Addiction destroys lives. In The Addicted Brain, leading neuroscientist Michael Kuhar, Ph.D., explains how and why this happens–and presents advances in drug addiction treatment and prevention. Using breathtaking brain imagery and other research, Kuhar shows the powerful, long-term brain changes that drugs can cause, revealing why it can be so difficult for addicts to escape their grip.

Discover why some people are far more susceptible to addiction than others as the author illuminates striking neural similarities between drugs and other pleasures potentially capable of causing abuse or addiction–including alcohol, gambling, sex, caffeine, and even Internet overuse. Kuhar concludes by outlining the 12 characteristics most often associated with successful drug addiction treatment.

Authoritative and easy to understand, The Addicted Brain offers today’s most up-to-date scientific explanation of addiction–and what addicts, their families, and society can do about it.

Evidence-Based Treatments for Alcohol and Drug Abuse encompasses the developments in the field over the last decade, blending theory, techniques and clinical flexibility.

Research in the past decade has shown that substance abuse and substance dependence are treatable. The field has witnessed the introduction of evidence-based psychological and specific pharmacological treatments. Unfortunately, many of the empirical supported therapies for addictions are still not widely applied by practitioners. The third volume in the Practical Clinical Guidebooks Series (PCG), Evidence-Based Treatments for Alcohol and Drug Abuse, defines the characteristics, classification, and prevalence of substance use disorders, and provides the clinician with practical guidelines applicable across a variety of treatment settings and patient groups.

Drawing on the recent research in the field, the authors provide the practicing clinician and student with an up-to-date understanding of the epidemiology, etiology, course and prognosis of substance abuse disorders that would be relevant to clinical practice. In addition to describing phenomenology and etiology, the book provides a comprehensive guide to the assessment and treatment of DSM-IV-TR substance abuse disorders (SUDs), including abuse and dependence of alcohol, stimulants, opiates, hallucinogens, cannabis/marijuana, sedative, and party drugs.

Later, when the money ran out, or the romance of the wandering life faded, the Walls retreated to the dismal West Virginia mining town -- and the family -- Rex Walls had done everything he could to escape. He drank. He stole the grocery money and disappeared for days. As the dysfunction of the family escalated, Jeannette and her brother and sisters had to fend for themselves, supporting one another as they weathered their parents' betrayals and, finally, found the resources and will to leave home.

What is so astonishing about Jeannette Walls is not just that she had the guts and tenacity and intelligence to get out, but that she describes her parents with such deep affection and generosity. Hers is a story of triumph against all odds, but also a tender, moving tale of unconditional love in a family that despite its profound flaws gave her the fiery determination to carve out a successful life on her own terms.

For two decades, Jeannette Walls hid her roots. Now she tells her own story. A regular contributor to MSNBC.com, she lives in New York and Long Island and is married to the writer John Taylor.

Chest. 2012 Oct 1; 142(4_MeetingAbstracts): 272A
Usta Y, Shealey W

SESSION TYPE: Infectious Disease Student/Resident Case Report Posters IIIPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PMINTRODUCTION: Erythema nodosum are tender, erythematous, subcutaneous nodules that typically are located symmetrically on the anterior surface of the lower extremities. Erythema nodosum may be the first sign of a systemic disease such as tuberculosis, viral, bacterial or fungal infections (1).CASE PRESENTATION: 24 year old, 8 weeks pregnant Mexican American female presents with symptoms of shortness of breath, pleuritic chest pain, productive cough and a new painful rash on her lower extremities of two weeks duration. As an outpatient, patient was found to have a left lower lobe consolidation on chest Xray and was treated with azithromycin. Patient has lived in Phoenix Arizona for the past 17 years. She denies any sick contacts or recent travel. She denies alcohol, tobacco and drug abuse. Sexual history includes her husband only. Past medical history includes latent tuberculosis treated with nine months of isoniazide one year ago. Throughout her stay, patient was afebrile and had no leukoctosis. Sputum and blood cultures were negative. Urine strep antigen, viral cultures, infuenza, and rapid strep antigen detection test were negative. Coccidioidomycosis IgM and IgG serologies were positive. Skin biopsy was consistent for erythema nodosum. She was started on IV fluconazole, and her symptoms of shortness of breath, chest pain, and rash all subsided within a few days.DISCUSSION: Coccidioides immitis is endemic in certain parts of the desert south west region. It is a fungus that resides in the soil that breaks off into airborne spores. Infection is caused by inhalation of the particles and is not transmitted from person to person. Serious complications include severe pneumonia, lung nodules, and disseminated disease. The disseminated form of valley fever can devastate almost any organ in the body, causing skin ulcers, abscesses, bone lesions, meningitis, and often death(2). Coccidioidomycosis during pregnancy is a serious illness for which high rates of mortality have been reported in many studies. It has been associated with a greater likelihood of extra-pulmonary dissemination and more serious outcomes. Although when erythema nodosum was present, outcomes were more favorable(3).CONCLUSIONS: Diagnosing the precipitating source of erythema nodosum may be quite challenging. Having a broad differential diagnosis for erythema nodosum will avoid missing rare and life threatening infections. Keeping coccidioidomycosis as a differential in almost all infectious workups in the desert south west will help clinicians not miss this commonly seen "Valley Fever."1) Schwartz RA, Nervi SJ. Erythema nodosum: a sign of systemic disease. Am Fam Physician. 2007 Mar 1;75(5):695-700.2) Stevens DA. Coccidioidomycosis. N Engl J Med. 1995 Apr 20;332(16):1077-823) Arsura EL, Kilgore WB, Ratnayake SN. Erythema nodosum in pregnant patients with coccidioidomycosis. Clin Infect Dis. 1998 Nov;27(5):1201-3.DISCLOSURE: The following authors have nothing to disclose: Yousef Usta, Wesley ShealeyNo Product/Research Disclosure InformationSt. Joseph Hospital Medical Center, Phoenix, AZ.

