BackgroundAcute Coronary Syndrome (ACS) is one of the leading causes of death worldwide and studies have shown higher mortality rates and premature death in South Asian countries. The occurrence and effect of risk factors differ by type ofACS.Epidemiological studies in the Sri Lankan population are limited.MethodsThis is a cross sectional descriptive study conducted at the Teaching Hospital Peradeniya, Sri Lanka among patients presenting with ACS. Data was collected by an interviewer administered structured questionnaire and epidemiological patterns and risk factors were analyzed.ResultsThe sample of 300 patients had a mean age of 61.3+/− 12.6 and male sex showed higher association with all three type of ACS compared to female with a P value of 0.001. This study showed higher mean age of 62.2 ± 11.4 years amongst unstable angina (UA) patients and 61.9 ± 14.5 years amongst non ST elevation myocardial infarction (NSTEMI) patients compared to 59.2 ± 11.2 years for ST elevation myocardial infarction (STEMI) patients with no significant statistical difference (P = 0.246). Approximately 55.8% STEMI patients, 39.8% UA and 35.5% NSTEMI patients were smokers indicating a significant association between smoking and STEMI (P = 0.017). Nearly 54.5% STEMI, 35.4% UA and 32.7% NSTEMI patients consumed alcohol and there was a very strong association between alcohol consumption and STEMI (P = 0.006). Almost 51.8% NSTEMI patients, 47.8% UA patients and 29.9% STEMI patients had hypertension(HT) (P = 0.008) indicating significant association of HT with UA and NSTEMI. About 33.6% UA patients and 30.0% NSTEMI patients had DM whilst only 22.1% of STEMI patients had DM of no significance (p = 0.225). Around 15.0% patients with UA, 25.5% with NSTEMI and 11.7% with STEMI had dyslipidemia (P = 0.032). There was a very strong association between a past history of ACS or stable angina with NSTEMI and UA (P = 0.001).ConclusionSmoking and alcohol abuse are significantly associated with STEMI.Patients with NSTEMI or Unstable Angina had higher rates of hypertension and were more likely to have a history of ACS or stable angina than STEMI patients. Patients with NSTEMI were more likely than patients with STEMI or UA to have dyslipidemia.

BackgroundDengue has global importance as a dreaded arboviral infection. It has 4 serotypes of epidemiological imporatnce. The classification denotes two clinical spectrums- dengue fever (DF) and dengue haemorragic fever (DHF). Most cases are stereotype and amenable to fluid resuscitation. However, unusual manifestations cause fatalities and often overlooked. This study describes 10 such dengue cases to fill the knowledge gaps.Case presentationAll 10 patients presented to the Teaching Hospital, Peradeniya, Sri Lanka during mid-year epidemic of dengue in 2016. The mean age is 27 years (range 12-51 years) comprising 6 females and 4 males. The group had 7 DHF, 3 DF and 2 primary dengue infections who predominantly had severe bleeding into gut. Other potentially life threatening problems were acute severe hepatitis, severe septic shock, myocarditis, erratic rapid plasma leak, intracranial bleeding, diarrhoea and decompenstaed dengue shock due to 3rd space fluid leak. Blood transfusions and other empirical therapeutic methods were used apart from meticulous fluid management to suit issues of each patient. Bedside ultrasound scanning helped early detection of critical phase. All recovered fully.ConclusionsDengue is an extremely challenging infection to treat in the globe today. Above unusual presentation and complications could be fatal, if not detected early where therapeutic window period is very short. Clinicians need awareness of these problems which are not uncommon, but underreported and often overlooked. The clinical management of each patient was described for the purpose sharing the experiences.

Background Dengue fever is a common mosquito borne viral infection. Severe dengue fever associated severe hepatitis carries high mortality. Based on the beneficial effect of N-acetylcysteine (NAC) in paracetamol poisoning and non-acetaminophen induced liver failure, it is used in dengue fever associated hepatitis in clinical practice. We aim to study the reversal of liver enzymes with NAC in the setting of severe hepatitis due to severe dengue infection. Methods A retrospective analysis was conducted on hospitalized 30 adults with severe dengue fever with severe hepatitis. These 30 patients had aspartate transaminase (AST) and alanine transaminases (ALT) more than 500 U/L and/or PT INR (prothrombin time and international normalized ratio) more than 1.5. They were treated with NAC infusion of 100 mg/h for 3 to 5 days. Results The mean age of the group was 49.9 ± 11.46 years and 18 (60%) patients were males. Nineteen patients (63%) developed dengue shock. Of them 12 patients (40%) developed hepatic encephalopathy. Median AST on the day of administration of NAC was 1125 U/L interquartile range (IQR) 1653.25 while median ALT was 752 (IQR 459.25). There was a statistically significant reduction of both ALT (p = 0.034) and AST (p = 0.049) from day 1 to 4 after NAC infusion. Rise of platelet count between day 1 and day 4 also showed statistically significant difference (p = 0.011) but the reduction of prothrombin time and international normalized ratio (PT/INR) from 1 to day 4 did not show statistical significance difference. Mean duration of treatment with NAC was 3.61 ± 0.75 days while mean length of hospital stay was 6.2 ± 1.27 days. Only one patient died (3.3%). None of the patients reported adverse drug reaction due to NAC. Conclusion Majority of patients demonstrated marked clinical and biochemical improvements and they recovered fully. We observed faster and significant recovery of liver enzymes following administration of NAC. Based on the above findings, this study provides preliminary evidence for the beneficial effect of NAC in severe hepatitis in dengue infection with greater survival benefits.

