Introduction:Venous thromboembolism (VTE) is associated with significant morbidity and mortality in cancer patients. Our study compares the mortality in hospitalized VTE patients among the four most common gastrointestinal (GI) malignancies which include esophageal, gastric, pancreatic, and colorectal cancer. Methods:A retrospective study was conducted utilizing the Nationwide Inpatient Sample database (NIS) from 2016 to 2019. Patients with VTE were identified using ICD-10 codes from all primary discharge diagnoses. Only deep venous thrombosis (DVT) and pulmonary embolism (PE) were considered. Patients with VTE were further divided into groups: esophageal cancer, gastric cancer, pancreatic cancer, and colorectal cancer, and compared with patients who did not have these malignancies. The adjusted odds ratio (aOR) was calculated using multivariate regression analysis. Results:Among 999,559 patients discharged with a VTE diagnosis, 25,775 (2.6%) had one of the four GI malignancies. Among patients with one of the four included GI malignancy diagnosis, 18,816 (73%) patients had PE and 6,959 (27%) patients had DVT. The study shows that adults admitted to the hospitals for VTE have higher mortality when compared to patients who did not have GI malignancies, with esophageal cancer having the highest inpatient mortality with an aOR of 2.701; 95% confidence interval (CI) 1.989-3.669, p value <0.000. For the remaining GI cancers, gastric cancer had an aOR 1.576; CI: 1.094-2.269, p value 0.015, and pancreatic cancer had an aOR of 1.736; 95% CI: 1.445-2.085, p value <0.000. Patients with colorectal cancer had no significant increase in the odds of mortality with aOR of 1.213; 95% CI: 0.988-1.489, p value 0.066. Conclusions:This study demonstrates that VTE in hospitalized patients with esophageal cancer is associated with greater mortality compared to other GI malignancies.

SESSION TITLE: Chest Infections Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/09/2023 12:00 pm - 12:45 pm INTRODUCTION: Granulomatous lung diseases represent a diverse group of infectious and non-infectious disorders. Among infectious etiologies, mycobacterial and fungal infections are the most common. Hypercalcemia is frequently seen in patients with granulomatous disease (GD). Here, we present a rare case of pulmonary cryptococcus infection in a hypercalcemic, immunocompetent individual that is thought to have triggered the development of extrapulmonary sarcoidosis. CASE PRESENTATION: A 58-year-old male with a past medical history of atrial fibrillation, non-alcoholic fatty liver disease, and pacemaker insertion was admitted due to hypercalcemia. The patient complained of dry mouth, polyuria, polydipsia, and significant nocturia for several weeks. Laboratory findings showed elevated ionized calcium level 1.86 mmol/L, low-normal parathyroid hormone level of 7.6 pg/mL, elevated angiotensin-converting enzyme of 123 U/L, elevated 1,25-dihydroxy-vitamin D levels of 69 pg/mL, normal creatinine level. He also had normal parathyroid hormone-related peptide. HIV studies were negative. Computed tomography (CT) chest revealed a small upper lobe nodule, while CT abdomen and pelvis showed development of innumerable low attenuation lesions in the spleen. The patient was treated with zoledronic acid and calcitonin. He underwent endobronchial ultrasound bronchoscopy (EBUS) with bronchoalveolar lavage (BAL). While needle aspirations of the subcarinal lymph node and transbronchial biopsies were negative for GD, BAL cultures were positive for Cryptococcus neoformans. The patient was readmitted and underwent lumbar puncture which did not reveal infection. A repeat CT of the abdomen and pelvis two months later showed numerous hepatic lesions, liver cirrhosis, evidence of portal hypertension, and a lytic lesion of the fourth lumbar vertebral body. A follow-up positron emission tomography (PET) scan redemonstrated innumerable hypermetabolic foci involving the liver, spleen, lymph nodes, and bones. A liver biopsy was negative for malignancy, but it showed non-caseating granulomatous inflammation extensively disrupting