A 46-year-old man with non-Hodgkin lymphoma (NHL) in remission since 2014 presented with progressive dizziness, fatigue, and dark-colored urine. Laboratory workup revealed hemoglobin levels of 5.9 g/dL, elevated lactate dehydrogenase (LDH), hyperbilirubinemia, low haptoglobin, and a positive direct Coombs test for IgG, C3, and poly-specific antibodies, confirming warm autoimmune hemolytic anemia (wAIHA). Immunoglobulin profiling showed low IgM and IgA with high-normal IgG, suggesting chronic immune dysregulation, whereas abdominal imaging revealed mesenteric calcifications, raising concern for residual lymphomatous tissue potentially driving ongoing autoimmune activation. Despite corticosteroids and intravenous immunoglobulin (IVIG), persistent hemolysis necessitated four units of packed red blood cell (PRBC) transfusions and escalation to rituximab, after which gradual clinical stabilization was achieved, highlighting the refractory nature of wAIHA in the setting of previous lymphoproliferative malignancy. Serial monitoring of hemoglobin, reticulocyte count, and LDH throughout the clinical course demonstrated dynamic trends consistent with partial but meaningful immunosuppression, underscoring the value of longitudinal laboratory surveillance in guiding therapeutic escalation decisions. The presence of mesenteric calcifications, combined with a skewed immunoglobulin profile, provided important structural and immunologic clues to the underlying pathophysiology, illustrating how multimodal diagnostic evaluation can reveal occult contributors to delayed autoimmune phenomena even in the absence of overt malignancy recurrence. This case underscores the importance of recognizing delayed AHA in NHL survivors and the necessity of long-term hematologic surveillance, periodic cross-sectional imaging, and a low threshold for multidisciplinary consultation even after prolonged remission.

Amoxicillin is a broad-spectrum β-lactam antibiotic widely used in both human and veterinary medicine. Following administration, approximately 60-80% of the dose is excreted, largely unmetabolized, via urine within a few hours. Consequently, environmental contamination with amoxicillin, especially in aquatic systems, is a significant concern. Due to its potential ecological risks and the current scarcity of data required for a full assessment, it was included in two consecutive European Union Watch Lists (2018, 2020) of substances for comprehensive monitoring to inform water policy. However, data on amoxicillin levels in aquatic environments are contradictory, ranging from high concentrations in some studies to non-detection in others. The presence of intact amoxicillin in aquatic environments is inherently transient, and the risk of substantial analytical errors in its detection, identification, and quantification is considerable unless stringent methodological precautions are applied. Driven by the need for reliable environmental data, inconsistencies in the existing literature and our own extensive analytical experience, we comprehensively investigated amoxicillin degradation in surface water, influent and effluent wastewater under various conditions. Experiments were conducted under both dark and sunlight conditions using water samples spiked with amoxicillin at 5 μg/L and 50 μg/L. The parent compound was quantified by liquid chromatography-tandem mass spectrometry, whereas transformation products were identified by high-resolution mass spectrometry. By critically assessing the factors that influence the analysis and environmental occurrence of amoxicillin, this study resolves discrepancies in prior reports and clarifies the realistic prospects for its detection. We demonstrate that the parent antibiotic should be rarely found in water samples due to its rapid degradation. Therefore, future monitoring efforts should be focused on its primary degradation product, amoxicillin penicilloic acid, as more reliable indicator of contamination in aquatic environments.

We present a case of a man in his early 70s who presented to the emergency department with two weeks of diffuse muscle weakness and dark-colored urine. His history of present illness was negative for obvious inciting events based on the admission history and physical exam. Laboratory tests in the emergency department (ED) showed evidence of end-organ dysfunction, including elevated liver enzymes with aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels of 1,197 and 1,718 IU/L, respectively, an elevated creatinine (Cr) level of 1.44 mg/dL, and significant muscle injury indicated by a creatine phosphokinase (CPK) level of 20,000 IU/L. An unspecified myopathy was high on the differential. Workup was negative for autoimmune or rheumatologic causes of myositis, and statin-induced necrotizing myopathy became the top differential. The patient was treated with pulse-dose steroids. His hospital course was complicated by acute kidney failure requiring dialysis, with eventual recovery of kidney function and normalization of clinical and laboratory findings.

