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This case aims to characterize an unusual cutaneous manifestation in a patient with confirmed cutaneous leishmaniasis, highlighting clinical features that are often underrecognized and may contribute to diagnostic uncertainty. By exploring this atypical presentation, it underscores the potential for misdiagnosis and its implications for patient management. Additionally, it emphasizes the broad spectrum of cutaneous lesions that can mimic Old World cutaneous leishmaniasis, further increasing the risk of diagnostic error.

Digoxin-Like Toxicity After Tejocote Root and Yellow Oleander Ingestion: The Hidden Dangers of Herbal Supplements | Annals of Internal Medicine: Clinical Cases

Tejocote root (Crataegus mexicana) is a common herbal supplement used for weight loss and to induce bowel movements. In recent years, there has been an increase in the number of cases of digoxin-like toxicity associated with consumption of tejocote root, and substitution of tejocote root with yellow oleander. We present a case of excess tejocote ingestion to induce a bowel movement that resulted in subsequent gastrointestinal upset and cardiac arrhythmia. This report highlights the potential risks associated with the consumption of tejocote root, particularly due to suspected inclusion of yellow oleander after a Food and Drug Administration–issued warning of several supplements.

A Case of Dacrystic Seizure in a 72-Year-Old Man | Annals of Internal Medicine: Clinical Cases

Dacrystic seizures are rare, stereotyped episodes of ictal crying. We describe a 72-year-old man with recurrent crying spells, initially attributed to orthostatic hypotension with psychogenic episodes. Electroencephalography monitoring captured interictal left frontal spikes and diffuse background slowing. Magnetic resonance imaging demonstrated a prominent left mesial temporal lesion, though no episodes were identified in the 24-hour monitoring period. The patient was treated with levetiracetam and reported significantly fewer events at home. Clinical response confirms the diagnosis. This case highlights the diagnostic challenge of emotional seizure semiologies and the critical role of multidisciplinary evaluation, particularly for hospitalists encountering atypical neurologic presentations.

Tremors and Memory Loss From Hypomagnesemia and Hypocalcemia Secondary to Long-Term Proton Pump Inhibitor Use | Annals of Internal Medicine: Clinical Cases

Proton pump inhibitors (PPIs) are commonly prescribed for short-term use but are often taken chronically, including through over-the-counter (OTC) access. Long-term use has been linked to hypomagnesemia and hypocalcemia, which may cause serious complications. A 47-year-old man on PPIs for 5 years presented with cramps, spasms, tremors, disorientation, and amnesia. Tests showed low magnesium and calcium, with other causes excluded. Proton pump inhibitor treatment was discontinued and supplementation initiated, leading to marked recovery. Chronic PPI use should be considered in unexplained electrolyte abnormalities, even in patients not at high risk, highlighting the need for cautious prescribing, periodic monitoring, and reassessment of OTC availability.

Persistent Hypoxemia on Home Sleep Apnea Testing Prompting Further Evaluation for Pulmonary Embolism: A Case Report | Annals of Internal Medicine: Clinical Cases

Obstructive sleep apnea is a condition characterized by recurrent upper airway collapse during sleep, which may be associated with sleep disruption and repetitive oxygen desaturations. It is diagnosed by nocturnal in-lab polysomnography or home sleep apnea testing. We present a case of an otherwise healthy individual who had home sleep apnea testing that revealed persistent, unexplained hypoxemia which, on further investigation, was found to be due to a saddle pulmonary embolism.

Hyperbaric Oxygen for Refractory Colonic Ulcerations in a Patient With Immunotherapy-Induced Colitis: A Case Report | Annals of Internal Medicine: Clinical Cases

Colitis is a common complication of immune checkpoint inhibitors (ICIs), often responsive to steroids or biologics. However, persistent symptoms may occur in patients with complicating factors such as altered gastrointestinal anatomy. In this context, hyperbaric oxygen therapy (HBOT) may be a novel treatment. We present a woman with lung cancer who developed refractory ICI colitis. She had a history of partial colectomy. Despite corticosteroids, vedolizumab ×3 doses, and fecal microbiota transplantation, she experienced persistent bleeding and ulcerations in the distal rectum with suspected ischemia. The patient had HBOT, resulting in complete resolution of clinical symptoms within 2 weeks.

A Case Report of Syphilitic Hepatitis | Annals of Internal Medicine: Clinical Cases

A 49-year-old woman presented to the emergency department with acute right upper quadrant pain. Laboratory results were consistent with cholestatic liver injury. Potential common causes—such as obstructive, viral, and autoimmune conditions—were excluded. She began developing systemic symptoms, including rash, vision changes, and headaches. The patient was subsequently found to have secondary syphilis with neurosyphilis and syphilitic hepatitis. Although syphilitic hepatitis is a rare presentation of the disease, syphilis should be considered as a possible cause of transaminitis with a cholestatic pattern of liver injury.

Fever of Unknown Origin Due to Legionella dumoffii Bioprosthetic Aortic Valve Endocarditis | Annals of Internal Medicine: Clinical Cases

Legionella dumoffii is a rare human pathogen but has been known to cause infective endocarditis. The diagnosis is challenging as this bacterium is difficult to grow in standard culture media. We present a case of a patient with fever of unknown origin (FUO) who was diagnosed with L dumoffii bioprosthetic aortic valve endocarditis using metagenomic next-generation sequencing. After identification of this pathogen and targeted antibiotic treatment, the patient experienced complete resolution of symptoms. Legionella dumoffii infective endocarditis should be considered in patients with FUO and prosthetic heart valves.

Coexistence of Wild-Type Transthyretin Cardiac Amyloidosis and Monoclonal Gammopathy in a Patient With Polycythemia Vera | Annals of Internal Medicine: Clinical Cases

Polycythemia vera is a type of myeloproliferative neoplasm characterized by panmyelosis, with a predominant increase in erythrocyte mass. In contrast, monoclonal gammopathy of undetermined significance is classified as a premalignant plasma cell disorder and is characterized by elevated levels of monoclonal γ-globulin without associated bone lesions or clinical symptoms. Here, we present a case of the concurrent presence of wild-type transthyretin cardiac amyloidosis—not the amyloid light-chain type—and monoclonal gammopathy of undetermined significance in a patient with polycythemia vera. This case underscores the crucial importance of preforming histologic subtyping to ensure accurate diagnosis in older patients with undiagnosed cardiac amyloidosis.

Isolated Subcutaneous Sarcoidosis (Darier–Roussy Disease) Without Systemic Involvement: Diagnostic Challenge and Remission Following Intralesional Therapy | Annals of Internal Medicine: Clinical Cases

Subcutaneous sarcoidosis (Darier–Roussy disease) is a rare variant of cutaneous sarcoidosis characterized by painless subcutaneous nodules. We present the case of a 55-year-old woman with a firm, nontender mass overlying her right triceps region, initially misdiagnosed as cellulitis. Biopsy revealed a noncaseating granuloma consistent with subcutaneous sarcoidosis. Extensive systemic work-up was unremarkable, confirming isolated disease. The lesion resolved within 6 months following 2 intralesional corticosteroid injections administered 2 months apart, with no recurrence over 4 years. This case highlights the diagnostic challenges of subcutaneous sarcoidosis and the importance of histopathologic confirmation and multidisciplinary evaluation, even in the absence of systemic symptoms.

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