the liver parenchyma with a negative fungal stain. He was discharged on long-term fluconazole and flucytosine. DISCUSSION: Hypercalcemia has always been associated with GD, and sarcoidosis and tuberculosis are the most common GDs that cause hypercalcemia. Other less frequent GDs that cause hypercalcemia have been reported, including fungal infections, such as Cryptococcus infection. However, the mechanism of fungal hypercalcemia is not yet clear. Extrapulmonary sarcoidosis is very rare, and the exact cause is not known. Genetic susceptibility, environmental factors, putative antigens, and autoimmunity have been hypothesized in the development of this disease. In rare cases, Cryptococcus may be associated with the development of extra pulmonary sarcoid-like reactions (SLR). We postulate that our patient had a SLR from pulmonary cryptococcus due to his initial negative EBUS and hepatic imaging. CONCLUSIONS: Cryptococcus neoformans is a rare cause of significant hypercalcemia and can be associated with the development of sarcoidosis. More studies are needed to explain the mechanism of SLR caused by fungal infections to prevent possible consequences. REFERENCE #1: Sharma OP. Hypercalcemia in granulomatous disorders: a clinical review. Curr Opin Pulm Med. 2000 Sep;6(5):442-7. doi: 10.1097/00063198-200009000-00010. PMID: 10958237. REFERENCE #2: Spindel SJ, Hamill RJ, Georghiou PR, Lacke CE, Green LK, Mallette LE. Case report: vitamin D-mediated hypercalcemia in fungal infections. Am J Med Sci. 1995 Aug;310(2):71-6. doi: 10.1097/00000441-199508000-00007. PMID: 7631647. REFERENCE #3: Judson MA. Environmental Risk Factors for Sarcoidosis. Front Immunol. 2020 Jun 26;11:1340. doi: 10.3389/fimmu.2020.01340. PMID: 32676081; PMCID: PMC7333358. DISCLOSURES: No relevant relationships by Mohamad Al-Momani No relevant relationships by Rami Dalbah No relevant relationships by Adel El Abbassi No relevant relationships by Ahmad Othman No relevant relationships by Mohammad Qureshi No relevant relationships by Krupa Solanki

Abstract Aims The coronavirus disease 2019 (COVID‐19) pandemic has resulted in more than 6 million deaths worldwide. Studies on the impact of obesity on patients hospitalized with COVID‐19 pneumonia have been conflicting, with some studies describing worse outcomes in patients with obesity, while other studies reporting no difference in outcomes. Previous studies on obesity and critical illness have described improved outcomes in patients with obesity, termed the “obesity paradox.” The study assessed the impact of obesity on the outcomes of COVID‐19 hospitalizations, using a nationally representative database. Materials and Methods ICD‐10 code U071 was used to identify all hospitalizations with the principal diagnosis of COVID‐19 infection in the National Inpatient Database 2020. ICD‐10 codes were used to identify outcomes and comorbidities. Hospitalizations were grouped based on body mass index (BMI). Multivariable logistic regression was used to adjust for demographic characteristics and comorbidities. Results A total of 56,033 hospitalizations were identified. 48% were male, 49% were white and 22% were black. Patients hospitalized with COVID‐19 pneumonia in the setting of obesity and clinically severe obesity were often younger. Adjusted for differences in comorbidities, there was a significant increase in mortality, incidence of mechanical ventilation, shock, and sepsis with increased BMI. The mortality was highest among hospitalizations with BMI ≥60, with an adjusted odds ratio of 2.66 (95% Confidence interval 2.18–3.24) compared to hospitalizations with normal BMI. There were increased odds of mechanical ventilation across all BMI groups above normal, with the odds of mechanical ventilation increasing with increasing BMI. Conclusion The results show that obesity is independently associated with worse patient outcomes in COVID‐19 hospitalizations and is associated with higher in‐patient mortality and higher rates of mechanical ventilation. The underlying mechanism of this is unclear, and further studies are needed to investigate the cause of this.

