We present two case reports of twin reversed arterial perfusion sequence- a rare type of twin-twin transfusion syndrome wherein there is abnormal development of one fetus which derives its blood supply from the normal fetus. It is present in cases of monochorionic twin pregnancies and is also known as chorangiopagusparasiticus. Prompt diagnosis and intervention are needed to prevent the death of the normal twin. We discuss the importance of diagnosing this entity.

Von Hipple-Lindau (vHL) is an autosomal dominant disorder that predisposes individuals to an increased risk of developing multi-organ neoplasms. Pancreatic involvement with subsequent development of type II diabetes mellitus is a well-documented complication of this disorder. In this case report, we present a case of a young man who presented with primary symptoms of polyuria and polydipsia. Patient was later found to be in diabetic ketoacidosis and upon further investigation, was diagnosed with diabetes mellitus type I. Patient’s history of persistent abdominal pain prompted further imaging studies, which demonstrated a left sided pheochromocytoma and right sided renal cell carcinoma. Genetic studies confirmed presence of 384delT frame-shift mutation in exon 2 of the tumor suppressor, E3 ubiquitin protein ligase, vHL gene. This case report represents the only one in literature with a rare association of vHL and islet cell autoantibody positive, type I diabetes mellitus.

Bilateral traumatic hip dislocation is a very rare condition. While traumatic unilateral hip dislocation has been commonly reported, simultaneous anterior and posterior traumatic dislocation of both hips is even more unusual. Early diagnosis and timely reduction of such dislocations under anesthesia are necessary for prevention of complications. A case report of a bilateral asymmetrical hip joint dislocation with an unusual mechanism for this injury in a 45 year-old pedestrian woman is presented here. To the best of our knowledge, this case report is the first of its kind in a female patient.

Gastropleural fistula frequently occurs as a complication of peptic ulcer, surgery, or as a consequence of trauma or malignant disease. Here, we report the case of a 59-year old woman with a history of metastatic ovarian cancer, who was hospitalized with a suspected diagnosis of pneumonia. During hospitalization, a left pneumothorax was found requiring a thoracic drain. After drainage, chest X-ray showed a massive pleural effusion and thoracic Computed Tomography (CT) scan demonstrated a gastropleural fistula. Because of the patient’s clinical condition, surgery was not possible and the patient was treated with supportive care. This case report illustrates a rare complication of an oncological disease which could be treated, in optimal clinical conditions, with a surgical approach.

Introduction of tyrosine kinase inhibitors was a great milestone towards treatment of chronic myeloid leukaemia (CML). Increment in specificity for inhibition of tyrosine kinase enzyme in leukemic cells led to the development of new BCR-ABL fusion protein inhibitors. The anticipation of improved efficacy of drugs and decreased side effects profile was met with encouraging response when Nilotinib as a next step to Imatinib was introduced. However, side effects did occur with nilotinib. Here is a case report of a patient with CML, treated with nilotinib, who later developed an undescribed side effect of permanent sensorineural hearing loss.  We could not find any literature support regarding occurrence of this side effect with very potent drug nilotinib. We have to bear in mind that the fantasy of superior specificity and efficacy of nilotinib as compared to imatinib could not prevent it from causing a side effect that had already been described in literature for imatinib.

BACKGROUND: Parapneumonic effusions and empyema are side effects of pneumonia that cause significant morbidity and mortality. Current guidelines recommend drainage of these effusions with tube thoracostomy or surgical debridement in addition to systemic antibiotics. This case series examines the technique to maximize drainage of complicated parapneumonic effusions (cPPE) through tube thoracostomy by instilling tissue plasminogen activator (tPA)/ deoxyribonuclease (DNase) tPA and DNase into the pleural cavity in a community hospital setting.

METHODS: We retrospectively reviewed all patients admitted to Erlanger hospital in Chattanooga from Jan 2010 to April 2015 who presented with cPPE and were treated with intrapleural medications to increase drainage. Data was collected, tabulated, and summarized with mean (standard deviation)or frequencies as appropriate.

RESULTS: We reviewed 9 cases; 6 women and 3 men (age range: 44 to 86 years). In total, there were 6 patients with empyema and 3 patients with cPPE. The decrease in size of the pleural effusion was seen qualitatively on CXR, and quantitatively, the output from the chest tube after the tPA and DNase treatment. The decrease in chest tube output ranged from 2-4 L. Of the 6 patients who had empyema, 4 required surgical lung decortication. The 3 patients with cPPE were managed with medical therapy and had adequate clinical improvement. The average hospital stay was 16.1 days.

CONCLUSION: In this small series, the intrapleural tPA and DNase was effective in reducing the size of pleural effusion as well as reducing the rate of surgical consultation.