LEARNING OBJECTIVES: 1. Recognize iliac vein compression (May-Thurner) syndrome as rare cause of left leg swelling in patient with negative venous dopplers 2. Recognize potential for endovascular damage and thrombosis resulting from condition 3. Recognize endovascular stenting as potential cure CASE INFORMATION: 38 year old Caucasian male with history of alcohol abuse presented with three days of abdominal pain and increasing abdominal girth. Serum lipase was markedly elevated and paracentesis showed ascitic fluid consistent with pancreatic ascites. He was started on total parenteral nutrition. He subsequently developed left leg and scrotal swelling. Lower extremity venous duplex imaging was negative for deep venous thrombosis, but contrast venography revealed compression of the iliac vein by the right iliac artery. The patient underwent endovascular stenting of the femoral vein with complete resolution of leg and scrotal swelling. His swelling has not recurred since then. His pancreatitis and ascites also gradually resolved. IMPLICATIONS/DISCUSSION: The potential for obstruction of the left common iliac vein by the overlying right common iliac artery against the pelvic brim was first noted by Virchow. Later, May and Thurner described the``iliac compression syndrome.'' In this patient, it was believed that the ascites coupled with intravascular volume burden of parenteral nutrition led to the patients symptoms. The syndrome, which can be acute or chronic, predisposes patients to thrombosis. Thus, contrast venography should be considered in patients with unilateral left lower extremity swelling and negative duplex imaging. Therapy with endovascular stenting of femoral vein offers patients the chance of cure. angiogram showed a beaded segmental narrowing involving the right internal carotid artery from the bifurcation to the base of the skull. Fibromuscular dysplasia was considered, but a repeat angiogram 3 days later showed that the vessels had returned to normal. The patient was discharged on a calcium channel blocker and coumadin. IMPLICATIONS/DISCUSSION: Stroke in young adults is usually due to cardiac embolism, dissection of arteries, vasculitis, and conditions associated with hypercoagulable states. Reversible cerebral segmental vasoconstriction' also known as Call-Fleming syndrome is a rare cause of stroke or TIA and is characterized angiographically by multiple areas of reversible segmental arterial narrowing. Symptom onset can be spontaneous, but has also been associated with pregnancy, migraine, and use of sympathomimetic drugs. Most patients present with headache. Symptoms can last from few minutes to 6 months. The mechanism of vascular narrowing is not understood. Repeat angiogram may be needed to demonstrate the reversible nature of the angiographic changes. LEARNING OBJECTIVES: 1. Consider scurvy in the differential diagnosis when patients appear to have vasculitis, especially in populations at high risk. 2. Appreciate that early diagnosis, facilitated by taking a good dietary history, is important, as scurvy is potentially fatal. CASE INFORMATION: A 54-year-old schizophrenic man presented to rheumatology clinic with a vasculitis-like skin rash, joint swelling and tenderness, edema of a lower extremity and poor dentition. He was a chronic smoker and had a history of alcoholism. He was not on any medication other than haloperidol on a prn basis. An extensive work up for vasculitis was negative. The patient was referred for biopsy of his skin lesions and scurvy was clinically suspected and confirmed with a low vitamin-C level. Biopsy did not show evidence of vasculitis. The patient's symptoms and signs resolved rapidly with oral vitamin-C. IMPLICATIONS/DISCUSSION: Scurvy is a disorder caused by vitamin C deficiency. Its protean manifestations include petechiae, ecchymoses, hyperkeratoses, arthralgias, malaise, fatigue, impaired wound healing, hair with corkscrew deformity and swollen, red purple gums. Our case is unusual because our patient presented predominantly with joint symptoms and a vasculitic-appearing rash. The diagnosis was missed by the rheumatologist, but was later made based on a dermatologist's suspicion. Scurvy is rare in industrialized nations but can occur in certain high-risk groups because of poor intake of vegetables and fruits or an increased need for vitamin C. High-risk