Medicine
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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty
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Item Repeated dengue shock syndrome and "Dengue myocarditis" responding dramatically to a single dose methyl prednisolone(Sri Lanka Medical Association, 2012) Premaratna, R.; Rodrigo, K.M.D.; Anuratha, A.; de Alwis, V.K.D.; Perera, U.D.C.A.; de Silva, H.J.INTRODUCTION: Place of steroids in the management of severe dengue is unclear. A retrospective observational study appeared to show benefit of methylprednisolone (MP) in a highly selected group of patients. CASE REPORT: A 14-year-old schoolboy developed "myocarditis" (4th day) and on the fifth day, he collapsed with Dengue shock syndrome DSS needing rapid resuscitation with intravenous fluid boluses and dextran. He continued to have high fever (39-410C), and pulse rate (PR)>110/min and developed two further episodes of DSS and was resuscitated with further boluses of dextran. As there was no response with temperature 40.20C, PR 160/min, mid-arm systolic BP 70 mmHg, confused, restless, respiratory rate 36/min, dropping capillary 02 saturation, moderate pleural effusions and ascites, urine output <0.2ml/kg/Hr, made it extremely difficult to select the amount and type of fluid for resuscitation. Due to rapid deterioration a single dose of methylprednisolone (MP) (SOOmg in 200ml saline iv over 20 minutes) was administered as a rescue medication. He had deferversence within 30 minutes, became conscious and alert in 1 hour, PR reduced to 96/minute, BP remained stable above 100/80mmHg and urine output increased to 0.8-1.4ml/Kg/Hr. His ECG became normal after 3 hours, and the echo cardiogram in 12 hours (EF-55%). CONCLUSIONS: This patient with dengue developed three episodes of severe haemodynamic compromise within 12 hours while having third space fluid accumulation, "myocardits" and altered level of consciousness making it difficult to institute fluid therapy. A single dose of MP given as rescue measure resulted in a dramatic recovery suggesting a beneficial effect of MP in sever dengue.byItem Predicting acute liver failure in dengue infection(Wiley Blackwell Scientific Publications, 2012) Ranawaka, C.K.; Kumarasena, R.S.; Niriella, M.A.; Miththinda, J.K.N.D.; Pathmeswaran, A.; Dassanayake, A.S.; de Silva, A.P.; Premaratna, R.; de Silva, H.J.BACKGROUND AND AIM: Dengue infections (DI) have a diverse clinical spectrum ranging from asymptomatic illness to severe dengue. Unusual manifestations such as encephalitis, myocarditis, and acute liver failure (ALF) are increasingly recognized. Though ALF is less common has a poor prognosis. Aim of this study was to identify possible predictors of ALF in DI. METHOD: Serologically confirmed patients with DI, admitted to university medical unit, Ragama, Sri Lanka from January 2009 to March 2010 were included. Patients were consisted of direct admission as well as referrals with deranged liver functions. Data was obtained from patient records. RESULTS AND DISCUSSION: Out of 240 patients (male : female 57.7%:42.5%; mean age 35.6 years [SD 15.4 years]), 164 had dengue with warning signs, 27 had dengue without warning signs and 49 had severe dengue. 15/49 severe dengue patients had profound shock. Abdominal pain, persistent vomiting (PV), bleeding, hepatomegaly and ascites were present in 125, 92, 39,129 and 28 cases respectively. Elevated AST/ALT, serum bilirubin (SB), alkaline phosphatase (ALP) and gamma glutamyl transpeptide (GGT) were observed in 208, 20, 18 and 60 patients respectively. Of the 240 patients 41 had AST/ALT > 1000 IU/ml and 199 had AST/ALT < 1000 IU/ml. Only 16/41 patients with AST/ALT > 1000 IU/ml developed ALF while none from the AST/ALT < 1000 IU/ml group. Only 4/15 of profound shock had ALF. Patients with AST/ALT > 1000 IU/ml, presence of 2 or 3 of; elevated SB, elevated ALP or PV predicted the development of ALF with 93.8% sensitivity, 98.7% specificity, 83.3% positive predictive value (PPV) and 99% negative predictive value (NPV) with p < 0.001. CONCLUSIONS: Dengue patients who’s AST/ALT < 1000 IU/ml, excluded patients at risk of ALF. Presence of 2 or 3 of: PV, elevated SB or elevated ALP in a patient with AST/ALT > 1000 IU/ml may indicate impending ALF. This needs further validation in a larger populationItem Early predictors of