BackgroundPyrexia of unknown origin is a difficult and challenging problem for the physician. Endocrine disorders, such as subacute thyroiditis, rarely present with pyrexia of unknown origin. Subacute thyroiditis can have a broad spectrum of clinical presentations including fever and biochemical thyrotoxicosis without overt signs or symptoms.Case presentationA previously healthy 42-year-old Sri Lankan Sinhalese man was extensively investigated for a prolonged fever of 3 weeks with high inflammatory markers. He had mild tenderness over his neck with cervical lymphadenopathy with no thyrotoxic symptoms or signs. An ultrasound scan revealed an enlarged thyroid with increased vascularity and he had suppressed thyroid-stimulating hormone with elevated free thyroxine and free triiodothyronine hormone levels. Fine-needle aspiration cytology confirmed thyroiditis. He responded well to low-dose steroids.ConclusionSubacute thyroiditis should be considered in the diagnostic workup of pyrexia of unknown origin even in the absence of overt toxic symptoms of thyroid hormone excess.

BackgroundDengue is a common arboviral infection with a diverse spectrum of clinical manifestations. Dengue hemorrhagic fever is a more severe form of infection characterized by plasma leak and hemoconcentration. Although hepatic dysfunction is common in dengue illness, massive liver necrosis is rarely reported. Lactic acidosis is a poor prognostic marker in liver failure related to dengue. Management of acute renal injury in dengue hemorrhagic fever due to prolonged shock is challenging as the fluid reabsorption during the recovery phase expands the intravascular volume and precipitates heart failure and pulmonary edema.Case presentationWe report the case of a 43-year-old Sri Lankan Sinhalese woman with serologically confirmed dengue fever presenting with evidence of plasma leakage developing acute liver failure evidenced by deranged liver functions, coagulopathy, and altered sensorium and acute kidney injury with anuria. She had elevated serum lactate levels. In addition to the “standard care,” she was managed with intravenously administered N-acetyl cysteine and blood transfusions, even in the absence of bleeding or dropping packed cell volume, targeting a higher packed cell volume anticipating a better oxygenation at tissue level. Continuous veno-venous hemodialysis was employed and continued for 138 hours removing the fluids reabsorbed during the recovery phase to prevent her from developing heart failure and pulmonary edema. She made full recovery with no sequelae.ConclusionsN-acetyl cysteine and packed cell transfusion aiming at a higher packed cell volume to maintain adequate tissue perfusion during shock may be beneficial in acute liver failure due to dengue virus. The use of a continuous form of renal replacement such as continuous veno-venous hemodialysis is of paramount importance in managing fluid states in the recovery phase of dengue hemorrhagic fever in those with renal impairment. Interesting observations made in the fluid dynamics during the reabsorption phase need further studies preferably with an animal model.

BackgroundDengue is a common arboviral infection with a clinically diverse spectrum of presentations. Although hepatic dysfunction is commonly identified in patients will dengue illness, acute liver failure is rare. The etiopathogenesis of hepatic dysfunction is multifactorial and related to direct viral invasion of hepatocytes, immunological factors and hypoxia particularly in cases of shock in dengue hemorrhagic fever. Ideal management of dengue-related hepatic dysfunction and acute liver failure is still debated.Case presentationWe report a 53-year-old Sri Lankan Sinhalese male with serologically confirmed dengue fever presenting with evidence of plasma leakage developing acute liver failure evidenced by deranged liver functions, coagulopathy and altered sensorium. In addition to the ‘standard care’, the patient was managed with intravenous N-acetyl cysteine and blood transfusions even in the absence of bleeding or dropping packed cell volume (PCV), targeting a higher PCV in anticipation of better oxygenation at tissue level. He made a full recovery with no sequential infections.Conclusion N-acetyl cysteine and packed cell transfusion aiming at a higher PCV to maintain adequate tissue perfusion during shock may be beneficial in acute liver failure due to dengue virus. Large randomized trials should be carried out to establish the efficacy of these treatment strategies to support these observations and change the current practice.

