Melioidosis with a subdural collection - a case report.

BACKGROUND: Melioidosis is an infection caused by Burkholderia pseudomallei, which is more prevalent in the tropics and leads to significant morbidity and mortality. It characteristically produces widespread caseous lesions and abscesses, and can present with varied clinical manifestations. Melioidosis involving the central nervous system is uncommon. CASE PRESENTATION: A 42-year-old Sri Lankan male with type 2 diabetes presented with a febrile illness of 6 days with headache and constitutional symptoms. Clinical examination was unremarkable. Four days later, he developed focal seizures involving the left leg and numbness of the left side. Initial laboratory investigations were suggestive of a bacterial infection. Blood culture was reported as positive for a Pseudomonas species, which was resistant to gentamicin. Contrast enhanced CT and MRI scans of the brain showed a subdural collection in the right fronto-temporo-parietal region with possible abscess formation. Melioidosis antibody testing using indirect hemagglutination method was reactive with a titre more than 1/10,240. He was treated with intravenous meropenem and oral co-trimoxazole for 8 weeks (Intensive phase). The subdural collection was managed conservatively, and seizures were treated with oral antiepileptics. At 7 weeks, follow-up contrast enhanced MRI showed improvement of the subdural collection, and inflammatory markers had normalized. He was discharged after 8 weeks, and treated with oral co-trimoxazole and doxycycline for 6 months (eradication phase). At 6 months follow-up, the patient is asymptomatic. CONCLUSIONS: Cerebral melioidosis is an unusual presentation of melioidosis where the diagnosis can be easily missed. Knowledge of the protean manifestations of melioidosis is of paramount importance in order to detect and treat this potentially fatal infection appropriately, especially in tropical countries where the disease is endemic.

Extended spectrum beta lactamase producing organisms causing urinary tract infections in Sri Lanka and their antibiotic susceptibility pattern -A hospital based cross sectional study.

BACKGROUND: Extended Spectrum Beta- Lactamase producing organisms causing urinary tract infections (ESBL-UTI) are increasing in incidence and pose a major burden to health care. While ESBL producing Klebsiella species seem to account for most nosocomial outbreaks, ESBL-producing E. coli have been isolated from both hospitalized and non-hospitalized patients. Although 95-100% ESBL organisms are still considered sensitive to meropenem, rapid emergence of carbapenem resistance has been documented in many countries. The objective of this study was to evaluate urinary tract infections caused by ESBL producers and the antibiotic susceptibility patterns in Sri Lanka. METHODS: Patients with confirmed ESBL-UTI admitted to Professorial Medical Unit, Colombo North Teaching Hospital from January - June 2015 were recruited to the study. Their urine culture and antibiotic susceptibility reports were evaluated after obtaining informed written consent. RESULTS: Of 61 culture positive ESBL-UTIs, E. coli caused 53 (86.8%), followed by Klebsiella in 8 (13.1%).30 (49.1%) had a history of hospitalization within the past three months and included 6/8(75%) of Klebsiella UTI and 24/53(45.2%) of E.coli UTI. Antibiotic susceptibility of ESBL organisms were; Meropenem 58 (95%), Imipenem 45 (73.7%), Amikacin 37 (60.6%) and Nitrofurantoin 28(45.9%). In 3(4.9%), E.coli were resistant to Meropenem. These three patients had received multiple antibiotics including meropenem in the recent past for recurrent UTI. CONCLUSIONS: We observed a higher percentage of E. coli over Klebsiella as ESBL producing organisms suggesting most ESBL-UTIs to be community acquired, Carbapenems seem to remain as the first line therapy for majority of ESBL-UTIs in the local setting. However 4.9% prevalence of meropenem resistance is alarming compared to other countries. Although prior antibiotic utilization and hospitalization may contribute to emergence of ESBL producing Klebsiella and E.coli in Sri Lanka, high prevalence of community acquired ESBL-E. coli needs further investigations to identify potential causes . Being a third world country with a free health care system, observed alarming rate of carbapenem resistance is likely to add a significant burden to health budget. We feel that treatment of infections in general needs a careful approach adhering to recommended antibiotic guidelines in order to prevent emergence of multi drug resistant organisms.

