A study on knowledge, attitudes and practices regarding dengue fever, its prevention and management among dengue patients presenting to a tertiary care hospital in Sri Lanka.

BACKGROUND: The World Health Organization (WHO) has ranked dengue as one of the top ten threats to Global health in 2019. Sri Lanka faced a massive dengue epidemic in 2017, the largest outbreak in the country during the last three decades, consisting of 186,101 reported cases, and over 320 deaths. The epidemic was controlled by intense measures taken by the health sector. However, the reported dengue cases and dengue deaths in 2019 were significantly higher than that of 2018. Deaths were mostly due to delay in hospitalization of severe dengue patients. The mortality of dengue hemorrhagic fever is 2-5% if detected early and treated promptly, but is high as 20% if left untreated. METHODS: A descriptive cross-sectional study was done among patients with dengue fever presenting to the Sri Jayawardenepura General Hospital during October 2019. Data was collected using a questionnaire comprising 20 questions based on knowledge, attitudes and practices on dengue, which were categorized into questions on awareness of mortality and severity of dengue burden, prevention of dengue vector mosquito breeding and acquiring the infection, patient's role in dengue management, and warning signs requiring prompt hospitalization. RESULTS: The mean KAP score on all questions was 55%, while a majority of 65.2% patients scored moderate KAP scores (50-75%) on all questions, and only 7.6% had high KAP scores (> 75%). The highest categorical mean score of 62% was on awareness of dengue prevention, followed by 54% on awareness of dengue burden, and only 51% on dengue management. Only 5.3% patients scored high scores on awareness of dengue management, followed by 28.5%, and 40.9% patients scoring high scores on awareness of dengue burden, and awareness of prevention of dengue respectively. The mean KAP scores on all questions increased with increasing age category. CONCLUSION: The population relatively has a better awareness of dengue prevention, as compared to awareness of dengue mortality and dengue management. The identified weak point is patient awareness of the patients' role in dengue management, and identifying warning signs requiring prompt hospitalization. This results in delay in treatment, which is a major cause for increased mortality. There was a correlation between those who had good knowledge on dengue burden and those who were aware of patients' role in dengue management. An action plan should be implemented to improve public awareness through education programs on the role of the public and patients in dengue management to drive a better outcome.

A young girl with chronic isolated cervical lymphadenopathy found to have lupus lymphadenopathy, progressing to develop lupus nephritis: a case report.

BACKGROUND: Systemic lupus erythematosus is a rare autoimmune disorder, with the prevalence in Asia ranging from 30 to 50/100,000. The diagnosis of systemic lupus erythematosus is made according to the 2019 European League Against Rheumatism/American College of Rheumatology classification criteria, and it does not contain lymphadenopathy as diagnostic criteria. However, lupus lymphadenopathy has an estimated prevalence of 5-7% at the onset of disease, and 12-15% at any stage of the disease. CASE PRESENTATION: A 19-year-old Sinhalese girl had neck nodules since the age of 5 years, which increased in size and became tender since 1 year. She had alopecia and joint stiffness for 6 months. She presented with a 5-day history of worsening joint pain, fever, and painful, enlarging cervical nodules. She had tender cervical lymphadenopathy, and a vasculitic rash on both lower limbs. She had pancytopenia, an erythrocyte sedimentation rate of 92, positive antinuclear antibody titer, and high anti-double-stranded deoxyribonucleic acid (DNA), with low C3 and C4 complements. She had a high reticulocyte count of 5%, with direct and indirect antiglobulin tests being positive, indicating autoimmune hemolytic anemia. Lymph node biopsy showed moderate reactive follicular hyperplasia, with scattered plasma cells and immunoblasts, with varying degree of coagulative necrosis, suggestive of lupus lymphadenopathy. On immunohistochemistry of the lymph node biopsy, Bcl2 was negative, excluding lymphoma. Contrast-enhanced computed tomography of abdomen and chest was normal with no hepatosplenomegaly or lymphadenopathy. Skin biopsy showed leukocytoclastic vasculitis. Later, with development of generalized edema, she was found to have impaired renal function, and renal biopsy showed lupus nephritis. She was started on hydroxychloroquine, prednisolone, and mycophenolate mofetil, and her symptoms improved and lymphadenopathy regressed. CONCLUSION: In the case of cervical lymphadenopathy in a patient with systemic lupus erythematosus, the possibilities of lupus lymphadenopathy, Kikuchi-Fujimoto disease, and lymphoma should all be considered, after excluding secondary infection due to immunosuppression. Histology confirms the differentiation of these pathologies. It is important to differentiate the cause for lymphadenopathy in systemic lupus erythematosus as the outcome and treatment varies. Lupus lymphadenopathy is usually generalized, but isolated cervical lymphadenopathy could also rarely be the first presentation of systemic lupus erythematosus. Lupus lymphadenopathy can be the only presenting feature, and needs a high index in suspecting systemic lupus erythematosus, though it is not included in the diagnostic criteria.

Complicated Dengue Fever and Its Treatment Dilemmas: A Single-Center Experience in Sri Lanka.

Dengue is an arboviral infection that affects humanscausing significant morbidity and mortality in tropical countries. Our first patient who had diabetes presented with shock and was managed as dengue hemorrhagic fever with superadded sepsis which required noradrenalin plus broad-spectrum intravenous antibiotics. The second patient developed severe bradycardia during the ascending limb of the critical phase with hemodynamic stability, which recovered on discharge. Third patient presented with severe and rapid leaking; we used intravenous albumin as an alternative colloid with good outcome. The fourth patient was a pregnant mother at term, and she went into spontaneous labor during the latter half of the critical phase. The fifth patient developed dengue hemorrhagic fever complicated with probable haemophagocytic lymphohistiocytosis. She was treated with intravenous steroids andimmunoglobulin, yet succumbed on day 7. Conclusion. Dengue is an extremely challenging and dynamic disease, which can lead to many unusual complications.A high index of suspicion is key to diagnose and treat promptly.

Unknowing ingestion of Brugmansia suaveolens leaves presenting with signs of anticholinergic toxicity: a case report.

BACKGROUND: Brugmansia suaveolens is the commonest species under the Solanacea ("Angels Trumpet" in English; "Attana" in Sinhalese) plant family in Sri Lanka. It contains alkaloids like scopolamine, atropine and hyoscyamine which can cause an anticholinergic toxindrome. There have been a few reported cases of accidental ingestion of Brugmansia seeds among children, seeds being the most toxic part, but no such reported cases of Brugmansia leaves poisoning among adults. CASE PRESENTATION: A 60-year-old-female Sinhalese presented with acute confusion, delirium, and agitation. She had ingested a herbal drink made from leaves of an unknown plant from her garden prior to onset of symptoms. She had urinary retention, mydriasis and sinus tachycardia. She was managed supportively with activated charcoal and hydration and the delirium completely resolved within 15 hours. The presented unkown plant leaves were identified as Brugmansia suaveolens. CONCLUSION: Although seeds are the most toxic plant part in most cases of Brugmansia poisoning, leaves also have a significant degree of toxicity. It is important that medical professionals promptly recognize the features of anticholinergic syndrome, and have a high index to suspect Brugmansia poisoning and start prompt treatment. It is also important to improve awareness of toxic plants among the general community to prevent toxicities and fatalities.