BackgroundNon alcoholic fatty liver disease is an independent risk factor for coronary artery disease. But its effect on acute coronary syndrome is not clear. We performed this study to identify the prevalence of NAFLD in patients with ACS admitted to a tertiary care center in Sri Lanka. We also described the association of NAFLD with the severity of ACS predicted by the GRACE score.MethodsWe performed a descriptive study including all consecutive patients with non-fatal ACS admitted to Colombo South Teaching Hospital from 01/02/2014 to 30/04/2014. Patients with excessive alcohol consumption, established cirrhosis and patients with identified risk factors for liver disease were excluded from the study. All patients underwent ultrasound scan of liver.ResultsThere were 120 participants, 75 (62.5 %) males and 45 (37.5 %) females with acute coronary syndrome. Average age was 61.28 ± 11.83 years. NAFLD was seen in 56 (46.7 %) patients with ACS. Patients with NAFLD had a higher GRACE score than patients without NAFLD (120.2 ± 26.9 Vs 92.3 ± 24.2, p < 0.001). Increased age and presence of NAFLD conferred a higher mortality risk from ACS as predicted by GRACE score. Patients with NAFLD had a higher predicted mortality during in-ward stay (adjusted OR 31.3, CI 2.2–439.8, p = 0.011) and at 6 months after discharge (adjusted OR 15.59, CI 1.6–130.6, p = 0.011).ConclusionsPatients with NAFLD have a higher predicted mortality from acute coronary syndrome and thus require aggressive treatment of CAD. It is important to consider this novel risk factor when risk stratifying patients with ACS.
BackgroundLeptospirosis is the most widespread zoonosis in the world. Cardiac involvement is a frequent complication of leptospirosis although significant left ventricular dysfunction is rare. We report a case of fatal leptospira myocarditis leading to cardiogenic shock on the second day of illness. This early occurrence of myocarditis is not previously reported.Case presentationA 36-yr-old previously healthy Sri Lankan male who takes care of a horse presented to the medical casualty ward with a one day history of fever, arthralgia and severe myalgia. He developed hypotension on the second day of illness. Electrocardiogram showed sinus tachycardia with ST segment depression in lateral leads which evolved in to rapid atrial fibrillation in the subsequent days. 2D echocardiogram showed dilated cardiac chambers with severe global hypokinesia and an ejection fraction of 20%. His renal and liver functions were within normal limits. He developed multi organ dysfunction syndrome and refractory shock, later in the course of illness.Leptospirosis was confirmed by positive leptospira IgM and negative IgG. Patient died on the fifth day of illness despite optimal medical treatment with intravenous penicillin, meropenem, levofloxacin, inotropes and supportive care in the intensive care unit.ConclusionsWe describe a rare and unusual early complication of leptospirosis which has not been reported before. It is important to bear in mind that leptospirosis could present as myocarditis during the early phase of illness.
BackgroundTricyclic antidepressants (TCA) are becoming one of the most frequently used substances in self poisoning. Significant morbidity and mortality associated with TCA overdose are often related to and refractory hypotension. We report the first case of survival after severe amitriptyline poisoning, leading to prolonged cardiac arrest and ventricular tachycardia (VT), resuscitated with 3 h of uninterrupted cardiac massage and Direct current (DC) shocks.Case presentationA 25 year old girl presented with severe amitriptyline poisoning causing pulseless VT and prolonged cardiac arrest. After 3 h of uninterrupted external cardiac massage, together with nine DC shocks and intra venous bicarbonate injections the rhythm reverted to a nodal tachycardia, initial 2D echocardiogram showed left ventricular dysfunction, which recovered to normal after 2 weeks and the patient had a complete recovery subsequently.ConclusionOur case highlights the importance of continued resuscitation in patients presenting with TCA poisoning and resistant arrhythmia, especially in young and otherwise healthy patients.
