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A 69-year-old man with smoldering IgA lambda multiple myeloma developed progressive bilateral peripheral corneal opacities initially concerning for paraproteinemic keratopathy (PK). Despite recommendations for systemic therapy, histopathologic analysis of corneal tissue obtained during penetrating keratoplasty (PKP) demonstrated lipid-laden stromal deposits without immunoglobulin staining, confirming lipid keratopathy (LK). This case illustrates the diagnostic challenge of distinguishing LK from PK in patients with monoclonal gammopathies and emphasizes the need for histopathologic confirmation before initiating systemic therapy. Accurate differentiation can prevent unnecessary treatment and guide appropriate management of corneal deposition disorders associated with plasma cell dyscrasias.

Spontaneous Ecchymosis as Initial Presentation of Acquired Hemophilia A | Annals of Internal Medicine: Clinical Cases

Hemophilia A, a deficiency of clotting factor VIII, can be congenital, presenting with joint bleeding in childhood, or acquired, a rare subtype presenting as spontaneous bleeding most commonly seen in older adult patients. This report outlines an older adult patient with no history of bleeding disorders who developed acute-onset spontaneous ecchymoses and was found to have acquired hemophilia A. This case demonstrates the importance of a broad differential diagnosis in ecchymoses in older adult patients that includes coagulation factor deficiencies despite a lack of hematologic history. Early diagnosis and treatment of hemophilia A with hemostatic control and inhibitor eradication are imperative to prevent life-threatening bleeding.

Rifampin-Induced Loss of Glucocorticosteroid Therapeutic Effect | Annals of Internal Medicine: Clinical Cases

Drug–drug interactions between rifampin and glucocorticosteroids are uncommonly reported in the literature but can have significant impact on patient management. We report a case in which this drug–drug interaction complicated the management of a patient with active lupus arthritis flare on prednisone changing to biological therapy with concurrent rifampin given for latent tuberculous infection. Lack of therapeutic response to prednisone with subsequent control of her flare was finally achieved by discontinuing rifampin and changing to methylprednisolone and rituximab given that use of B-cell–directed biological therapy does not require concomitant latent tuberculosis treatment. This case underscores the importance of conducting a thorough evaluation of medications for any potential drug–drug interactions in immunosuppressed individuals.

Insulin Autoimmune Syndrome Presenting With Recurrent Hypoglycemia and Extreme Hyperinsulinemia | Annals of Internal Medicine: Clinical Cases

Insulin autoimmune syndrome (IAS) is a rare but important cause of hypoglycemia. Herein, we describe a case of a 67-year-old White man with recurrent episodes of confusion and fatigue relieved by food intake. Biochemical evaluation revealed profound hyperinsulinemia and an elevated C-peptide level, suggesting endogenous insulin production, with no pancreatic lesion on imaging. The presence of insulin autoantibodies confirmed the diagnosis. Fluctuating beta-hydroxybutyrate levels provided an additional physiologic clue, reflecting variable insulin activity resulting from antibody binding and release. This case highlights how characteristic biochemical patterns, including variable ketone levels, can facilitate timely recognition of IAS and help avoid unnecessary diagnostic procedures.

Symptomatic Methemoglobinemia at Low Levels in a Patient With Obstructive Sleep Apnea | Annals of Internal Medicine: Clinical Cases

Previously reported cases of hypoxemia secondary to methemoglobinemia usually had measured methemoglobin percentages of around 20% or greater. We report an unusual case of methemoglobinemia secondary to dapsone use in a 66-year-old man with obstructive sleep apnea who presented with dyspnea and hypoxia with a methemoglobin percentage of less than 10%.

Attenuated Cardiac–Ocular Phenotype of Sanfilippo Syndrome (MPS IIIA) Presenting With Hypertrophic Cardiomyopathy and Cone-Rod Dystrophy | Annals of Internal Medicine: Clinical Cases

We describe a 39-year-old woman with cone-rod dystrophy and hypertrophic obstructive cardiomyopathy complicated by an apical aneurysm, ventricular tachycardia, and ischemic stroke, ultimately requiring heart transplantation. Histopathology revealed myocardial storage vacuoles, and biochemical and genetic testing confirmed Sanfilippo syndrome type IIIA (MPS IIIA) with 1 known pathogenic and 1 novel likely pathogenic SGSH mutation. This case illustrates an attenuated cardiac–ocular phenotype of MPS IIIA and emphasizes the need to consider late-onset lysosomal storage disorders in adults with unexplained hypertrophic cardiomyopathy.

An Unusual Rash in a Febrile Adult | Annals of Internal Medicine: Clinical Cases

We report a 38-year-old man who presented with nonpruritic flagellate erythema, symmetrical polyarthritis, daily high-grade fevers, and unintentional weight loss. Skin biopsy supported the diagnosis of adult-onset Still disease (AOSD), which was established after exclusion of alternative diagnoses. The patient improved with oral corticosteroid therapy. Flagellate erythema is a rare cutaneous manifestation of AOSD, which may delay diagnosis. Awareness of this presentation is important for timely recognition and management.

Autopsy Case of Colonic Plasmablastic Lymphoma Exhibiting Unique Endoscopic Phenotypic Changes During Ulcerative Colitis Therapy | Annals of Internal Medicine: Clinical Cases

Plasmablastic lymphoma (PBL), a rare and aggressive CD20-negative B-cell lymphoma, has been increasingly recognized in individuals who are HIV-negative and who are also immunosuppressed. To our knowledge, we report the first autopsy case of a 74-year-old woman with ulcerative colitis (UC) who developed colonic PBL under immunosuppressive therapy. Serial colonoscopies demonstrated a morphologic transformation from serpiginous ulcers to elevated lesions. The patient ultimately died because of carcinomatous lymphangitis. Autopsy showed widespread metastases and numerous flat elevated lesions with lobulations throughout the colon. This case demonstrates a unique endoscopic phenotypic transition in colonic PBL, suggesting the importance of careful monitoring for timely diagnosis in immunosuppressed UC patients.

Insights From a Case of MRSA Enterocolitis in the Setting of Rectal Cancer | Annals of Internal Medicine: Clinical Cases

Methicillin-resistant Staphylococcus aureus (MRSA) is a rare cause of infectious enterocolitis. We present a patient undergoing chemoradiation for rectal squamous cell carcinoma who presented with acute watery diarrhea, neutropenia, and radiographic findings consistent with colitis. Failure to improve with empirical antibiotics prompted readmission and repeat stool culture, which resulted with heavy growth MRSA responsive to oral vancomycin. Low clinical suspicion for MRSA as the causing agent led to a delay in appropriate antibiotics and prolonged hospitalization, which ultimately resulted in death. In patients who are immunocompromised with active malignancy and undifferentiated infectious enterocolitis, early MRSA screening and empirical coverage should be considered.

Left Wrist Osteomyelitis Secondary to Mycoplasma orale: A Case Report | Annals of Internal Medicine: Clinical Cases

Mycoplasma orale is a fastidious oropharyngeal commensal that rarely causes invasive disease. We report a 73-year-old immunocompromised man with destructive, culture-negative wrist osteomyelitis/septic arthritis refractory to multiple antibiotic regimens. Broad-range bacterial polymerase chain reaction at 2 independent reference laboratories concordantly identified M orale. He had staged surgical debridements and received a short course of high-dose daptomycin selected on the basis of in vitro susceptibility data, with resolution and no recurrence. This case underscores early molecular diagnostics and suggests daptomycin, alongside aggressive source control, as a salvage option when conventional Mycoplasma-active regimens fail.

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