UCLA Department of Medicine Clinical Insights

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Language and culture are foundational to patient-centered care, and their importance is often magnified in the care of older adults with limited English proficiency (LEP). This narrative essay describes the clinical encounter of a 92-year-old Japanese-speaking patient whose medical needs, autonomy, and dignity became fully visible only through language-concordant care. By engaging the patient in her native language and drawing upon culturally familiar practices, a shared understanding was established that led to improved medication adherence and clinical stability. The case highlights how aging-related cognitive changes can diminish proficiency in non-native languages and how cultural norms may further limit self-advocacy in healthcare settings. Framed within the broader literature on health disparities affecting older adults with LEP, this reflection underscores the role of linguistic and cultural concordance in reducing barriers to care, enhancing trust, and improving outcomes. The essay argues that cultural humility, professional interpretation, and language proficiency training are essential tools for clinicians caring for an increasingly diverse aging population. Small, culturally attuned interventions can have outsized impacts, reaffirming that inclusive care begins with listening—often in the patient’s own language.

No abstract

Immune checkpoint inhibitors have transformed the treatment of advanced malignancies, but their capacity to amplify immune activity extends beyond tumor cells, producing a spectrum of immune-related adverse events that increasingly bring patients to rheumatology clinics. Inflammatory arthritis is among the most common rheumatologic manifestations, occurring in roughly 4–6% of patients, and may present as seronegative symmetric polyarthritis, oligoarthritis, or polymyalgia rheumatica–like disease. This essay reflects on a clinical encounter with an older woman receiving checkpoint inhibitor therapy for metastatic melanoma who developed functionally limiting inflammatory arthritis at the very moment her cancer treatment appeared to be working. Her experience illuminates the central paradox of immunotherapy: the mechanism that enables tumor destruction can simultaneously turn against the patient’s own tissues. Through this encounter, the essay explores the clinical features, pathophysiology, and management of checkpoint inhibitor–associated arthritis, and reflects on the broader challenge of helping patients navigate the sustained tension between a therapy that is both healing and causing harm. The role of the rheumatologist in this era extends beyond suppressing inflammation—it includes bearing witness to the complexity that modern oncology has introduced into patients’ lives.

In this article we present two images of ring-enhancing brain lesions secondary to PTLD manifesting as primary CNS lymphoma. 

A 58-year-old female with a complex medical history, including type 2 diabetes mellitus (T2DM), hypertension, hyperlipidemia, peripheral artery disease (PAD), coronary artery disease (CAD) status post coronary artery bypass graft (CABG) four months prior, and never tobacco smoker presented with a painful, non-healing ulcer on the left lower extremity over a month. This case highlights the diagnostic challenge of mixed-etiology ulcers, as they often have clinically overlapping features. They can also be difficult to treat. Ultimately, a multi-disciplinary plan encompassing treatments for both arterial and venous ulcers was instituted for this patient to promote optimal wound healing.  

Acromegaly is a rare endocrine disorder caused by excess growth hormone (GH), most commonly from a pituitary adenoma. Diagnosis is frequently delayed due to insidious onset and subtle clinical manifestations. We report a 37-year-old male who presented with fatigue and weight gain, initially prompting evaluation for hypogonadism. Laboratory testing revealed low testosterone and mild hyperprolactinemia, leading to a broader pituitary evaluation. Insulin-like growth factor-1 (IGF-1) was elevated on repeated testing, and GH failed to suppress during oral glucose tolerance testing, confirming acromegaly. Pituitary MRI demonstrated a 9 mm sellar lesion. The patient underwent transnasal transsphenoidal surgery with gross total resection. Pathology confirmed a GH-secreting adenoma. Postoperative GH levels were consistent with biochemical remission. This case highlights the importance of considering acromegaly in patients with nonspecific symptoms and minimal physical findings.

In this article we show a unique slide image of acute interstitial nephritis with eosinophils due to a single dose of brentuximab vedotin.  

Case report

A 31-year-old female patient came to our clinic with a complaint of a bald spot on her head for more than a year. She denied any history of trauma to that area of her head. The patient mentioned that she had been under a lot of stress over the past year due to conflicts with her husband. Initially, she felt embarrassed to see a doctor and tried to cover the bald spot, which significantly decreased her self-confidence. However, she eventually decided to seek treatment.

She denied any family history of hair loss. The patient did not smoke or consume alcohol and had no other medical history. There was a family history of hypertension in her father.

On examination, a bald spot was noted at the top center of her head, with broken hair of varying lengths. The rest of the examination was normal. After further questioning, the patient admitted that when she gets stressed, she pulls her hair, which gives her a sense of relief. She was referred to a dermatologist, who confirmed the diagnosis of trichotillomania.
 

The patient was then referred to a psychologist, where they began cognitive-behavioral therapy (CBT) focused on identifying triggers for hair-pulling and teaching coping strategies. After several sessions, the patient reported a decrease in her hair-pulling habits, and gradually her hair began to regrow in that area, leading to an increase in her self-confidence.

