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A 37-year-old man presented with dyspnea and erythematous, nodular facial lesions. An examination revealed nasopharyngeal edema, and imaging showed prevertebral swelling. An extensive infectious and autoimmune evaluation was negative. A cheek biopsy was done, and polymerase chain reaction was positive for Leishmania braziliensis, confirming the diagnosis of mucocutaneous leishmaniasis. This is a progressive manifestation of a parasitic infection by Leishmania spp. It may present several years following resolution of an initial cutaneous infection. In this case, 26 years. Negative serology for leishmaniasis does not exclude active disease, and a high index of suspicion leads to early diagnosis and treatment.

Movement Disorder Following Hypoglycemic Encephalopathy in Mitochondrial 3-Hydroxy-3-methylglutaryl-CoA Synthase-2 (mHS) Deficiency | Annals of Internal Medicine: Clinical Cases

Mitochondrial 3-hydroxy-3-methylglutaryl-coenzyme A synthase (mHS) deficiency is an ultra-rare inborn error of ketone body synthesis that is caused by biallelic mutations in HMGCS2. The manifestations of mHS deficiency can include hypoketotic hypoglycemia, metabolic acidosis, lethargy, encephalopathy, hyperammonemia, and hepatomegaly. Here, we report a case of movement disorder following hypoglycemic encephalopathy involving the basal ganglia in a patient with mHS deficiency. Exome sequencing showed novel compound heterozygous variants in HMGCS2, a partial gene deletion (classified as pathogenic) and c.704T>A (p.M235K) variant that was deemed to be likely pathogenic. Our findings suggest that mHS deficiency can result in basal ganglia injury and movement disorder.

A Patient Presenting With Hematochezia Found to Have Geophagia-Induced Electrolyte Derangements | Annals of Internal Medicine: Clinical Cases

Geophagia is the deliberate practice of eating earth or other soil-like substances. Although associated with nutritional deficiency, it may occur as a culturally sanctioned practice outside the context of illness. A patient with kidney failure on home hemodialysis presented with hematochezia, myalgias, and fatigue. She was found to have constipation with radiopacities in the gastrointestinal tract, symptomatic hypokalemia, hypocalcemia, and relative hypophosphatemia in the setting of end-stage kidney disease. History revealed significant geophagia and intake of bentonite clay, which is primarily composed of aluminum, a phosphorus binder, and silica, a potassium binder. Her electrolyte abnormalities resolved with clay discontinuation.

Eosinophilic Pustular Folliculitis in a Patient With HIV Receiving Antiretrovirals | Annals of Internal Medicine: Clinical Cases

This case report describes eosinophilic pustular folliculitis in a patient with long-standing, well-controlled HIV. Eosinophilic pustular folliculitis is an uncommon inflammatory skin disease often associated with low CD4 counts and immune dysregulation in uncontrolled HIV, but its occurrence in patients with well-controlled HIV has not been previously described. This case highlights the importance of considering eosinophilic pustular folliculitis as a diagnosis in individuals with well-controlled HIV who have suboptimal CD4+ T cell functional recovery. The report emphasizes that while antiretrovirals have significantly improved HIV management, unique issues related to immune dysregulation are emerging in aging patients with long-standing, well-controlled HIV.

A Young Patient With Pancytopenia and Cirrhosis: Unraveling a Telomere Biology Disorder | Annals of Internal Medicine: Clinical Cases

Telomere biology disorders represent a rare spectrum of disease caused by genetic defects of telomere maintenance with multisystem involvement, most often related to organ failure and aging. Ranging in severity, telomere biology disorders can appear in the absence of known risk factors. We present a young patient who developed rapid onset of bone marrow failure and cirrhosis, ultimately found to be due to an underlying disorder of telomere biology with mutations within the PARN and TERT genes.

A Case of Chronic Granulomatous Pancreatitis | Annals of Internal Medicine: Clinical Cases

We present a 23-year-old woman with a 4-year history of an ambiguous, nonmalignant pancreatic head mass and recurrent nausea/vomiting, right upper quadrant abdominal pain, jaundice, oral feeding intolerance, chronic portal vein thrombosis, and pancytopenia. A multidisciplinary effort with extensive history-taking, laboratory work-up, and repeated endoscopic ultrasound with fine-needle aspiration narrowed her differential diagnosis—which included IgG4-related disease—into the seventh instance of chronic granulomatous pancreatitis secondary to histoplasmosis that has been reported in the literature to our knowledge. The patient remains symptom free on her year-long course of itraconazole, and her satisfactory outcome is an exemplification of the diagnostic and therapeutic power in specialty consultation by hospitalists.

