THE TUMOR THAT MELTED AWAY. J. Cunningham 1 , M. Panda 1 ; 1 University of Tennessee±Chattanooga Unit, Chattanooga, TN (Tracking ID #76984) LEARNING OBJECTIVES: 1. To recognize the similarity in the radiographical and clinical presentation of pulmonary blastomycosis and neoplasms. 2. Stress the importance of a high index of suspicion to avoid misdiagnosis and unnecessary invasive diagnostic procedures. CASE INFORMATION: 57 year old white female with a 40 pack/year history of tobacco abuse presented with persistent cough, mucoid and occasionally bloody sputum for 2 months. She denied fever, chills, night sweats, dyspnea, or recent travel. Her vital signs and room air oxygenation were normal. Physical exam revealed diffusely diminished breath sounds with no accessory muscle use or clubbing. Labs were normal except for a normocytic anemia, and thrombocytosis. CXR showed a right upper lobe infiltrate. CT revealed a large right hilar structure surrounding the distal main stem bronchus with impingement, infiltrative changes surrounding the mass, and an enlarged precarinal lymph node. An endobronchial biopsy and aspiration of the mass revealed no neoplastic cells. Gram stain was negative, and cultures revealed no fungal growth after 28 days. Aspiration smears from the precarinal area were nondiagnostic, but smears from the postcarinal area revealed Blastomyces dermatitidis. She was treated with Itraconazole with complete resolution on repeat CT scan after 6 months. IMPLICATIONS/DISCUSSION: Blastomycosis is a pyogranulomatous infection that can involve many organ systems, but primarily affects the lungs. Infection results from inhalation of the Blastomyces conidia, which may be asymptomatic or present in ways indistinguishable from TB, bacterial pneumonia, ARDS, histoplasmosis, and most ominously bronchogenic carcinoma. Most cases occur in areas surrounding main waterways in North America. Demographics indicate no specific sex, age, race, occupation or seasonal predilection, but exposure to soil is a common factor linking infections. Blastomycosis radiographically mimics many lung diseases with carcinoma being the most common primary diagnosis. Definitive diagnosis is made by isolation in sputum smears or growth in sputum culture which may take up to 30 days. Bronchoscopy requires special considerations in order to obtain a higher yield of fungus. Treatment with lidocaine inhibits growth & limiting concentration to 1g/dL has been recommended. B. dermatitidis can be missed on H&E specimens, so silver or PAS stains should be used. If no diagnosis results invasive thoracoscopy or thorocotomy are often done hastily before the fungus has had time to grow in culture because of the common presentation of Blastomycosis and carcinoma. Blastomycosis infection has been known as``the great masquerader'', therefore, it is very important for physicians to be familiar with the epidemiology in order to develop an index of suspicion for the fungus in endemic areas. Thus, patients can be spared from the distress of undergoing unnecessary testing and invasive surgical procedures. year old Latino male presented to the emergency room with a five day history of severe sharp, pulsatile left sided neck pain, worsened with exertion and head movement with flexion and lateral rotation. This neck pain waxed and waned in intensity throughout the five days prior to admission. The patient reported weakness and numbness of the left arm, which he had used while driving to the emergency room. This weakness resolved with lowering of the left arm. He denied having associated headaches or visual disturbances. The patient was afebrile with a blood pressure of 127/76. Physical examination revealed marked tenderness upon palpation over the left carotid artery. Carotid artery bruits were not present on auscultation. No thyroid tenderness, enlargement, or nodularity was evident. Funduscopic examination, evaluation of cranial nerve function, and assessment of motor and sensory function in the upper and lower extremities were within normal limits. The patient was admitted for treatment of possible left carotid artery dissection and anticoagulation therapy with unfractionated heparin was initiated. An MRI/MRA of the neck was subsequently performed to evaluate for carotid artery dissection. No abnormal flow voids or evidence of dissection were noted. A sonogram of the neck failed to reveal evidence of dissection. ESR was 5, CBC was within normal limits. The diagnosis of carotidynia was made, and the patient's symptoms resolved with prednisone and NSAIDS. IMPLICATIONS/DISCUSSION: Carotidynia is an idiopathic neck pain syndrome arising from the cervical carotid artery resulting in unilateral neck pain that frequently radiates to the ipsilateral face and ear and sometimes to the head. Facial pain is a common primary symptom and carotid artery tenderness and overlying soft tissue swelling are the major physical findings. Two forms of this disorder have been described, an acute form that results in a monophasic illness usually lasting less than two weeks and tending not to recur, and a chronic recurring form which manifests as a vascular headache variant, responsive to antimigraine therapy. Both forms are responsive to the administration of corticosteroids. An evaluation for structural disease of the carotid arteries should be considered in patients with ipsilateral neck pain. MRI/ MRA of the neck has proven highly sensitive. Other imaging modalities to consider include ultrasound and angiography. The diagnosis of carotidynia should be considered only after careful evaluation for other etiologies of neck pain. Considerations for ipsilateral neck pain in the region of the carotid artery near its bifurcation include carotid dissection, migraine headache, thyroiditis, aneurysm of the carotid system, neck neoplasms, or rarely, temporal arteritis.