Chest. 2012 Oct 1; 142(4_MeetingAbstracts): 751A
Choi H, Krantz A, Smith J, Trick W

SESSION TYPE: Occupational/ Environmental Lung Disease PostersPRESENTED ON: Wednesday, October 24, 2012 at 01:30 PM - 02:30 PMPURPOSE: Substance dependence is associated with several health related problems and higher societal cost. There are limited data on respiratory conditions associated with substance abuse. The purpose of our study is to compare the respiratory discharge diagnoses between substance-dependent and non-dependent patients.METHODS: We conducted a retrospective cohort study using data previously collected by the SBIRT program, which is a federally-funded program designed to screen patients for substance dependence at the Cook County Health and Hospitals System. We included all patients admitted on the medicine services or short stay unit who were screened during July 2006-June 2008. Patients were stratified by type of substance used (heroin, cocaine, alcohol) and the first diagnosis listed in the ICD-9 coding schema was considered as the primary discharge diagnosis.RESULTS: Of 11,397 patients, 341 (3.0%) were dependent on inhalational heroin, 260 (2.3%) on non-injection cocaine, and 106 (0.9%) on injection heroin. Compared to non-dependent patients, inhalational heroin-dependent patients were over three-fold more likely to have been admitted for respiratory diseases (28% vs. 8%, p<0.01); this association was strongest for asthma exacerbation (OR=7.0; 95% CI, 4.7 to 70.4, p<0.01). Of the 225 admissions for an asthma exacerbation, 44 (19.6%) had co-occurrent heroin-dependence.CONCLUSIONS: There is a strong association between heroin dependence and hospital admission for an asthma exacerbation.CLINICAL IMPLICATIONS: Provision of specialized substance-use treatment for inhalational heroin users will be necessary to reduce the frequency of exacerbations and repeat hospital admissions.DISCLOSURE: The following authors have nothing to disclose: Humberto Choi, Anne Krantz, Jennifer Smith, William TrickNo Product/Research Disclosure InformationCleveland Clinic Foundation - Respiratory Institute, Cleveland, OH.

Chest. 2012 Oct 1; 142(4_MeetingAbstracts): 499A
Gulati N, Vadde R, Patolia S, Schmidt F, Perwaiz M, Narendra D, Quist J, Enriquez D, Pokharel S

SESSION TYPE: Pleural Case Report PostersPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PMINTRODUCTION: Primary spontaneous pneumothoraces are usually due to rupture of apical pleural blebs,small cystic spaces that lie within or immediately under the visceral pleura. Recurrent spontaneous pneumothorax (SP) may present either as a primary pneumothorax in young and otherwise healthy patients or as a secondary pneumothorax because of a complication of an underlying lung disease.CASE PRESENTATION: 48 year old male presented to emergency department with complaint of multiple episodes of vomiting and upper abdominal pain of 2 days duration.Past medical history comprised of seizure disorder,chronic alcoholism,chronic pancreatitis,hypertension, heroin and marijuana abuse and cigarette smoking.Review of systems revealed mild chest discomfort. He denied shortness of breath,cough or trauma. On examination,patient was tall and thin built. Vitals including pulse oximetry were normal.System examination revealed absent air entry on right side of chest and tenderness in epigastrium.Chest xray revealed large right pneumothorax which was drained with a chest tube( 32 F ) in emergency department. Boerhaave's syndrome was ruled out by imaging studies.CT chest showed bilateral sub pleural blebs and bullae. Repeat CXR showed improvement in pneumothorax with mild re expansion pulmonary edema. Follow up CXR next day showed pneumothorax on left side,however the patient was asymptomatic.Chest tube was put on left side and connected to suction.Right chest tube was successfully removed after few days but the left side had persistent air leak suggesting broncho pleural fistula. VATS was done on the left hemi thorax with removal of blebs and pleurodesis.Subsequently, patient developed pneumothorax on right side again.He underwent VATS with adhenolysis, removal of apical sub pleural blebs,mechanical and talc pleurodesis. Patient was eventually discontinued off the chest tubes and discharged home. Patient was counseled for smoking cessation.DISCUSSION: This patient had bilateral blebs and bullae likely related to his smoking history(cigarette and marijuana). In cases of primary SP, there is a tendency of bullous lesions of the lung to be bilateral, so SP on one side often recurs on the opposite side as in this patient. Male gender,tall stature,low body weight and failure to stop smoking is associated with an increased risk of recurrence. This patient underwent VATS sequentially on both sides with removal of blebs and pleurodesis.CONCLUSIONS: Bilateral VATS approach can be done safely in selected patients with bilateral simultaneous and non simultaneous SP. It avoids the need for subsequent procedures.The procedure is usually well tolerated and has excellent long-term results.1) Bilateral Video-Assisted Thoracoscopic Surgery for Bilateral Spontaneous Pneumothorax.Adel K Ayed.CHEST December 2002 vol. 122 no. 6 2234-22372) Simultaneous Bilateral Spontaneous Pneumothorax. Sayar A,Turna A, Metin M,Kucukyagci N,Solak O, Gurses A. Acta chir belg 2004,104:572-576DISCLOSURE: The following authors have nothing to disclose: Neerja Gulati, Rakesh Vadde, Setu Patolia, Frances Schmidt, Muhammad Perwaiz, Dharani Narendra, Joseph Quist, Danilo Enriquez, Saurav PokharelNo Product/Research Disclosure Information, Brooklyn, NY.

Biol Psychol. 2013 May 18;
Cacciaglia R, Nees F, Pohlack ST, Ruttorf M, Winkelmann T, Witt SH, Nieratschker V, Rietschel M, Flor H

People at high risk for alcoholism show deficits in aversive learning, as indicated by impaired electrodermal responses during fear conditioning, a basic form of associative learning that depends on the amygdala. A positive family history of alcohol dependence has also been related to decreased amygdala responses during emotional processing. In the present study we report reduced amygdala activity during the acquisition of conditioned fear in healthy carriers of a risk variant for alcoholism (rs2072450) in the NR2A subunit-containing N-Methyl-D-aspartate(NMDA)-receptor. These results indicate that rs2072450 might confer risk for alcohol dependence through deficient fear acquisition indexed by a diminished amygdala response during aversive learning, and provide a neural basis for a weak behavioral inhibition previously documented in individuals at high risk for alcohol dependence. Carriers of the risk variant additionally exhibit dampened insula activation, a finding that further strengthens our data, given the importance of this brain region in fear conditioning.

