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Recurrent pulmonary embolism (PE) is uncommon. We report a 39-year-old man with a pacemaker who developed recurrent PEs while receiving rivaroxaban, warfarin, and therapeutic enoxaparin. Evaluation for autoimmunity and thrombophilia was negative. Each episode was preceded by fever, malaise, and myalgia. During admission, 18-fluorodeoxyglucose positron emission tomography–computed tomography (18FDG PET/CT) showed focal uptake (maximum standardized uptake value, 2.3) along the right-ventricular pacemaker lead, suggesting device-related infection or thrombosis. Transvenous extraction failed; subsequently, surgical removal was performed. Cultures remained negative. This case highlights pacemaker-associated infection as a treatable cause of septic embolization and underscores the diagnostic value of 18FDG PET/CT in recurrent PE.

Long-Standing Shunts and Recurrent Cerebrospinal Fluid Pseudocyst Causing Small Bowel Obstruction in an Adult | Annals of Internal Medicine: Clinical Cases

We report a rare case of a recurrent cerebrospinal fluid (CSF) pseudocyst causing small bowel obstruction in an adult with a long-standing ventriculoperitoneal (VP) shunt for congenital hydrocephalus. Cerebrospinal fluid pseudocysts are uncommon complications of VP shunts and are most frequently described in pediatric populations. Adult cases leading to mechanical small bowel obstruction are exceedingly rare. This case highlights the importance of considering CSF pseudocysts in the differential diagnosis of VP shunt patients presenting with abdominal pain or obstructive symptoms, emphasizing the need for prompt imaging and multidisciplinary management to prevent complications.

A Case of Transverse Colon Volvulus With Hemoperitoneum in Menkes Disease | Annals of Internal Medicine: Clinical Cases

Menkes disease is an X-linked recessive disorder of copper metabolism resulting in impaired activity of lysyl oxidase, a cuproenzyme essential for collagen and elastin cross-linking. The resulting connective tissue fragility underlies many phenotypic features of the disease. We report the case of a 23-year-old man with Menkes disease who developed massive hemoperitoneum secondary to transverse colon volvulus around an intra-abdominal adhesion band. We hypothesize that copper-dependent connective tissue abnormalities predisposed this patient to adhesion formation. This case highlights a potential mechanistic link between copper transport deficiency, abnormal peritoneal healing, and life-threatening gastrointestinal complications.

Atypical Presentation of Infratemporal Fossa Abscess With Intracranial Extension | Annals of Internal Medicine: Clinical Cases

A previously healthy 19-year-old man presented with subacute, nonspecific gastrointestinal symptoms following maxillary molar extraction. Examination and subsequent evaluation revealed a large abscess in the left masticator space with intracranial extension, resulting in subdural empyema and parameningeal meningitis. Although the initial presentation appeared benign, the underlying pathology was deeply seated and rapidly progressive. Abscesses involving the masticator space, particularly the infratemporal fossa, carry high risk owing to proximity to critical neurovascular structures and the potential for life-threatening intracranial infection. Early recognition through imaging, timely initiation of broad-spectrum antibiotics, and surgical intervention are crucial to preventing serious complications and ensuring favorable outcomes.

Renal Subcapsular Hematoma: A Rare Potentially Reversible Cause of Acute Graft Dysfunction With Immediate Intervention | Annals of Internal Medicine: Clinical Cases

Subcapsular hematoma of the kidney allograft is an often underrecognized but reversible cause of acute graft dysfunction, which occurs most commonly after percutaneous biopsy. We retrospectively reviewed 4 cases diagnosed with subcapsular hematoma between 2020 and 2023. All patients developed acute kidney injury, hypertension, and graft pain following kidney biopsy. Only 1 recovered fully after prompt surgical evacuation; delayed presentation and intervention in the others resulted in permanent graft loss. These findings emphasize the need for high index of suspicion in post-biopsy patients with acute graft dysfunction, as early diagnosis and timely intervention are essential for preserving graft function.

Fulminant Vibrio vulnificus Infection Following Dog Scratch in a Transplant Recipient Who Is Immunosuppressed: A Case Report | Annals of Internal Medicine: Clinical Cases

A 58-year-old man who is immunosuppressed presented with severe left leg pain 1 day after sustaining a scratch from his dog, which had been swimming in warm coastal water. He quickly developed necrotizing bullae secondary to Vibrio vulnificus bacteremia, progressing to septic shock and multiorgan failure. Management included prompt surgical intervention, targeted antibiotics, and immunosuppressant de-escalation. Despite his grave prognosis, he recovered after 23 days. This case highlights an unconventional V vulnificus transmission route, underscoring the need for rapid diagnosis and treatment in high-risk patients with compatible symptoms, regardless of direct water exposure.

Unmasking the Diagnosis: A Case of Hemicrania Continua | Annals of Internal Medicine: Clinical Cases

Hemicrania continua is a rare unilateral headache disorder characterized by autonomic symptoms and complete resolution when treated with indomethacin. We present a case of a woman with a continuous unilateral headache without autonomic features, who had been self-medicating with over-the-counter ibuprofen. After extensive evaluation, it was determined that ibuprofen had likely been masking the autonomic features of hemicrania continua. Upon discontinuation of ibuprofen and initiation of indomethacin, her symptoms resolved rapidly. This case highlights the potential for symptomatic medications to obscure diagnostic features, leading to delayed diagnosis and unnecessary testing.

Infectious Aortitis Secondary to Gastrointestinal Pathogens: A Case Series and Syndromic Review | Annals of Internal Medicine: Clinical Cases

Aortitis is a rare but serious complication of infection that results in high morbidity and mortality. The most common location is in preexisting aneurysmal disease in a patient with multiple chronic comorbidities. The pathogens often reflect gastrointestinal bacteria, the classic example being Salmonella spp., but also include other enteric flora, Staphylococcus aureus, Streptococcus spp., and more. Herein, we describe 2 cases of aortitis caused by gastrointestinal bacteria and review management of this complex syndrome.

Complete Response to Pembrolizumab in Prostate Cancer With Microsatellite Instability–High, Deficient Mismatch Repair, Tumor Mutational Burden–High, and Programmed Death–Ligand 1 Positivity | Annals of Internal Medicine: Clinical Cases

A 72-year-old man initially presented with prostate cancer and a metastatic right rib lesion. He developed rapid progression on androgen deprivation therapy in 7 months and subsequent treatment with enzalutamide in 3 months. Biomarker studies after progression to castration-resistant prostate cancer revealed deficient mismatch repair, microsatellite instability–high, tumor mutational burden of 21 mut/Mb, and programmed death–ligand 1–positive disease. Based on the results of the KEYNOTE 158 study, immunotherapy with pembrolizumab was initiated. The patient had a complete clinical, radiologic, and biochemical response with an undetectable prostate-specific antigen level within 3 months and continued pembrolizumab 8 years after diagnosis.

When Sarcoidosis Looks Like Myeloma: A Diagnostic Pitfall | Annals of Internal Medicine: Clinical Cases

Multiple myeloma (MM) is a plasma cell malignant disorder with variable clinical presentations. Because MM is the most prevalent hematologic malignancy among Black patients, a high index of suspicion is often applied in this population. However, premature diagnostic closure may occur when initial findings appear consistent with MM, while conflicting information is overlooked. This case describes a 46-year-old Black man initially diagnosed with active MM but ultimately found to have active sarcoidosis and smoldering myeloma. This case illustrates the importance of recognizing cognitive bias and considering granulomatous disease in the differential diagnosis of hypercalcemia, lytic lesions, and systemic abnormalities.

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