Introduction: Metastatic colon cancer of the umbilicus is an uncommon phenomenon. An estimated 1%-3% of abdominopelvic malignancies have been shown to metastasize to the umbilicus. These metastatic umbilical nodules, also known as Sister Mary Joseph’s nodules, can vary in size, cause pain, and may discharge fluid. Although these nodules are rare, they are an important finding on physical exam as they are a sign of malignancy with metastasis. Herein, we are presenting a case of a 46-year-old man with metastatic colon cancer presenting with an ulcerated umbilical nodule, which was later diagnosed as Sister Mary Joseph’s nodule. Case Description/Methods: 46-year-old man with a past medical history of colon cancer with metastasis to the liver status post transverse colectomy and transverse colostomy, thrombosis of the right and left brachiocephalic arteries and thrombosis of the proximal superior vena cava presents to the clinic for evaluation complaining of a protruding umbilical mass of 2 months duration. The umbilical mass is ulcerated with some drainage at the site. He never had any preventative screening workup, including a colonoscopy. On physical exam, the patient was a healthy-appearing man. No signs of scleral icterus or jaundice. He had a soft, non-tender pendulous abdomen with a protuberant well defined, soft, non-tender, verrucous mass of 2 cm tethered to the umbilicus. Palpation did not elicit tenderness or bleeding. The patient was admitted to the hospital for further evaluation. The umbilicus was prepped with chloroprep and local anesthetic of 1% lidocaine was injected. The patient underwent a biopsy of the umbilicus. Histopathology showed adenocarcinoma likely metastasized from the colon. Discussion: Sister Mary Joseph nodule represents metastasis to Umbilical skin from visceral malignancy. The approach to the diagnosis demands thorough knowledge of underlying causes. The causes are not limited to GI, renal and GYN malignancies but also benign causes like endometriosis are possible. Thorough physical examination, basic blood tests, and imaging guide in diagnosis the primary tumor in case of metastasis. Biopsy and histochemical staining are invaluable tools in diagnosis majority of the cases. Endoscopy, colonoscopy, and PET scan are warranted for complete evaluation. Management depends on the nature of the underlying cause which includes resection, chemotherapy and radiation. Medical therapy alone may be sufficient in case of benign causes (Figure 1).Figure 1.: A. Sister Mary Joseph nodule. B, C. HPE showing adenocarcinoma.

Kaposi sarcoma (KS) was first described by Moritz Kaposi as a vascular tumor that mainly involves the skin but can affect any organ system. It is typically an acquired immunodeficiency syndrome defining illness but has emerged as a neoplasm also seen in patients on immunosuppressive therapy. Few KS cases have been reported in the literature associated with inflammatory bowel diseases. We report the case of a 39-year-old male with well-controlled human immunodeficiency virus (HIV) and ulcerative colitis (UC) who presented to the hospital with new skin lesions shortly after the initiation of vedolizumab to treat his refractory UC. Immunohistochemistry of the skin lesions was consistent with Kaposi's sarcoma secondary to human herpesvirus-8. This is a rare case of iatrogenic KS in a well-controlled HIV patient secondary to immunosuppressive therapy.

Abstract Background Kaposi’s sarcoma (KS) is a vascular tumor caused by human herpes virus-8 infection (HHV-8) commonly involving the skin. We report a case of a patient with controlled HIV who developed Kaposi’s sarcoma on vedolizumab. Darkened hyperkeratotic plaque on his left medial foot Methods A 39-year-old homosexual male with a history of Ulcerative Colitis (UC), Hodgkin’s lymphoma in remission and HIV presented with complaints of abdominal pain and bloody diarrhea. He had new tender lesions on his left foot which was absent at his previous admission a month ago. The lesions started as macules and later progressed to tender lesions. Mesalamine and oral corticosteroids were previously prescribed without symptomatic relief and he was started on vedolizumab 2 months ago. On physical exam he had abdominal tenderness, tender cervical and inguinal lymph nodes, and dark macules on his feet. Digital rectal exam revealed bloody mucoid stool. Laboratory showed white blood cell count of 12,600/mm3, ESR of 132 mm/hr and CRP of 4.6 mg/dL. His CD4 T-cell count was 873 cells/mm3 and viral load was 50 copies per milliliter. Cervical lymph node biopsy showed polymorphous population of lymphocytes but was negative for malignant cells. Biopsy of the foot plaques showed atypical intradermal vascular and spindle cell proliferation positive for HHV-8 and for vascular marker CD34. The results were consistent with the diagnosis of KS. Serology was also positive for HHV-8 with high viral titers of 74 copies/mL. Colonoscopy showed severe proctitis with deep ulcerations in a continuous pattern in the rectum with a normal sigmoid colon. Follow up colonoscopy showed improved proctitis and he was started on doxorubicin to treat KS with improvement of the foot lesion a month later following treatment. Dark macules on the sole of both feet Figure 3a: Spindle cells with irregular small vessel proliferation and red blood cell extravasation between tumor cells Figure 3b: Immunohistochemical stain showing HHV-8 expression of spindle cells Improvement of the foot lesion Results Vedolizumab is a monoclonal antibody that prevents the recruitment of lymphocytes to the inflamed tissue. It is approved for the treatment of IBD and has shown efficacy and safety. The iatrogenic form of Kaposi’s sarcoma occurs in patients on immunosuppressive therapy, as this patient. Conclusion Patients with IBD on immunosuppressive drugs should be followed up closely and screened for latent viral infections prior to initiating therapy. As in the patient, HHV-8 should be recognized as a likely underlying opportunistic infection in immunocompromised patients with IBD. Disclosures All Authors: No reported disclosures