Chest. 2012 Oct 1; 142(4_MeetingAbstracts): 103A
Logue J, Al Damluji A

SESSION TYPE: Cardiovascular Student/Resident Case Report Posters IPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PMINTRODUCTION: Many harbor the diagnosis of asymptomatic patent foramen ovale(PFO). The annual incidence is close to 27%(1). Clinical syndromes including paradoxical embolism, gas embolism in decompression sickness, platypnea-orthodeoxia syndrome, and recurrent migraine headaches can result. We report a case of PFO with recurrent transient ischemic attacks and migraine headaches.CASE PRESENTATION: A 68 year old male with emphysema, CAD, multiple TIAs, and chronic migraines presented with confusion and expressive aphasia suspicious for CVA. He was intubated for airway protection. After intubation, he developed hypoxemia with use of high positive airway pressures. He had no prior cardiopulmonary symptoms. His history includes smoking and alcoholism. Vitals were T 36.6C, BP 106/61, HR 76, RR 30, and SpO2 89% at 100% FiO2. He had decreased breath sounds at lung bases. Heart sounds were distant without murmur, S3 or S4. No jugular venous distension or peripheral edema was present. Laboratory values were WBC of 13.2, normal troponin, BNP 345. Arterial blood gas showed pH 7.48, PaO2 54 mmHg, PaCO2 36 mmHg, HCO3 of 35. ECG was normal. Imaging showed bibasilar opacities, small pleural effusions, emphysema, and no pulmonary embolism. Evaluation by transthoracic echocardiogram(TTE) with bubble study showed an EF of 55% without systolic dysfunction. There was right-to-left intracardiac shunt. Transesophageal echocardiogram (TEE) confirmed the diagnosis of PFO with passage of contrast from the right to left atrium. Right heart catheterization showed pulmonary hypertension with AVO2 difference elevated at 5.28 vol%. Neurologic work up was negative for CVA. In addition to reducing PEEP on the ventilator, he received systemic corticosteroids for underlying chronic lung disease and vancomycin for suspected pneumonia. He received anticoagulation, antiplatelet therapy, and IV fluids were filtered to prevent air embolism. No surgical intervention was considered. He was successfully extubated.DISCUSSION: The diagnosis of PFO is common in adults, but it can remain asymptomatic for many years. Stroke, TIA, recurrent migraines, and vascular headaches are linked with PFO. It is hyothesized that vasoactive substances that trigger migraines are inactivated in the lungs. Via a PFO with right-to-left shunt the lungs are bypassed and vasoactive substances like emboli can enter the cranial circulation(2). Recurrent headaches are the result. TTE, TEE, and transcranial doppler with saline contrast are diagnostic. Antiplatelet agents and anticoagulation are recommended therapy. Closure can be considered in certain situations.CONCLUSIONS: We demonstrated a case of PFO with recurrent TIAs and chronic migraines. This patient developed hypoxemia with increased airway pressures. We feel these phenomena are consistent with right-to-left shunt associated with our patient's PFO.1) Hagen PT et al. Mayo Clin Proc 1984;59(1):17-202) Tobis JM et al. Current Issues in Cardiology. 2005;32(3):362-365DISCLOSURE: The following authors have nothing to disclose: Jonathan Logue, Abdulla Al DamlujiNo Product/Research Disclosure Information.

Chest. 2012 Oct 1; 142(4_MeetingAbstracts): 174A
Andre E, Thurm C, Bhawal J, Cervellione K, Patel K

SESSION TYPE: Infectious Disease Case Report Posters IIPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PMINTRODUCTION: Legionella pneumophila is a recognized cause of rhabdomyolysis. There are reports of severe rhabdomyolysis and subsequent kidney failure related to Legionella with significant mortality. We present a case of Legionella pneumonia in an alcoholic man who presented with severe rhabdomyolysis and acute renal failure who recovered successfully.CASE PRESENTATION: A 42-year-old alcoholic male presented with three days of fever, chills, productive cough with yellowish sputum and shortness of breath. He also complained of myalgia and watery non-bloody diarrhea. A few days prior to admission the patient had cleaned an air conditioning system in a restaurant. He had a 20-pack/year smoking history. On admission he was normotensive but tachycardic and febrile (102.1F); his oxygen saturation was 90% on two liters nasal cannula. He was diaphoretic with normal mental status. Scattered rales were auscultated in the right lower lobe. Laboratory studies revealed a leukocytosis with bandemia and thrombocytopenia. He was hyponatremic. His BUN was 24 and creatinine of 1.9. Lactic acid was normal. CPK was 19,086. The ABG revealed a metabolic acidosis. A chest X-ray show right upper lobe infiltrate. CT scan showed extensive consolidation of the right upper lobe and the superior segment of the right lower lobe. Legionella urine antigen was positive and levofloxacin and rifampin were started. The following day the patient developed respiratory distress and was intubated. A lorazepam drip was started for possible delirium tremens (DTs). His CPK initially decreased to a nadir of 7,450 on day 4, but subsequently increased to a maximum of 110,355 on day 8. He developed worsening renal failure that required hemodialysis on day 4. Daily fevers continued for more than 15 days despite antibiotic therapy. Chest x-ray showed significant improvement by day 12. Kidney function recovered completely and hemodialysis was discontinued. Patient was extubated on day 21. Muscle weakness persisted.DISCUSSION: Legionella is a known cause of pneumonia requiring ICU admission. Severe rhabdomyolysis leading to renal failure has been reported with Legionella Pneumonia. Mortality is high. We report a case of Legionella pneumonia associated with severe rhabdomyolysis (CPK level>100 000), renal failure, and protracted fevers despite appropriate antibiotic treatment. A possible confounding factor was our patient's history of alcohol abuse and possible DTs, which can be associated with rhabdomyolysis. However our patient's CPK level continued to rise despite the absence of clinical evidence of DTs. The patient survived after a prolonged ICU course.CONCLUSIONS: The current case illustrates the potential for severe rhabdomyolysis in patients with Legionella pneumonia as well as other confounding comorbidities.1) McConkey J, Obeis M, Valentini J, & Beeson MS. Legionella pneumonia presenting with rhabdomyolysis and acute renal failure: a case report. J Emerg Med 2006;30(4):389-392.DISCLOSURE: The following authors have nothing to disclose: Eduardo Andre, Craig Thurm, Javeria Bhawal, Kelly Cervellione, Kunal PatelNo Product/Research Disclosure InformationJamaica Hospital Medical Center, Jamaica, NY.

Chest. 2012 Oct 1; 142(4_MeetingAbstracts): 344A
Rhee JH, Yadavalli VS, Mekaroonkamol P, Franco R, Young KR, Rowden A