severe dengue in adults(Elsevier, 2012) Wijewantha, H.; Premaratna, R.; Mabharana, I.; Nishad, N.; de Silva, A.; de Silva, H.J.BACKGROUND: Dengue is the main infectious disease causing high morbidity and mortality among adults in dengue endemic regions of Sri Lanka. Prediction of severe illness at an earlier stage of infection helps to arrive at management decisions. Studies to identify predictors of severe dengue in adults are sparse. METHODS: In order to identify predictors of severe dengue by the third day of illness, symptoms, signs and investigation results of first 3 days of illness between two groups A and B (defined below) were compared in a prospective cohort study of consecutive 117 adult patients (age>12 years) with serologically confirmed dengue admitted to the professorial medical unit, Colombo North Teaching Hospital, Ragama, Sri Lanka over 6 month from 1st of March 2011. Group A (Severe illness): development of ascites or pleural effusions (evidence of fluid leakage), compensated shock and profound shock (as defined by WHO guidelines for Dengue 2010), Group B: all others who did not fall into Group A. Severity of symptoms was assessed by a visual analogue scale, and rest of the clinical parameters, investigation results were documented prospectively. RESULTS: Of the 117 adults (95 males) mean age 31.95years (SD=13.34); 27 fell into Group A and 90 into group B. On the 3rd day of illness, mean Aspartate aminotransferase (AST); Group A 260 iu/L (SD=168.8) vs Group B-145 iu/L (SD=135.11) (p=0.005). Mean Alanine aminotransferase (ALT); Group A-247 iu/L (SD=161.5) vs Group B-105iu/L (SD-91.5) (p=0.002). None of the symptoms, signs and other investigations including platelet count, packed cell volume (PCV) and white blood cell count was significantly different. Analysis of the whole 117, pearson correlation test showed a positive correlation of AST(r=0.3) (p=0.038) and ALT(r=0.3) (P=0.045) with PCV and a negative correlation (r=-0.3) with platelet count (p=0.014). AST(r=0.25) and ALT (r=0.3) on day 3 was positively correlated with development of malena at any stage (p=0.05). CONCLUSION: Higher AST and ALT levels on 3rd day of dengue seems to be useful predictors of severe dengue. © 2012 Elsevier Inc.Item Predictors of duration and degree of third space fluid accumulation in adult patients with dengue(Elsevier, 2012) Premaratna, R.; Ragupathy, A.; Miththinda, N.; de Silva, H.J.BACKGROUND: Fluid leakage is the hallmark of dengue shock syndrome. It is important to identify clinical and biochemical parameters which predict duration and degree of fluid leakage in dengue. METHODS: 102 patients with confirmed dengue were prospectively followed up for clinical, haematological and biochemical parameters parameters, and those were correlated with ultrasonographic evidence of third space fluid accumulation (TSFA). RESULTS: Of the 102 patients (52 males; mean age 28.3 years (SD 11.8), TSFA was detected in 34/95(36%) after hospital admission; 33/95 had pleural effusions which included all except one of 21/95 who had ascites. The majority of pleural effusions (72.7%) lasted 3 or more days and in most cases (52.4%) ascites lasted less than 3 days. Duration of pleural effusion showed a significant positive correlation with severity of body aches (assessed on a visual analogue scale) (r=0.523, p=0.001), maximum percentage rise of PCV (r=0.526, p=0.001) and maximum percentage rise of Hb (r=0.525, p=0.001). It was negatively correlated with WBC count (r= -0.361, p=0.020) and platelet count (r= -0.585, p=0.000). There was no correlation with admission weight (p=0.125), duration of fever (p=0.387), lowest pulse pressure (p=0.299), ALT(p=0.241), AST(p=0.328), average fluid intake per day (p=0.118) and fluid balance per day (p=0.129). The mean lowest WBC count of 3005/mm3 that was recorded for patients who developed bilateral pleural effusions (n=21) was significantly less (p=0.042) than the mean lowest WBC count of 4091/mm3 that was detected for unilateral effusions (n=12). There was no significant difference in other parameters between these 2 groups. Duration of ascites was significantly positively correlated with highest AST (r=0.598, p=0.002) and highest ALT (r=0.721, p=0.000). CONCLUSION: Severity of body aches on detecting effusions, maximum percentage rise of Hb and PCV, lower WBC and platelet counts seem to be