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Nonbacterial thrombotic endocarditis (NBTE) is a rare underdiagnosed cause of systemic embolism, typically associated with advanced malignancy. We report a previously healthy 64-year-old woman who developed fulminant systemic thromboembolic phenomena with multiorgan infarcts and thrombotic coronary occlusion. Echocardiography revealed rapidly progressive mitral valve vegetations. NBTE was diagnosed in the absence of bacteremia and a presumed metastatic ovarian cancer. Despite anticoagulation and percutaneous coronary intervention, cerebral and systemic embolization persisted, ultimately leading to multiorgan failure and death. This case underscores the devastating prognosis of NBTE, which is deadly in rapidly progressive presentations, with the need for early suspicion and prompt multidisciplinary management.

Unusual Presentation of Vaginal Squamous Cell Carcinoma in Older Woman With Hyperarousal and Unwanted Orgasms | Annals of Internal Medicine: Clinical Cases

Vaginal squamous cell carcinoma is a rare gynecologic malignancy that typically presents with nonspecific symptoms, such as abnormal vaginal bleeding, discharge, and pelvic pain. It most often arises in postmenopausal women and is strongly associated with persistent high-risk human papillomavirus infections. Here, we discuss a unique case of an 87-year-old woman who presented with spontaneous orgasmic sensations. Pelvic magnetic resonance imaging revealed a vaginal mass and necrotic inguinal lymph node; biopsy confirmed squamous cell carcinoma. This case highlights considering vaginal cancer in postmenopausal women with atypical sexual symptoms.

Emphysematous Pancreatitis Complicated by Hemoperitoneum: A Rare Presentation | Annals of Internal Medicine: Clinical Cases

We report a rare case of emphysematous pancreatitis complicated by hemoperitoneum and abdominal compartment syndrome in a 54-year-old male with a history of alcohol use. This patient had drainage, antibiotics, and eventual surgical debridement guided by a step-up approach.

Salivary Gland Choristoma at the Esophagogastric Junction Associated With Chronic Gastroesophageal Reflux Disease | Annals of Internal Medicine: Clinical Cases

Salivary gland choristoma at the esophagogastric junction (EGJ) is a rare benign lesion, typically presenting as a nodule. Though heterotopic salivary tissue can appear in the head, neck, or GI tract, its occurrence at the EGJ is uncommon. It is often discovered incidentally during endoscopy for chronic GERD. The origin remains unclear, with theories including embryologic misplacement, inflammation-induced differentiation, or proliferation of native glandular cells. We report two cases of EGJ choristomas in patients with Barrett's esophagus and chronic GERD. We aim to emphasize the importance of recognizing choristoma as a potential differential diagnosis when encountering a new nodule.

Plaque Erosion as a Cause for STEMI in a Marathon Runner Treated With a Stent Retrieval System | Annals of Internal Medicine: Clinical Cases

A 53-year-old runner presented with an anterior ST-segment elevation myocardial infarction (STEMI) during a marathon. Coronary angiography revealed high thrombus burden in the proximal left anterior descending (LAD) artery. Initial manual thrombus aspiration was inadequate, prompting use of a TREVO XP stent retriever system, which successfully removed the thrombus. Optical coherence tomography (OCT) revealed plaque erosion without significant stenosis, and stenting was deferred. The patient was treated with tirofiban and recovered uneventfully. This case highlights plaque erosion as an important STEMI mechanism and demonstrates the feasibility of stent retriever systems for managing high thrombus burden in select cases without stenting.

Muscle Tear and Subsequent Muscle Infarction in a Patient With Uncontrolled Type 2 Diabetes Mellitus | Annals of Internal Medicine: Clinical Cases

Diabetes mellitus is associated with multiple microvascular and macrovascular complications. Musculoskeletal complications, such as diabetic muscle infarction, diabetic tendinopathy, Dupuytren contracture, cheiroarthropathy, and adhesive capsulitis, remain under-reported. Diabetic muscle infarction typically affects individuals with poorly controlled, long-standing diabetes and presents with sudden, nontraumatic muscle pain. Although some case reports exist on thigh muscle infarction and Achilles tendon tear in type 2 diabetes mellitus, upper limb involvement is extremely rare. We report such a case of a 65-year-old woman with diabetes who presented with a supraspinatus tear, subsequent diabetic muscle infarction, subscapularis and teres major myositis, and intramuscular hematoma, complicated by secondary infection and prolonged hospitalization.

Delayed Diagnosis of Genitourinary Tuberculosis Masquerading as Refractory Bacterial Cystitis | Annals of Internal Medicine: Clinical Cases

We report a case of genitourinary tuberculosis in a 34-year-old HIV-negative Filipino woman with diabetes mellitus. She presented with chronic cystitis with only partial response to antibiotics. Diagnosis was delayed owing to nonspecific symptoms and prior fluoroquinolone use, which may have partially suppressed Mycobacterium tuberculosis. Reactivation of tuberculosis may have been facilitated by worsening diabetes. This case underscores the importance of considering genitourinary tuberculosis in patients with risk factors of tuberculosis, persistent urinary symptoms, and sterile pyuria. It also highlights the need for early diagnosis to prevent renal damage.

