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Aerococcus urinae, although primarily associated with urinary tract infections, is an infrequent cause of infective endocarditis (IE). We report the case of a 55-year-old man with worsening dyspnea and chest pain, ultimately diagnosed with A urinae–induced IE complicated by severe aortic regurgitation requiring valve replacement. This case contributes to the growing body of literature on the clinical presentation of A urinae IE as a rare yet potentially fatal cause of IE.

A Case of Hypercalcemia Secondary to Disseminated Cryptococcus neoformans Infection | Annals of Internal Medicine: Clinical Cases

Fungal infection is a rare cause of hypercalcemia, thought to be mediated by extrarenal conversion of 25-hydroxy-vitamin-D to 1,25-dihydroxy-vitamin-D within granulomas. Only 6 cases involving Cryptococcus neoformans have been reported in the literature, with prior cases varying in their treatment approach. We report a 7th case in a patient with disseminated infection and laboratory findings consistent with the proposed mechanism. This case underscores the importance of checking calcium levels in all patients with cryptococcal infection, regardless of symptoms, to identify hypercalcemia warranting treatment. Furthermore, this case demonstrates the efficacy of fluids, calcitonin, and bisphosphonate in treating cryptococcal hypercalcemia.

A Case of Thrombotic Cutaneous Gangrene in a Patient With Pan-Ulcerative Colitis | Annals of Internal Medicine: Clinical Cases

The most common extraintestinal manifestations of inflammatory bowel disease (IBD) involve the musculoskeletal and cutaneous systems, with cutaneous manifestations occurring in up to 50% of patients with IBD. Hypercoagulability is a known complication of IBD; however, cutaneous gangrene secondary to thrombotic vasculopathy is a rarely described extraintestinal complication of ulcerative colitis. This case underlines the importance of recognizing early manifestations of gangrene in patients with ulcerative colitis and pursuing timely evaluation with a hypercoagulability work-up and skin biopsy. Anticoagulation should be promptly initiated to prevent further complications.

The Hidden Impact: Insulin Lipohypertrophy | Annals of Internal Medicine: Clinical Cases

Insulin lipohypertrophies (LH) consist of soft-tissue nodules caused by insulin's anabolic properties, potentially leading to erratic insulin absorption, hypoglycemia, and uncontrolled diabetes. A thorough physical examination of insulin injection and pump-insertion sites is crucial for detecting such changes in patients with diabetes. Counseling on rotating injection sites helps prevent LH. Here, we present 2 cases of LH, one in a Hispanic man and one in an African American man, both with long-standing type 1 diabetes mellitus.

Epididymo-Orchitis Leading to Testicular Infarction: Revealing a Potentially Severe Complication of SGLT2 Inhibitors | Annals of Internal Medicine: Clinical Cases

Sodium-glucose cotransporter 2 (SGLT2) inhibitors are not only used for managing type 2 diabetes mellitus (T2DM) but also have been shown to be effective in reducing major cardiovascular events and slowing chronic kidney disease progression. However, they cause glycosuria, which increases the risk for genitourinary (GU) infections. We report a patient with uncontrolled T2DM who developed epididymo-orchitis 6 weeks after starting empagliflozin, which progressed to testicular infarction. Although not well documented, SGLT2 inhibitors may increase the risk for epididymo-orchitis because infections may ascend from the urinary tract. This case highlights the importance of close observation to avoid serious events associated with SGLT2 inhibitors.

Debilitating Periorbital Edema Secondary to Anti-SAE Dermatomyositis | Annals of Internal Medicine: Clinical Cases

Dermatomyositis (DM) is an autoimmune inflammatory myopathy with heterogeneous systemic and cutaneous manifestations. Certain forms of DM have isolated skin findings without overt myositis and are called amyopathic DM. Myositis-specific autoantibodies are associated with distinct phenotypes of DM that can support the diagnosis and better define management and prognostication. We describe a case of amyopathic DM with the presence of the small ubiquitin-like modifier activation enzyme 1 autoantibody presenting with severe, debilitating periorbital edema.

Necrotizing Cavitary Pneumonia by Serratia marcescens in a Patient Treated With Dupilumab: Correlation or Causation? | Annals of Internal Medicine: Clinical Cases

Serratia species are gram-negative bacilli causing opportunistic and nosocomial infections, often in patients who are immunocompromised. A 61-year-old man with severe asthma receiving dupilumab presented with fever and chills. A chest computed tomography scan revealed bilateral cavitary lesions suggestive of necrotizing pneumonia. Bronchoalveolar lavage grew Serratia marcescens, and he was treated with prolonged antibiotics. Serratia marcescens should be considered in necrotizing pneumonia, even in patients who are immunocompetent, with dupilumab potentially as the inciting factor.

Unveiling CYP24A1 Mutation in Unexplained Hypercalcemia in an Adult: A Case Report | Annals of Internal Medicine: Clinical Cases

We present the clinical history of a 60-year-old man with persistent skeletal pain and recurrent renal stones associated to chronic hypercalcemia with fluctuating serum calcium levels. Elevated 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D concentrations in the absence of vitamin D supplementation together with a decreased 24,25-dihydroxyvitamin D concentration suggested altered vitamin D metabolism. Genetic testing demonstrated a biallelic loss-of-function mutation in the CYP24A1 gene, responsible for reduced vitamin D inactivation. This rare condition, usually associated with idiopathic infantile hypercalcemia, may manifest later in life. Early recognition and management are critical to prevent complications such as recurrent nephrolithiasis, nephrocalcinosis, and renal failure.

The Mystery of Dropped Gallstones: A Case Series and Review of the Literature | Annals of Internal Medicine: Clinical Cases

Laparoscopic cholecystectomy (LC) is the gold standard general surgical procedure for symptomatic gallbladder (GB) disease. The 2 most common complications of LC are GB perforation and dropped gallstones (DGs). Dropped gallstones mostly stay asymptomatic but can rarely serve as a nidus for infection with delayed formation of abscesses, granulomas, and fistulas after many years. We describe a case series of 2 patients with abdominal abscesses and fistula formation from symptomatic retained DGs presenting many years later as a delayed complication of LC.

From Clonidine Withdrawal to Posterior Reversible Encephalopathy Syndrome: Imaging and Cerebrospinal Fluid Clues in a Case of Hypertensive Emergency | Annals of Internal Medicine: Clinical Cases

We report the case of a 33-year-old man who developed posterior reversible encephalopathy syndrome (PRES) after clonidine withdrawal, which led to a hypertensive crisis. The patient presented with rapid neurologic decline, including vision loss and confusion. Due to the initial unavailability of magnetic resonance imaging (MRI), cerebrospinal fluid (CSF) analysis revealing albuminocytologic dissociation was pivotal in establishing the diagnosis. Subsequent MRI confirmed parieto-occipital hyperintensities, solidifying the PRES diagnosis. This case underscores the diagnostic value of CSF analysis in rapidly evolving neurologic conditions when MRI is delayed or unavailable and highlights the risk for PRES as a complication of clonidine withdrawal.

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