SESSION TITLE: Chest Infections Case Report Posters 27 SESSION TYPE: Case Report Posters PRESENTED ON: 10/10/2023 09:40 am - 10:25 am INTRODUCTION: A lung abscess is defined as a circumscribed collection of pus resulting from necrosis of pulmonary parenchyma secondary to infectious etiology. We present a case of a patient who presented to the emergency department (ED) due to a fall and was incidentally found to have a lung abscess caused by methicillin-resistant Staphylococcus aureus (MRSA). CASE PRESENTATION: A 52-year-old female with 30 pack years of smoking history presented to ED for lower back pain after a fall from a ladder. The patient also complained of chronic fatigue. The physical exam was remarkable for tachycardia, decreased air entry on the right lung field, and tenderness to palpation over the lumbar region. Lab workup was remarkable for elevated CRP, ESR, and D-dimer. The patient underwent a CT scan of the lumbar spine with contrast which showed an L2 compression fracture and sacral alar fracture, along with a loculated right-sided pleural effusion and right pleural wall thickening. A CT angiogram was obtained, which demonstrated a 3.5 cm rounded mass in the right upper lobe with curvilinear parenchymal opacities in the posterior right upper lobe. The CT scan findings were suspicious of lung malignancy. The patient underwent a diagnostic US-guided thoracentesis which drained 30 cc of cloudy red fluid. Fluid analysis showed exudative fluid with negative microorganism growth. Fluid cytology revealed mesothelial cells and proteinaceous material. A CT-guided fine needle aspiration (FNA) of the right lung lesion was performed. Cytology from FNA showed abundant acute inflammation suggestive of an abscess. Tissue culture from FNA was positive for MRSA. As the patient lacked risk factors for hospital-acquired MRSA infection, it was presumed that the infection was due to community-associated MRSA (CA-MRSA). Due to insurance issues, she was treated with one dose of intravenous Dalbavancin and was switched to oral clindamycin for four weeks upon discharge. DISCUSSION: Anaerobic bacteria and streptococcus spp remain the most common bacteria causing community-acquired lung abscesses (CALA). Staphylococcus aureus (including MRSA) is another important cause, and it usually presents as a rapid, severe, mono-microbial infection. MRSA should be suspected if the patient has been exposed to healthcare settings three months prior to presentation. Cases of CA-MRSA infections have been on the rise lately. Several studies have shown that CA-MRSA is more prevalent in pediatric and young adult age groups, low-income families, and minorities. Almost all CA-MRSA strains carry a gene that produces Panton–Valentine leukocidin, a cytotoxin that leads to the destruction of leukocytes and induces tissue necrosis. Acute lung abscesses appear on chest CT as an area of cavitation with thick walls, and air-fluid levels are commonly seen within the abscess. Vancomycin or linezolid should be added to the empirical antibiotic regimen if there is suspicion of MRSA infection. CONCLUSIONS: It is difficult to suspect a diagnosis of lung abscess in patients lacking characteristic symptoms and imaging findings. Moreover, it is more challenging to suspect CA-MRSA as the causative microorganism due to patients lacking typical risk factors for MRSA infections. More studies are needed to evaluate the risk factors of contracting CA-MRSA. REFERENCE #1: Kuhajda I, Zarogoulidis K, Tsirgogianni K, Tsavlis D, Kioumis I, Kosmidis C, Tsakiridis K, Mpakas A, Zarogoulidis P, Zissimopoulos A, Baloukas D, Kuhajda D. Lung abscess-etiology, diagnostic and treatment options. Ann Transl Med. 2015 Aug;3(13):183. doi: 10.3978/j.issn.2305-5839.2015.07.08. PMID: 26366400; PMCID: PMC4543327. REFERENCE #2: Essentials of Clinical Infectious Diseases, edited by William F. Wright, Springer Publishing Company, Incorporated, 2013. ProQuest Ebook Central REFERENCE #3: Maltezou HC, Giamarellou H. Community-acquired methicillin-resistant Staphylococcus aureus infections. Int J Antimicrob Agents. 2006 Feb;27(2):87-96. doi: 10.1016/j.ijantimicag.2005.11.004. Epub 2006 Jan 19. PMID: 16423509. DISCLOSURES: No relevant relationships by Rami Dalbah No relevant relationships by Sai Karthik Kommineni No relevant relationships by Ahmad Othman No relevant relationships by supriya peshin No relevant relationships by Dipsa Shastri No relevant relationships by Venkata Vedantam

BACKGROUND:The use of echocardiography in pulmonary hypertension (PH) in advanced chronic obstructive pulmonary disease (COPD) is understudied. We aimed to compare the performance of echocardiography with right heart catheterization (RHC) in the diagnosis of PH in COPD patients undergoing lung transplant evaluation. METHODS:We included 111 patients with severe COPD who underwent RHC in a single center as part of lung transplantation evaluation. COPD-PH and severe COPD-PH were defined based on RHC per the 6th world symposium on pulmonary hypertension. Echocardiographic probability of PH was described according to the European Society of Cardiology guidelines. Summary and univariate analyses were performed. RESULTS:The mean age (±SD) was 62 (8) and 47% (n=52) were men. A total of 82 patients (74 %) had COPD-PH. The sensitivity, specificity, positive predictive, and negative predictive values of echocardiography in diagnosing COPD-PH were 43 %, 83 %, 88 %, and 34 % respectively and for severe COPD-PH were 67 %, 75 %, 50 %, and 86 % respectively. Echocardiography was consistent with RHC in ruling in/out PH in 53% (n=59) of patients. After controlling for age, sex. BMI, pack year, echocardiography-RHC time difference, GOLD class, FVC, and CT finding of emphysema, higher TLC decreased consistency (parameter estimate=-0.031; odds ratio: 0.97, 95%CI 0.94-0.99; p=0.037) and higher DLCO increased consistency (parameter estimate=0.070; odds ratio: 1.07, 95%CI 0.94-0.99; p=0.026). CONCLUSIONS:Echocardiography has high specificity but low sensitivity for the diagnosis of PH in advanced COPD. Its performance improves when ruling out severe COPD-PH. This performance correlates inversely with lung hyperinflation.

