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We present a case of a 35-year-old pregnant woman (second pregnancy, 0 term or preterm births, 1 abortion/miscarriage, and 0 living children) with new-onset hypertension, lower extremity edema, and proteinuria in the third trimester who was initially diagnosed with preeclampsia. After delivery, her edema and proteinuria continued to increase, prompting consideration of alternative diagnoses. Her evaluation included a kidney biopsy that revealed minimal change disease/focal segmental glomerulosclerosis. Treatment with prednisone resulted in a rapid, but only partial, response. She was later treated with tacrolimus, with steady improvement. This case highlights the importance of looking beyond preeclampsia when a pregnant or postpartum patient has persistent hypertension and nephrotic-range proteinuria.

Cutaneous Leukocytoclastic Vasculitis in a Patient With Metastatic Breast Cancer: A Diagnostic Dilemma | Annals of Internal Medicine: Clinical Cases

Elacestrant, a novel selective estrogen receptor degrader, offers new treatment options for metastatic estrogen receptor–positive, human epidermal growth factor receptor 2–negative, estrogen receptor 1–mutated breast cancer. While its efficacy and safety are established, rare adverse effects such as drug-induced vasculitis remain unreported, posing diagnostic challenges. We report a case of biopsy-confirmed cutaneous leukocytoclastic vasculitis in a 33-year-old woman with advanced estrogen receptor/progesterone receptor–positive breast cancer after starting elacestrant. She developed palpable purpura on her lower extremities 2 weeks into therapy. An extensive work-up was unremarkable, and symptoms resolved after stopping elacestrant treatment and initiating corticosteroid therapy. This case highlights the need for awareness of rare immune-mediated reactions as elacestrant's use increases.

De Novo Esophageal Small-Cell Neuroendocrine Carcinoma in a Patient With Achalasia: A Case Report | Annals of Internal Medicine: Clinical Cases

Esophageal neuroendocrine carcinoma (NEC) is rare and aggressive, representing 0.4% to 2% of esophageal cancers, with small-cell NEC comprising 95% of cases. Achalasia is known to increase the risk for esophageal malignancy, particularly squamous cell carcinoma. We describe an 81-year-old woman with longstanding achalasia who developed dysphagia. Endoscopy showed a fungating mass, and biopsy confirmed small-cell NEC. She was treated with platinum–etoposide chemotherapy, resulting in complete resolution. This case demonstrates remission with chemotherapy alone, challenging traditional surgical approaches. To our knowledge, this is the first reported case of esophageal small-cell NEC arising in conjunction with achalasia. Further research is warranted to establish optimal management strategies for such rare presentations.

Large Paranasal Cyst Severely Compressing the Extraocular Muscles and the Optic Nerve Without Any Visual Symptoms | Annals of Internal Medicine: Clinical Cases

Large sinus cysts often present with ocular symptoms, including visual disturbance and diplopia. We present the case of an 80-year-old woman with a large paranasal cyst that had protruded into the cranium and orbit, compressing the extraocular muscles and optic nerve. Despite these findings, the patient reported no symptoms. She had endoscopic sinus surgery and the cyst was found to contain ochreous, cholesterol-like contents. The reason for this paradoxical situation is that the enlargement was slow and gradual, causing no damage to the visual organs. However, once sudden changes occur, such as an infection, severe visual symptoms may develop.

Familial Metastatic Bladder Paraganglioma With Multisystem Complications | Annals of Internal Medicine: Clinical Cases

Bladder paragangliomas represent less than 0.05% of bladder tumors, with familial metastatic cases being exceptionally rare. This case outlines a relatively healthy 44-year-old woman presenting with classic symptoms of paraganglioma that initially manifested as cardiac dysrhythmia, new-onset heart failure with reduced ejection fraction, and hypercoagulability. Subsequent questioning and genetic testing identified a family history of paragangliomas and a pathogenic SDHB pR46 mutation. This case highlights the importance of early recognition of signs and symptoms associated with catecholamine-secreting tumors, indications for diagnostic testing, and appropriate genetic testing to prevent devastating complications associated with multisystem failure.

