Candida empyema is a rare presentation seen in immunocompromised patients, with a high mortality rate if not treated appropriately. We present a rare case of Candida albicans empyema in a patient with gastric cancer undergoing chemotherapy who recently underwent cholecystectomy, successfully treated with fluconazole and drainage. This case not only highlights an unusual presentation of a common pathogen but stresses the fact that when patients with malignancy, present with pleural effusion, candida should be in the differential. Early detection is key in such cases, as outcomes are poor if diagnosis and treatment are delayed.

Multiple myeloma (MM) typically presents as lytic bony lesions, hypercalcemia, anemia, and renal failure. Only a few cases of hyperammonemic encephalopathy (HE) attributed to multiple myeloma have been reported. We report a case of a 68-year-old Hispanic female diagnosed with multiple myeloma and presented with altered mental status and elevated ammonia levels found to have HE. The pathology behind HE is associated with higher ammonia levels produced by myeloma cell lines in the absence of liver disease. Due to the wide range of differentials for altered mental status (AMS), HE often gets missed and causes delayed treatment and the associated higher mortality. The primary treatment is chemotherapy. Lactulose and rifaximin must be initiated; however, it is ineffective if solely used. In our case, chemotherapy was not considered a treatment option in light of the patient's pancytopenia and infection. Our case is unique, as despite adequately treating other commonly suspected causes of AMS such as infection, there was no expected improvement in the patient's clinical status noticed, eventually leading to intubation due to worsening AMS. Given the patient's history of multiple myeloma, non-compliance with chemotherapy before presentation, and elevated ammonia levels raised suspicion for HE. Clinicians are encouraged to acquaint themselves with HE as a differential for patients presenting with MM flare and AMS, specifically when other potential causes of AMS are ruled out and addressed.

Dermatomyositis sine dermatitis (DMSD) is one of the rare idiopathic inflammatory myopathies. Based on predominant symptoms faced by patients, it is classified into 3 types: (1) classic dermatomyositis (DM), where patients have both muscle and skin symptoms; and (2) amyopathic DM, when only skin symptoms present with no muscle involvement. Whereas (3) DMSD has mainly muscle symptoms with muscle antibodies but no skin rashes. There have been only nearly 10 published articles about DMSD proving this disease’s scarcity. At the same time, it shows the importance of discussing the unusual presentation of such a rare disease. Here we present, a 28-year-old woman with worsening proximal muscle weakness. The decreased muscle strength on physical examination and elevated creatinine kinase required more work up for autoimmune disease. Interestingly, on muscle biopsy, anti-melanoma differentiation-associated gene 5 (anti-MDA5) antibody returned positive, and the patient responded well to 3 days course of steroids. The lack of skin involvement, the predominance of muscle symptoms, and positive anti-MDA5 antibody indispensably diagnosed patients with DMSD. The previously published articles have proved the association between anti-NXP-2 antibody and DMSD, which was not seen in our case. The systemic involvement of DMSD can lead to interstitial lung disease, where due to diffuse alveolar damage and pulmonary fibrosis, patients end up requiring intubation and may be associated with higher-level mortality. In our case, chest X-rays and computed tomography (CT) scans were unremarkable for lung involvement, so as no paraneoplastic syndromes were present, which has also been reported in DMSD patients previously.

Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired X-linked, clonal hematopoietic stem cell disease. Patients with PNH may complain of vague symptomatology that contributes to the challenge of its diagnosis. This is especially true in the clinical context of a coinciding hematologic disorder. Aplastic anemia (AA) is an additional immune-mediated illness that results in the destruction of hematopoietic precursors and pancytopenia. The authors encourage screening for PNH clones in patients initially diagnosed with AA, treating underlying hematologic disease to prevent clonal expansion, and further research to investigate the effectiveness of eculizumab in an unusual "classical" PNH secondary to AA with hypercellular bone marrow.