In March 2001, he developed Mediport related Staphylococcus aureus sepsis and was treated with cefazolin for two weeks. Patient was re-admitted in April with worsening back pain. MRI examination revealed worsening inflammatory changes within L3 and L4 vertebral bodies and small epidural abscess. CT guided aspiration was performed and cultures grew methicillin sensitive Staphylococcus aureus. We started treatment with Nafcillin 2 gm IV every 4 hours in addition to fluconazole. Surgical debridement followed by physical therapy and long term IV antibiotics controlled our patient's symptoms. IMPLICATIONS/DISCUSSION: Candidal vertebral osteomyelitis is a rare disease with 65 cases identified in literature. Risk factors have been associated with hyperalimentation, surgical procedures, abdominal surgeries, immunosuppressive therapy and IV drug abuse. The usual mode of spread is hematogenous during episodes of fungemia. The most frequent mode of presentation is severe back pain and diagnosis can reliably be made only when the organism is isolated from the lesion. Both medical and surgical treatment resulted in more favorable outcome for most patients. This case demonstrates the importance of recognizing fungal vertebral osteomyelitis as a cause of worsening back pain in patients with history of back trauma and multiple back surgeries even in the absence of risk factors.