Diabetes incurs heavy burden to patients and the healthcare system. Assessment of disease burden is important in taking necessary precautions and management decisions. We aimed to determine the prevalence of macro- and microvascular complications, their risk factors, and coronary artery disease (CAD) risk factors among patients with type 2 diabetes mellitus (T2DM). A descriptive cross-sectional single-centre study was carried out among 3000 patients with T2DM attending the diabetic clinic at the National Hospital of Sri Lanka from January to July 2016. The study population had 72.7% females and 27.3% males. Mean age and disease duration were 58.3 ± 10.3 and 10.8 ± 7 years, respectively. Prevalence of CAD, stroke, and peripheral vascular disease were 10.6%, 1.1%, and 4.7% while diabetic retinopathy, neuropathy, nephropathy, diabetic foot, and lower extremity amputation (LEA) were 26.1%, 62.6%, 50.8%, 2.6%, and 1.3%, respectively. Prevalence of overweight/obesity, hypertension, dyslipidemia, and smoking were 80%, 77.6%, 76.7%, and 11%, respectively. Increased age, disease duration, and HBA1c were risk factors for microvascular disease and diabetic foot while age was the only risk factor for macrovascular complications. Occurrence of CAD, peripheral neuropathy, diabetic foot, and LEA was significantly higher among males than when compared to females. This study highlights the major burden of chronic complications and high prevalence of CAD risk factors in this population.

Background. Research focusing on the psychological aspect of diabetes is limited in Sri Lanka. Aim. Determine the prevalence of depression among patients with type 2 diabetes mellitus (T2DM) attending an out-patient clinic at a tertiary care hospital in Colombo, the capital of Sri Lanka. Methods. A descriptive cross-sectional study carried out among patients diagnosed with T2DM. Pregnant and patients with a prior psychiatric history were excluded. Depression assessed using validated Sinhala and Tamil version of the Beck’s Depression Index. Sociodemographic data and health related data were obtained from interviewer-based questionnaires and health records. Results. Of the 3000 patients, 72.7% were female. Mean age was 58.3 ±10.3 years and mean duration of diabetes 10.8 ± 7.3 years. Percentage of depression was 5.9% in the entire patient population with mild, moderate, and severe depression in 4.0%, 1.6%, and 0.3%, respectively. In multiple logistic regression, depression was significantly associated with female gender (OR 2.63, 95% CI 1.26-5.46; P=0.009), living without a spouse (single/divorced/widowed) (OR 1.83, 95% CI 1.12-2.98; P=0.01), lower education level (OR 1.92, 95% CI 1.14-3.22; P=0.01), and peripheral neuropathy (OR 1.79, 95% CI 1.00-3.18; P=0.04). Only 13.3% of the respondents said that doctors have ever inquired to their mental well-being. Conclusion. Depression was low in prevalence comparative to neighboring countries in the region. Patients were much more affected by the social factors than disease related factors. An individualized holistic approach taking psychosocial issues to consideration should be focused in the comprehensive plan of management.

BackgroundHypernatremia is a frequent occurrence among hospitalized patients. Severe hypernatremia is associated with mortality rates of over 60 %. Extreme hypernatremia, defined as sodium levels >190 mmol/l, is a rare occurrence. The literature on electrocardiographic changes occurring with this degree of hypernatremia is extremely scarce. We report the case of an 11-year-old Sri Lankan girl who presented with sodium levels of 226 mmol/l following infusion with 3 % hypertonic saline who developed diffuse QT prolongation leading to fatal ventricular tachycardia.Case presentationAn 11-year-old Sri Lankan girl presented with fever, headache, vomiting, and altered level of consciousness. Following admission she developed generalized tonic–clonic seizures and was intubated and ventilated. She had a recent history of polyuria and polydipsia. Magnetic resonance imaging of her brain revealed hydrocephalus due to possible craniopharyngioma. A ventriculoperitoneal shunt was inserted and she was infused with 3 % hypertonic saline in an attempt to reduce intracranial pressure. The following day she became polyuric and dehydrated with tachycardia and low blood pressure. Biochemistry revealed serum sodium of 226 mmol/l, measured serum osmolality of 470 mOsm/kg, urine osmolality of 280 mOsm/kg, urine spot sodium of 116 mmol/l, blood urea of 8.1 mmol/l, and blood glucose of 8.5 mmol/l. Her serum potassium, calcium, and magnesium levels were normal. Extreme hypernatremia due to infusion of 3 % hypertonic saline in the background of cranial diabetes insipidus was considered. She was managed aggressively with 5 % dextrose infusion and clear water via nasogastric feeding to correct the fluid deficit of 7 liters over 36 hours. Her sodium levels dropped to 160 mmol/l the following day. However, she developed electrocardiographic changes with widespread gross QT prolongation with ST segment deviations followed by fatal ventricular tachycardia.ConclusionsExtreme hypernatremia is rare, and the literature on electrocardiographic changes occurring at such high levels of sodium is scarce. At present there are no established guidelines on rate and mode of correction of such high sodium levels. This case highlights the electrocardiographic changes observed during extreme hypernatremia, controversies in managing increased intracranial pressure with hypertonic saline, and dilemmas encountered in managing extreme hypernatremia.

