BackgroundDengue is an arboviral infection that classically presents with fever, joint pain, headaches, skin flush and morbilliform rashes. The incidence of neurological symptoms and complications in dengue varies from 1 to 25 % that include encephalopathy, Guillain–Barre syndrome (GBS), acute motor weakness, seizures, neuritis, hypokalaemic paralysis, pyramidal tract signs, and a few more. Dengue fever as an antecedent infection in GBS is uncommon.Case presentationA 34-years-old Sri Lankan Sinhalese male presented with fever, headache and myalgia of 3 days and developed leucopenia and thrombocytopenia without evidence of haemoconcentration. The diagnosis of dengue fever was confirmed as he had positive dengue NS1 antigen test on the third day of fever. He made full recovery and was discharged after 4 days of hospital stay. Six days later, he presented with history of acute flaccid weakness of both lower limbs and upper limbs which was of progressive ascending nature. The electromyography had evidence of demyelinating neuropathy and cerebrospinal fluid showed albuminocytological dissociation. Subsequently, IgM for dengue virus was positive.ConclusionDengue is endemic in Sri Lanka. Post dengue Guillain–Barre syndrome is a potential neurological complications of this infection.
BackgroundVitamin B12 deficiency is often diagnosed with hematological manifestations of megaloblastic macrocytic anemia, which is usually the initial presentation. Neurological symptoms are often considered to be late manifestations and usually occur after the onset of anemia. Sub acute combined cord degeneration, which is a rare cause of myelopathy is however the commonest neurological manifestation of vitamin B12 deficiency.Case presentationWe present a case of a 66 year old Sinhalese Sri Lankan female, who is a strict vegetarian, presenting with one month’s history suggestive of Sub-acute combined cord degeneration in the absence of haematological manifestations of anaemia. Her Serum B12 levels were significantly low, after which she was treated with hydroxycobalamine supplementation, showing marked clinical improvement of symptoms, with normalization of serum B12 levels. Hence, the diagnosis of vitamin B12 deficiency was confirmed retrospectively.ConclusionVitamin B12 deficiency could rarely present with neurological manifestations in the absence of anaemia. Therefore a high index of suspicion is necessary for the early diagnosis and prompt treatment in order to reverse neurological manifestations, as the response to treatment is inversely proportionate to the severity and duration of the disease.
BackgroundAdvanced life support (ALS) and cardio pulmonary resuscitation, provided at the right time is essential for improving mortality in medical emergencies. Accurate knowledge and skills on this regard, in all medical personals is an essential part of medical education and it should be up to date with varying protocols. The aim of this study is to assess the knowledge and attitudes among the undergraduate medical students and medical officers in the Teaching Hospital Peradeniya and provide suggestions to improve the training programme on ALS.MethodsA standardized self-administered questionnaire regarding knowledge and attitudes on ALS was filled by 4th and final year medical students, and medical officers, and the data was analyzed.ResultsThere were 411 eligible candidates and of them 130 (31.6 %) were 4th year medical students, 221 (53.8 %) were final year medical students and 60 (14.6 %) were medical officers. Of the medical officers, only 15.8 % indicated that the internship training was adequate to handle an emergency confidently. Approximately 45 % of the medical officers and 34.6 % of the final year medical students were confident of saving lives with their current ALS knowledge. However, only 22 % of 4th year medical students were confident in saving the life of a patient.ConclusionsOverall, just over 10 % of participants demonstrated inadequate ALS knowledge scores. A significantly higher proportion of final year medical students had good knowledge, compared to medical officers and 4th year students. Only one-third of participants were confident in saving a life with their current ALS knowledge. Nearly all participants thought that the ALS course should be reevaluated frequently.
BackgroundAcute coronary syndrome after hymenoptera stings or exposure to environment toxins is referred to as the Kounis syndrome or allergic myocardial ischaemia with or without infarction. We report a case of hornet (Vespa affinis) sting causing Kounis syndrome in Sri Lanka and present a review of literature.Case presentationA 60-year -old female with diabetes mellitus and known allergy to bee venom was stung by a hornet on the right hand. Within 30 minutes she developed hypotension and wide spread T wave inversion in the 12 leads ECG that remained unchanged about 5 hours and reversed back to normal.ConclusionHymenoptera stings can induce acute coronary syndrome either by direct effect of venom constituents on the coronary endothelium or through inflammatory mediators induced allergic reaction on coronary vasculature. Early recognition of Kounis syndrome is needed in hornet stings to implement necessary treatments.
BackgroundRabies is a global problem which occurs in more than 150 countries and territories including Sri Lanka, where human deaths from rabies are in decline whilst resources incurred for prevention of rabies are in sharp incline over the years. In this backdrop, we aim to audit the post-exposure treatment (PET) in rabies and the pattern of animal bites in a tertiary care hospital in Sri Lanka.MethodsThis study was carried out at Teaching Hospital Peradeniya (THP), in the Central Province of Sri Lanka from 2007-2012 where a registry of all PET has been maintained. The data from registries were extracted after obtaining permission from the hospital authority for analysis.ResultsThere were 19 661 cases of animal exposure presented to the THP over the study period of 5 years. Of them, the majority-17431(88.66 %) were definitive animal bites whilst scratches accounted for 2147(10.92 %) and 83(0.42 %) were miscellaneous exposures. According to the severity grading of injuries, 7 362(37 %) were major bites and 12 226(62 %) were minor bites. The domestic unvaccinated dogs and cats were responsible for 10,662 (54 %) and 3,982 (20 %) of exposures respectively. The total cost incurred for both anti-rabies vaccine and anti rabies serum during the study period is 24,795,888.00 Sri Lankan rupees (190,737.60US$).ConclusionsThe pattern of animal bite shows high dominance of domestic dogs and cats exposures. The age of victims ranged from infancy to old-age with higher incidence among children. Even though PET is costly, continued surveillance and rabies control is still necessary along with public education and vaccination of domestic pets.