Discussion

Trichotillomania is a disorder where an individual compulsively pulls out their hair. This can occur on the scalp or other areas of the body, but pulling hair from the scalp is the most common. Typically, a thorough history and examination are sufficient for diagnosis, and a biopsy is not necessary unless there is doubt about the diagnosis or similarity to another type of hair loss known as alopecia areata, in which case a biopsy may be performed. The bald spots in trichotillomania show broken hair of varying lengths, while alopecia areata presents with very smooth bald patches. The etiology of the disorder is unclear, but a twin study suggest that genetic factors may play a role.(1)

The most common age of onset is between 9 and 13 years, but it can occur at any age. Most patients suffer from anxiety and obsessive-compulsive disorder (OCD). In one study of 131 individuals, 87% had OCD, 64% had mood disorders, 52% had generalized anxiety, and 44% had skin-picking disorder. (2)

Some patients also exhibit behaviors such as hair biting and hair ingestion, known as trichophagy.

Alongside physical treatment for hair loss provided by dermatologists, these patients often require psychiatric referral. cognitive-behavioral psychotherapy is usually more beneficial than medication.

Habit Reversal Training (HRT) is part of this treatment approach. HRT provides patients with practical tools to manage their urges. By increasing awareness of their hair-pulling behavior and replacing it with alternative actions, patients learn to regain control over their impulses. Our patient experienced an increase in self-esteem after treatment, and her relationship with her husband also improved. This highlights how effective treatment not only benefits the individual but also positively influences their interpersonal relationships.

 
This case serves as a reminder to approach disorders like trichotillomania with a broader, multidisciplinary perspective and to ensure patients are connected with appropriate treatment that supports recovery. It also highlights the need for greater awareness and understanding of trichotillomania to avoid unnecessary testing and delays in diagnosis. Lastly,  it reminds clinicians the importance of patient education to reduce stigma and encourage engagement in care.
 

References

1.  Novak CE, Keuthen NJ, Stewart SE, Pauls DL. A twin concordance study of trichotillomania. Am J Med Genet B Neuropsychiatr Genet 2009; 150B:944.

2.    Gerstenblith TA, Jaramillo-Huff A, Ruutiainen T, et al. Trichotillomania comorbidity in a sample enriched for familial obsessive-compulsive disorder. Compr Psychiatry 2019; 94:152123.

Rash in Syphilis: the great mimicker

A 32-year-old Caucasian male presented to his annual  preventive visit with a six-month history of a persistent, nonpruritic chest rash. He had been treated multiple times for presumed allergies and eczema with antihistamines, oral prednisone, and topical corticosteroids without improvement. The rash fluctuated in intensity without clear triggers. He also reported a painless, nonhealing lesion beneath his tongue following minor trauma.

Examination revealed a faint erythematous macular rash on the chest and upper arms, without palm or sole involvement, and a 5 mm white ulcer on the ventral tongue. Laboratory studies were unremarkable; however, sexually transmitted infection screening showed a reactive rapid plasma reagin (RPR) with positive treponemal testing (TP-PA) and a titer >1:1024. Other STI testing, including HIV, was negative.

He was treated with intramuscular penicillin G benzathine (2.4 million units). At six months, symptoms improved, and RPR declined to 1:128.

Discussion

Secondary syphilis remains a diagnostic challenge due to its variable and often nonspecific presentation. Despite longstanding recognition of Treponema pallidum infection [1], the secondary stage can mimic numerous dermatologic and systemic conditions, frequently leading to misdiagnosis as illustrated by this case. While a maculopapular rash involving the palms and soles is characteristic, it may be absent or subtle. Mucosal lesions, including oral involvement, can be mistaken for more common conditions or traumatic lesions, further complicating diagnosis.

Serologic testing adds another layer of complexity. Nontreponemal tests may be falsely negative in early infection prior to antibody development, and discordant results can occur in patients with

prior treated disease [2]. These factors necessitate careful interpretation and, in some cases, repeat testing.

In addition, given the known association with HIV coinfection [2], maintaining a high index of suspicion is critical. Early recognition of secondary syphilis through clinical awareness and appropriate testing is essential to prevent delayed treatment and ongoing transmission.

This case serves as a reminder that syphilis should remain an important consideration in the differential diagnosis particularly in patients with relevant risk factors or unusual dermatological and mucosal presentations.

References

1.     Rockwell DH, Yobs AR, Moore MB Jr.: The Tuskegee study of untreated syphilis; the 30th year of observation. Arch Intern Med. 1964, 114:792. 10.1001/archinte.1964.03860120104011