BackgroundPrimary hyperparathyroidism (PHPT) is uncommon among children with an incidence of 1:300,000. This diagnosis is often missed in children in contrast to adults where it is detected at a pre symptomatic stage due to routine blood investigations. Etiology of PHPT can be due to adenoma, hyperplasia or rarely carcinoma.Case presentationA 12 year old Sri Lankan girl presented with progressive difficulty in walking since 1 year. On examination she had bilateral genu valgum. Skeletal survey revealed valgus deformity of knee joints, bilateral subluxation of upper femoral epiphysis(SUFE), epiphyseal displacement of bilateral humeri, rugger jersey spine and subperiosteal bone resorptions in lateral aspects of 2nd and 3rd middle phalanges. There were no radiological manifestations of rickets. Metabolic profile revealed hypercalcemia with hypophosphatemia. Intact parathyroid hormone levels were elevated at 790 pg/ml. Vitamin D levels were deficient. She had low bone mineral density with Z score of −3.4. Vitamin D supplementation resulted in worsening of hypercalcemia without reduction in PTH levels. Tc 99 Sestamibi uptake scan showed abnormal tracer retention in left inferior pole of thyroid. A large parathyroid gland was removed with histology favoring parathyroid adenoma. Post operatively she developed hypocalcemia. Bilateral osteotomy was done for SUFE and further surgeries for correction of limb deformities planned.ConclusionPHPT in children is usually diagnosed late when irreversible organ damage has occurred. Children can present with non specific symptoms involving gastrointestinal, musculoskeletal, renal and neurological systems. PHPT can cause disarray in bone and epiphysis in children during pubertal growth spurt. Genu valgum and SUFE are rare skeletal manifestations in PHPT and only 10 cases of genu valgum and 9 cases of SUFE have been reported up to now. So far no cases have been reported on epiphyseal displacement of humeri. Awareness regarding the occurrence of these rare skeletal manifestations especially during puberty is important for early diagnosis to prevent irreversible outcomes.

IntroductionAcromegaly is an endocrine disorder arising from excessive serum growth hormone levels in adulthood and is characterized by progressive somatic enlargement. Biochemical confirmation is achieved by demonstration of elevated baseline serum growth hormone levels which are not suppressed during an oral glucose tolerance test, and by increased levels of serum insulin-like growth factor-1. The serum insulin-like growth factor-1 level provides an assessment of integrated growth hormone secretion and is recommended for diagnosis, monitoring, and screening of acromegaly. We report a case of a patient with acromegaly secondary to a pituitary microadenoma who presented with low insulin-like growth factor-1.Case presentationAn 83-year-old Sinhalese woman presented to our hospital with an enlarging multinodular goiter. She was observed to have macroglossia, thickened coarse skin, acral enlargement, and newly detected, uncontrolled diabetes. A diagnosis of acromegaly was suspected. She did not complain of recent headaches, vomiting, visual difficulties, or galactorrhea and was clinically euthyroid. Her pulse rate was 84 beats/min, and her blood pressure was 150/90 mmHg. A visual field assessment did not reveal a defect. Her random growth hormone levels were 149 mU/L (<10 mU/L), and her oral glucose tolerance test was supportive of acromegaly with a paradoxical rise of growth hormone. Her serum age-specific insulin-like growth factor-1 level was below normal at 124.7 ng/ml (normal range 150–350 ng/ml). Her serum insulin-like growth factor-1 level, measured after glycemic control was achieved with metformin and insulin, was elevated, which is characteristic of acromegaly. Magnetic resonance imaging of her pituitary revealed a pituitary microadenoma. Acromegaly secondary to a growth hormone–secreting pituitary microadenoma was confirmed.ConclusionsSystemic illnesses, including catabolic states, hepatic or renal failure, malnutrition, and diabetes mellitus, are known to decrease insulin-like growth factor-1 levels and may result in false-negative values in patients with acromegaly A low insulin-like growth factor-1 level does not exclude acromegaly in a patient with supportive clinical features and poorly controlled diabetes.

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Acute hypokalemic periodic paralysis (HPP), a clinical syndrome characterised by acute systemic weakness and low serum potassium (K+), is a rare but treatable cause of acute limb weakness. Hypokalemia can be caused by K+ loss via the kidneys or extra renal routes mainly the gut, or due to transcellular potassium shifts where extracellular K+ will move into the cell. In the latter situation, although there is hypokalaemia, there is no deficit of K+ in the body. The main causes for intracellular shift of K+ are familial hypokalemic periodic paralysis, thyrotoxic periodic paralysis, barium poisoning, insulin excess and alkalosis. Although the association between thyrotoxicosis and HPP is known, HPP with hypothyroidism is extremely rare. We report a case of hypokalemic periodic paralysis associated with hypothyroidism and neuromyotonia.

Primary adrenal insufficiency (PAI) is a potentially fatal disease. Adrenal tuberculosis(TB) causing PAI is rare in the developed world. We present a seemingly well, 78-year-old Caucasianwoman in the UK who developed adrenal crisis following elective hip surgery. Biochemical tests confirmed PAI and steroid replacement was initiated. Imaging of the abdomen demonstrated bilateral adrenal masses and a fluorodeoxyglucose positron emission tomography (FDG-PET) scan showed increased uptake in both adrenals suggestive of malignancy. Following a retroperitoneoscopic left adrenalectomy, histology showed caseating necrosis with xanthogranulomatous inflammation favouring a diagnosis of TB. She was commenced on anti-TB treatment. Diagnosing adrenal TB in the west can be challenging especially in the absence of extra-adrenal TB. FDG-PET scans can be falsely positive in presence of chronic active inflammatory conditions, such as TB, and a tissue diagnosis is required. It is important that clinicians remain vigilant of this important disease, which can masquerade as malignancy.