SESSION TYPE: Critical Care Student/Resident Case Report Posters IIPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PMINTRODUCTION: Cocaine washout syndrome (CWS) is a rare complication caused by prolonged cocaine use, manifested by brief coma that resolves spontaneously. The proposed mechanism is depletion of adrenergic neurotransmitters due to prolonged and persistent stimulation. There are only 3 cases reported in the literature and the incidence of this syndrome is unknown. Here, we report an unusually extreme case of CWS presenting with coma and refractory shock.CASE PRESENTATION: A 33-year-old African-American woman with history of chronic cocaine abuse was brought to the emergency department unresponsive. The patient was last seen "stoned" [sic] by her mother 6 hours prior to arrival. She was given naloxone in the field with no improvement in mental status. In the ED, vital signs showed hypotension (61/24mmHg), tachycardia (132bpm), hypoxia (90% on ambient air) and hypothermia (33.9°C). Physical examination revealed a comatose patient with GCS of 3, covered in vomit, with sluggishly reactive non-dilated pupils, no gag, cough or corneal reflexes and no nystagmus. The patient was intubated for airway protection. Chest radiograph and head CT were normal while lab results showed acute kidney injury, increased liver enzymes up to 1000s, leukocytosis, respiratory and anion gap metabolic acidosis with pH 7.08, pCO2 48mmHg, HCO3 12mmol/L and lactate of 64mg/dL. Urine toxicological screening was positive for cocaine, benzodiazepines, opioids and PCP, while blood analyses were negative for alcohol, acetaminophen, salicylates and serum osmolar gap. Despite aggressive fluid resuscitation and 3 pressors at maximal infusion rates, she remained hypotensive and anuric. Stress dose steroids and antibiotics were empirically started. However, only 8 hours after admission, she regained brainstem reflexes. Hemodynamic status also dramatically improved and pressors were being successfully weaned. The following day, she was off pressors, mental status returned to baseline and she was ready to resume spontaneous ventilation. As blood cultures and cosyntropin test were negative, antibiotics and steroids were discontinued. After being extubated on day 2, she admitted to daily cocaine use for several months, with a binge episode on the day of admission. After psychiatry was consulted and ancillary support was set up, she was discharged home in a stable condition. [Image1]DISCUSSION: CWS remains a diagnosis of exclusion in patients with corroborative history and high clinical suspicion. Differential diagnoses are listed in table1.CONCLUSIONS: This case outlines a rare but potentially fatal complication of acute cocaine intoxication in chronic cocaine users. Patients should be admitted to the appropriate level of monitoring ; i.e. intensive care unit. Aggressive fluid resuscitation with meticulous hemodynamic and ventilatory support is the cornerstone of management in cocaine washout syndrome.1) Cocaine washout syndrome, Greenberg MI, Roberts JR, Ann of Int Med, 2000 Apr18;132(8):679-802) .DISCLOSURE: The following authors have nothing to disclose: Ji Hyun Rhee, V. Sandeep Yadavalli, Parit Mekaroonkamol, Rene Franco, K. Randall Young, Adam RowdenNo Product/Research Disclosure InformationInternal Medicine, Albert Einstein Medical Center, Philadelphia, PA.

Neuropsychiatr Dis Treat. 2013; 9: 667-673
Pandya NS, Vrbancic M, Ladino LD, Téllez-Zenteno JF

We report the rare case of a patient with intractable epilepsy and escalating aggression, resulting in murder, who had complete resolution of her seizures and explosive behavior following a right temporal lobectomy.We searched the available literature from 1880 to 2013 for cases of epilepsy being used as a court defense for murder and collected information regarding the final sentencing outcomes. We selected 15 papers with a total of 50 homicides.We describe the case of a 47-year-old woman with drug-resistant right temporal epilepsy who developed increasing emotional lability, outbursts of anger and escalating violent behavior culminating in a violent murder. The patient was imprisoned while awaiting trial. In the interim, she underwent a successful temporal lobectomy with full resolution of seizures, interictal rage and aggressive behaviors. After the surgery, her charges were downgraded and she was transferred to a psychiatric facility.The aggressive behavior associated with epilepsy has been described in the literature for over a century. A link between epilepsy and aggression has been disproportionally emphasized. These patients share some common characteristics: they are usually young men with a long history of epilepsy and lower than average intelligence. The violent act is postictal, sudden-onset, more likely to occur after a cluster of seizures and is usually related with alcohol abuse.

Chest. 2012 Oct 1; 142(4_MeetingAbstracts): 528A
Ali M, Mathew J, Haroon A, Mahmood N, Khan MA

SESSION TYPE: Pleural Cases IIPRESENTED ON: Wednesday, October 24, 2012 at 11:15 AM - 12:30 PMINTRODUCTION: Spontaneous pneumothorax is the presence of air in the pleural space as a result of a rupture of the lung parenchyma and visceral pleura with no demonstrable cause. Primary pneumothorax most often occurs in younger individuals (in their 20's) at rest with no precipitating events while Secondary occurs as a complication of underlying lung disease. We present a case of a patient who presents with simultaneous spontaneous bilateral pneumothoraces; a relatively rare occurrence.CASE PRESENTATION: A 58 year-old male with past medical history of mild mental retardation, alcohol abuse, and a 92 pack year history who reported sudden onset of shortness of breath with cough while eating pizza, that subsequently resolved on its own. The following morning, he reported that the shortness of breath returned and that it became progressively worse. The gentleman also reports that he had been experiencing dry cough for approximately 3-4 days, but that he had no chest pain, fevers, chills, sick contacts, or similar experiences in the past. In the emergency department, he was found to have an oxygen saturation of 92% on room air, heart rate of 82, blood pressure of 163/98, respiratory rate of 30, and was afebrile. On physical exam, he was noted to have bilateral scattered expiratory wheezing. Chest x-ray demonstrated bilateral pneumothoraces. CT scan provided additional information including the existence of bilateral blebs. Bilateral thoracostomies were performed with significant resolution, however pneumothoraces persisted. Bilateral video-assisted thorascopic surgery with apical bleb resections as well as bilateral talc pleurodesis was performed. Despite resolution of the right pneumothorax, the left pneumothorax persisted necessitating left thoracotomy with formal lung decortication, as well as parietal pleurectomy.DISCUSSION: Bilateral spontaneous pneumothoraces is a rare occurrence, with potentially more complications in those with secondary pneumothoraces because of likely diminished pulmonary reserve due to underlying lung disease. The likelihood that our patient had pre-existing apical blebs with some degree of rupture secondary to coughing/possible aspiration with development of bilateral pneumothoraces is fairly high. Treatment involves placement of bilateral chest tubes for large pneumothoraces, and possibly mechanical ventilation with subsequent VATS. Prevention includes VATS with stapling of blebs and pleural abrasion. Chemical pleurodesis via chest tube can be done for poor operative candidates.CONCLUSIONS: Simultaneous bilateral spontaneous pneumothorax is a rare cause of respiratory distress which needs prompt diagnosis and management to prevent high mortality.1) Graf-Deuel E, Knoblauch A; Simultaneous bilateral spontaneous pneumothorax. Chest. 1994 Apr;105(4):1142-6DISCLOSURE: The following authors have nothing to disclose: Muhammad Ali, Jacob Mathew, Aasiya Haroon, Nader Mahmood, M Anees KhanNo Product/Research Disclosure InformationSt. Josephs's Regional Medical Center/Seton Hall Universtiy, Paterson, NJ.

