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Endoscopic transpapillary gallbladder drainage is considered an alternative procedure in patients with acute cholecystitis who are not surgical candidates; however, it remains challenging, especially in cases with a stone impacted into the cystic duct (CD). In cases in which a stone is impacted at the CD orifice, a cholangioscope and forceps may be used to release the stone. In cases in which the stone is impacted in the middle of the CD, contrast pressure from above the injection retrieval balloon may be used to push the stone toward the gallbladder. We believe this is the first report of such cases in the literature.

A Case of Relugolix-Associated Rhabdomyolysis | Annals of Internal Medicine: Clinical Cases

Androgen deprivation therapy is an integral component of systemic therapy for advanced prostate cancer. However, androgen deprivation therapy causes an array of adverse events secondary to castrate levels of testosterone. A relatively uncommon adverse event of androgen deprivation agents is rhabdomyolysis. The novel oral gonadotrophin-releasing hormone receptor antagonist relugolix received Food and Drug Administration approval recently for treatment of advanced prostate cancer. However, there are no case reports in the literature of rhabdomyolysis associated with relugolix use. Here, we report a case of a 76-year-old man who developed this uncommon toxicity associated with relugolix taken concomitantly with rosuvastatin, with a fatal outcome.

A Case of Turmeric-Induced Liver Injury | Annals of Internal Medicine: Clinical Cases

Turmeric spice and its active ingredient, curcumin, are becoming more commonly used, despite a simultaneous increase in reports of turmeric-induced hepatotoxicity. Our report demonstrates an additional case of turmeric-induced liver injury with concurrent ingestion of bioavailability-increasing substances. Despite known underreporting, a significant proportion of documented drug-induced liver injuries are secondary to herbal and dietary supplements. There are also high variabilities in supplement dosage and delivery, as well as lack of regulation in the supplements industry. Our case highlights the importance of discussing supplement-specific medical histories and educating patient on the risks for unregulated supplement use.

Infectious Proctitis From Cytomegalovirus in an Immunocompetent Patient | Annals of Internal Medicine: Clinical Cases

Cytomegalovirus colitis typically causes immunocompromised patients to present with hematochezia, abdominal pain, fever, or diarrhea and rarely as perforation. Here we report an 83-year-old woman with no other traditional immunocompromising risk factors who presented with cytomegalovirus proctitis. Providers should be aware of the potential for this severity of presentation even in immunocompetent patients.

Opsoclonus Associated With Cat Scratch Disease | Annals of Internal Medicine: Clinical Cases

A 49-year-old woman presented with fever, malaise, and enlarged left axillary lymph nodes after a cat bit her left hand, leading to the diagnosis of cat scratch disease. On the fifth day of admission, she had rapid, chaotic, and impulsive eye movements that appeared to be opsoclonus. Opsoclonus is a characteristic and rare ocular manifestation that occurs in association with infections and other diseases, and which will be shown in the accompanying video.

Apolipoprotein E Dyslipidemia and Nephrotic Syndrome: A Rare Connection | Annals of Internal Medicine: Clinical Cases

Severe hyperlipidemia warrants an extensive evaluation. We report a case of a 25-year-old man of Chinese descent seen in the cardiology-lipid clinic. He was found to have a serum low-density lipoprotein cholesterol of 12.12 mmol/L (468 mg/dL) and serum triglycerides of 2.29 mmol/L (203 mg/dL) during routine screening. Work-up revealed nephrotic-range proteinuria, and renal biopsy showed dilated glomerular capillary loops with lipid deposits, pathognomonic of lipoprotein glomerulopathy. Genetic studies showed apolipoprotein E3/E4 phenotype. He was treated with a high-intensity statin and fibrate therapy, which resulted in a marked improvement in dyslipidemia and proteinuria.

Rapid Diagnosis of Capnocytophaga Infection Made by Peripheral Blood Smear | Annals of Internal Medicine: Clinical Cases

Dog bites causing local infection are common but seldom lead to life-threatening complications. We present a case of a 52-year-old woman who presented with septic shock and multiorgan failure after sustaining a dog bite. At presentation, she was in multiorgan failure with a necrotic bite wound on her finger and a petechial rash on her face, arms, and legs. Abdominal imaging revealed asplenia. Her peripheral smear showed rod-like inclusions within neutrophils, consistent with intracellular bacilli. A diagnosis of Capnocytophaga infection was made. She was started on broad-spectrum antibiotics, including piperacillin–tazobactam, and made a full recovery.

Thymic Hyperplasia in Graves’ Disease: A Case Report | Annals of Internal Medicine: Clinical Cases

Thymic hyperplasia can occur secondary to Graves’ disease, although the exact mechanism is not yet entirely understood. Thymic hyperplasia in this setting is typically benign and improves with treatment of Graves’ disease. Invasive procedures are generally not required but should be considered if suspicion for other underlying disease processes (including malignancy) is suspected and/or imaging does not show thymus regression after antithyroid therapy.

Syphilitic Meningoencephalitis Presenting as Status Epilepticus in a Patient With HIV | Annals of Internal Medicine: Clinical Cases

Neurosyphilis constitutes a heterogenous clinical presentation that, in rare cases, can include seizures. The immunosuppression caused by HIV may influence the clinical presentation of syphilis, leading to severe complications. We report a case of a 27-year-old man who presented with status epilepticus as a manifestation of syphilitic meningoencephalitis and a new diagnosis of HIV.

A Heterozygous Variant of TGFB3 in a Patient With an Atypical Presentation of Loeys–Dietz Syndrome: A Case Report | Annals of Internal Medicine: Clinical Cases

Loeys–Dietz syndrome (LDS) 5 is characterized by aortic aneurysms, hypertelorism, and cleft palate/bifid uvula. We describe a woman with a transforming growth factor beta3 (TGFβ3) mutation who displays a forme fruste phenotype of LDS5. A 43-year-old woman with joint pain and hypermobile joints underwent evaluation for hypermobile Ehlers–Danlos syndrome. Her features included pes planus, treated high-arched palate, and increased joint mobility. Genetic analysis identified a pathogenic TGFβ3 variant (c.427A>T, p.Arg143*), clarifying the diagnosis of LDS5. Comparing our patient with others with TGFB3 mutations illustrated the diversity of LDS5 features, often a milder forme fruste form, which warrants more investigation due to insufficient characterization.

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