Background Leptospirosis is a zoonotic illness caused by pathogenic spirochetes of the genus Leptospira. The disease spectrum ranges from a mild influenza-like presentation to a more serious Weil’s syndrome. Leptospirosis rarely presents as a primary neurological syndrome. We report two cases of Leptospira borgpetersenii serovar Tarasssovi presenting as aseptic meningitis in Sri Lanka. Case presentation We describe case reports of two patients presenting as symptomatic aseptic meningitis due to neuroleptospirosis. Both patients had significant neurological involvement at presentation in the absence of common clinical features of leptospirosis. These patients were initially managed as bacterial or viral meningitis and leptospirosis was suspected due to a history of exposure to contaminated water. Subsequently, they were diagnosed to have neuroleptospirosis by positive Leptospira serology and both patients gained full recovery. Conclusion Our report highlights the importance of considering leptospirosis as a differential diagnosis in patients with aseptic meningitis in endemic settings. Obtaining a detailed occupational and recreational history is helpful in diagnosing neuroleptospirosis promptly. We report the association of Leptospira borgpetersenii serovar (sv.) Tarassovi (strain bakeri) in causing aseptic meningitis, which has not been reported to the best of our knowledge.
Streptokinase is the main thrombolytic used for the management of ST Elevated Myocardial Infarctions (STEMI) in Sri Lanka. We assessed the efficacy of streptokinase in restoring myocardial perfusion following acute STEMI. One hundred and eight patients were studied. Sixty eight (56%) patients responded to streptokinase. Forty five (41.7%) had anterior STEMI and 20 (44.4%) responded (p=<0.001). Forty four had inferior STEMI and 32 (72.7%) responded (p=0.007). Fifteen had antero-lateral STEMI and 13.3% responded. Time from the onset of pain to arrival at hospital was 137 in responders and 339 minutes in non responders (p=0.004). Eight (11.8%) responders and four (10%) non responders were on aspirin. Thirty two (47.1%) responders and 16 (40%) non responders were smokers. Twenty (29.4%) responders and 9 (22.5%) non responders were having diabetes mellitus. Considerably higher percentage responded to streptokinase. Inferior myocardial infarctions have significantly high reperfusion rates. Delayed hospital admission had a major impact in the non responders.
In Sri Lanka, a majority of patients with ACS were physically inactive. Physical inactivity is one of the remediable major risk factors of ACS and an active life style should be promoted.
BackgroundClozapine is a second generation antipsychotic used to treat resistant schizophrenia and other psychotic illnesses. Leucopenia or agranulocytosis is a rare side effect of this drug. Pancytopenia is an extremely rare side effect of clozapine and literature review showed only one such case in where the pancytopenia developed several months after starting clozapine together with other antipsychotic drugs.Case presentationA 26-year-old Sri Lankan male was admitted with fever for 3 days. Apart from generalized body aches there were no other significant symptoms. His blood counts showed pancytopenia. He was being treated for a resistant schizophrenia and clozapine was started only 4 weeks before. Common causes for pancytopenia were excluded, and a diagnosis of clozapine induced pancytopenia was made. He was managed in the intensive care unit with broad spectrum antibiotics, antifungals and granulocyte colony stimulating factors. He made a complete recovery after 4 weeks.ConclusionThis is a rare and probably the first reported case of early onset clozapine induced pancytopenia complicated by severe sepsis recovering completely.
BackgroundThe electrocardiogram (ECG) is useful in the diagnosis of cardiac and non-cardiac conditions. Rigors due to shivering can cause electrocardiogram artifacts mimicking various cardiac rhythm abnormalities.Case presentationWe describe an 80-year-old Sri Lankan man with an abnormal electrocardiogram mimicking narrow complex tachycardia during the immediate post-operative period. Electrocardiogram changes caused by muscle tremor during rigors could mimic a narrow complex tachycardia.ConclusionsIdentification of muscle tremor as a cause of electrocardiogram artifact can avoid unnecessary pharmacological and non-pharmacological intervention to prevent arrhythmias.
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