BackgroundPurpura fulminans is an acute life-threatening disorder characterized by intravascular thrombosis and hemorrhagic infarction of the skin complicated with disseminated intravascular coagulation. It is commonly seen in acute infections following meningococcal and streptococcal infections. Few cases of purpura fulminans following rickettsial infections have been described in the literature.Case presentationWe report a case of a 55-year-old Sri Lankan woman who presented to Teaching Hospital Peradeniya with a febrile illness, headache, and myalgia that progressed to an erythematous rash starting over the bilateral lover limbs and hands and that became black and necrotic with a few hemorrhagic blebs. She had normocytic anemia, platelet clumps, and monocytosis as well as a deranged clotting profile. The result of immunofluorescence antibody testing for rickettsial immunoglobulin G was strongly positive for Rickettsia conorii with a rise in titer convalescent sera, and a diagnosis of purpura fulminans following rickettsial infection was made. The patient made an excellent recovery with chloramphenicol treatment.ConclusionsThe treating physician should consider the rare but very treatable condition of rickettsial infection as a differential diagnosis in the etiological diagnostic workup of patients presenting with severe purpuric and hemorrhagic rash with fever.

BackgroundDengue is an arboviral infection classically presenting with fever, arthralgia, headache, and rashes. It is hyperendemic in Sri Lanka and has a major impact on health. Neurological complications of dengue fever are rare but have been reported in the literature.Case presentationA 60-year-old Sri Lankan man presented with a history of fever, arthralgia, and generalized malaise of 2 days duration. A diagnosis of dengue was confirmed with leukopenia, thrombocytopenia, and positive NS1 antigen done on day 2 without evidence of hemoconcentration. On admission, our patient had weakness of the bilateral lower limbs, which progressed in an ascending pattern involving both upper limbs and neck muscles, requiring assisted ventilation. Electromyography confirmed a demyelinating polyneuropathy and cerebrospinal fluid showed albumincytological dissociation. He was treated with intravenous immunoglobulins and made an uneventful recovery. Subsequently, his immunoglobulin M test result for dengue virus was positive.ConclusionsGuillain-Barré syndrome is a rare but possible neurological sequel following dengue fever. In regions where dengue is hyperendemic, screening for dengue illness may be important in patients presenting with acute flaccid paralysis.

BackgroundKikuchi Fujimoto disease is an uncommon benign condition of necrotizing histiocytic lymphadenitis commonly seen in East Asian and Japanese populations. It commonly presents with fever, cervical lymphadenopathy, and elevated inflammatory markers. Diagnosis of Kikuchi Fujimoto disease is based on histopathological studies of the involved lymph nodes. The presentation of Kikuchi Fujimoto disease can mimic many sinister conditions including lymphoma. Treatment is mainly supportive provided that accurate diagnosis is made and sinister conditions like lymphoma ruled out.Case presentationWe report the case of an 18-year-old Sri Lankan Moor woman who presented with fever and cervical lymphadenopathy for 1 month. She had elevated inflammatory markers with high lactate dehydrogenase and ferritin levels. She had an extensive work-up including an excision biopsy of an involved lymph node and bone marrow biopsy. Finally, a diagnosis of Kikuchi Fujimoto disease was based on histopathology of the lymph node and negative bone marrow biopsy.ConclusionsAlthough Kikuchi Fujimoto disease is a self-limiting condition, it is a great masquerader which mimics the clinical features of many sinister conditions including tuberculosis, lymphoma, and adult-onset Still’s disease. Early recognition of the disease is of crucial importance in minimizing potentially harmful and unnecessary evaluations and treatments.

Dengue is an arboviral infection that is hyperendemic in tropical and subtropical climates. Clinical manifestations of dengue can range from asymptomatic infection to severe infection with multi-organ failure. Dengue haemorrhagic fever (DHF) is a subcategory in dengue infection with a hallmark of plasma leak (ie critical phase). The plasma leak in DHF is selective (pleuroperitoneal spaces), transient and dynamic, and needs careful monitoring and meticulous fluid resuscitation. In addition, dengue fever may present with extended and unusual manifestations affecting any organ, including the heart, liver, kidney and brain. Studies on vaccine development and vector control are ongoing to prevent this infection of global importance. In this article, the clinicopathological features and management aspects of dengue are discussed.

BackgroundWasp stings are commonly encountered worldwide and result in a variety of clinical manifestations including local and systemic reactions. Neurological and vascular complications are rarely reported following a wasp sting.Case presentationA 69-year-old Sri Lankan Tamil man presented to our hospital with focal neurological deficit following multiple wasp stings; the deficit was confirmed to be an acute infarction on magnetic resonance imaging scan. He was screened for metabolic risk factors which were negative and he had a normal two-dimensional echocardiogram and normal carotid arteries in carotid duplex which excluded potential sources of thromboembolism.ConclusionTreating physicians should be aware of the rare but possible complication of ischemic stroke following a case of wasp sting.