Unexplained Headache After Surfing: Diagnosis of a Spinal Cerebrospinal Fluid Leak | Annals of Internal Medicine: Clinical Cases

A 35-year-old woman developed a severe orthostatic headache following a surfing trip. Initial work-up, including blood tests and computed tomography scans of the brain, was unremarkable. She was initially misdiagnosed with viral meningitis owing to a positive enterovirus result on a respiratory viral panel. Persistent symptoms prompted magnetic resonance imaging of the brain and spine, which revealed intracranial hypotension and a spinal cerebrospinal fluid (CSF) leak. Her symptoms resolved after an epidural blood patch. This case highlights the diagnostic challenges of spontaneous spinal CSF leaks and emphasizes the importance of early recognition, particularly in patients presenting with postural (orthostatic) headaches after recent mechanical stress, such as surfing.

Report of Concomitant Intracranial Cysts in Unrelated Patients With Heterozygous Germline NF1 Pathogenic Variants | Annals of Internal Medicine: Clinical Cases

Neurofibromatosis 1 (NF1) is one of the most common genetic diseases of the central nervous system. The nature of intracranial lesions that are associated with NF1 are yet to be fully defined. Arachnoid, velum interpositum, and odontogenic cysts are among the more common intracranial cystic lesions that can be congenital. Although odontogenic cysts are well known to be associated with Gorlin–Goltz syndrome, the possibilities of other genetic disorders in patients with odontogenic and other intracranial cystic lesions have continued to stir research interests. Here, we report 2 cases of unrelated patients, each patient having concurrent intracranial cystic lesions in the setting of a diagnosis of NF1. Individual I had concomitant arachnoid and odontogenic cysts in parallel with a novel heterozygous germline NF1 pathogenic frameshift variant, NF1 [NM_000267.3] c.40del (p.Val14Serfs*10). Individual II had concomitant arachnoid and vellum interpositum cysts in the context of a heterozygous likely pathogenic NF1 germline variant [NF1 (NM_000267.3) c.4265C>T, p.(Ser1422Leu)]. Our observations suggest that clinicians should consider NF1 among the differential diagnosis for intracranial cystic lesions such as arachnoid, vellum interpositum, and odontogenic cysts.

Adult Diagnosis of Cystic Fibrosis: A Cause of Recurrent Pneumonia | Annals of Internal Medicine: Clinical Cases

We describe a patient presenting for evaluation of nearly annual pneumonias since the age of 9 years, eventually requiring multiple hospitalizations. Genetic testing revealed compound heterozygous mutations for 2184insA and L206W, indicative of cystic fibrosis. The patient received Trikafta (combination of ivacaftor, tezacaftor, and elexacaftor), a cystic fibrosis transmembrane regulator modulator with subsequent improvement of her symptoms. This case highlights the importance of maintaining a broad differential diagnosis for recurrent pulmonary infections, including diagnoses not typical for a patient's population or age group. Initiation of therapies such as Trikafta has been associated with improvement in lung function in a life-limiting disease.

Radiation Therapy for Endobronchial Chronic Lymphocytic Leukemia Causing Extrinsic Airway Compression—A Novel Treatment Strategy | Annals of Internal Medicine: Clinical Cases

Here, we report a case of a very rare manifestation of chronic lymphocytic leukemia (CLL)—lobar lung collapse and partial airway occlusion from direct endobronchial involvement of the disease, complicated by bacterial infections requiring antibiotics. Because this was the only symptomatic site of disease, the patient was not treated systemically, which is the typical treatment strategy for CLL, but with focal radiation therapy, resulting in good symptomatic improvement. Radiation therapy for endobronchial CLL has never been reported, to our knowledge, and given the patient's good clinical outcome, could be a feasible alternative to avoid the side effects of systemic therapy for similar cases in the future.

Guttate Psoriasis: Rash With a Diagnostic Dilemma in a Patient With AIDS | Annals of Internal Medicine: Clinical Cases

Guttate psoriasis is a clinical subtype of psoriasis seen most commonly following a streptococcal infection in younger patients. We present a case of an adult man with advanced untreated HIV who developed a diffuse, scaly rash unresponsive to empiric antibiotics. Extensive infectious work-up was unrevealing. Skin biopsy confirmed guttate psoriasis, which improved with topical corticosteroids. This case highlights the diagnostic complexity of dermatologic presentations in HIV-positive patients, in which both infectious and noninfectious causes must be considered. It also illustrates the multifactorial relationship between HIV and psoriasis, including paradoxical immune dysregulation and the individualized approach required for diagnosis and management.

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