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While hyporesponsiveness to proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) has been reported, a rise in low-density lipoprotein cholesterol (LDL-C) is undocumented. This case describes a paradoxical increase in LDL-C following PCSK9i therapy. Possible mechanisms include genetic variability, altered hepatic receptor activity, or compensatory lipid metabolism. A 39-year-old woman with insulin-dependent type II diabetes, hypertension, hypothyroidism, and familial dyslipidemia experienced elevated cholesterol and LDL-C after starting evolocumab, which normalized after discontinuation. Further research is needed to clarify the mechanisms underlying this paradoxical response and assess its clinical relevance.

A Case of Cutaneous and Systemic Plasmacytosis Treated With Tocilizumab | Annals of Internal Medicine: Clinical Cases

Cutaneous and systemic plasmacytosis is a rare lymphoproliferative plasma cell disorder characterized by cutaneous lesions, constitutional symptoms, and polyclonal plasma cell infiltrates. Herein, we describe a middle-aged Vietnamese man diagnosed with cutaneous and systemic plasmacytosis who responded to anti–interleukin-6 receptor antibody tocilizumab and has remained in remission for more than 3 years without tocilizumab-related adverse events.

Rocky Mountain Spotted Fever–Associated Myocarditis | Annals of Internal Medicine: Clinical Cases

A previously healthy 23-year-old enlisted man presented for 2 days of fever, gastrointestinal symptoms, cough, and disseminated rash involving the palms and soles. Initial evaluation revealed leukocytosis, elevated liver enzymes, and hyponatremia. Despite antibiotic therapy for pneumonia, his condition worsened, with development of bilateral pleural effusions and myocarditis. After treatment with doxycycline, methylprednisolone, and furosemide, his symptoms improved. He completed a 7-day antibiotic course. Rocky Mountain spotted fever serology was positive 5 weeks after symptom onset. This case highlights the importance of maintaining a broad differential diagnosis and remaining vigilant for atypical presentations of infections to prevent life-threatening complications.

A Combination Regimen of Adalimumab and Methotrexate in a Challenging Case of Recalcitrant Gut and Cutaneous Sweet Syndrome | Annals of Internal Medicine: Clinical Cases

We report a case of a 50-year-old woman with cutaneous Sweet syndrome (SS) presenting with symptomatic iron deficiency anemia. Main clinical findings were cutaneous papules and small bowel ulcers, visualized on enteroscopy. She was eventually diagnosed with gut and cutaneous SS. After not responding to different treatment regimens, she was given subcutaneous adalimumab and oral methotrexate combination therapy, and finally achieved clinical remission. To our knowledge, this is the first reported case of such a treatment combination for recalcitrant gut and cutaneous SS. Although rare, a diagnosis of gut SS should be considered in similar clinical situations. In recalcitrant cases, anti–tumor necrosis factor-α agents may be considered.

Pott Puffy Tumor: A Rare Disorder of Childhood Presenting With New Seizures in an Adult | Annals of Internal Medicine: Clinical Cases

Pott puffy tumor (PPT) is defined as frontal bone osteomyelitis associated with subperiosteal abscess resulting from sinus disease, which occurs most commonly in the pediatric population. This case report details a 62-year-old man who developed fever, seizures, and encephalopathy and was ultimately diagnosed with PPT, making him both the oldest adult documented with this condition, as well as the first adult documented to present with seizures, to the best of our knowledge. Clinicians should include PPT on their differential diagnosis for adults presenting with fevers and seizures, as prompt management of frontal bone osteomyelitis is critical to preventing associated central nervous system complications.

Meningitis Caused by Campylobacter jejuni in a Patient With Immunodeficiency Due to Bispecific Antibody Therapy | Annals of Internal Medicine: Clinical Cases

Bispecific antibodies, such as talquetamab and teclistamab, offer promising treatment options for refractory multiple myeloma but are associated with significant immunosuppression and susceptibility to atypical infections. We report a case of recurrent Campylobacter jejuni meningitis in a 44-year-old man undergoing talquetamab and teclistamab therapy, highlighting the role of hypogammaglobulinemia in disease recurrence. Diagnosis was confirmed using molecular tools, emphasizing their value in detecting pathogens with low bacterial loads. This case underscores the need for vigilance, advanced diagnostics, and tailored prophylaxis to mitigate infection risks in immunocompromised patients receiving novel therapies.

