Internal Medicine and Non-Infectious Syndromes

Sixteen days of unexplained fever, a first-line workup that has found nothing, and a patient who is visibly declining while everyone debates whether the next move is another scan or a treatment.

A patient doing well clinically on the one antibiotic that actually covers his infection develops a new, otherwise-unexplained fever — the debate is whether that fever is reason enough to give up the only drug that's working.

A young woman with genetically confirmed FMF keeps having attacks despite colchicine dose increases — the real question underneath the biologic decision is whether her disease is resistant, or whether GI side effects have kept her from ever actually reaching an adequate dose.

Steroid-refractory adult-onset Still's disease needs a biologic, but the two reasonable choices don't just differ in convenience — one of them can also mask the exact lab pattern that would warn of macrophage activation syndrome developing underneath it.

The diagnosis is named after a TNF receptor, which makes an anti-TNF drug feel like the obvious next step — but the strongest trial evidence for this exact syndrome points to blocking a different cytokine entirely.

Reactive arthritis after a chlamydial infection raises a question that doesn't have one universal answer — whether antibiotics change the arthritis course turns on which organism triggered it and on how long the arthritis has already been running, and the trials answering each question enrolled different patients.

A fever on the second day after major surgery, in a patient who otherwise looks well, tests a piece of teaching — that early atelectasis explains postoperative fever — against a literature that has actually moved past it.

The acute DRESS picture has already improved on steroids — the genuinely unresolved question now is how slowly to taper, since the disease is well known for relapsing on a taper that moves too fast, without a trial to say exactly how slow is enough.

A serum sickness-like reaction after her second rituximab infusion raises a real question with a real cost either way — switch away from the only drug that has kept her disease controlled, or manage the reaction and continue.

Painful shin nodules, bilateral hilar adenopathy, and ankle arthralgia together describe a recognizable, usually self-limited syndrome — but the same imaging picture can also mean tuberculosis, and the two calls for very different next steps.

A biopsy showing non-caseating granulomas fits sarcoidosis well — but sarcoidosis is a diagnosis of exclusion, and the specific thing being excluded, an indolent mycobacterial or fungal infection, takes weeks to rule out by culture, weeks a genuinely breathless patient may not want to wait.

IgG4-related disease masquerading as pancreatic cancer is treated with glucocorticoids by default — but this patient's own poorly controlled diabetes turns the default first-line choice into a genuine judgment call rather than a formality.

Severe pancreatitis meets every criterion a sepsis alert is built to catch — fever, tachycardia, leukocytosis — without there necessarily being any infection behind it, and the multiple negative trials testing exactly this scenario say something the order set doesn't know.

A biopsy has ruled out lymphoma and lupus and confirmed a benign, self-limited disease — but self-limited doesn't mean symptom-free, and how much steroid exposure is worth trading for a faster recovery has no settled answer.

A young man's macrophage activation syndrome is worsening on maximal anakinra and steroids — the choice ahead is between a drug approved for exactly his diagnosis but resting on a very small evidence base, and the older, more toxic protocol with by far the longest track record.