Secondary bacteraemia in adult patients with prolonged dengue fever.

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.

Pringle manoeuvre versus selective hepatic vascular exclusion: outcome of a case series in a tertiary referral centre.

A retrospective comparative study was done to compare the outcome of intermittent Pringle manoeuvre (IPM) and selective hepatic vascular exclusion (SHVE) in 19 major hepatectomies in non-cirrhotic patients that were done from October 2003 to June 2009. Intra-operative blood loss (IBL), total operative time (TOT) and immediate outcome were assessed in the two groups. Thirteen underwent IPM and the others underwent SHVE. The mean age was 50 years (SHVE) and 39.2 years (IPM). Mean IBL was 641 ml and 802 ml in the SHVE and IPM groups respectively (p > .05). TOT was 4.7 hours in both groups. There was one mortality from myocardial infarction in the IPM group and no morbidities in both groups. The results obtained from this study shows that IPM is equivalent to SHVE, with regards to IBL, TOT and immediate outcome in major hepatectomies in non-cirrhotic patients.

A Case Report of Takotsubo Cardiomyopathy With Dengue.

A 74-year-old woman with well-controlled hypertension and dyslipidemia with acute fever was diagnosed with dengue infection. She had non-anginal central chest pain which was associated with ST elevation and T inversions in V1 to V6 with prolonged QT interval. Her high-sensitivity troponin was elevated. There was echocardiographic evidence of severe left ventricular dysfunction (ejection fraction 35%; Simpson method) with apical ballooning suggestive of takotsubo cardiomyopathy. No left ventricular basal hyperkinesia was noted. The patient was managed as per the national dengue guidelines of Sri Lanka. Her cardiac condition was managed conservatively. She did not experience dengue complications such as dengue shock syndrome or dengue hemorrhagic fever or pulmonary edema secondary to severe LV dysfunction. The clinical symptoms and echocardiographic findings of takotsubo cardiomyopathy resolved parallel to dengue fever.

Rhinocerebral Mucormycosis with Extensive Cranial Nerve Palsies in a Diabetic Patient.

Mucormycosis is a common opportunistic fungal infection with a disseminated nature. Despite being a devastating disease with the involvement of multiple upper cranial nerves, the implications of the seventh cranial nerve have been infrequently encountered. Although the radiological evidence with sinus destruction supports the diagnosis, histological specimen showing fungal elements confirms it as fungal culture doesn't always demonstrate a high diagnostic yield. Early detection and multimodal treatment are mandatory to prevent detrimental outcomes and to control the disease progression. We, hereby present a rare case of rhinocerebral mucormycosis with multiple cranial nerve involvement including the facial nerve in a 70-year-old female with long-standing poorly controlled diabetes mellitus.

A Case Report on Pseudo-Internuclear Ophthalmoplegia: A Rare Manifestation of Myasthenia Gravis.

A 41-year-old male with recently diagnosed diabetes mellitus type 2 presented with drooping of the left eyelid with double vision and was found to have an adduction deficit in the left eye and nystagmus in the abducting right eye during conjugated gaze: a left-sided internuclear ophthalmoplegia (INO). A medial longitudinal fasciculus (MLF) lesion was excluded exhaustively with brain imaging. The possibility of a pseudo-INO was considered. The autoantibody profile demonstrated positivity to acetylcholine receptor (AChR) antibody. Repetitive nerve stimulation (RNS) and electromyography (EMG) were unremarkable. An acetylcholinesterase inhibitor trial showed a significant improvement in the ocular symptoms. Hence, the diagnosis of ocular myasthenia was confirmed. There was no evidence of a thymic hyperplasia. Herein, we discuss pseudo-INO being an atypical presentation of myasthenia gravis (MG), emphasizing the importance of having a strong suspicion despite unremarkable test results.