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This repository contains the published and unpublished research of the Faculty of Medicine by the staff members of the faculty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 Acute appendicitis during the recovery phase of dengue hemorrhagic fever: two case reports(BioMed Central, 2022) Thadchanamoorthy, V.; Ganeshrajah, A.; Dayasiri, K.; Jayasekara, N.P.Background: Dengue fever is one of the most common tropical diseases, with high prevalence in many tropical countries including Sri Lanka. Dengue infection can present from subclinical infection to dengue shock syndrome. Further, the disease also shows a variety of atypical presentations and has been reported to mimic a number of causes of acute abdomen. Case presentation: The authors report two children (a 6-year-old Tamil girl and an 8-year-old Muslim girl) who were diagnosed to have acute appendicitis during the early recovery phase of dengue hemorrhagic fever (DHF) and late recovery period of dengue hemorrhagic fever with platelet count of 92 × 103/cumm and 102 × 103/cumm, respectively. Both children were investigated with abdomen ultrasound as they developed severe abdominal pain and tenderness on palpation during the recovery phase, which was felt to be very unusual. Acute appendicitis was diagnosed in one child, while the other child had a ruptured appendicular abscess. Both children were treated with laparoscopic appendectomy and a 7-day course of intravenous antibiotics. Both children were reviewed in 1 month following treatment and had complete recovery. Conclusion: Although precise pathophysiology and associations of the surgical abdomen with dengue fever remain to be elucidated, there are known factors in dengue fever that can potentially lead to secondary bacterial infections and surgical abdomen. Awareness and increased suspicion by the clinician are paramount to detect such complications early, especially in children who demonstrate unusual clinical features during various stages of dengue infection.Item Expanded dengue syndrome presenting with acute liver failure, acute kidney injury, pancreatic involvement, coagulopathy, and multiple intracranial hemorrhages in a young child: a case report(BioMed Central, 2022) Thadchanamoorthy, V.; Dayasiri, K.Background: Dengue is a mosquito-borne viral infection that typically occurs in tropical and subtropical countries. The clinical manifestations of dengue infection range from an asymptomatic subclinical course to severe dengue shock syndrome. Besides, dengue can affect any organ in the body and can present with atypical manifestations. Case presentation: We report a 6-year-old previously healthy Tamil child who had dengue complicated with multiorgan involvement. She initially presented with high fever, headache, body aches for 5 days, blood and mucus diarrhea, hematuria, and right knee joint swelling for 2 days. Dengue NS1 antigen was positive on day 2 of febrile illness. She was managed symptomatically in the local hospital for 3 days and transferred to the tertiary care hospital for further management. She was eventually diagnosed as having dengue hemorrhagic fever complicated with multiorgan involvement including acute liver failure, pancreatic involvement, coagulopathy, arthritis, acute kidney injury, and multiple intracranial hemorrhages. The constellation of disease manifestations was identified as expanded dengue syndrome. She was managed with fresh blood, platelet, and cryoprecipitate transfusions and intravenous antibiotics in addition to renal and liver support in the intensive care unit. On day 14 of illness, she deteriorated while on the ventilator and died due to multiple intracranial hemorrhages. Conclusion: The reported child with dengue hemorrhagic fever developed several unusual presentations such as acute liver and renal failure, disseminated intravascular coagulopathy, pancreatic involvement, and multiple intracranial hemorrhages, which form part of expanded dengue syndrome. In the seriously unwell child, it is important to look for unusual complications actively to improve outcomes.Item Case Report: Dengue hemorrhagic fever with ischemic stroke.(American Society of Tropical Medicine and Hygiene, 2022) Basnayake, B.W.M.K.E.; Somaratne, K.G.S.K.; Goonetilleke, C.U.; Tilakaratna, P.M.Y.I.; Ranawaka, U.K.Several neurological manifestations are recognized in dengue infection, but stroke is a rare complication. We report a case of ischemic stroke in a patient with dengue hemorrhagic fever. A 52-year-old previously healthy male presented with a history of fever for 2 days, and left-sided weakness and numbness of sudden onset. MRI scanning showed a right-sided thalamic lacunar infarct. Diagnosis of dengue fever was made based on leuco-thrombocytopenia, positive dengue nonstructural protein-1 (NS-1) antigen, and positive dengue IgM antibodies. Severity of limb weakness correlated with the critical phase of dengue hemorrhagic fever (DHF). He was discharged home with good recovery from neurological symptoms and disability. Strokes are rare in dengue, and are mainly hemorrhagic strokes related to thrombocytopenia. Ischemic stroke is even rarer. More