A. George 1 , R.D. Hobbs 1 ; 1 Oakwood Healthcare System, Dearborn, MI (Tracking ID #76605) LEARNING OBJECTIVES: To recognize that shingles, although most commonly thought of as a sensory problem with a characteristic rash, can cause diaphragmatic paralysis. CASE INFORMATION: A 71 year-old white male with stable hypertension, CHF and COPD, presented to the emergency room with severe dyspnea. He had a 12-year history of chronic elevation of the left hemidiaphragm and had been well except for recent right-sided neck pain. There was no rash. He was intubated. The following day he developed a classic shingles rash involving the right side of the neck. An EMG revealed a right-sided C3-C4 motor neuropathy. Phrenic nerve function did not return. He died six weeks later when he extubated himself at a nursing facility. Autopsy revealed that the chronic elevation of the left hemidiaphragm was due to a benign angiolipoma and unrelated to the viral infection. IMPLICATIONS/DISCUSSION: Sir William Broadbent first described muscular paralysis in association with zoster in 1866. In 1949, Halpern and Covner published the first description of zoster induced diagphragmatic paralysis. Since then, anecdotal cases have been reported although complete historical data is frequently missing and it has been difficult to elucidate the natural history of the condition. Based upon cumulative data from 10 well-documented cases, several tentative conclusions can be made. The average patient is 69 years of age (range 54±79). The time from rash to paralysis can vary widely from almost immediately to 210 days. In 7/10 cases phrenic nerve function did not recover. In the remaining cases, recovery occurred between 30 and 540 days later. The right side was affected in 7/10 cases although this is not statistically significant. The ratio between male and female patients is 7/3 but not statistically significant in this series. Pathologically, zoster induces a myelitis that involves the dorsal root ganglia. Why certain individual develop this rare complication is unknown and will require many further observations. At present, though, the point is clear±herpes zoster can cause diaphragmatic paralysis in the elderly. In such cases the paralysis may develop as a late complication with a poor chance of recovery. CASE INFORMATION: A 63-year-old woman was referred to our center for evaluation of tinnitus in her right ear for 9 months. She described the sensation as,`like the sounds of a steam engine pumping in my ear,' and that it coincided with her heart beat. She noted that applying pressure with fingers over an area in the right retroauricular area would reduce this abnormal noise. Work-up at an outside hospital was negative including, carotid ultrasound, CT scan of mastoid and temporal bone, audiometry and MRI of the head and internal auditory canal. Examination was significant only for a loud continuos bruit over the retro-mastoid area. Complete blood counts, serum chemistry, and electrocardiogram was normal. Cerebral angiogram showed an extensive dural arteriovenous fistula (AVF) affecting the distal transverse and sigmoid sinuses with supply through both internal and external carotid arteries as well as right vertebral artery. There was no evidence of cortical venous thrombosis. Thrombophilia work-up was normal. She underwent a combined transarterial embolization and stereotactic radiosurgery using gamma knife. Tinnitus resolved completely after intervention. She remains asymptomatic at the 3-month follow-up visit. IMPLICATIONS/DISCUSSION: Pulsatile tinnitus resulting in audible retro-auricular bruit could result either from systemic diseases, causing alteration in hemodynamic, or due to local disorders within or close to the petrous bone. The most common causes of pulsatile tinnitus includes benign intracranial hypertension, atherosclerotic disease, and glomus tumor. Dural AVF is a rare cause of pulsatile tinnitus (2%).However, 90% of patients with dural AVF present with pulsatile tinnitus. Dural AVF has been reported following trauma, infection, pregnancy related thrombophlebitis, surgery on the sigmoid and ethmoid sinuses. Cerebral angiogram remains the diagnostic modality of choice. If untreated, a third of dural AVF's develop intracranial bleeding or infarction. Treatment of dural AVF involves transarterial particulate embolization and radiosurgery using a gamma knife .High index of suspicion and thorough physical examination remains crucial in the early recognition of dural AVF. 2) Recognize principles of management of diabetes mellitus during Ramadan. CASE INFORMATION: A 40-year old female immigrant from Somalia with the history of poorly controlled type II diabetes for the past seven years was enrolled in our continuity clinic. She had been on numerous oral hypoglycemic agents without adequate benefit. Her blood glucose ranged from 200±380 mg/dl and glycosylated hemoglobin was 10.7%. She was started on insulin 70/30, 100 units in the morning and 70 units in the evening with addition of oral thiaglitazone agent. During the month of Ramadan her insulin dose was decreased to 50 units in the morning and evening and she was advised to take her oral medication in the evening as most of her meals were spread over night till dawn. While accompanying her daughter for routine checkup she complained of feeling of generalized``shakiness'' which was new to her. We obtained a random blood glucose level, which revealed a blood glucose of 37mg/dl. She was treated with supplemental glucose with complete resolution of her symptoms. Her insulin regimen was subsequently adjusted further and dietary education and hypoglycemia education was given. Frequent telephone calls were made to adjust her insulin doses and monitor her blood sugars. IMPLICATIONS/DISCUSSION: Fasting in the month of Ramadan represents a recurring annual event in the life of a Muslim patient. Patients with brittle type I diabetes and poorly controlled type II diabetes could develop complications during month long fasting with change in dietary habits. Physicians should monitor their diabetic patients closely and adjustment in the insulin regimen should be made to prevent hypoglycemia. Long acting oral hypoglycemics and premixed insulin should be avoided. Dietary principles should be reinforced. Education regarding home monitoring of blood glucose, hypoglycemia episodes is recommended. After Ramadan, patient's therapeutic regimen will need to be changed back with repeat overall education. Obtaining detailed history could help in ascertaining additional cultural factors which could interfere with management of chronic illnesses.