groups include the elderly, pregnant and lactating women, infants, the urban poor, the malnourished, food faddists, alcoholics and those with cancer. Scurvy has also been reported in psychiatric patients with depression, schizophrenia and anorexia nervosa. Schizophrenic patients are predisposed to abnormal dietary patterns, food fads and self neglect which subject them to a risk of scurvy. Our patient was at risk because of underlying schizophrenia, a history of alcoholism, and malnutrition, which predisposed him to poor intake. His smoking history probably contributed to his deficiency by increasing vitamin C needs. LEARNING OBJECTIVES: Recognize that pulmonary edema is one of the many causes of localized upper lobe infiltrates, especially when patients at risk for heart failure have been in dependent positions for prolonged periods of time. CASE INFORMATION: A 52-year old man with type-2 diabetes and severe atherosclerotic cardiovascular disease, who had had a toe amputated for an infected ulcer two days before, was admitted with a 3-day history of orthopnea and dyspnea on exertion. He had been on prolonged bed rest to facilitate healing of his foot. On admission he was hypoxic, with coarse crackles at the apices of the lungs and decreased breath sounds at the lung bases. There was no elevation of JVP and the rest of the cardiovascular exam was unremarkable. CXR showed upper lobe alveolar shadows bilaterally with bilateral pleural effusions and Kerley B lines. Spiral CT of the chest done to rule out pulmonary embolism showed bilateral pleural effusions and bilateral nodular upper lobe infiltrates without evidence of embolism. Atypical pulmonary edema was suspected and the patient was propped up in bed, and given furosemide. His symptoms and CXR abnormalities resolved in 2 days. Natriuretic peptide was found to be markedly elevated at 857 pg/ml and an echocardiogram confirmed LV dysfunction with an EF of 20%. The atypical presentation of this patients pulmonary edema was explained by a gravitational effect on the pulmonary circulation, caused by his prolonged assumption of the Trendelenberg position as part of the management of his diabetic foot problems. IMPLICATIONS/DISCUSSION: Pulmonary edema presents classically with bilateral parahilar alveolar shadows producing a bat wing appearance on CXR. In situations characterized by gravitational effects or alterations in lung perfusion, as in COPD or pulmonary embolism, pulmonary edema may present in less typical ways. Acute mitral regurgitation has been reported as causing right upper lobe pulmonary edema and unilateral pulmonary edema has been attributed to the gravitational effects of posture. These atypical presentations can be confused with pneumonia and aspiration. To make the correct diagnosis in patients with atypical CXR's, clinicians must rely on other clinical and radiologic signs of heart failure and take a careful history. Workup revealed pulmonary infiltrates, anemia with left-shift, and a sputum KOH preparation demonstrating round, non-staining elements felt to be consistent with blastomycosis. After four days of intravenous amphotericin, the patient developed progressive pulmonary infiltrates requiring ventilatory support. Subsequent evaluation with broncho-alveolar lavage revealed alveolar hemorrhage and red cell ghosts within macrophages; these findings were consistent with a vasculitic rather than an infectious disease process. Eleven years later, the patient presented with hemoptysis, fatigue and arthralgias leading to initiation of immunosuppresants for presumed autoimmune disease. After discharge, however, sputum cultures grew Blastomyces dermatitidis, and followup chest CT revealed bibasilar consolidation with cavitary changes prompting a reduction in steroid dose and initiation of anti-fungal therapy. IMPLICATIONS/DISCUSSION: The literature contains multiple cases of blastomycosis mimicking a variety of illnesses, from neoplastic to autoimmune disease. Certain confounding factors can limit the differential diagnosis: (i) the indolent course of blastomycosis with nonspecific presenting symptoms may catch the unwary off-guard, (ii) blastomycosis may present in a manner similar to a variety of disease processes, (iii) and finally, blastomycosis may be superimposed upon another illness, clouding both diagnosis and management.