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Displaying 1 - 10 of 500 in Annals of Internal Medicine: Clinical Cases
Generalized Weakness Due to Hypocalcemia and Hypophosphatemia From Potent Acid Suppression | Annals of Internal Medicine: Clinical Cases
Potent gastric acid suppression can disrupt mineral homeostasis. An older woman receiving alfacalcidol developed weakness accompanied by profound hypophosphatemia with hypocalcemia and secondary hyperparathyroidism after initiation of the potassium-competitive acid blocker vonoprazan. Laboratory findings showed an elevated intact parathyroid hormone level and renal phosphate wasting, whereas her serum magnesium level was 2.7 mg/dL (reference range, 1.7–2.6 mg/dL) and her intact fibroblast growth factor 23 was 41.7 pg/mL (reference range, 19.9–52.9 pg/mL). The patient's weakness and calcium–phosphate abnormalities resolved with mineral repletion and switching from vonoprazan to a proton-pump inhibitor. This case highlights that strong acid suppression may precipitate significant calcium–phosphate derangements despite active vitamin D therapy. Early evaluation of mineral metabolism and reassessment of acid-suppressive therapy are especially important in patients with unexplained weakness.
Atypical Epigastric Pain Reveals Obstructive Urosepsis in a Horseshoe Kidney | Annals of Internal Medicine: Clinical Cases
A 61-year-old woman presented with 2 days of nausea, vomiting and severe mid- to upper abdominal pain radiating to the right flank without any urinary symptoms. She was hypotensive, with leukocytosis and pyuria. Contrast-enhanced computed tomography demonstrated a horseshoe kidney and a 12- × 8- × 18-mm right ureteropelvic junction stone causing mild to moderate hydronephrosis. Blood and urine cultures were obtained before administration of antibiotics and remained negative. She received intravenous crystalloid therapy, ceftriaxone, and emergent percutaneous nephrostomy, with rapid hemodynamic recovery and normalization of leukocytosis by hospital day 1. This case highlights atypical presentations of obstructive urosepsis and the importance of early decompression.
Glomerulonephritis Caused by Bartonella quintana Endocarditis | Annals of Internal Medicine: Clinical Cases
We describe the case of a 60-year-old man who presented with rash and renal failure and was subsequently diagnosed with Bartonella quintana mitral valve endocarditis. Key findings included skin biopsy showing leukocytoclastic vasculitis, renal biopsy showing crescentic glomerulonephritis, and high-titer IgM and IgG antibodies against B quintana. This case underscores the varied presentations of culture-negative endocarditis and its association with glomerulonephritis in infectious diseases such as Bartonella.
Favre–Racouchot Disease: Extensive Comedonal Lesions on Severely Photodamaged Facial Skin | Annals of Internal Medicine: Clinical Cases
Favre–Racouchot disease is a manifestation of chronic actinic damage characterized by multiple open and closed comedones on severely photodamaged skin. The accompanying images illustrate classic malar and periorbital involvement with prominent solar elastosis and absence of inflammatory acneiform lesions in an older adult Latino man (Fitzpatrick skin type IV), underscoring that this condition can occur in darker-skinned phototypes with sufficient cumulative ultraviolet exposure.
Intracardiac Migration of a TIPS Stent Causing Ventricular Tachycardia | Annals of Internal Medicine: Clinical Cases
Intracardiac migration of a transjugular intrahepatic portosystemic shunt (TIPS) stent is a rare but potentially life-threatening complication. A 52-year-old man developed asymptomatic nonsustained ventricular tachycardia within 24 hours of elective TIPS creation. Echocardiography demonstrated a migrated TIPS bare-metal stent segment protruding into the right ventricle and interacting with the tricuspid valve. The stent was retrieved endovascularly using balloon and snare techniques via dual venous access under echocardiographic and fluoroscopic guidance. Arrhythmias resolved after stent removal. This case highlights the importance of early post-TIPS monitoring and prompt endovascular intervention for intracardiac stent migration presenting with ventricular arrhythmias.
Case of Splenic Marginal Zone Lymphoma Presenting as Acquired Angioedema | Annals of Internal Medicine: Clinical Cases
Acquired angioedema (AAE-C1INH) is a rare, potentially life-threatening disorder resulting from acquired C1 esterase inhibitor deficiency, often secondary to lymphoproliferative diseases such as splenic marginal zone lymphoma (SMZL). We report on a 68-year-old woman presenting with facial and tongue swelling, gastrointestinal symptoms, and splenomegaly. Laboratory work-up revealed low C1 esterase inhibitor and C1q complement levels, consistent with AAE-C1INH. Imaging showed marked splenomegaly with increased fluorodeoxyglucose uptake; bone marrow biopsy confirmed SMZL. Treatment with rituximab and bendamustine chemotherapy led to clinical improvement, normalization of complement levels, and cessation of angioedema episodes.
Hydroxychloroquine Cardiomyopathy—A Case Series and Review of the Literature | Annals of Internal Medicine: Clinical Cases
Cardiomyopathy is a rare but serious adverse effect of long-term hydroxychloroquine therapy, manifesting as conduction abnormalities and heart failure. Its incidence is not well established. We present the largest case series, to our knowledge, of 13 patients with endomyocardial biopsy–proven hydroxychloroquine cardiomyopathy conducted over an 8-year period at one institution. Outcomes after therapy discontinuation varied, ranging from complete resolution to progressive heart failure requiring advanced therapies, including the first reported cases of left ventricle assist device as destination therapy. Early recognition and timely drug cessation may allow for partial or full recovery of cardiac function.