THROMBOTIC THROMBOCYTOPENIC PURPURA AND EXTENSIVE BONE MARROW NECROSIS SECONDARY TO METASTATIC SIGNET RING CELL ADENOCARCINOMA. I.D. Bucaloiu 1 , J. Brady 1 , S. Walker 1 , K.K. Pachipala 1 ; 1 Geisinger Medical Center, Danville, PA (Tracking ID #76352) LEARNING OBJECTIVES: Although rare, the association between Thrombotic Thrombcytopenic Purpura and extensive Bone Marrow Necrosis can be the presenting picture of metastatic adenocarcinoma. CASE INFORMATION: A previously healthy 49 years old male was transferred from another hospital with a two-week history of severe, intractable back pain, short-term memory loss fatigue and shortness of breath. On exam he was afebrile, icteric and had multiple ecchymoses on the trunk. Complete blood count revealed severe anemia and trombocytopenia, with serum hemoglobin of 4.6 g/dl, a platelet count of 16 Â 109/L and white blood bell count of 3.22 x 109/L. There was evidence of severe hemolysis with serum lactate dehydrogenase of 2659 U/L and Serum Haptoglobin of 7 mg/dL. Direct Coombs test was negative. The absolute reticulocyte count was 42.6 K/uL. The peripheral smear revealed schystocytes and thrombocytopenia. A CT scan of chest, abdomen and pelvis showed splenomegaly, and was otherwise unremarkable. The initial bone marrow aspirate and biopsy revealed extensive necrosis of bone marrow with marked reduction of normal hematopoietic elements. Flow cytometry was negative for a clonal lymphoid proliferation. The repeat contralateral iliac crest biopsy revealed among the extensive necrosis, small aggregates of highly atypical cells with pleomorphic hyperchromatic nuclei. Some cells had signet ring morphology and they stained positive with mucicarmin and cytokeratin stains, which indicate a carcinomatous origin. The patient received multiple blood transfusions, high dose steroids and plasmapheresis, but none of these interventions had a significant impact on the clinical course. His delirium worsened, developed respiratory failure and expired on the 7th day of hospitalization. IMPLICATIONS/DISCUSSION: Massive bone marrow necrosis is known to occur in the context of malignancy, usually hematopoietic, lymphomas, leukemias, but also solid tumors. At the same time TTP has been reported to occur in the setting of neoplasms, especially adenocarcinomas, usually gastric, pancreatic and breast. The association of TTP and massive bone marrow necrosis, although rarely reported in the literature may represent as illustrated in our case report the heralding picture of metastatic cancer. It is important for physicians to be aware of this association as it forces one to search for an unapparent neoplasm. and pelvis with subsequent abdominal MRI confirmed cavitary lesions in the left upper lobe and revealed a 12 Â 10 Â 7.5 cm adrenal mass. A serum ACTH was low at 3 pg/mL (normal 9± 52 pg/mL) and a serum free morning cortisol of greater than 50 mcg/dL (normal 6±20 pg/mL) confiming a diagnosis of Cushing syndrome. Urine catacholamines were normal. The adrenal mass was later surgically removed with pathology confirming a diagnosis of adrenocortical carcinoma. Sputum cultures obtained by bronchoscopy grew significant colonies of Nocardia Farcinica and Nocardia Nova. The patient was started on intravenous trimethoprimsulfamethoxazole for six weeks followed by oral therapy. IMPLICATIONS/DISCUSSION: Nocardiosis is a rare finding in immunocompromised patients with an estimate of 500±1000 new cases per year. Most cases involve the lung with inhalation as the mode of entry. Although an immunocompromised state predisposes patients to Nocardia infection, steroid use is considered to be an independent risk factor. Our patient, while not taking exogenous steroids, did have very high levels of endogenous cortisol. Definitive diagnosis is typically made by routine culture of an isolated specimen. The most effective treatment for Nocardiosis remains speculative and is based mostly on small retrospective studies and case reports. Trimethoprim-sulfamethoxazole demonstrates synergy against Nocardia and general consensus supports high doses of this drug initially followed by long-term treatment with lower doses for up to one year due to the high degree of recurrence of disease. As demonstrated in this case, one should consider Cushing syndrome as a risk factor for the development of Nocardia infections. year-old man presented with one day of abdominal and back pain. He was a daily heroin user and his last injection was two hours prior to presentation. During his evaluation, he became uncooperative and combative, subsequently leaving against medical advice. Two hours later he was found disoriented on the street. His temperature was 39 C; he had nuchal rigidity and tenderness to palpation over the lumbar spine. There were no murmurs, purpura, or petechiae. He rapidly developed respiratory failure and was intubated. Blood, urine, and CSF cultures grew methicillin-resistant Staphylococcus aureus. He received seven days of vancomycin, and rifampin, After stopping a seven day course of antibiotics, his fever returned. A repeat lumbar puncture revealed persistently positive MRSA. Vancomycin and rifampin were restarted , and his fever resolved. An MRI of the lumbar spine demonstrated pyomyosits of the paraspinal muscles. He received 42 days of vancomycin and rifampin with clinical improvement. IMPLICATIONS/DISCUSSION: Back pain in the intravenous drug user, especially when associated with fever, must prompt high suspicion for meningitis, discitis, oteomyelitis of pyomyositis. Although meningitis from Staphyloccocus aureus is usually secondary to neurosurgical procedures, intravenous drug users are susceptible to staph CNS infections due to their frequent innoculation and impaired immunity. With the increased availability of antibiotics on the street, methicillin-resistant Staphyloccocus aureus is increasingly becoming a community acquired pathogen. As this case illustrates, serious CNS infections in an intravenous drug user may warrant empiric vancomycin until definitive cultures return. Staphyloccocus aureus bacteremia requires at least two weeks of intravenous antibiotics; longer courses are required for deep-seated infections. A secondary focus should always be sought, as Staph is a rare primary infection. This case illustrates the importance of maintaining a high degree of suspicion for Methicillin-resistant Staphyloccocus aureus in intravenous drug users presenting with back pain and fever.