We report the case of a 29-year-old male from the Indian subcontinent (a tuberculosis (TB)-endemic region) residing in Qatar, who presented with a three-day history of epigastric pain, dark urine, and pale stools. He had no known TB exposure, was HIV-negative, and had received the Bacillus Calmette-Guérin or BCG vaccination in childhood. Physical examination revealed scleral icterus without peripheral lymphadenopathy. Initial imaging showed a dilated common bile duct (CBD) (10 mm) and an overdistended gallbladder with sludge. Magnetic resonance imaging demonstrated conglomerated necrotic lymphadenopathy in the portacaval and precaval regions (the largest measuring 44 × 25 mm), causing smooth extrinsic compression of the distal CBD. Contrast-enhanced CT confirmed central necrosis with peripheral rim enhancement, favoring a tuberculous etiology over a malignant one. Endoscopic ultrasound-guided fine needle biopsy of the peripancreatic lymph nodes revealed necrotizing granulomatous inflammation with caseous necrosis. Ziehl-Neelsen staining for acid-fast bacilli was negative, which can occur in paucibacillary TB. Xpert MTB/RIF Ultra assay detected Mycobacterium tuberculosis complex DNA without rifampicin resistance mutations. Mycobacterial culture was sent and remains pending. The patient was HIV-negative, and QuantiFERON-TB Gold Plus was positive. After consultation with the infectious diseases team, he started a hepatoprotective anti-tubercular regimen (moxifloxacin, ethambutol, amikacin, and linezolid with pyridoxine) due to significant baseline hepatocellular injury (alanine aminotransferase peaking at 465 U/L), resulting in significant clinical and biochemical improvement. At three- and six-month follow-up, liver function tests normalized, and repeat imaging showed near-complete resolution of lymphadenopathy with no residual biliary dilatation. He was discharged on therapy with close outpatient follow-up. This case highlights the importance of considering tuberculous peripancreatic lymphadenitis in the differential diagnosis of obstructive jaundice, particularly in young patients from TB-endemic regions, and underscores the critical role of tissue acquisition for definitive diagnosis.

Painless jaundice in elderly patients typically suggests primary pancreaticobiliary malignancy, but metastatic disease to the periampullary region represents an uncommon yet important differential diagnosis that can present with identical clinical features. We present a case of a 65-year-old woman with a history of Stage IIIB endometrial adenocarcinoma with known pelvic and mesenteric metastases, previously treated with salvage chemotherapy, who presented with 3 days of progressive painless jaundice, dark urine, and a year-long history of worsening diarrhea with significant weight loss. Laboratory evaluation revealed a cholestatic pattern of liver injury (total bilirubin 8.1 mg/dL and alkaline phosphatase 862 U/L), and imaging demonstrated new intra- and extrahepatic biliary ductal dilation with a spiculated duodenal mass infiltrating the ampulla and pancreatic head, along with bilateral hydroureteronephrosis from pelvic disease. Endoscopic retrograde cholangiopancreatography confirmed an infiltrative ampullary mass with successful biliary stent placement for decompression, resulting in improvement of hyperbilirubinemia. This case demonstrates that metastatic endometrial carcinoma can present as painless obstructive jaundice through duodenal and ampullary involvement, closely mimicking primary pancreatic adenocarcinoma both clinically and radiographically. Recognition of atypical metastatic patterns is essential for appropriate oncologic management, as treatment strategies and prognosis differ significantly between primary pancreaticobiliary malignancy and metastatic disease.