Arch Ital Urol Androl. 2013; 85(1): 14-9
Mondaini N, Silvani M, Zenico T, Gallo F, Rosso F, Cai T, Ughi G, Scarano P, Orlando V, Bartoletti R

Introduction: Few studies on the prevalence of male sexual diseases are currently available due to difficult application of observational studies or andrological disease prevention campaigns on large series of apparently healthy subjects. The medical check-up linked to compulsory military service represented in Italy a valid tool for epidemiological and observational study for 18 year old boys from 1861 to 2004. The stopping of compulsory military service and its related medical check-up could have determined an important social impact in terms of a lower level of attention and care on male genital/sexual diseases. The aim of the present observational study was to check the prevalence of genital/sexual diseases among young male high-school students and promote an alternative campaign of information among young students. Methods: A prospective observational analytical study on young male students was conducted by 6 urological centres. Genital and sexually transmitted diseases were presented with slides to students in a general assembly. Some students were then counselled and filled out a short questionnaire on their lifestyle. Results: 12,535 students (10,432 males-83.6%) followed the presentation. and 4,897 males (46.7%) decided to be checked-up by the urologist and out of them 1554 (31.7%) presented relevant andrological diseases. Five-hundred students completed the questionnaire concerning their lifestyle. Many of them had not yet experienced condom use during sexual intercourse (27.8%). Drug abuse was reported by 39.6% of subjects and alcohol consumption in 80.8% of them. Conclusions: These data suggest the need for a national information campaign on male sexual disorders to promote sexual health.

Curr Opin Psychiatry. 2013 May 20;
Winters KC

PURPOSE OF REVIEW: Adolescence is a developmental period characterized by relatively high rates of substance use and substance use disorders. Precise assessment and classification of adolescent drug use behaviors are essential in gaining an accurate understanding of the nature and extent of adolescent drug use, and possible intervention or treatment needs. There has been a select group of recently published research reports and manuscripts that address critical and emerging issues pertaining to the classification and assessment of alcohol and other drug use behaviors among adolescents. An overview of these publications is provided and their clinical relevance is discussed. RECENT FINDINGS: The paper will focus on recent research, most from the United States, that addresses four main issues. One is the application of the new DSM-5 criteria to adolescents, including the advantages and disadvantages of the new criteria for substance use disorders. The second issue pertains to advances in instrumentation that provide new tools for researchers and clinicians in assessing substance use in adolescents. A significant public health issue is addressed as the third theme in the paper - screening for alcohol abuse in college settings. Finally, the paper reviews how the emerging science of brain development can inform the assessment process. SUMMARY: Recent advances in the adolescent drug abuse assessment field continue to inform clinical service and research. As a whole, these advances have strengthened the field, but continued research is needed to further refine assessment practices and standards and to better understand how to define a substance use disorder in youth.

Alcohol Alcohol. 2013 May 21;
López-Caneda E, Cadaveira F, Crego A, Doallo S, Corral M, Gómez-Suárez A, Rodríguez Holguín S

AIMS: The objective of this study was to examine brain activity related to visual attention processes in youths who had maintained a binge drinking (BD) pattern of alcohol consumption for >2 years. METHODS: The participants were 57 university students (26 binge drinkers: BDs) with no personal or family history of alcoholism or psychopathological disorders in first-degree relatives. Event-related potentials (ERPs) were recorded while participants performed a visual oddball task (twice within a 2-year interval). The latency and amplitude of the P3b component of the ERPs were analysed. RESULTS: The P3b amplitude was larger in young BDs than in aged-matched controls at both evaluation times, and the difference was more pronounced after 2 years of maintenance of a BD pattern of consumption. The larger P3b amplitude was associated with an earlier onset of regular drinking and with a greater quantity and intensity of consumption. CONCLUSIONS: These findings suggest that young BDs exhibit anomalies in neural activity involved in attentional/working memory processes, which increase after 2 years of maintenance of BD. This anomalous neural activity may reflect underlying dysfunctions in neurophysiological mechanisms as well as the recruitment of additional attentional/working memory resources to enable the binge drinkers to perform the task adequately.

Chest. 2012 Oct 1; 142(4_MeetingAbstracts): 357A
Raju S, Kumar A, Joseph R, Lahiri B

SESSION TYPE: Critical Care Student/Resident Case Report Posters IIPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PMINTRODUCTION: Bacterial pericarditis, a rare entity in the modern antibiotic era, has high mortality rates. We describe a case of purulent pericarditis and tamponade caused by Methicillin-Resistant Staphylococcus aureus (MRSA) secondary to MRSA urosepsis.CASE PRESENTATION: A 67-year-old male was brought to the Emergency Department after being found unresponsive. He was hypothermic and hypotensive. Laboratory testing revealed a leukocyte count of 29400 cells/µL and 27% bands. Patient was resuscitated and started on empiric antibiotics. Blood and urine cultures grew MRSA sensitive to vancomycin. On day 12, patient became hypotensive with systolic blood pressure ranging from 70-80 mm of Hg. He had a jugular venous pressure (JVP) of 12 cm and muffled heart sounds. ECG showed low voltages in precordial leads. An emergent echocardiogram revealed impending tamponade due to a 4.6 cm circumferential fluid accumulation in the pericardium. This was absent in a study done 5 days prior. A computerized tomography (CT) scan of the chest showed a large pericardial effusion (Fig. 1 & 2). Pericardiocentesis yielded 800 cc of purulent fluid which grew MRSA. His condition improved and a subsequent echocardiogram showed residual fibrinous pericardial stranding.DISCUSSION: Bacterial pericarditis is associated with mortality rates reaching 40% despite treatment. Staphylococcus aureus and Streptococcus pneumoniae are the commonest causative pathogens, but gram-negative and anerobic organisms are gaining prevalence.[1] Primary infection of the pericardium is rare. It typically occurs as a result of hematogenous spread, direct trauma or local extension of a suppurative focus in the lung, myocardium or sub-diaphragmatic source.[2] Patients typically present with high fevers, chills and tachycardia.[3] Predisposing factors include underlying infection, recent thoracic surgery, immunosuppression, alcohol abuse, malignancy and rarely acute myocardial infarction.[1] Prompt surgical drainage and appropriate antibiotic therapy is the treatment of choice. Subsequent placement of an indwelling pericardial catheter is useful for cardiac tamponade. Pericardiectomy can be done if percutaneous drainage is insufficient or ineffective.[1] Major long-term complications are recurrence and constrictive pericarditis.CONCLUSIONS: Bacterial pericarditis is uncommon but potentially life-threatening. Surviving this catastrophic illness requires a high index of suspicion, early diagnosis, prompt pericardial drainage and appropriate antibiotic therapy.1) Parikh SV, Memon N, Eschols M: Purulent pericarditis: report of 2 cases and review of literature: Medicine. 2009;88:52-652) Klacsmann PG, Bulkley BH, Hutchins GM: The changed spectrum of purulent pericarditis: an 86-year autopsy experience in 200 patients: Am J Med. 1977;63:666-6733) Rubin RH, Moellering RC Jr: Clinical, microbiologic and therapeutic aspects of purulent pericarditis. Am J Med. 1975;59:68-78DISCLOSURE: The following authors have nothing to disclose: Shine Raju, Anupam Kumar, Ranjit Joseph, Bimalin LahiriNo Product/Research Disclosure InformationUConn Health Center, Farmington, CT.