Squamous Cell Carcinoma Arising in Chronic Hidradenitis Suppurativa | Annals of Internal Medicine: Clinical Cases

While chronic inflammation is a well-established risk factor for carcinogenesis, the varied cutaneous manifestations of long-standing hidradenitis suppurativa (HS) can delay early detection of squamous cell carcinoma (SCC). Here, we present the clinical vignette of a patient with rapidly progressive treatment refractory HS paired with striking interval imaging demonstrating the development of superimposed cutaneous SCC.

Disseminated Cutaneous Mycobacterium haemophilum in a Patient Receiving Mycophenolate Mofetil: A Case Report | Annals of Internal Medicine: Clinical Cases

Mycobacterium haemophilum is a slow-growing acid-fast bacillus that causes a broad spectrum of cutaneous lesions among infected patients. It usually presents in those who are immunocompromised. This case report describes an 81-year-old man taking mycophenolate mofetil immunosuppression for myasthenia gravis who was admitted to a Canadian tertiary care center presenting with atraumatic disseminated cutaneous M haemophilum. Diagnosis was delayed because a dermatomal rash distribution and positive mpox polymerase chain reaction invoked alternate diagnoses of possible herpes zoster and mpox. This report highlights a novel presentation of M haemophilum and the importance of timely identification among other possible and emerging cutaneous infections.

Combination Immunotherapy (Relatlimab/Nivolumab)–Associated Capillary Leak Syndrome: A Case Report | Annals of Internal Medicine: Clinical Cases

Immune checkpoint inhibitors (ICIs) are the preferred first-line treatment of metastatic melanoma. While dual immunotherapy improves efficacy, it also increases the risk for immune-related adverse events (irAEs). Capillary leak syndrome (CLS) is a rare and potentially serious irAE that can be challenging to recognize. We present a woman with metastatic melanoma who developed dyspnea, peripheral edema, and pleural effusions after 6 cycles of relatlimab–nivolumab. She was diagnosed with secondary CLS, likely triggered by immunotherapy. Treatment with intravenous immunoglobulin led to significant clinical improvement. This case highlights the importance of early recognition and management of rare irAEs such as CLS.

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ACP QI Curriculum Module 2: Identify How to Measure Change

ACP Quality Improvement Curriculum The ACP Quality Improvement curriculum focuses on simple, core concepts that can be applied to help achieve meaningful quality goals in a practical manner. A step-wise approach guides you through each stage of the QI journey from establishing the “what” and “why” for change to implementing and sustaining change. This online curriculum, developed by physicians for physicians and their teams, is offered as a series of four modules. Physicians who complete all four modules are eligible for up to3.75 AMA PRA Category 1 CreditsTM and ABIM MOC points. Physicians are also eligible to earn patient safety credit.

ACP QI Curriculum Module 1: Establish the What and Why for Change

ACP Quality Improvement Curriculum The ACP Quality Improvement Curriculum focuses on simple, core concepts that can be applied to help achieve meaningful quality goals in a practical manner. A step-wise approach guides you through each stage of the QI journey from establishing the “what” and “why” for change to implementing and sustaining change. This online curriculum, developed by physicians for physicians and their teams, is offered as a series of four modules. Physicians who complete all four modules are eligible for up to3.75 AMA PRA Category 1 CreditsTM and ABIM MOC points. Physicians are also eligible to earn patient safety credit.

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ITEM DETAILS:Upgrade and Save!The Works video library Add-on Already purchased ACP CME 165 or Premium Access to the ACP Internal Medicine Meeting 2025? Take your recordings library to the next level. Upgrade to The Works package add-on for immediate, online access to 63 additional hours of in-depth course recordings. For one special price of $929, you'll receive nine 7-hour, in-depth courses designed to reinforce your knowledge and help you meet state licensure or maintenance of certification needs. Learn MoreLimited-time offer includes: ACP 2025 9-Course Recordings BundleKeep current with these dynamic, on-demand multimedia sessions applicable to your daily patient care. Earn CME and MOC credit. See details.ü Advancing Nutrition in Medical Practiceü Critical Care Medicine 2025ü Diabetes for Internal Medicine Physicians 2025ü Perioperative Medicine 2025ü Advances in Therapy 2025ü Cardiology for Internal Medicine Physicians 2025: The Key Pointsü Geriatrics and Palliative Medicine for Internal Medicine Physiciansü Hospital Medicine: Success in a Complex Environmentü Primary Care Psychiatry: Practical Skills for Internal Medicine Physicians This upgrade is the perfect solution for busy professionals seeking to get more out of their learning investment. Expand your learning library and gain the additional CME/MOC credits you need. Order your upgrade today. Important Information about Recordings Access and CME/MOCAccess to CME 165 Recordings is 1 year from the date of purchase. Access to the 2025 Course Recordings is 3 years from the date of purchase. Deadline to claim CME credit and MOC points is 5/6/2027. ACP Member and Product Support can assist with upgrades or questions concerning your order: 1-800-ACP-1915 or 1-215-351-2600 (outside of the USA and Canada); Monday – Friday, 9am-5pm ET or by email at help@acponline.org.Product Code: WORKS25UPGRADE

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