Hydropneumopericardium Due to Esophageal-Pericardial Fistula: A Rare Complication of Esophageal Stenting | Annals of Internal Medicine: Clinical Cases

We present a case of a 53-year-old woman with a history of ulcerative esophagitis and esophageal stricture status post esophageal stenting that was complicated by stent migration. She presented with fatigue, melena, and dark output from her percutaneous endoscopic gastrostomy tube. An echocardiogram showed hydropneumopericardium with cardiac tamponade physiology requiring emergent pericardiocentesis. The aspirated fluid was brown and cloudy; pathology of the fluid showed meat and vegetable matter consistent with food. She ultimately required esophagectomy with esophagostomy. This case highlights the importance of early recognition of esophageal-pericardial fistulas, as delay in the management carries a high risk for morbidity and mortality.

Metastatic Pancreatic Adenocarcinoma Manifesting as Otomastoiditis and Collet–Sicard Syndrome | Annals of Internal Medicine: Clinical Cases

Otomastoiditis is not prevalent in immunocompetent adults and in some cases can be caused by insidious malignancies of the temporal bone. Collet–Sicard syndrome (CSS) is a constellation of symptoms associated with unilateral lower cranial nerve deficits that can occur in the setting of radiologically elusive temporal bone malignancies. We present a rare case of an adult man with temporal bone biopsy–confirmed pancreatic cancer that initially presented with otomastoiditis and CSS. This case demonstrates how malignancy should remain a top differential diagnosis for clinicians who encounter immunocompetent adults with otomastoiditis, even when unsupported by advanced imaging modalities.

Emerging Threat: A Case of Neuroinvasive Powassan Virus Infection | Annals of Internal Medicine: Clinical Cases

Powassan virus (POWV) infection is a tickborne illness that may cause neuroinvasive disease with high morbidity and mortality. The incidence of this disease is increasing in the United States. We present a confirmed case of neuroinvasive POWV infection acquired in December 2023. This case illustrates the need for increased awareness of neuroinvasive POWV infection owing to severity of illness and rising incidence. Climate change and tick expansion are likely major contributors to the evolving seasonality and increasing incidence of POWV infection. Early testing may minimize unnecessary antimicrobials and diagnostic studies.

Cefepime-Induced Cotard Syndrome in a Patient With End-Stage Renal Disease: A Rare Manifestation of Neurotoxicity | Annals of Internal Medicine: Clinical Cases

Cefepime is a fourth-generation cephalosporin used for severe infections but is associated with neurotoxicity, particularly in patients with renal impairment. We report a rare case of Cotard syndrome, a delusion of being dead, in a 76-year-old woman with end-stage renal disease receiving cefepime. She developed sudden neuropsychiatric symptoms, repeatedly insisting she was dead, stating, “I have no heartbeat” and “I need to be brought back to life.” Laboratory results and imaging were unremarkable, and electroencephalogram showed toxic-metabolic encephalopathy. Symptoms resolved rapidly after cefepime discontinuation and dialysis. This case underscores the importance of monitoring for neuropsychiatric effects in vulnerable patients receiving cefepime.

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Expert clinician-educators will provide a practical, evidence-based update for internal medicine physicians on approaches to interviewing patients with the goal of recognizing, diagnosing, treating, and/or referring patients with commonly encountered mental health disorders. Faculty with training in both internal medicine and psychiatry will emphasize the importance of a patient-centered approach, motivational interviewing, and quick cognitive behavioral techniques that can be quickly used in medical settings. A practical overview of psychopharmacology strategies in the general medical setting will also be discussed. Faculty will focus on psychiatric diagnoses that are prevalent in general medical practice, including major depressive disorder, anxiety disorders, trauma-related disorders, substance use disorders, chronic pain, and bipolar mood disorders, with a goal of improving recognition, confidence in management, and effectiveness of referral.

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Expert clinician-educators will provide a focused update of the diagnostic, preventive, and therapeutic approaches to the patient at risk for, or with known, cardiovascular disease. Faculty will focus on the cardiovascular disease issues that internal medicine physicians most frequently encounter and will provide “key points” to update the audience and foster patient care.

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