BackgroundKounis syndrome is the concurrence of acute coronary syndromes with mast cells activation induced by hypersensitivity and anaphylactoid insults and is increasingly encountered in clinical practice. The main pathophysiological mechanism is vasospasm of the epicardial coronary arteries due to increased inflammatory mediators that are released during a hypersensitivity reaction.Case presentationA 74-year -old Sinhalese man with diabetes mellitus was admitted with four day history of high fever with chills and rigors. His urine analysis and blood investigations revealed evidence of urinary tract infection. After excluding allergic conditions, he was given amoxicillin/clavulanic acid intravenously. About 20 minutes after the first dose he felt severe itching of body, nausea , dizziness and sever retrosternal chest pain. Urgent electrocardiogram was taken and it showed widespread ST segment elevations. He was treated for anaphylactic shock as well as acute coronary syndrome and was able to be discharged within a few days.ConclusionThis case highlights the occurrence of acute coronary syndrome following drug induced anaphylaxis. Acute coronary syndrome of this nature may be completely atypical and overlooked. Kounis syndrome should be borne in mind in the event of anaphylactic episode wherein the electrocardiogram becomes essential.
BackgroundEwing sarcoma is a primary bone neoplasm, which is a high grade aggressive small round blue cell tumour, and is currently recognized as a part of the Ewing family of tumours. It is the most lethal bone tumor, and is a rare malignant bone tumor accounting for 10% of all primary bone tumors, and 6% of malignant bone tumors. It has an average annual incidence of 3 per 1 million, found almost exclusively in Caucasians. It commonly occurs in long bones and pelvis but rarely involves the scapula. 85% of cases have metastasis within 2 years of diagnosis, rarely involving the meninges.Case presentationWe report a case of a 25 year old Sinhalese Sri Lankan female, presenting with a 1 day history of bilateral lower limb weakness and urinary incontinence. She had a sensory level with flaccid paralysis of lower limbs and a painless bony lump in the left dorsal scapula. Investigations showed scapular primary Ewing sarcoma giving rise to spinal intradural metastasis. For the best of our knowledge this is the first reported case of a scapular Ewing sarcoma with spinal intradural metastasis presenting with lower limb paralysis.ConclusionIntradural spinal metastasis of Ewing sarcoma presenting with lower limb weakness, without a history of pain, though rarely, can be the first presentation, and can rapidly progress to brainstem involvement and death.
BackgroundEosinophilic myocarditis is one of the fatal complications of idiopathic hypereosinophilic syndromes. Given the rarity of this form of myocarditis, it is often under-recognized. We describe a young girl who presented with features of heart failure. To our knowledge, this is the first reported case of eosinophilic myocarditis in a young Sri Lankan female.Case presentationA previously healthy 21 year old Sri Lankan female admitted with shortness of breath for 1 week duration with associated low grade fever and profuse sweating. She was mildly febrile and dyspnoeic with absent ankle oedema. She was tachycardic and had elevated Jugular venous pressure with negative Kussmaul sign. Blood pressure was 100/70 mmHg. Clinically there was no cardiomegaly and heart sounds were slightly muffled with gallop rhythm. Bilateral basal fine end inspiratory crackles and mild hepatosplenomegaly were noted. The laboratory examinations showed leucocytosis with severe eosinophilia with no abnormal cells. Her ESR, Troponin I and Brain natriuretic peptide were elevated with normal CRP and electrocardiogram showed sinus tachycardia with wide spread ST depression. Heart failure was evident on chest X-ray and 2D-echocardiogram showed global left ventricular hypokinesia with 40% ejection fraction and a thin layer of pericardial effusion. Mild hepatosplenomegaly without lymphadenopathy was detected in the ultrasound scan. Bone marrow biopsy showed hypereosinophilia with no evidence of bone marrow infiltration. FIP1L1–PDGFRA fusion transcript and BCR–ABL transcript were not detected. Secondary causes for hypereosinophilia were excluded and the diagnosis of idiopathic hypereosinophilic syndrome and eosinophilic myocarditis was made. She had good response to steroids clinically and biochemically with complete recovery of left ventricular function. She is now on steroid to be continued at least 6 months to 1 year.ConclusionEosinophilic myocarditis is a rare but fatal disease if left untreated. Hence clinicians should have high index of suspicion to diagnose eosinophilic myocarditis in clinical context of heart failure due to myocarditis. The diagnoses of eosinophilic myocarditis may often be challenged especially in a poor recourse setting. However available investigation should be used to diagnose this condition without delay. Early treatment with systemic steroids may prevent fatal outcome and therapies for this disease have yet to be validated in large prospective studies.
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