Chest. 2012 Oct 1; 142(4_MeetingAbstracts): 996A
Trinidad Hernandez R, Guerra-Garofalo H, Jimenez-Velazquez I, Vergara M

SESSION TYPE: Miscellaneous Global Case Report PostersPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PMINTRODUCTION: Rheumatoid arthritis has multiple affections that may include the lungs. The later are associated with disease stage and progression as well. In his report, we present the case of a male patient with long standing, veneer treated, rheumatoid arthritis presenting with a rather challenging pulmonary complication.CASE PRESENTATION: A 64 years old bedridden male was admitted to the hospital after 5 days of chills, shortness of breath and persistent cough with moderate yellow sputum and left base pleuritic pain. Medical history was remarkable for alcoholism and heavy smoking that quit more than 10 years ago. He had history of rheumatoid arthritis (RA) for more than 20 years never treated, and arterial hypertension (HTN). On admission his temperature was 36 C, blood pressure 87/55 mmHg , pulse 98 bpm, and respiratory rate 22/min with O2 sat at 96%. The white blood cell count was 6.38 (42% neutrophil, 0% band, lymphocyte 38%, monocytes 4.5% and eosinophils 11.8%); the hemoglobin levels was 8.1mg/dL , ESR=24mm, HIV negative, and VDRL negative. The PaO2 at room air was 100 mmHg. A chest X-rays on admission showed bilateral basal infiltrates and left pleural effusion. Patient started on IV antibiotics with minimal clinical response, gram stain of the sputum revealed gram positive cocci, three blood cultures obtained on admission yielded negative. On day 9, patient developed hemoptysis, night fever and sweats. Chest CT scan on day 10 revealed right upper lobe cavity, bilateral emphysematous changes and large loculated fluid collection (abscess). PPD test negative, and second chest CT on day 20 demonstrated multiple irregular shaped cavity lesions at upper lobes, persistent consolidation at the lower lobe with empyema and abscess, and mediastinal adenopathy.DISCUSSION: A cavity has been defined in the radiology literature as "gas filled space within a zone of pulmonary consolidation or within a mass or nodule produced by the expulsion of necrotic part of the lesion via the bronchial tree"(1). Cavity lesion is the result of any pathological processes including suppurative necrosis (e.g., pyogenic lung abscess), caseous necrosis (e.g, tuberculosis), ischemic necrosis (e.g, pulmonary infarction), cystic dilatation of the lung structure (e.g, PCP pneumonia), or displacement of lung tissue by cystic structure (e.g, Echicoccocus)(1). Many autoimmune diseases can affect the lung, but cavitation is relatively uncommon in most of these diseases. Rheumatoid arthritis is also commonly associated with pulmonary abnormalities, but cavities due primarily to rheumatoid arthritis are rare (1,2). Lung cavities in patients with rheumatoid arthritis often represent infection or carcinoma, thus, aggressive diagnostic evaluation is warrant for new cavitary lesions in these patients (1-3).CONCLUSIONS: Rheumatoid arthritis (RA) is a generally progressive systemic autoimmune process characterized by chronic symmetrical erosive synovitis. Nonarticular manifestations of RA include subcutaneous nodules, vasculitis, pericarditis, mononeuritis multiplex, and episcleritis (4,5). In rare cases, rheumatoid nodules may appear in the lung and cavitate, presumably due to ongoing vasculitis with ischemic necrosis (1-3).1) Cavitary pulmonary diseases; l. Beth Gadkowski and Jason E. Stout: Clinical Microbiology Review. 2008 April; 21(2): 305-333.2) A 64-year-old woman with a history of rheumatoid arthritis and new cavitary lung lesions. Boé DM, Schwarz mi, Groshong SD, Maloney JP. Chest. 2007 dec; 132(6):2046-52.3) Cavitary lung lesion in a patient with Sjögren's syndrome. Pérez-Castrillón JL, González-Castañeda C, Del Campo F, González JI, Martín-Escudero JC,DISCLOSURE: The following authors have nothing to disclose: Rafael Trinidad Hernandez, Hector Guerra-Garofalo, Ivonne Jimenez-Velazquez, Mark VergaraNo Product/Research Disclosure InformationUniversity of Puerto Rico, School of Medicine, San Juan, Puerto Rico.

Chest. 2012 Oct 1; 142(4_MeetingAbstracts): 583A
Preciado-Yepez C, Moreno-Hoyos-Abril JF, Mercado-Longoria R, Villegas-Elizondo JF, Acosta-Moreno M, Escobedo-Bernal JI, Cavazos A

