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A 50-year-old man arrived with prolonged and progressive low back pain accompanied by weakness in his left leg. Magnetic resonance imaging of the lumbar spine demonstrated a purely extradural, well-encapsulated mass measuring 6 × 5 × 4 cm originating from the third lumbar spinal root. The lesion exhibited the characteristic T2 “target sign,” suggesting a spinal nerve schwannoma residing completely outside the neural foramina, which was confirmed with histopathology. Although rare, lumbar schwannoma should be included in the differential diagnosis of radicular low back pain; the T2 “target sign” and well-encapsulated morphology are key diagnostic clues.

Monosodium Glutamate and Atrial Fibrillation in a 78-Year-Old Woman: A Case Report | Annals of Internal Medicine: Clinical Cases

Monosodium glutamate (MSG) is a widely used flavor enhancer that may contribute to adverse cardiovascular effects, including atrial fibrillation (AF). We present a 78-year-old woman with severe chronic pain with limited activities who developed new-onset AF. While she had some traditional risk factors, such as age and hypertension, she lacked structural heart disease, alcohol use, sleep apnea, or other arrhythmogenic conditions. A detailed dietary assessment revealed excessive MSG consumption, which she eliminated from her diet, leading to sinus rhythm restoration. This case highlights MSG as a potential arrhythmic trigger, meriting further investigation.

Delayed Diagnosis of a Massive Pericardial Effusion With Tamponade Physiology in a Patient Who Was Nonverbal | Annals of Internal Medicine: Clinical Cases

We present the case of a 19-year-old man with a medical history of developmental delay and no cardiac history who had prolonged time to diagnosis of massive pericardial effusion with tamponade physiology. Cardiac tamponade is an uncommon medical emergency. Our case includes all classic echocardiographic findings of tamponade and a notable massive effusion. Given the notable paucity of literature in the diagnostic approach with patients who are nonverbal, using nonverbal cues, implementing a broad work-up, and relying on objective data to guide the diagnostic approach are imperative.

Kidney Aplasia, Inferior Vena Cava Anomaly, and Leg Thrombosis in a Man With a Herniated Disc | Annals of Internal Medicine: Clinical Cases

KILT syndrome refers to Kidney, Inferior vena cava (IVC) abnormalities and Leg Thrombosis. This is the case of a 31-year-old man who presented with lower back and buttock pain. Initial work-up did not reveal any thrombi. Six months later, imaging revealed absence of a right kidney, an IVC anomaly and thrombi involving the IVC, iliac, common femoral, saphenous, profunda, popliteal and tibial veins. He did not report a history of nephrectomy, suggesting an aplastic right kidney. IVC anomalies may increase the risk for aplastic or hypoplastic kidneys and may increase the risk for lower extremity thrombosis. Unprovoked thrombosis may warrant further investigation.

An Atypical Case of Whipple Disease With Mesenteric Lymphadenopathy and an Exudative Pleural Effusion | Annals of Internal Medicine: Clinical Cases

Whipple disease is a rare, multisystemic infection caused by the bacterium Tropheryma whipplei, primarily affecting middle-aged White men and targeting the joints, small intestine, and central nervous system. We present an atypical case of Whipple disease with mesenteric lymphadenopathy and an exudative pleural effusion. The patient was treated with intravenous ceftriaxone followed by oral trimethoprim-sulfamethoxazole. Owing to intolerance, the regimen was changed to doxycycline and hydroxychloroquine. He showed marked clinical improvement, with resolution of gastrointestinal symptoms. Whipple disease should be considered in patients with unexplained weight loss, abdominal pain, and mesenteric lymphadenopathy after malignancy and common infections have been excluded.

Correction: Uremic Pericarditis as a Complication of Coral Reef Aorta | Annals of Internal Medicine: Clinical Cases

Rothia-Associated Meningitis in a Patient With HIV: A Case Report | Annals of Internal Medicine: Clinical Cases

A 47-year-old man with HIV, off antiretroviral therapy for 4 months since losing insurance coverage, presented to the emergency department after he was found unresponsive with blood around the mouth. A seizure was suspected, and cerebrospinal fluid culture grew Rothia mucilaginosa, Rothia dentocariosa, and Streptococcus viridans. While it is well established that HIV-infected individuals are at higher risk for opportunistic infections, reports identifying commensal oral microbiota as the source of invasive disease are rare. This case underscores the importance of recognizing the pathogenic potential of atypical pathogens and diverse clinical presentations of meningitis in immunocompromised patients.

Urinothorax in the Setting of Acute Renal Failure Secondary to Bilateral Ureteropelvic Junction Obstruction | Annals of Internal Medicine: Clinical Cases

Urinothorax refers to urine within the pleural space; it is an exceptionally rare type of transudative pleural effusion. The existence of urinothorax as a clinical entity is largely unknown to the average general internist. We describe a case of left-sided urinothorax in a patient who presented in acute renal failure in the setting of bilateral obstructing ureteropelvic renal calculi. This memorable and comprehensive case report serves to increase awareness and knowledge among clinicians of this relatively novel clinical phenomenon as well as to describe a typical approach to diagnosis and management.

Fulminant Rheumatoid Vasculitis Presenting Shortly After Onset of Rheumatoid Arthritis | Annals of Internal Medicine: Clinical Cases

Rheumatoid vasculitis (RV) is a rare but severe extraarticular manifestation of rheumatoid arthritis (RA) associated with high mortality. We present a case of a 45-year-old man who developed rapidly progressive RV within 6 months of RA onset, manifesting with neuropathy, cutaneous necrosis, and multiorgan involvement confirmed on histopathology. His RV was refractory to treatment and he suffered fatal cardiac arrest. RV classically presents many years after onset of RA. Rapid onset, such as in this case, is unusual, highlighting the need for early recognition and improved treatment strategies in fulminant RV.

Nontypeable Hemophilus influenzae (NTHi) Septic Arthritis of Atypical Joints With Tenosynovitis in a Healthy Adult | Annals of Internal Medicine: Clinical Cases

Hemophilus influenzae septic arthritis is uncommon in the postvaccine era, but cases caused by nontypeable strains (NTHi) are rising in adults. A healthy 47-year-old African American man presented with bilateral wrist pain, swelling, and back pain. A computed tomography scan of the chest revealed pneumonia; however, he had no respiratory symptoms. Blood cultures grew NTHi. Magnetic resonance imaging revealed bilateral wrist tenosynovitis, sacroiliac joint septic arthritis, and piriformis abscess. He required surgical joint washout and prolonged intravenous antibiotics. This case highlights the evolving epidemiology of NTHi, its potential for invasive infections in healthy individuals, and the need for early recognition and thorough diagnostic evaluation in atypical presentations.

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