Abstract. Global leptospirosis disease burden estimates are hampered by the lack of scientifically sound data from countries with probable high endemicity and limited diagnostic capacities. We describe the seroepidemiologic and clinical characteristics of the leptospirosis outbreak in 2008 in Sri Lanka. Definitive/presumptive case definitions proposed by the World Health Organization Leptospirosis Epidemiology Reference Group were used for case confirmation. Of the 404 possible cases, 155 were confirmed to have leptospirosis. Highest titers of patient seum samples reacted with serovars Pyrogenes (28.7%), Hardjo (18.8%), Javanica (11.5%), and Hebdomadis (11.5%). Sequencing of the 16S ribosomal DNA gene identified six infections: five with Leptospira interrogans and one with L. weilli . In this patient population, acute renal failure was the main complication (14.8%), followed by myocarditis (7.1%) and heart failure (3.9%). The case-fatality rate was 1.3%. This report strengthens the urgent need for increasing laboratory diagnostic capabilities to determine the causes of epidemic and endemic infectious diseases in Sri Lanka, a finding relevant to other tropical regions.

Dengue fever (DF) is a mosquito borne virus infection which is endemic to the tropical regions of the world. In Sri Lanka, the first sero-positive case was reported in the 1960s; since then the island has experienced several outbreaks of DF/dengue haemorrhagic fever (DHF). The disease is more prevalent in some parts of the country where rapid urbanisation has taken place. Diagnosis of DF/DHF is mainly done using the clinical features only due to the unavailability of laboratory diagnosis in many parts of the country and this might lead to over or under diagnosis of the disease. A rational diagnostic approach which combines the history and clinical profiles together with specific virological laboratory data would help in the correct identification of the disease. Furthermore, a feasible algorithm for the laboratory diagnosis of dengue will help to confirm the cases with a high level of clinical suspicion. This would then facilitate the notification of correctly identified cases to the public health authorities to assess the dengue burden. The scope of this review is to improve the existing laboratory diagnosis of DF/DHF by proposing a feasible algorithm to implement in Sri Lanka that would enable better detection of cases.

Dengue virus (DENV) infections are increasing with respect to incidence and severity in the Central Province of Sri Lanka. The objective of this study was to define the clinical, immunological, and virological profiles of patients admitted to the General Hospital, Kandy with clinically apparent dengue. Demographic, clinical, hematological parameters, liver enzymes (ALT and AST), and blood samples were collected from 292 patients with fever <5 days post onset and fulfilling the WHO criteria for the diagnosis of dengue fever/dengue hemorrhagic fever (DF/DHF). Samples were analyzed for, anti-DENV IgM, IgG, and DENV nucleic acid. Myalgia was the commonest complaint by 65% of the patients. Packed cell volume was >45% in 27% of the patients while 42.12% had reduced platelets and 62.67% had reduced white blood cell counts. In contrast to other studies, positive tourniquet test (PTT) and petechiae were not major indicators of DENV infection or severity of the disease. Clinical profiles were significantly different between DF and DHF/DSS and showed many similarities to that reported elsewhere. Altogether, 43 patients (14.73%) were viremic as detected by RT-PCR; 181 patients (62%) were positive for anti-DENV IgM, and 245 (84%) patients were positive for anti-DENV IgG. In combination, anti-DENV IgM and RT-PCR assays detected 224 (77.5%) of DENV infected cases, thus improving the DENV diagnosis rate. Hence, the diagnostic utility of PTT, anti-DENV IgM/IgG serology, or RT-PCR used alone in the early phase of illness is low in Sri Lanka but the diagnostic value can be improved by a combination of serology and RT-PCR. J. Med. Virol. 88:1703-1710, 2016. © 2016 Wiley Periodicals, Inc.

The objective of the present study was to assess the circulating TNF-α and IL-2 levels in dengue virus (DENV) infected patients and to correlate these with clinical severity of DENV infections. A single analyte quantitative immunoassay was used to detect TNF-α and IL-2 in 24 dengue fever (DF) and 43 dengue haemorrhagic fever (DHF) patients, 15 healthy adults and 6 typhoid patients. The mean TNF-α and IL-2 levels of DENV- infected patients were higher than that of healthy adults and typhoid patients. No significant difference in TNF-α levels was noted between DF and DHF patients (p=0.5) but a significant increase in IL-2 levels was observed in DHF compared with DF patients (mean of DF=59.7pg/mL, mean of DHF=166.9pg/mL; p=0.02). No significant association of TNF-α or IL-2 levels was noted with packed cell volume (>45), thrombocytopenia, leucopenia or the presence of viraemia. The liver function tests measuring AST (aspartate aminotransferase) (p=0.01) and ALT (alanine aminotransferase) (p=0.02) levels were significantly elevated in DENV-infected patients. AST:ALT was significantly elevated in DHF/DSS (dengue shock syndrome) compared with DF patients. A significant positive linear correlation was noted between AST and IL-2 (r=0.31; p=0.01) and ALT and IL-2 elevations (r=0.2; p=0.02). Thus, AST and ALT levels correlate with both disease severity and circulating IL-2 levels. We suggest a role for circulating IL-2 in liver dysfunction and propose that a combined assessment of AST/ALT in conjunction with IL-2 at the early stages of symptomatic DENV infection may be useful to predict the severe forms of dengue.

Introduction Lack of point of care diagnostics is a major challenge for control of human leptospirosis. Immunoglobulin M enzyme linked immunosorbent assays (IgM ELISA) have been widely used for the diagnosis of leptospirosis. The purpose of the present study was to determine the validity of IgM ELISA in the diagnosis of leptospirosis in a Sri Lankan context. Methods Confirmed cases of leptospirosis from the 2008 Sri Lankan outbreak of leptospirosis and a group of leptospirosis excluded febrile patients were selected for the validation study. Disease confirmation and exclusion was carried out using either paired sample MAT (optimized for the region) or qPCR or both. A commercially available IgM ELISA kit was used and the procedure performed according to the manufacturers' instruction in the Department of Microbiology, Faculty of Medicine, University of Peradeniya. Results The study sample included 88 confirmed cases of leptospirosis and a comparison group of 71 acute fever patients. Of the 88 confirmed cases selected, 53 reacted in IgM ELISA and of the comparison group, 38 gave a positive reaction. Sensitivity and specificity of IgM ELISA, as a point of care diagnostic test for patients in this sample with acute leptospirosis, was 60.23% (95% CI 49.78, 69.82) and 46.48% (95% CI (35.36, 57.96) respectively. Diagnostic accuracy of the test was 54.09% (95% CI 46.34, 61.65 %). The ROC (Receiver-operator characteristic curve) curve for the IgM ELISA showed a value of .669 for area under the curve. Optimal cut off points were not detected due to the poor test parameters in this sample. Conclusion This study shows the limited diagnostic capabilities of IgM ELISA during the acute phase of leptospirosis in high endemic settings