evidence is needed for confirmation of dengue as a pathogenic mechanism of ischemic stroke.Item The Impact of empirical hydrocortisone therapy on clinical outcomes in dengue fever: A retrospective chart review(Oxford University Press, 2020) de Mel, S.; Thilakawardana, B.U.; de Mel, P.; de Silva, A.P.; de Mel, C.; Chandrasena, L.; Seneviratne, S.L.; Abeysuriya, V.BACKGROUND: The role of steroids in dengue infection (DI) remains uncertain. METHODS: A retrospective chart review was conducted on patients ≥18 y of age diagnosed with DI based on positivity for dengue non-structural antigen 1 or immunoglobulin M between October 2017 and November 2018. RESULTS: Hydrocortisone was administered to 106 of 406 patients. DI with warning signs occurred in nine patients (9.5%) in the steroid cohort and eight patients (2.5%) in the non-steroid group. The incidence of severe DI, bleeding and admission duration were similar between the groups. CONCLUSIONS: Our study shows no significant benefit of empirical steroids in DI. KEYWORDS: clinical outcomes; corticosteroids; dengue.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 Breeding of aedes Aegypti and Aedes albopictus in some dengue endemic areas.(Sri Lanka College of Microbiologists, 2000) Hapugoda, G.P.G.M.D.; de Silva, N.R.; Abeyewickreme, W.Dengue fever (DF)/Dengue haemorrnagic fever (DHF) is now- the most important and rapidly spreading vector borne disease in the world. Since 1956, over 350 000 patients have been hospitalized and nearly 12 000 deaths have been reported. In Sri Lanka the incidence of DF/DHF has increased cyclically since the first outbreak in Sri Lanka during which 26 deaths were reported. Aedes aegypti is classified as the predominant vector of dengue in Sri Lanka. Ae, albopictus is considered as an important vector in the absence of Ae. aegypti. In this study, larval surveillance was carried out in fixed monitoring stations / hot-spots and random monitoring stations. Fixed monitoring stations were selected based on high incidence of DF/DHF recorded since 1996 in Kurunegala district. Ten premises within one fixed monitoring station were checked for mosquito breeding weekly using ovitraps and the average monthly ovitrap index (%) was calculated. During outbreaks larval surveillance was conducted in fifteen random monitoring stations including 66 houses which were selected based on serologically confirmed DPI DHF cases in and around Kurunegala and Ragama. Observations on average monthly ovitrap index (%) in the fixed monitoring stations showed that the highest ovitrap index was in Kurunegala town area, Ovitrap index of Ae. albopictus was higher than of Ae. aegypti all localities in and around Kurunegala throughout the study period. Data obtained from random monitoring-stations in and around Kurunegala and Ragama revealed that only Ae. albopictus larvae were present in seven stations. There were no stations in which only Ae.aegypti larvae were present. House index of Ae. albopictus was 28% whereas it was 10.6% for both species in random monitoring stations. Results suggest that Ae.albopictus may play a major role in transmitting dengue in some localities in Sri Lanka. This investigation received financial support from University of Kelaniya (Research Grant no-97/1-23) and from the IAEA (Technical Corporation Grant no-SRL/06/024).Item Potential use of IGR Pyriproxifen for control of dengue vector Aedes albopictus(Sri Lanka College of Microbiologists, 1999) Gunawardene, Y.I.N.S.; de Silva, N.R.; Abeyewickreme, W.Dengue Fever (DF) Dengue Haernorrhagic Fever (DHF) is now a significant problem in Sri Lanka. The incidence of DHF has increased cyclically since the first recognized outbreak in 1989. Of the 203 suspected DHF cases recorded in 1989, 87 were confirmed and 26 deaths were reported. By 1997, 5882 clinical cases, 1558 serologically confirmed cases and over 300 deaths have been reported. Without an effective vaccine against dengue, and considering the clinical difficulty in managing DHF cases, vector control has become an important com¬ponent in the integrated attempts for dengue con¬trol. Aedes aegypti and Aedes albopictus not only transmit dengue but are also a nuisance and cause annoyance by their day biting behaviour. In this study an attempt was made to control Ae. albopictus by exploiting its oviposition behaviour, us¬ing an Insect Growth Regulator (IGR), Pyriproxifen. The IGR is known to interfere with the synthesis and deposition of chitin in insects and thereby prevent growth and development. Different concentrations of the IGR (0.01 g/1 -0.08g/1) were tested against Ae.albopictus, in laboratory experiments. The most effective larvisidal concentration of Pyriproxifen for Ae.albopictus was determined to be 0.03g/1. Field trials were also carried out to determine the feasi¬bility of employing used automobile tyres contain¬ing Pyriproxifen as ovitraps against Ae.albopictus. Tyres containing water were treated with Pyriproxifen (0.03g/1) and the emergence of adults was recorded. Pyriproxifen at a concentration of 0.03g/1 was found to inhibit the emergence of adult Aedes mosquitoes up to 6 weeks.Item 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.