Ixodes scapularis is responsible for transmission of Borrelia burgdorferi, B. miyamotoi, Babesia microti, Anaplasma phagocytophilum and Powassan virus to humans. We present a case of an 87-year-old man who presented with fever and altered mental status. Initial workup revealed haemolytic anaemia, thrombocytopenia, mild hepatitis and acute kidney injury. Patient tested positive for B. burgdorferi and Babesia microti, and was started on doxycycline, atovaquone and azithromycin. He also underwent exchange transfusion twice. After some initial improvement, patient had acute deterioration of mental status and appearance of neurological findings like myoclonus and tremors. Therefore, testing for arboviruses was done and results were positive for Powassan virus. During a protracted course of hospitalisation, patient required intubation for respiratory failure and temporary pacemaker for unstable arrythmias from Lyme carditis. Patient developed permanent neurological deficits even after recovery from the acute illness.

4072 Background: While the overall incidence of colorectal cancer (CRC) is decreasing, the rate has increased in population under 50, with higher stages at diagnosis and a greater proportion of African Americans (AA). Hence, there is an ongoing debate about the age of CRC screening. These trends have not been studied in the VA population. Methods: ICD-10 codes C18-C20 were used to identify the cases of colon and rectal cancer in National VA Cancer Cube Registry. 43,544 cases of colon cancer, 1,278 below and 42,254 above age 50, and 19,815 cases of rectal cancer, 862 below and 18,948 above age 50 were identified between 2003-17. Younger age group was defined as patients less than 50 years old. IRB approval was obtained. Results: Our data comprised > 97% of male patients. In younger group, in the 5 year periods, 2003-07, 2008-12 and 2013-17, colon cancer rate increased from 2.59% to 2.79% to 3.59%, while for rectal cancer it increased from 3.5% to 4.3% to 5.3% (p < .0001). Blacks comprise 31.6% cases of colon cancer and 27.15% cases of rectal cancer in under 50 group, compared to 18.5% and 15.9% of cases in above 50 group respectively (p < .0001). For under 50 group, 48.6% cases of colon and 42.2% cases of rectal cancer were diagnosed in stage III or IV compared to 35.7% and 34.05% cases in above 50 group respectively (p < .0001). For colon cancer, 51.87% of patients in the younger group have a < 5 year survival, worse compared to 45.05% in 50-60 group (p < .0001) and similar to 49.3% in 60-70 group (p = .08). For rectal cancer, 5 year survival showed no difference between these groups. Stage specific survival shows no difference for either colon or rectal cancer across < 50, 50-60 and 60-70 age groups. Conclusions: Rate of CRC is rising in < 50 age group with more advanced stage at diagnosis and higher proportion of African Americans. For colon cancer, < 50 group has a worse 5 year survival as compared to 50-60 age group likely due to increased proportion of patients in stage III or IV, as there is no difference in stage specific survival. For rectal cancer, the 5 year survival or stage specific survival shows no difference in < 50, 50-60 and 60-70 groups. These results add to our understanding of the trends of CRC and should be accounted for in the screening guidelines.

INTRODUCTION: Acute Myeloid Leukemia (AML) is a group of blood cancers that arise from clonal proliferation of malignant hematopoietic precursor cells in bone marrow. We report a case of AML that presented as esophagitis secondary to leukemic infiltration of the esophagus. CASE DESCRIPTION/METHODS: A 60 year male who presented with 1 month history of worsening retrosternal pain, worsened with eating & drinking, leading to a 9 kg weight loss. Patient was taking increasing doses of NSAIDS to treat this pain unsuccessfully. Patient’s past medical history included hypertension, hyperlipidemia & Bell's palsy. Patient’s EKG & 3 troponins were normal. He had no melena, hematochezia but stool guaiac tested positive. Initial CBC showed a WBC 20.5 k/mm3, Hgb 7.7 g/dL, & Platelets 28 k/mm3 with peripheral smear revealing 86% blasts with rare Auer rods. Patient was diagnosed with AML with NSAID associated gastritis & was started on IV Proton pump inhibitor therapy. Patient underwent a bone marrow biopsy that showed 95% blasts and 5% erythroid. On flow cytometry 95% were myeloblasts. Fluorescence in-situ hybridizationtesting showed MLL mutation with 11q23 rearrangement. While awaiting induction 7 + 3 chemotherapy, patient underwent EGD due to continued odynophagia. It showed multiple discreet large non-bleeding ulcers in the proximal & middle third of the esophagus. CMV esophagitis was suspected & the patient received empiric ganciclovir for 3 days. The final biopsy showed no CMV and colonisation without invasion by Actinomycetes, but it also showed atypical mononucleated cells consistent with leukemic infiltrates in the ulcer bed. Patient received induction chemo 7 + 3 but had partial response based on day 14 bone marrow & was successfully reinducted. He is currently awaiting a bone marrow transplant on consolidation chemotherapy. He is symptom free of esophagitis. DISCUSSION: In AML, large numbers of immature myeloid cells are seen in the bone marrow & in peripheral blood resulting in a crowding out effect of other cell lines. Presentation is usually symptoms of anemia, bleeding from thrombocytopenia or immune deficiency. In previous autopsy series, gastrointestinal involvement of leukemia have been noted, with involvement of the esophagus being less common. There have been reports of leukemic infiltration of the esophagus developing during treatment for AML, but our case is a rare initial presentation with esophagitis from leukemic infiltration which led to the diagnosis and treatment of AML.

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INTRODUCTION: Factor V Leiden (FVL) results from mutation in the F5 gene resulting in hypercoagulable state. Although, venous thromboembolism (VTE) is frequently reported with FVL, cases of arterial thrombosis, especially MI in setting of FVL are rare.