associated with longer periods of TSFA. Among these, lower WBC counts appear to be more predictive of the degree of fluid leakage. Higher ALT and AST levels seem to be useful in predicting the duration of ascites. © 2012 Elsevier Inc.Item To identify the role of haemoglobin (Hb), pack cell volume (PCV) and pulse pressure (PP) in predicting fluid leakage in patients with dengue who consume adequate amounts of fluids(Elsevier, 2012) Premaratna, R.; Ragupathy, A.; Miththinda, N.; de Silva, H.J.BACKGROUND: Early detection of fluid leakage is important in identifying patients who are likely to develop shock syndrome in dengue. As patients with dengue are advised to consume adequate amounts of fluids such behaviours may alter the clinical and haematological parameters predicting fluid leakage. METHODS: In 102 confirmed dengue patients admitted to Professorial Medical Unit, Colombo North Teaching Hospital Ragama from September 2011,quantity and quality of fluids consumed, Hb, PCV, PP and their percentage rise or decline were documented and compared between those who developed and did not develop moderate third space fluid accumulation (3rdSFA) [either pleural effusions, ascites or both detected by ultrasonography. RESULTS: In 102 patients (52 males) with mean (SD) age 28.3 (11.8) years, 3rd SFA was detected in 7/102 (6.8%) on admission and 34/95 (37%) after admission. Compared with those who had 3rdSFA and did not have 3rdSFA at admission; average consumption of water 1044cc/day vs 1091cc/day (p=0.8) and solutes 1050cc/day vs 805cc/day (P=0.26); the mean(SD) Hb 14.7 (2.0) g/dl vs 13.6 (1.8) g/dl (p=0.1); PCV 43.8 (6.5) vs 41.2 (5) (p=0.19); mean pulse pressure 32.8mmHg vs 33.8 (p=0.76). In those who developed 3rdSFA and did not develop 3rdSFA after admission, average consumption of water 620cc/day vs 491cc/day (p=0.14); solutes 1461cc/day vs 1481cc/day (p=0.83); the highest mean (SD) Hb 14.66g/dl (1.82)g/dl vs 14.28 (1.6)g/dl (p=0.3) and highest mean(SD) PCV 44.16 (5.19) vs 43.4 (4.5) (p=0.46); the mean (SD) pulse pressure 29.9mmHg vs 28.4 (p=0.29); The maximum percentage rise in Hb 8% vs 4.6% (p=0.02); PCV 8.6% vs 4.5% (p=0.006); mean pulse pressure drop 6.9% vs 5.9% (p=0.84). CONCLUSION: In the presence of fluid consumption the quality or quantity of fluids consumed did not seems to have played a role in 3rdSFA. A single value of Hb, PCV or pulse pressure was not helpful in predicting early fluid leakage. While percentage reduction in pulse pressure was not helpful, percentage rise in Hb and PCV remained predictive of early fluid leakage in dengue. © 2012 Elsevier Inc.Item Secondary bacteraemia in adult patients with prolonged dengue fever(Sri Lanka Medical Association, 2015) Premaratna, R.; Dissanayake, D; Silva, F.H.D.S.; Dassanayake, M.; de Silva, H.J.INTRODUCTION: Although dengue management guidelines do not advice on use of antibiotics in dengue shock syndrome, unrecognised bactraemia is likely to contribute to morbidity and mortality. OBJECTIVES: To assess the occurance of secondary bacteraemia in adult patients with prolonged dengue fever. METHODS: A prospective study was conducted recruiting patients with confirmed acute dengue infection who had prolonged fever (>5 days). Two sets of blood cultures were taken in such patients prior to institution of antibiotic therapy. Demographic, clinical, haematological and biochemical parameters were recorded. Development of ascites and pleural effusions were detected using ultrasonography. RESULTS: Fourty patients (52.5% males) with a mean age of 29.8 years (SD 13.6) were studied. The average duration of fever was 7.9 days (SD 1.8). Ten patients (25%) had bacterial isolates in their blood cultures; Staphylococcus aureus (n=2), coliforms (n=3), pseudomonas (n=1) and 4 had mixed growths. The culture positive group had severe body aches at admission and higher fever, third space fluid accumulation, a significant drop in platelets and a higher CRP. CONCLUSIONS: A quarter of dengue patients with prolonged fever had a bacterial isolate. Culture positive patients appeared more ill with body aches and had higher degrees of fever during the latter part of the illness. Increased vascular permeability may predispose to bacterial seepage into blood. Although white cell count is not helpful in detecting bacteraemia, low platelet count and elevation of CRP seem to be helpful.