INTRODUCTION: Right-to-left shunt (RLS) is an important cause of refractory hypoxemia as it allows the passage of deoxygenated venous blood into the arterial system [1].RLS can be anatomic (intracardiac and intrapulmonary) or physiologic.Intracardiac RLS can present with platypnea-orthodeoxia syndrome (POS) which is characterized by dyspnea and hypoxemia, accentuated by standing or sitting positions and minimized when supine [1].We present a case of intracardiac RLS with POS manifesting during dialysis. CASE PRESENTATION:A 60-year-old woman with end-stage renal disease was hospitalized for syncope and acute hypoxemia during dialysis.She reported recent episodic oxygen desaturation at the home of 73-88% on room air.Bilateral pulmonary emboli (PE) were seen on CT scan and transthoracic echocardiogram (TTE) was normal.Discharged on apixaban and oxygen, she was readmitted the next month for self-limited dialysis-related hypoxemia, dyspnea, and altered mentation.Admitted again several weeks later with severe desaturation during dialysis, a PaO2 of 48 mm Hg was seen on 100% facemask oxygen.Resolving PE was seen on CT scan with no new findings.TTE showed a right atrial mass near the jugular Ash Split dialysis catheter tip without right ventricular strain.O2 saturation on 8 liters of nasal oxygen declined from 92% supine to 74% standing with marked platypnea and PaO2 42 mm/Hg.TTE with bubble contrast revealed a large atrial RLS (image 1).Transesophageal echocardiography found a 3x3 cm right atrial mass prolapsing across the tricuspid valve and impeding flow, with an aneurysmal interatrial septum (images 1 and 2).Surgical excision of the mass (image 3) from the atrial free wall and repair of a secundum atrial septal defect (ASD) eliminated the RLS.Pathology found the mass to be a large, organized thrombus.She was discharged with no supplemental oxygen.DISCUSSION: Intracardiac RLS can be seen in patients with patent foramen ovale (PFO) and less often with ASD2.RLS typically occurs when the right atrial pressure is higher than the left atrial pressure as in Eisenmenger's physiology.RLS with normal atrial pressures can occur by altered venous flow directed at a PFO after pneumonectomy or in similar conditions of altered atrial anatomy [2].Also, a case of RLS attributed to venous flow changes caused by right atrial thrombus was described [3].However, in our case, we believe that decreased preload in the right atrium caused by standing or during dialysis resulted in worsening obstruction of the tricuspid valve by thrombus, causing accentuated RLS through the ASD.This variable obstruction explains many of the transient phenomena seen in this case as well as the prominent role dialysis played in the patient's presentation.CONCLUSIONS: Anatomical shunt should be considered in refractory hypoxemia cases, with TTE with contrast as the best initial test.RLS can occur in the setting of normal atrial pressures by several mechanisms.