2.     Ratnam S: The laboratory diagnosis of syphilis. Can J Infect Dis Med Microbiol. 2005, 16:45. 10.1155/2005/597580

25yo non-verbal Asian male born with cerebral palsy with spastic quadriparesis, restrictive lung disease s/p chronic tracheostomy, GJ tube dependence was found on labs over several years to have leukocytosis (WBC 10-18), mild microcytic anemia (Hgb 10-12.8), and thrombocytosis (platelets 400-1000). Per his parents, patient appears to be comfortable and at his baseline mental state, denying fevers, cough, bleeding, urinary changes, diarrhea or signs of pain. Initial exam without lymphadenopathy, changes in cardiopulmonary status, abdominal changes, and without decubitus ulcers. Differential diagnosis at the time was indolent infections (ie atypical/fungal pneumonia, osteomyelitis), lymphoproliferative disorders, hematologic/bone marrow disorders, and autoimmune conditions. Additional labs showed elevated Erythrocyte Sedimentation Rate (ESR) >130, C-Reactive Protein (CRP) 7.3, IgA 473, IgG 3154. Iron levels were low. Peripheral blood smear with leukocytosis with few reactive lymphocytes, thrombocytosis and microcytic anemia. JAK2 mutation was negative, SPEP/Immunofixation was without monoclonal antibodies, TSH normal, Quantiferon-Gold negative, LDH normal. Repeat exam on follow up visit revealed signs of severe tophaceous gout on helix of the ear and multiple joints (bilateral wrists and bilateral ankles). There were also small, hard subcutaneous nodules on right forearm. Initial exam missed these signs because his hands and feet are chronically contracted and covered with clothing. Uric acid was 15.6, HLA-B*58:01 was negative. Father revealed he has gout too. Patient was started on allopurinol and colchicine (both crushed and given via G tube) after rheumatology consultation. 

On subsequent follow ups over the next four months, tophi on ear improved but tophi on right ankle got slightly worse, with increased skin ulceration (without infection), and new development of exposed yellow nodules on right forearm, indicating deposits of urate crystals. WBC 13.9, Hgb 11.8, platelets 673, uric acid 11.4, ESR 83, CRP 6.4. Allopurinol dose was increased several times and patient was advised to see Rheumatology for evaluation for partial response of disease vs refractory disease.

Gout is the most common form of inflammatory arthritis, affecting approximately 9.2 million adults in the United States (1). Synovial fluid analysis showing monosodium urate crystals under polarized light microscopy is the gold standard for diagnosis, but blood tests can also show neutrophilic leukocytosis and elevation of inflammatory markers (2). In this case, patient also had significant thrombocytosis and IgA and IgG elevations due to inflammation from gout. In a young patient such as this, it would also be prudent to consider secondary causes for gout.

Tophaecous gout is a form of advanced gout characterized by tophi, which are nodular deposits formed in joints and soft tissue comprised of monosodium urate crystals surrounded by multinucleated giant cells and an outside fibrovascular area. Tophi formation is a chronic granulomatous inflammatory response to urate crystals and takes years to develop. The most common sites of tophi are joints, helix of ear, olecranon bursa, finger pads and Achilles tendon. Classic inflammatory findings like erythema and even tenderness are not necessarily present. However tophaceous gout can lead to joint destruction and deformities. Bone erosions and skin ulcerations can also occur, as seen in this case. Infection is a risk at the site of skin breakdown and ulceration. In this patient, the yellow and white nodular deposits on the arm are representative of a high urate burden (3)

American College of Rheumatology recommends a treat-to-target strategy with urate-lowering therapies (ULT), with allopurinol as the preferred first line therapy, to maintain a serum urate level of <6 mg/dl (4). If a patient fails all standard therapies, refractory gout can be treated with IL-1 inhibitors and other therapies such as Pegloticase (5, 6). In cases of tophi causing complications (ie infections) or those at risk for permanent joint destruction, surgical intervention may be appropriate (7).

A 64-year-old woman presented to the emergency department (ED) with chest, left arm and jaw pain in the setting of severely elevated blood pressure. Patient subsequently noted chronic headaches as well and during workup for chronic headache was found to have chronic neurocysticeercosis. 

A 89-year-old woman presented to the emergency department after referral by her retinal specialist for acute right eye vision loss of eight days duration. On further workup of giant cell arteritis patient was incidentally noted to have a rim enhancing cerebellar cystic lesion of unknown etiology.

This case describes a 36-year-old woman who presents with a palpable left-sided thyroid nodule and laboratory evidence of dual endocrine dysfunction: subclinical hyperthyroidism and primary hyperparathyroidism). While thyroid autoantibodies were negative, imaging revealed a 2.85 cm complex nodule in the left inferior thyroid lobe.

Diagnostic challenges arose when a sestamibi scan and parathyroid CT failed to identify a distinct parathyroid adenoma, showing only a hyperfunctioning focus corresponding to the known thyroid nodule. The suspicion of an intrathyroidal parathyroid adenoma (IPA) was confirmed via fine-needle aspiration (FNA) with PTH washout, which returned a significantly elevated level of 549 pg/mL.

The patient underwent a left thyroid lobectomy. Histopathology confirmed a 1.0 cm parathyroid adenoma embedded within the thyroid tissue. Postoperatively, intraoperative PTH levels dropped by over 95%, and at the three-month follow-up, both TSH and calcium levels had normalized. This case highlights the importance of considering IPA in the differential diagnosis of concomitant thyroid nodules and hypercalcemia, illustrating that PTH washout remains a critical tool when localized imaging is ambiguous. Five-year follow-up confirms sustained biochemical remission.