Dietary supplements such as creatine, β-alanine, citrulline malate (CM), phosphatidic acid (PA), and β-ecdysterone are widely used to enhance exercise performance and muscle hypertrophy. Although generally considered safe, their combined use with high-intensity training may increase the risk of exertional rhabdomyolysis and secondary liver or kidney injury. We report the case of a 23-year-old physically active man admitted with severe myalgia, muscle weakness, fever, and dark brown urine following a prolonged (>4 hours) resistance training session. The patient regularly used multiple dietary supplements, including creatine (5 g), β-alanine, CM (10 g), PA (1.5 g), β-ecdysterone, protein, vitamins, and other micronutrients. Laboratory evaluation revealed markedly elevated creatine kinase (>120,000 U/L) and increased aminotransferases (aspartate aminotransferase (AST) 1,275 U/L; alanine aminotransferase (ALT) 337 U/L), with preserved renal function (creatinine 1.0 mg/dL; estimated glomerular filtration rate (eGFR) 108 mL/min/1.73 m²). No electrolyte disturbances or cardiac injury were observed. The patient received intensive intravenous fluid therapy, resulting in gradual clinical and biochemical improvement over 10 days without development of acute kidney injury (AKI). Creatine and β-alanine enhance exercise capacity through complementary mechanisms involving adenosine triphosphate (ATP) resynthesis and intracellular buffering, potentially enabling greater training loads and increasing risk of muscle injury. The ergogenic efficacy of CM remains inconclusive, while PA and β-ecdysterone may stimulate anabolic signaling via mTOR-related and estrogen receptor-mediated pathways, respectively. Although β-ecdysterone has not previously been linked to rhabdomyolysis, its metabolic effects may theoretically exacerbate muscle damage after extreme exertion. Genetic predisposition, including LPIN1 variants, cannot be excluded and represents a limitation of our study, as genetic testing was not performed. This case highlights the potential risk of severe rhabdomyolysis associated with intensive exercise combined with multi-ingredient supplementation. Healthcare professionals should inquire about supplement use in patients presenting with muscle injury. Early recognition and prompt intravenous hydration remain essential to prevent renal complications. Further studies are needed to clarify the safety profile of emerging anabolic supplements, particularly β-ecdysterone.

Gallbladder anatomical variations are common, but positional anomalies such as subhepatic gallbladder are exceedingly rare. Recognition of these variants is crucial for preventing iatrogenic bile duct injury during laparoscopic cholecystectomy. A 35-year-old medically free male presented with a 3-day history of epigastric pain associated with nausea, vomiting, and dark urine. Laboratory investigations revealed elevated liver enzymes and hyperbilirubinemia. Ultrasonography showed gallstones with a dilated common bile duct. Magnetic resonance cholangiopancreatography (MRCP) demonstrated a subhepatic gallbladder containing multiple stones, an impacted neck stone, and a distal common bile duct (CBD) stone. Endoscopic retrograde cholangiopancreatography with sphincterotomy and stone extraction was performed, followed by stent placement. Laparoscopic cholecystectomy revealed the gallbladder in a subhepatic position surrounded by dense adhesions. Dissection of Calot's triangle was carefully performed to identify and secure the cystic duct and artery. The procedure was completed successfully, and the patient's postoperative recovery was uneventful. He was discharged home on postoperative Day 1 with improved liver function. Subhepatic gallbladder is a rare congenital anomaly that can mimic typical biliary disease but complicate surgical anatomy. Preoperative MRCP is invaluable in detecting such anomalies, guiding operative planning, and minimizing bile duct injury risk. Awareness of positional variations enhances surgical safety and decision-making. Preoperative imaging and intraoperative vigilance are essential when encountering atypical gallbladder anatomy. This case underscores the importance of anticipating anatomical variations to achieve safe and effective laparoscopic cholecystectomy.

Leptospirosis is a common zoonotic infection worldwide but remains rare in the Middle East, including the United Arab Emirates. We report a case of a 36-year-old male who presented with high-grade fever, severe myalgia, headache, vomiting, dark urine, and altered mental status following recent travel from an endemic area where he worked as a paddy field farmer. Clinical examination and laboratory findings revealed septic shock, acute kidney injury, marked hyperbilirubinemia, and severe thrombocytopenia, consistent with multi-organ dysfunction syndrome. Based on the clinical presentation and exposure history, leptospirosis was strongly suspected, and Leptospira IgM serology was sent. The patient was managed in the intensive care unit with supportive care and broad-spectrum antibiotics, leading to gradual clinical improvement. This case highlights the need to consider leptospirosis in acute febrile illness with jaundice and organ dysfunction, even in non-endemic regions.