LEARNING OBJECTIVES: 1. Recognize the clinical features of Kimura's disease. 2. Recognize that a constellation of nonspecific clinical signs can represent a specific entity when pursued. 3. Develop a differential diagnosis for lymphadenopathy and differentiate accordingly. CASE INFORMATION: A 63 year old man born in the Dominican Republic but residing in New York City for 30 years presented to a medical clinic with 2 years of right neck swelling. The gentleman initially noticed a small, painless bump in his neck. The bump enlarged to an eventual size of 8cm by 14cm. Similar bumps also arose in the right neck, left neck, and right axilla. Eventually the predominant lesion became painful and itchy. The patient felt healthy otherwise, denying fevers, fatigue, and weight loss. The patient had a history of hypertension, PPD positivity with negative CXRs, and remote microscopic hematuria. He was taking hydrochlorothiazide and prazosin for his hypertension. He was married with 2 children. A He traveled to the Dominican Republic every year for holiday. No other travel was noted. His physical exam was remarkable for a mobile nodular mass 8cm Â 14cm in the right anterior cervical neck. There were discrete subcutaneous nodules on both sides of the neck. There was lymphadenopathy in the left neck and right axilla. The nodules and lymph nodes were mobile and firm but without fluctuance. There was no hepatosplenomegaly or other lymphadenopathy present. Pertinent labs included a wbc count of 8100/mm3 with 38% eosinophils (absolute eos count 3078) IgE levels were high at >1800kIU/L. HIV test was negative. Excisional biopsy of lymph node revealed follicular hyperplasia with distinct lymphoid follicles with surrounding fibrosis, abundant eosinophils, post-capillary venules, no granulomas or necrosis, and preserved architecture. Cultures and smears were negative for AFB, fungi, bacteria, and Reed-Sternberg cells. Flow cytometry was negative for lymphoma. In addition, skin snips from the patient were negative for microfilariae. The patient was started on prednisone with rapid resolution of lymphadenopathy, however this recurred when prednisone was tapered. The patient was restarted on full dose prednisone and scheduled for curative radiotherapy. IMPLICATIONS/DISCUSSION: Kimura's disease is a rare disease usually seen in Asian men. They present with lymphadenopathy of the head and neck and eosilophilia. Pathology reveals preserved lymph node architecture with necrosis, predominant eosinophils, endothelial venules, and capsular fibrosis. Often lymphadenopathy is attributed to an infectious agent or malignancy. As this case illustrates, there are other causes to consider. A thorough evaluation and exclusion of important entities such as Hodgkin's disesase, extra-pulmonary TB, and Cat Scratch Disease is critical. Histological evaluation often provides a definitive diagnosis, but not always. The pathology along with the clinical signs (features) were required for the diagnosis in this case. osteomyelitis and an epidural phlegmon. Magnetic resonance imaging (MRI) showed cord compression. Needle biopsy of the abscess was performed, yielding prurulent material. In consultation with Infectious Disease and Pulmonary services, empiric treatment for TB was held as it could mask a pyogenic process. By the eleventh hospital day, needle biopsy failed to grow organisms. Polymerase chain reaction (PCR) results of the biopsy aspirate was positive for mycobacterium tuberculosis (M.Tb) and the patient began therapy with isoniazid, rifampin, pyrazinamide and ethambutol. He subsequently underwent surgery for spinal stabilization and was discharged on an 18 month course of antibiotics. IMPLICATIONS/DISCUSSION: Low back pain is the fifth leading reason for medical visits in the United States. A careful history identifies``danger'' signals of infection or malignancy, such as constitutional symptoms, immunosuppression, age and unremitting nocturnal pain unrelieved by recumbency. In Pott's disease, systemic symptoms are often absent, and patients do not undergo testing until the process is advanced. CXR is not useful in diagnosis since more than 50% of patients do not have lung disease. The primary focus starts in the anteroinferior aspect of the vertebral body of the thoraco-lumbar spine. Local destruction leads to collapse, disc herniation and cord compression. Likewise, a tuberculous abscess, seen in more than 50%, can impinge and compress the spinal cord. CT, myelography, and MRI are useful in diagnosis. While biopsy and culture are sensitive and specific, serology and PCR are useful for timely diagnostic confirmation. Literature reports culture sensitivity for mycobacterial detection is improved by culture media supplemented with oleic acid, albumin, dextrose, and catalase, however detection is not specific to M. Tb. PCR of fixed, paraffin-embedded tissue samples, was shown to have sensitivity and specificity of 94% and 83% respectively. In summary, TB remains a major public health problem. Before the disease can be treated it must be recognized. TB should be considered in cases of spinal osteomyelitis. Early institution of therapy reduces morbidity and mortality.