PURPOSE:The effect of cannabis use on asthma is not well-established in the medical literature.Some studies have shown an association between cannabis use and increased asthma symptoms and frequency of medical visits.A Norwegian study also suggested that cannabis use might be a risk factor for bronchial asthma and the use of asthma medications.In this study, we aimed to investigate the effect of cannabis use on patients admitted to hospitals with acute asthmatic attacks utilizing the National Inpatient Sample (NIS). METHODS:We conducted a retrospective study utilizing the NIS database from 2016 to 2019.Patients with acute asthma attacks and cannabis use (cannabis abuse and cannabis use in remission) were identified using the International Classification of Disease, Tenth Revision (ICD-10).We compared patients with cannabis use to patients without cannabis use who presented to hospitals with acute asthma attacks in terms of mortality, mechanical ventilation, altered mental status, bacterial pneumonia, and sepsis.Logistic regression was performed after adjusting to age, race, sex, obesity, tobacco use, and other comorbidities.Analyses were performed using IBM SPSS Statistics 26.RESULTS: There were 406,800 patients admitted with acute asthma exacerbation from 2016 to 2019 according to the NIS database.Of these, 16,915 had concurrent cannabis use.The mean age for the cannabis use group and non-cannabis use group was 35 years and 51 years, respectively.Compared to patients with no cannabis use, there was an increased risk of mortality rate, mechanical ventilation, and altered mental status in patients with cannabis use who presented with acute asthma attack with an odds ratio of 2.187 (95% CI 1.762 to 2.716, P-value <0.001), 1.421 (95% CI 1.358 to 1.486 P-value <0.001), 1.269 (95% CI 1.422 to 1.866 P-value <0.001), respectively.On the other hand, there was no difference in developing bacterial pneumonia or sepsis between the two groups.CONCLUSIONS: Our study suggests that cannabis use might increase mortality and morbidity in acute asthma exacerbation.CLINICAL IMPLICATIONS: Cannabis use may be very harmful to asthmatic patients and should be avoided.However, further research is required to investigate if the negative effect is dose-dependent.

SESSION TITLE: Vascular Complications in the ICU SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/09/2023 02:10 pm - 02:55 pm INTRODUCTION: Hemorrhagic shock is one of the main causes of death in patients with trauma, as severe blood loss can result in cellular and tissue hypoxia. Although hemorrhage from penetrating injury is usually easily identified, hemorrhage from blunt injuries can be concealed and difficult to localize. Early recognition of the hemorrhagic shock as well as adequate resuscitation during the evaluation to definitively treat the bleeding vessel is necessary to improve outcomes. Here we present a case of hemorrhagic shock due to intercostal artery bleeding after blunt trauma to the flank. CASE PRESENTATION: A 64-year-old female patient was brought to the emergency department after she sustained a backward ground-level fall in her home, impaling her left flank to a cabinet handle. Upon initial evaluation, the cabinet handle was located only within the subcutaneous tissue and easily removed. She was admitted for observation. However, about 24 hours after the initial presentation, she became hypotensive with a blood pressure of 68/34. She was cold, clammy, and lethargic. She was transferred to the intensive care unit. Initial labs showed a drop in her hemoglobin with metabolic acidosis. Two units of blood were transfused. CT angiography of the chest, abdomen, and pelvis showed a large area of hemorrhage overlying the left flank with findings suggestive of active contrast extravasation. The interventional radiology team performed angiography, which showed active arterial bleeding from the 12th left intercostal artery, and it was embolized successfully. The patient's hemodynamic status improved, and she was discharged. DISCUSSION: Intercostal artery (ICA) bleeding is rare, yet it can be life-threatening. It has many etiologies, but trauma (both blunt and penetrating) remains the most common, besides iatrogenic injury in many elective and emergency thoracic procedures. Also, spontaneous ICA bleeding was described in patients with some diseases like systemic lupus erythematosus, neurofibromatosis type 1, or coarctation of the aorta. Clinically, ICA injuries may manifest with different presentations, including hemothorax which can develop up to 16 days after the initial injury, extra-pleural hematomas, and rarely abdominal wall hematomas. When patients present with rapidly expanding hematomas or hemodynamic instability, urgent intervention in addition to correction of any coagulopathy is necessary. Transcatheter arterial embolization (TAE) is a dependable and generally safe approach for managing ICA bleeding, with a success rate of nearly 80%. However, if the hemorrhage is massive or if embolization