INTRODUCTION: Taenia is a rare infection in the developed world and its association with appendicitis is even rare. Taenia solium is mostly found in pork while saginata is primarily found in beef however determining can be difficult and requires microscopy for certain anatomic characteristics. Taenia is a growing concern in developed countries due to immigration from endemic areas and its potential to cause disseminated disease. Here we are presenting a case of Taenia infestation presented as an Appendicitis. CASE DESCRIPTION/METHODS: A 19 y/o male with no known past medical history presents to the Emergency Department with complaints of Right lower quadrant (RLQ) pain. Patient (Pt) stated the pain began in his RLQ that radiates all over his abdomen with 10/10 in intensity. Pt admits to dizziness and loss of appetite but denies nausea or vomiting. Pt appeared in acute distress with heart rate of 95 bpm but afebrile. Abdomen was non-distended, soft, and had tenderness to palpation it the RLQ with slight rebound tenderness. CT abdomen showed appendicitis and surgery was consulted for appendicectomy. Pathology report showed a mildly dilated and inflammed appendix as well as presence of strobili in the appendix. Pt was discharged home on anti-helminthics post-surgery with resolution of symptoms upon discharge. DISCUSSION: Taenia occurs in human hosts after ingestion of either undercooked pork or beef that contains the larvae of the tapeworm. The worm works its way to the intestine, where the scolex can attach itself to the intestinal wall and produce strobilla .The eggs of the tapeworm can obstruct the lumen of the appendix which will lead to inflammation and infection. Furthermore, the worm can migrate to the end of the digestive tract where it can be excreted with fecal material leaving proglottids in the soil and contaminating water. This leads to risk for ingestion of larvae and proglottids leading to further dissemination of the parasite to another host. Taenia infection is highly preventable by ensuring adequate cooking temperatures and timing of meat as well proper sanitary precautions. It is also important to take into consideration of examination of family members and others for possible infection from the same meals. Preziquantel and albendazole has shown to be effective in treating this infection. As immigration from endemic areas continues to grow due to Globalisation further understanding of the relationship between parasitic infection and appendicitis may be beneficial.Figure 1.: Inflammed Appendix.Figure 2Figure 3.: Inflammed appendix with Cestodes.

INTRODUCTION: Kaposi's sarcoma (KS) is a cancer that develops from the cells that line lymph or blood vessels. It usually appears as tumors on the skin or on mucosal surfaces such as inside the mouth, but these tumors can also develop in other parts of the body, such as in the lymph nodes, the lungs or digestive tract. KS involvement of GI tract may remain asymptomatic in the beginning or may present with mild non-specific abdominal symptoms, unlikely to be diagnosed in late stage. Here we are presenting a case of disseminated KS presented with rectal bleed in homosexual undiagnosed HIV patient. CASE DESCRIPTION/METHODS: A 33 yr old male with no significant past medical history, presented with 3-month history of constipation and progressive unintentional weight loss (40 lbs in 3 months). Lately, patient noticed his stool mixed with blood and mucus, early satiety and fatigue. Patient has family history significant for breast cancer and biliary cancer in mother. Patient is sexually active with 5 male partners. On presentation, vitals were stable and physical examination revealed multiple purple non-blanchable lesions on his extremities and trunk, a mass on the hard palate, supraclavicular and inguinal lymphadenopathy, external hemorrhoids, and a palpable mass in the rectum. Labs showing normocytic anemia with Hb of 10.3, ESR of 95 and CRP of 9.88. Patient was found to be positive for HIV with viral load of 118,255 and CD4 count of 236. Patient also had high IgG titers for Chlamydia trachomatis and CT abdomen and pelvis showed rectosigmoid mass with perirectal lymphadenopathy, inguinal adenopathy, and mild retroperitoneal lymphadenopathy. CT chest showed pulmonary metastasis and colonoscopy showed mild non-specific ileitis, nodule in descending colon and neoplasm in the rectum. Biopsy from the descending colon and rectal mass showed ulcerated Kaposi’s sarcoma and positive immunostaining for human herpes virus -8 (HHV-8). Patient was diagnosed with disseminated KS and started on anti-retroviral therapy (ART) and systemic chemotherapy. DISCUSSION: AIDS-associated disseminated KS is a rare entity. ART has resulted in marked decline in the incidence of KS. Due to the rapid and progressive nature of AIDS related KS, early diagnosis and institution of ART is crucial to achieving favorable prognosis. In addition, co-infection of HHV-8 with HIV promotes the oncogenicity of HHV-8 leading to rapid onset and progression of KS. Above patient responding well to the ART and Chemo going for surveillance Colonoscopy.Figure 1.: Kaposi Sarcoma on Hard Palate.Figure 2Figure 3.: Kaposi Sarcoma in Rectum.