SESSION TYPE: Cancer Student/Resident Case Report PostersPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PMINTRODUCTION: Mediastinal limited involvement in non-Hodgkin lymphoma is rare (about 5% of patients). The presence of endobronchial lesions occurs in less than 1% of cases, usually associated with spread from a mediastinal massCASE PRESENTATION: This is a 78 year old man with a history of smoking and chronic alcoholism without relevant medical history. He starts 6 months prior to admission with progressive dyspnea,present at rest at initial evaluation. He also refer dry cough, dysphagia and weight loss of 8 kg. On admission he is is tachycardic, polypneic, he has no fver, oxygen saturation 90% on room air. Physical examination is relevant by the presence of inspiratory and expiratory wheezing .Laboratory tests were within normal limits. On admission chest radiograph shows widening of the upper and middle mediastinum Chest CT is positive for the presence of adenopathies on anterior and posterior mediastinum, also in subcarinal lymph nodes associated with extrinsic compression on both main bronchi and the esophageal lumen. Bronchoscopy is performed, submucosal infiltration is observed in the carina. In the opening of the right superior lobe bronchus it is observed an exophytic mass. Biopsies of the tumor were taken. Pathology reports Large B Cell Non Hodgkin lymphoma. CHOP based chemotherapy was startedDISCUSSION: Endobronchial tree involvement is uncommon in Non hodgkin lymphoma, most frequently affecting main bronchi, lobar bronchi followed by lobar bronchi and trachea. Diverse mechanisms have been suggested for development of endobronchial lesions: 1) direct invasion of adjacent mediastinalor parenchymal lesions . 2) Lymphatic dissemination from peribronchial tissue. 3) transbronchial aspiration of tumor emboli Large B-cell lymphomas account for 20-25% of endobronchial NHL.Treatment of choice is based on CHOP combined with rituximab. Prognosis is good for endobronchial lymphoma (81% overall survival at 5 years) similar to other lymphomas with local presentationCONCLUSIONS: Endobronchial NHL is an uncommon presentation with a favorable prognosis and good overall survival1) Solomonov,A. Non-Hodgkin's lymphoma presenting as an endobronchial tumor:Report of eight cases and literature review. Am. J. Hematol. 83:416-419, 20082) Young,B. Cross-Sectional Evaluation of Thoracic Lymphoma. Radiol Clin N Am 46 (2008) 253-2643) Kilgore,T.L. Endobronchial non-Hodgkin's lymphoma. Chest 1983;84;58-61DISCLOSURE: The following authors have nothing to disclose: Cesar Preciado-Yepez, Juan Francisco Moreno-Hoyos-Abril, Roberto Mercado-Longoria, José Felipe Villegas - Elizondo, Michelle Acosta - Moreno, Juan Israel Escobedo - Bernal, Arnoldo CavazosNo Product/Research Disclosure InformationUniversidad Autónoma de Nuevo León, Monterrey, Mexico.

Rev Med Inst Mex Seguro Soc. 2013 Mar-Apr; 51(2): 218-21
Martínez-Martínez MU, Román-Acosta S, Alvarez-Reyes JM, Oros-Ovalle C, Abud-Mendoza C

Background: gout is an inflammatory arthritis that frequently is associated with obesity, alcohol consumption, hypertension and hypertriglyceridemia. The calciphylaxis is characterized by metastatic calcification to small and medium vessels. Both are associated independently with high mortality. When hyperuricemia and the calciphylaxis are present, the death risk is 80 %. Clinical case: a 51 year old man presented with clinical history of alcoholism and systemic arterial hypertension, and he developed limb ulcers, edema and uremic syndrome. Three week later, the patient died as a consequence of sepsis from Staphylococcus aureus. We emphasize the diagnostic approach of calciphylaxis, metabolic syndrome and comorbidities, cardiovascular and renal failure risk factors. Conclusions: the hyperuricemia is included in the metabolic syndrome, as the result of genetic and behavioral factors. It is recognized as a cardiovascular risk. For this reason we must consider it in the clinical practice guidelines for the prevention and treatment of diseases with high mortality.

Chest. 2012 Oct 1; 142(4_MeetingAbstracts): 974A
Abdel Nour S, Abdel Nour H, Mehta J, Byrd R, Roy T

SESSION TYPE: Miscellaneous Case Report Posters IPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PMINTRODUCTION: Wernicke's encephalopathy has historically been associated with chronic alcoholism; however, it can be related to multiple other conditions. A case of thiamine deficiency in a non-alcoholic patient is presented here.CASE PRESENTATION: A 24 year-old white female patient with a history of depression and morbid obesity presented with complaints of generalized weakness. She had history of recent bariatric surgery. The patient had been complaining of diffuse weakness for more than 3 weeks. She saw her primary care physician who reassured her by saying, "it's all in your head." Unfortunately, the patient continued to deteriorate and eventually became unable to ambulate. The patient's exam was remarkable for ophtalmoplegia, diffuse weakness with areflexia. Her sensation was intact and no tremor was noted. Upon admission, the patient had a lumbar puncture which showed benign cerebrospinal fluid. Magnetic resonance imaging of her brain showed abnormal signal through the caudate nuclei and bilateral basal ganglia in a symmetrical fashion. The patient's laboratory values including thyroid stimulating hormone, creatine phosphokinase, vitamin B-12 levels, sedimentation rate, antinuclear antibodies and anti-acetylcholine receptor (AChR) antibody all were normal. With concern about Wernicke's encephalopathy, the patient was started on thiamine 500 mg given intravenously every 8 hours. The next day, the patient's ophtalmoplegia dramatically improved. Also, her weakness resolved over the next few days.DISCUSSION: Wernicke's encephalopathy (WE) is an acute form of thiamine deficiency caused by diminished glucose utilization in the brain. The diagnosis of Wernicke's encephalopathy is challenging, especially in non-alcoholic patients. It is suspected clinically when patients present with symptoms of encephalopathy, ataxia, nystagmus or other forms of oculomotor dysfunction. However, patients rarely present with these classic symptoms, and a diagnosis of WE should not be discounted if patients do not fit the standard clinical picture. Normal MRI findings should not rule out or delay the treatment of suspected Wernicke's encephalopathy. The classic finding of mammillary bodies atrophy is not always observed in non-alcoholic WE. Since absorption of thiamine through the gastrointestinal system is limited, patients with suspected WE should be treated with intravenous thiamine.CONCLUSIONS: Thiamine deficiency remains clinically underdiagnosed. Physicians should remain vigilant for atypical presentation of WE in non-alcoholic patients.1) The Royal College of Physicians report on alcohol: guidelines for managing Wernicke's encephalopathy in the accident and Emergency Department. Thomson A; Alcohol Alcohol 2002 Nov-Dec;37(6):513-21DISCLOSURE: The following authors have nothing to disclose: Souheil Abdel Nour, Holly Abdel Nour, Jayantilal Mehta, Ryland Byrd, Thomas RoyNo Product/Research Disclosure InformationEast Tennessee State University, Johnson City, TN.