is not successful, surgical options should be considered. In our case, the patient was found to have ICA bleeding causing a large flank hematoma and hemorrhagic shock after flank trauma leaving a foreign body embedded in the superficial tissue. CONCLUSIONS: A high index of suspicion for concealed hemorrhage after blunt injuries in the appropriate clinical setting is necessary to improve outcomes. CT angiography may be a good initial study for confirming bleeding and localizing the bleeding vessel. REFERENCE #1: Matsumoto N, Hayashi N, Morita C, Taguchi Y, Chan M, Tagawa Y, Sakahira H, Takaoka M. A case of hemorrhagic shock due to intercostal artery injury that occurred during initial trauma care with multiple displaced rib fractures and traumatic head injury. Trauma Case Rep. 2022 May 25;40:100658. doi: 10.1016/j.tcr.2022.100658. PMID: 35665200; PMCID: PMC9157016. REFERENCE #2: Laeeq K, Cheung S, Phillips B. Hemoperitoneum secondary to intercostal arterial bleeding in a trauma patient. J Surg Case Rep. 2017 Jan 19;2017(1):rjw194. doi: 10.1093/jscr/rjw194. PMID: 28108633; PMCID: PMC5260848. REFERENCE #3: Shen, Ching-Yi, Chien-Han Hsiao, Weide Tsai, Ding-Kuo Chien, Wen-Han Chang, & Tse-Hao Chen. "Lethal intercostal artery injury after a fall." Quantitative Imaging in Medicine and Surgery [Online], 12.3 (2022): 2203-2205. Web. 31 Mar. 2023 DISCLOSURES: No relevant relationships by Saif Abu-Baker No relevant relationships by Mohamad Al-Momani No relevant relationships by Omar Ammari No relevant relationships by Rami Dalbah No relevant relationships by Adel El Abbassi No relevant relationships by Ahmad Othman

INTRODUCTION: Extrapulmonary small cell carcinomas (ESCC), which arise from multipotent progenitor cells of neural crest origin widely distributed in the human body, are rare and generally associated with poor prognosis.They can arise from: the head and neck, gastrointestinal tract, genitourinary tract, female reproductive system, breast, the skin and other sites as well.It can also be of unknown primary in up to 13% of cases.ESCC can occur as de novo tumors or as a differentiation process in the context of a pre-existing organ specific tumor.Small cell carcinoma of the prostate constitutes up to 2% of all primary prostate cancers -with prostate adenocarcinoma being the most common primary prostate cancer-and carries dismal prognosis.CASE PRESENTATION: Our patient was a 58 year-old male with a remote history of Hodgkin lymphoma in remission for 33 years, presented with abdominal pain, weight loss, fatigue and dizziness.Initial work-up revealed hypoglycemia, mild transaminitis, lactic acidosis with increased anion gap with no other major derangements.Initially treated for sepsis, nonetheless, lactic acidosis persisted and recurrent symptomatic hypoglycemia occurred with low C-peptide, low proinsulin and normal cortisol AM level.Concerns were raised towards liver dysfunction.CT chest, abdomen and pelvis revealed multiple hypoechoic liver lesions, upper abdominal lymphadenopathy and a left prostatic mass with extraprostatic extension with pelvic lymphadenopathy.Prostate-specific antigen was normal.CT-guided liver biopsy revealed high grade small cell neuroendocrine tumor staining positive for synaptophysin and chromogranin with 90% proliferation index.Patient's episodes of hypoglycemia improved with platinum-based chemotherapy with carboplatin and etoposide.Following a total of 4 cycles of treatment in outpatient, repeat CT showed interval improvement in the size of liver lesions and prostatic mass.DISCUSSION: ESCC are rare tumors that arise from kulchitsky cells found in many organs and carry poor prognosis with both, locoregional and metastatic disease, with median survival being 1.5-3.5 years and less than 1 year, respectively, even with aggressive platinum-based chemotherapy similarly utilized to treat SCLC.Unlike SCLC, ESCC do not have high rate of central nervous system (CNS) metastasis at time of diagnosis, and therefore, no universal recommendations to screen ESCC patients with brain MRI unless CNS symptoms exist.Prostate and head and neck ESCC do have higher rates of CNS involvement than other forms of ESCC, though.De novo prostate small cell carcinomas, specifically, are exceedingly rare; constituting up to 2% of all prostate primary cancers and more commonly arise on the top of preexisting prostate adenocarcinoma while on treatment, giving rise to aggressive castration resistant prostate cancer.We believe that our patient had widespread ESCC coming from de novo primary small cell cancer of the prostate based on initial imaging showing liver lesions and prostate mass, liver biopsy and interval response on platinum-based therapy.CONCLUSIONS: ESCC of prostate is a very rare primary cancer of prostate, as with SCLC, it is aggressive, with high tendency for metastasizing and can present with variety of paraneoplastic syndromes.Platinum based therapy is the standard of care.Unfortunately, even with treatment, prognosis remains poor overall.