INTRODUCTION: Hepatitis B (HB) virus is a global public health problem as it affects more than 300 million patients around the world. It's well known that once we have Anti-HBs, seroconversion takes place, and that's a marker of viral clearance and immunity. In view of their important protective role, occurrence of anti-HBs and HBsAg is perplexing. Although this has been reported in 5-20% of cases of Chronic Hep B, it remains a confusing finding to many physicians who are unaware of the existence, explanation and implications of this finding. Herein, we will present a case of such a pattern. CASE DESCRIPTION/METHODS: A 49-year-old male with diabetes and hypertension was found to have elevated liver enzymes on routine blood work. Further workup resulted in diagnosing chronic hepatitis B. The patient’s viral serology results were positive for HB core antibody, HB surface antibody, HB surface antigen, HB e antigen, and a viral load of 1,500,000 IU/ml. Liver enzymes were elevated with ALT of 250U/L and AST of 180U/L. No masses were detected on liver ultrasound. Blood sample was sent to Center for Disease Control and analysis revealed a mutation G130N within the major hydrophilic region of surface antigen. The patient was started on Entecavir. After 12 months, the VL became undetectable. Serology was still positive for both HB s Ag and Ab but he successfully achieved HB e Ab +ve status. Liver enzymes normalized. DISCUSSION: The expected pattern in chronic HB is the presence of HBsAg and lack of anti-HBs. The mechanism underlying the coexistence of HBsAg and anti-HBs remains unclear. Mutations in the viral DNA were initially suggested by researchers to explain how the subtypes of the HBsAg and anti-HBs were heterologous. It was shown that there is a relation between this special serological profile and mutations in S gene region, particularly in the 'a' determinant of the major hydrophilic region of the surface antigen, including one located at G130N. Aside from mutations in the S gene region, the presence of heterologous subtype-specific antibodies, superinfection with a new HB strain, occult HB reactivation and false positivity for anti-HBs are other possible explanations. These patients might harbor an augmented HBV replicative capacity and HBV reactivation upon receiving immunosuppression. Antiviral prophylaxis must be considered before starting immunosuppressive drugs. It was also reported that coexistent HBsAg and anti-HBs independently increased the risk of advanced fibrosis and hepatocellular carcinoma.

Abstract Background Pre-exposure prophylaxis (PrEP) is a highly effective method for preventing HIV transmission among at-risk patients. There is limited and conflicting data regarding the risk of other STIs following PrEP initiation. The objective of this study was to compare the incidence of STIs before and during PrEP therapy. Methods A retrospective observational study of patients seeking PrEP therapy at an inner-city clinic in Newark, New Jersey, between May 1, 2016 and March 30, 2018. Patients who were MSM, intravenous drug users, or heterosexual with multiple or HIV-positive partners were considered at risk for HIV and offered PrEP. Patients were initially screened and tested every 3 months for HIV, Chlamydia trachomatis, Neisseria gonorrhoea, syphilis, hepatitis B virus (HBV), hepatitis C virus (HCV), hepatitis A virus (HAV), herpes simplex virus (HSV), medication adherence and continued high-risk behavior. Patients were also counseled on risk-reduction behaviors. STI incidence before and during PrEP was compared. Results Between May 1, 2016 to March 30, 2018, 125 patients were considered at risk. Fifty-one (41%) patients were lost to follow-up after the initial visit and were excluded. Seventy-four (59%) patients completed screening and were included in the study. The mean age was 35.0 ± 11.6 years. The majority of the patients were males 74% (54). 29 (40%) were MSM, and 33 (45%) had HIV-positive partners. The mean duration of PrEP was 386 ± 183 days. Upon initial screening 14 (19%) patients were positive for at least one STI; 3 (21%) patients had HCV, 3 (21%) had chlamydia, 2 (14.3%) had HBV, 2 (14.3%) had gonorrhea, 2(14.3%) had syphilis, one had HSV II and one was found to have HIV. Two patients acquired a new STI on PreP. One tested positive for chlamydia and gonorrhea 1 month after initiating prep and another contracted syphilis after 6 months. No patient had recurrent STIs nor acquired HIV while on PrEP therapy. Conclusion The use of PrEP not only reduces the transmission of HIV but also appears to reduce the incidence of other STIs. Frequent STI screenings and behavioral counseling on risk reduction likely contributed toward lower STI incidence. Larger studies examining similar data over longer durations are needed to confirm these findings. Disclosures All authors: No reported disclosures.