Dengue fever has a wide range of clinical manifestations from asymptomatic disease to complicated dengue haemorrhagic fever and dengue shock syndrome. Bleeding manifestations in dengue is well known but thrombotic events complicating dengue is uncommon. ST elevation myocardial infarction during dengue is rare and poses important management dilemma. At present, there is no consensus on how to manage this situation. We present two patients with dengue fever developing ST elevation myocardial infarction and our experience in the management. We suggest case-based management of acute coronary syndrome in dengue, guided by the degree of thrombocytopaenia and bleeding risk. Further studies are needed to include this into existing dengue management guidelines.
Central pontine myelinolysis (CPM) and extrapontine myelinolysis (EPM) are syndromes of osmotic demyelination attributed to the rapid correction of hyponatraemia. Isolated EPM is a rare clinical entity which poses a significant diagnostic challenge especially in the absence of a rapid rise in sodium. Typical MRI findings aid in the diagnosis. Treatment for established osmotic demyelination syndrome (ODS) is nonstandardized and the prognosis is considered poor. Therefore, different strategies including plasmapheresis (TPE), immunoglobulins (IVIG), and steroids have been used. We present our findings from a series of successfully treated patients at a high-volume tertiary care center in Sri Lanka, with an appraisal of available literature. A total of 21 patients with established ODS are analyzed here, including 5 cases of EPM managed by the authors over a 2-year period. Thirteen (40.2%) patients were treated with plasmapheresis alone, 6 (28.5%) received dual therapy (TPE + IVIG or steroids) and 2 (9.5%) received triple therapy (TPE + IVIG + steroids). There was complete or near complete response in 18 (85.7%) and complete response in 10 (47.6%) patients. We conclude that although the management of CPM/EPM is largely symptomatic, patients may show a significant response to immunomodulatory therapy. The marked improvement in motor, cognitive, and functional domains supports an immune basis for osmotic demyelination. Plasmapheresis, in particular, leads to favorable outcomes in ODS which is supported by previously published case reports. We propose its utility as standard treatment.
Background and Objectives: The burden of stroke in Sri Lanka is on the increase with the current demographic transition toward an ageing population. However, the association of symptomatic extracranial carotid artery stenosis (CAS) in ischemic stroke has not been prospectively evaluated in a Sri Lankan cohort of ischemic stroke patients. Globally population-based studies have estimated about 15% of ischemic strokes are caused by large vessel occlusions. It is commonly believed that the prevalence of significant extracranial CAS is low in Sri Lanka compared to western populations. The purpose our study is to systematically analyses and assess this long held notion and to search for other associated causative factors. Methods: The study population comprised of 164 acute ischemic stroke patients admitted consecutively to the National hospital of Sri Lanka over a period of 3 months. Carotid artery duplex scans were done by a single well-trained operator within 2 weeks of presentation and degree of CAS was classified as low (<50%), moderate (50-69%), severe (>70%) and complete occlusion according to NASCET criteria. Factors associated with CAS were identified by stepwise multiple logistic regression analysis. Results: Out of 164 ischemic stroke patients 104 (63.4%) were male and 60 (36.6%) were female. The mean age of stroke patients was 62.2+- 14.21 years. 139 (84.8%) had low grade stenosis, 10 (6.1%) had moderate stenosis, 7 (4.2%) had severe stenosis and 8 (4.9 %) had complete stenosis of carotid artery. Older age and presence of previous TIAs were significantly associated with CAS. Gender, hypertension, diabetes mellitus, hypercholesterolemia, IHD, previous stroke, previous TIA, previous use of antiplatelets, family history of stroke, previous use of statins and presence of carotid bruit were not significantly associated. Conclusion: Extracranial carotid artery occlusion previously considered a rare cause of ischemic stroke in Sri Lanka was found to be having prevalence similar to western populations in this study with over 15% having significant stenosis. Hence, we emphasize that early carotid doppler studies must be performed in all ischemic strokes at least within two weeks and necessary interventions carried out where it is deemed necessary.
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