Chest. 2012 Oct 1; 142(4_MeetingAbstracts): 738A
Hijjawi S, Abu Minshar M, Wang Y, Sharma G

SESSION TYPE: COPD: Diagnosis and EvaluationPRESENTED ON: Sunday, October 21, 2012 at 01:15 PM - 02:45 PMPURPOSE: COPD is the third most common cause of 30-day readmission. Readmissions are costly and attributed to poor quality of care. National efforts are geared toward reducing 30-day readmission. However there are no validated risk prediction models for patients with COPD to predict 30-day readmissions and / or interventions to reduce these readmissions. We examined 30 day readmission and factors associated with early readmission in patients hospitalized with AECOPD. Our hypothesis was early readmissions among patients with COPD are not preventable.METHODS: We performed a retrospective chart review of all patients with primary discharge diagnosis of COPD based on ICD-9 code 491, 492 and 496.0 between 6/1/2010 to 5/30/2011. Detailed information on patient characteristics was obtained from electronic medical record to confirm the diagnosis of AECOPD. Patients were followed up to 30 days post discharge date for readmission. We examined the difference in baseline characteristics of patient who were readmitted with those who were not readmitted within 30-days. T-test and chisq test were used to compare continuous and categorical variables, respectively. A multivariate GEE model to adjust for clustering at patient level was used to examine the factors associated with 30-day readmission. All p-value <0.05 was considered statisticaly significant.RESULTS: 160 patients were admitted for a total of 193 hospitalizations during the study period. Of these 30 patients (18.8%) were re-admitted within 30 days. Patients who were readmitted were more likely to be black, had congestive heart failure, coronary artery disease, h/o alcohol abuse, and were on supplement oxygen. There was no difference in baseline medication use, length of stay, or serum bicarbonate, and whether or not the patient had a follow up post discharge. In a multivariate analysis, odds of 30-day readmission was 2.56 (95% CI: 1.18-5.38) in patients on supplement oxygen, and 2.17 (95% CI; 1.16-4.09) in patients with alcohol abuse.CONCLUSIONS: In our study population 30-day readmission in patients with COPD were related to advanced disease and psychosocial factors which are unlikely to be modifiable.CLINICAL IMPLICATIONS: Early readmissions in patients with COPD are not preventable.DISCLOSURE: The following authors have nothing to disclose: Shadi Hijjawi, Marwan Abu Minshar, Yue Wang, Gulshan SharmaNo Product/Research Disclosure InformationUTMB, Galveston, TX.

Sex Transm Infect. 2013 May 22;
Lee M, Rayment M, Scourfield A, Gazzard B

OBJECTIVES: We aimed to identify the factors associated with developing AIDS 6 months or more after an HIV diagnosis, and to examine how post-HIV diagnosis AIDS (PHDA) patients differed from true late presenters (HIV diagnosed concurrent with the first AIDS presenting event) in their demographics and comorbidities. METHODS: A retrospective analysis was undertaken of all inpatients admitted to a large HIV unit presenting with the following AIDS-defining infections: cryptococcal meningitis, cerebral toxoplasmosis or Pneumocystis jirovecii pneumonia between 1 January 2005 and 31 December 2010. RESULTS: 114 HIV-positive patients presented with AIDS-defining infections. Compared with late presenters, PHDA patients had a larger proportion of migrants and visitors (53.7% vs 34.0%, p=0.047), were more likely to inject drugs (9.3% vs 0.0%, p=0.032), had more previous HIV-associated diseases (57.4% vs 12.8%, p=0.000), psychiatric comorbidities (35.2% vs 12.8%, p=0.009), rates of alcohol abuse (24.1% vs 4.3%, p=0.005) and reported social issues (25.9% vs 0.00%, p=0.000). 88.9% of PHDA patients were lost to follow-up for a period of at least 4 months since diagnosis. Common reasons for clinic non-attendance included travel, social issues, transfer of care and treatment avoidance. Common reasons for antiretroviral treatment breaks included drug side effects, negative beliefs about medication, incompatible lifestyles and social issues. CONCLUSIONS: Compared with late presenters, PHDA patients demonstrate clear demographical differences including higher rates of psychiatric comorbidities, social issues, alcohol and substance abuse. Many PHDA patients default follow-up. The retention of HIV patients in care and on treatment must be addressed by clinicians to prevent avoidable morbidity.

Chest. 2012 Oct 1; 142(4_MeetingAbstracts): 613A
Deleanu O, Malaut A, Nebunoiu A, Ulmeanu R, Rohan I, Mihaltan F

SESSION TYPE: Cancer Global Case Report PostersPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PMINTRODUCTION: Association of pulmonary tuberculosis (TB) and lung cancer is controversial but not unusual, often neoplastic cells are localized on TB sequelae[1]. Studies have shown that incidence of lung cancer is 11 times greater in patients with TB[2].CASE PRESENTATION: Male patient, 55 years old, former heavy smoker, with history of: chronic alcoholism, treated pulmonary TB (2007), pharyngeal carcinoma (chemotherapy, radiotherapy 2006), Paget's disease. Sputum examination confirmed radiological findings: secondary infiltrative nodular pulmonary TB. After 2 weeks of treatment patient accused polyuria, associating intense confusional state and abnormal gait. Neurological consult associated with a cerebral computer-tomography (CT) ruled out the suspicion of neurological disorder. Laboratory: hypercalcemia with normal parathormone; diagnosis was paraneoplastic secondary hyperparathyroidism with unspecified starting point. After cardiopulmonary arrest the patient survived 6 weeks mechanically ventilated. Technical conditions did not allowed performing thoracic CT, the bronchoscopy did not showed endobronchial lesions, but the necropsy confirmed the suspicion of lung cancer - epidermoid carcinoma.DISCUSSION: Special attention must be drawn to the etiology of the hypercalcemia, as the cause may be the patient's previously known Paget's disease. Primary or secondary hyperparathyroidism (as paraneoplastic phenomenon) may be other causes of hypercalcemia. Studies have shown that responsible for paraneoplastic hypercalcemia are: head and neck, esophagus, lung, breast or renal carcinoma[3]. Also there must be established what determined the immunosuppresion causing pulmonary TB recurrence. Evidence suggests that the inflammatory processes and remodeling after pulmonary TB may play central role in carcinogenesis in patients associating both diseases. The reverse causality must also be considered as tuberculosis may have been the result of weakened immune system due to the lung cancer. In this case it is difficult to conclude whether TB sequelae caused lung cancer or the lung cancer simply associated in a patient with previously known pulmonary TB.CONCLUSIONS: Patients with pulmonary tuberculosis must be closely followed with thorough clinical examination and extensive paraclinical investigations to detect any existing or subsequently lung cancer that may mimic TB.1) Lung cancer in patients with tuberculosis. Saulius Cicenas, Vladislavas Vencevičius. World Journal of Surgical Oncology 2007, 5:22. 19 February 20072) Increased lung cancer risk among patients with pulmonary tuberculosis: a population cohort study, Yu YH, Liao CC, Hsu WH, Chen HJ, Liao WC, Muo CH, Sung FC, Chen CY, J Thorac Oncol., 2011 Jan; 6(1): 32-7.3) Andrew F. Stewart, Hypercalcemia Associated with Cancer, N Engl J Med 2005;352:373-9DISCLOSURE: The following authors have nothing to disclose: Oana Deleanu, Andra Malaut, Ana Nebunoiu, Ruxandra Ulmeanu, Ileana Rohan, Florin MihaltanNo Product/Research Disclosure InformationUniversity of Medicine and Pharmacy Carol Davila, Bucharest, Romania.