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.

Histoplasmosis is caused by Histoplasma capsulatum, and commonly it causes an asymptomatic illness. Although Histoplasma is the commonest organism to infect adrenal glands, disseminated histoplasmosis in an immune-competent host leading to adrenal insufficiency is rare in current literature. Here, we report a case of possible disseminated histoplasmosis leading to adrenal crisis in a young Asian immunocompetent male. A 42-year-old Sri Lankan male with noninsulin-dependent diabetes mellitus presented with constitutional symptoms and feverishness for three weeks’ duration. He was found to have hepatosplenomegaly with bilateral adrenal masses and pancytopenia. One week later, he developed severe vomiting and hemodynamic collapse and was found to have suppressed adrenal functions. Ultrasound-guided biopsy of adrenals showed fungal spores morphologically similar to Histoplasma. He was started on oral itraconazole and adrenal replacement therapy. He improved symptomatically with treatment and currently is on regular clinic follow-up with a plan to continue antifungal therapy for at least one year to prevent a relapse. Fungal infections, especially histoplasmosis, need to be considered in all immunocompetent patients with compatible history and bilateral adrenal masses. Adrenal insufficiency needs to be promptly diagnosed and treated to prevent Addisonian crisis in these patients.

BackgroundMelioidosis is considered endemic in certain areas of the world. Musculoskeletal and soft tissue involvement are relatively uncommon presentations in melioidosis. We present a case of infective myositis in a patient with melioidosis in Sri Lanka, which is not considered an endemic country. Even though multiple cases of melioidosis have been reported with an increasing number in Sri Lanka, infective myositis secondary to melioidosis was not reported previously.Case presentationA 60-year-old Sinhalese man with diabetes presented with fever of 4 months’ duration and a limp with a painful lump on the right side of the upper thigh of 2 months’ duration. He had been treated in a local hospital for community-acquired pneumonia 3 weeks prior to this admission, for which he had received intravenous meropenem and teicoplanin with intensive care unit admission. He had a 0.5-cm × 0.5-cm tender lump over the right vastus lateralis muscle, and contrast-enhanced computed tomography of the area showed an ill-defined, heterogeneously enhancing, hypodense area involving the vastus lateralis, vastus intermedius, and quadratus femoris, suggestive of infective myositis but without abscess formation. Histopathology of the muscle biopsied from the vastus lateralis showed suppurative inflammation of subcutaneous fat with connective tissue necrosis and muscle infiltrated by lymphocytes. These features are suggestive of infective myositis possibly due to melioidosis. Although the result of a culture taken from the muscle biopsy was negative, the patient’s antibody titer was strongly positive for melioidosis. He did not show any other areas with infected foci. He was treated with intravenous meropenem for 2 weeks and responded well. He was discharged with trimethoprim-sulfamethoxazole for 6 months as a maintenance therapy.ConclusionMelioidosis is commonly an undiagnosed disease that has a wide variety of clinical presentations. Myositis in melioidosis is uncommon, and careful evaluation is mandatory to avoid misdiagnosis of this treatable but fatal disease. The clinician should have a high index of clinical suspicion, and further clinical and epidemiological studies are needed to determine the true burden of the disease.

BackgroundPulmonary tuberculosis remains an important public health problem globally and one of the most prevalent infectious diseases in Sri Lanka. It can cause a wide variety of complications but hematological manifestations are rare. According to our literature survey, this is the first reported case of the disease associated with deep vein thrombosis in Sri Lanka.Case presentationA 37 year old Sri Lankan Sinhalese female presented with fever of one month’s duration with productive cough and two weeks painless left lower limb swelling. Chest X-ray showed bilateral inflammatory shadows with a cavitatory lesion on the right apical region. A computed tomographic pulmonary angiography scan excluded pulmonary embolism. She had rising mycoplasma antibody titre (four fold). Acute deep vein thrombosis of the left lower limb was confirmed by venous duplex. Pulmonary tuberculosis was confirmed with positive culture for Mycobacterium tuberculosis. She was treated with clarythromycin, enoxaparin, warfarin and anti tuberculus drugs. It was difficult to maintain her International Normalizing Ratio in the therapeutic range due to drug interactions and poor compliance. At five months of presentation she died of massive pulmonary embolism.ConclusionOur case emphasizes that patients with severe pulmonary tuberculosis are at risk of developing thromboembolism and superadded infections. It should be noted that even though starting anti tuberculosis drugs improved haemostatic disturbances, achieving the target International Normalizing Ratio was difficult due to drug interactions. Therefore these patients should be closely followed up to prevent complications and death from pulmonary embolism.Electronic supplementary materialThe online version of this article (doi:10.1186/s13104-015-0990-6) contains supplementary material, which is available to authorized users.