DYING TO BE THIN. R.E. Graham 1 ; 1 Lenox Hill Hospital, New York, NY (Tracking ID #75181) LEARNING OBJECTIVES: This case demonstrates the limitations of our current knowledge about herbal products, particularly in dose-related toxicities, and calls attention to the need for further studies. This case highlights the need for health care providers to be knowledgeable about the herbal products their patients may be using, and to be able to identify potential herbassociated adverse effects. I hope this case illustrates CAM's prevalence, benefits, and potential dangers but most importantly highlights the importance of obtaining a complete medical history; including asking our patients if they are using and/or incorporating alternative therapies into their general healthcare. CASE INFORMATION: 26 year old thin female presented to the ED at about 5:15 PM complaining of a frontal headache, nausea, and feeling weak after fainting. The patient stated to the triage nurse that she had eaten Mexican food at about 3:30 PM, went home and took``a fat burner pill'' at about 4PM. She has been on fat burner pills and herbal teas for about one year. Suddenly she began to feel nauseous, developed a worsening headache, then fainted which prompted her to seek medical attention. Initially, the patient was taken to the back of the ED. While awaiting physician examination, the patient syncopized and began to have a seizure. The patient was wheeled into trauma and found to be in Ventricular fibrillation with a potassium of 2.4. She was defibrillated and then became hypotensive and progressed into asystole, she was resuscitated and then intubated. She began posturing without corneal reflexes. After stabilization the patient was taken to CT; which revealed±Extensive subarachnoid hemorrhage with the presence of intraventricular hemorrhage. Saddly, over the next 48 hours she was placed on life support and an organ donation referral was made. Soon after she expired. IMPLICATIONS/DISCUSSION: Complementary and Alternative medicine (CAM) is one of the fastest growing sectors in health care today. In 1997 , Eisenberg & et al JAMA, 1998 :280:1569±1575, revealed that 42.1% of Americans (83million) used CAM over the past year. In the same article Eisenberg, showed that only 38% of patients disclose to their physicians their use of alternative therapies when not asked directly. As we continue to see an increase in the rate of obesity in the United States, our patients will incorporate both prescription and nonprescription products in hopes of obtaining their desired weight loss. This current vignette exemplifies the need for the health care provider to first, ask the unasked question, secondly, to have a basic understanding and knowledge regarding CAM, and finally to provide an important role in educating, advising and discussing the potential risks and benefits of CAM, and the need to closely monitor any use of them. CXR showed R mediastinal mass. CT showed diffuse LAN (mediastinal, peritoneal, retroperitoneal) and numerous liver metastases. HIV and hepatitis panel were negative. FNA of neck revealed atypical lymphoid cells. Excisional biopsy showed anaplastic carcinoma, no melanin but HMB-45 and melan A (melanocyte markers) were immunostain positive. IMPLICATIONS/DISCUSSION: Distinguishing between localized and generalized LAN helps guide the appropriate differential diagnosis. Diffuse LAN suggests HIV, mycobacterial infection, infectious mononucleosis, SLE, medications (i.e., phenytoin), metastatic carcinoma and lymphoma. The history and physical exam become crucial in the diagnostic work up of generalized LAN. The history should include signs and symptoms suggestive of infection or malignancy, exposures (cats±cat scratch disease; raw meat±toxoplasmosis; tick bite±lyme disease; unprotected sex or injection drug use-HIV), constitutional symptoms and medications. A complete physical exam should guide the appropriate diagnostic work-up. Patients with generalized LAN should have a CBC and CXR. If these are normal, consider PPD, HIV test, RPR, ANA, and heterophile test, although these tend to be low yield if not specifically indicated. An FNA for cytology is generally the first step due to ease and safety, especially for granulomatous versus malignancy and lymphoma versus carcinoma, yet an FNA fails to provide enough material to examine architectural detail or to perform immunostains. This is especially relevant with younger patients where hematologic malignancies or uncommon solid tumors are a consideration. Metastatic melanoma without a known skin primary accounts for around 3% of melanomas. Prior to melanocyte-specific immunostains, these cases were considered carcinoma of unkown primary. Cases of metastatic melanoma lacking primary skin lesion include primaries of mucosal surfaces (sinuses, oral mucosa, vulva, vagina and anorectum), occular and primary skin lesion which have regressed. Thus, the lack of skin lesion does not rule out metastatic melanoma.