Simultaneous ST-Segment Elevation Myocardial Infarction and Stroke: A Rare Case of Cardiocerebral Infarction | Annals of Internal Medicine: Clinical Cases

Cardiocerebral infarction is defined as the simultaneous or sequential occurrence of myocardial infarction and stroke. We present a 62-year-old woman with concurrent ST-segment elevation myocardial infarction and minor ischemic stroke. Coronary angiography revealed multivessel coronary artery disease, with the obtuse marginal branches (OM1 and OM2) identified as culprit lesions. Following multidisciplinary evaluation, heparin and dual antiplatelet therapy were initiated, leading to resolution of neurologic deficits and successful percutaneous coronary intervention of the OM1 lesion. This case highlights the complexity of managing simultaneous cardiac and neurologic emergencies.

Steroid-Responsive Retroperitoneal Fibrosis and Sclerosing Mesenteritis as the Initial Manifestation of an Occult Neuroendocrine Tumor | Annals of Internal Medicine: Clinical Cases

Retroperitoneal fibrosis (RPF) and sclerosing mesenteritis (SM) are rare entities characterized by fibrous inflammatory tissue that can surround and compress adjacent abdominal structures, leading to organ damage. RPF and SM have rarely been reported to present simultaneously. Idiopathic forms of RPF and SM are typically treated with immunosuppression, whereas treatment of RPF and SM secondary to malignancy relies on treating the underlying malignancy. We present a patient with steroid-responsive RPF and SM ultimately found to be secondary to an occult small intestinal neuroendocrine tumor who responded to octreotide therapy for the underlying neuroendocrine tumor.

A Case of Secondary Hemophagocytic Lymphohistiocytosis in a Patient With Acute HIV Infection | Annals of Internal Medicine: Clinical Cases

A 22-year-old man who has sex with men with no significant medical history presented with a 2-week history of fever and right upper abdominal pain. Initial blood tests revealed leukopenia, thrombocytopenia, and elevated liver enzymes. The diagnosis of secondary hemophagocytic lymphohistiocytosis (HLH) was supported by fever, splenomegaly, hypertriglyceridemia, hyperferritinemia, and high soluble interleukin-2 receptors, meeting the 5/8 criteria of the Histiocyte Society-2004. Further laboratory tests indicated an elevated HIV RNA viral load, supporting a diagnosis of acute HIV infection. Our case suggests that identifying acute HIV infection as a trigger for secondary HLH is crucial for enabling prompt initiation of therapy, potentially preventing fatal outcomes.

An Unusual Case of Abdominal Pain in the Postpartum Period: A Case Report of Vernix Caseosa Peritonitis | Annals of Internal Medicine: Clinical Cases

Vernix caseosa peritonitis is a rare cause of peritonitis that can occur in the postpartum period. We present a case of diffuse abdominal pain 5-week postpartum that was unrelieved with antibiotics. Computed tomography of the abdomen showed phlegmonous peritonitis with nodularities. Omental node biopsy revealed necroinflammatory debris and multinucleate giant cells suggesting a noninfectious granulomatous process. Treatment with steroids resulted in significant improvement and decreased nodularity. Vernix caseosa peritonitis is caused by an inflammatory response attributable to maternal amniotic fluid spilling into the peritoneal cavity. It should be considered in the differential diagnosis of postcesarean acute abdomen thereby avoiding laparotomy and the unnecessary work-up and treatment.

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Expert clinician-educators will provide physicians with evidence-based practical knowledge and skills to integrate nutrition into their practice, sharing updates based on the latest research. A range of practical topics will be covered, including culinary medicine, nutrition in chronic disease prevention and treatment, and the role of nutrition in hospital settings. Attendees will learn how to translate nutrition science into pragmatic applications, including cooking, dietary counseling, and providing patients with facts on dietary supplements. The course will promote interdisciplinary teamwork, including collaborative care with registered dieticians, and will approach nutrition through an inclusive lens that is respectful of diverse cultures and food traditions.

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Continuous Glucose Monitoring

Continuous Glucose Monitoring (CGM): (2 hours of CME) This is Part 1 of a two-part series focused on the use of continuous glucose monitoring (CGM) in the care of adult patients with type 2 diabetes mellitus. CGM technology captures glucose trend data because glucose levels are continually measured. The resulting awareness of rising or falling glucose levels allows patients to engage in more proactive management of their glucose. CGM is a common tool for individuals with type 1 diabetes. Recent improvements in CGM technology and decreasing costs have led to increasing use of this technology in the management of type 2 diabetes. Internal medicine physicians and clinicians will receive practical tips for patient engagement and shared decision making. A systematic process for interpretation of CGM glycemic data is also presented.

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