Super-refractory status epilepticus, rhabdomyolysis, central hyperthermia and cardiomyopathy attributable to spinal anesthesia: a case report and review of literature.

BACKGROUND: There are only six past reports of super-refractory status epilepticus induced by spinal anesthesia. None of those patients have died. Only < 15 mg of bupivacaine was administered to all six of them and to our case. Pathophysiology ensuing such cases remains unclear. CASE PRESENTATION: A 27 year old gravida 2, para 1, mother at 37 weeks of gestation came to the operating theater for an elective cesarean section. She had no significant medical history other than controlled hypothyroidism and one episode of food allergy. Her current pregnancy was uneventful. Her American Society of Anesthesiologists (ASA) grade was 2. She underwent spinal anesthesia and adequate anesthesia was achieved. After 5-7 min she developed a progressive myoclonus. After delivery of a healthy baby, she developed generalized tonic clonic seizures that continued despite the induction of general anesthesia. She had rhabdomyolysis, one brief cardiac arrest and resuscitation, followed by stress cardiomyopathy and central hyperthermia. She died on day four. There were no significant macroscopic or histopathological changes in her brain that explain her super refractory status epilepticus. Heavy bupivacaine samples of the same batch used for this patient were analyzed by two specialized laboratories. National Medicines Quality Assurance Laboratory of Sri Lanka reported that samples failed to confirm United States Pharmacopeia (USP) dextrose specifications and passed other tests. Subsequently, Therapeutic Goods Administration of Australia reported that the drug passed all standard USP quality tests applied to it. Nonetheless, they have detected an unidentified impurity in the medicine. CONCLUSIONS: After reviewing relevant literature, we believe that direct neurotoxicity by bupivacaine is the most probable cause of super-refractory status epilepticus. Super-refractory status epilepticus would have led to her other complications and death. We discuss probable patient factors that would have made her susceptible to neurotoxicity. The impurity in the drug detected by one laboratory also would have contributed to her status epilepticus. We propose several possible mechanisms that would have led to status epilepticus and her death. We discuss the factors that shall guide investigators on future such cases. We suggest ways to minimize similar future incidents. This is an idiosyncratic reaction as well.

Respiratory infection transmission risk and indoor air quality at outpatient departments and emergency treatment units of Sri Lankan teaching hospitals.

Indoor carbon dioxide (CO2) concentration has been used as a proxy of the degree of ventilation and, by extension, as an indicator of the risk of contracting respiratory infections. No publications exist regarding indoor air quality (IAQ) parameters of Sri Lankan hospitals.We measured the levels of CO2 and seven other IAQ parameters during morning rush hours for three days, in outpatient departments (OPDs) and emergency treatment units (ETUs) of all 21 teaching hospitals of Sri Lanka. We measured the same parameters of outdoor air also. We calculated the mean values of those parameters. We looked for correlations between outdoors and OPD and ETU levels of selected air quality parameters.The average CO2 levels of outdoors, OPDs and ETUs respectively were 514ppm (ppm = parts per million), 749ppm and 795ppm. The average levels of PM2.5 (particulate matter with diameters <2.5µm) outdoors, OPDs and ETUs respectively, were 28.7µg/m3,32µg/m3 and 25.6 µg/m3. The average levels of PM10 (particulate matter with diameters <10µm) outdoors, OPDs and ETUs respectively, were 49.4µg/m3, 55.5µg/m3 and 47.9 µg/m3. The median levels of formaldehyde outdoors, OPDs and ETUs respectively, were 0.03mg/m3, 0.04mg/m3 and 0.08mg/m3. The median levels of total volatile organic compounds (VOC) outdoors, OPDs and ETUs respectively were 0.12mg/m3, 0.19mg/m3 and 0.38mg/m3.CO2 levels of air in OPDs and ETUs generally were below the national ceilings but above the ceilings used by some developed countries. Outdoors, OPDs and ETUs air contain PM10, PM2.5 levels higher than WHO ceilings, although below the national ceilings. VOC and formaldehyde levels are generally below the national ceilings. Air in OPDs and ETUs is hotter and humid than national ceilings. Outdoor PM10, PM2.5 levels influence OPDs and ETUs levels. We propose methods to reduce the risk of nosocomial respiratory infections and to improve IAQ of Sri Lankan OPDs and ETUs.

A vegetable-induced hemolytic crisis in a G6PD deficient person: a case report.

BACKGROUND: Hemolysis can occur in people with G6PD deficiency under oxidative stress. Acalypha indica is a tropical plant used as a medicinal plant as well as a vegetable. There are a few reported cases of Acalypha indica ingestion induced hemolysis in G6PD deficient people. All except one of them are from Sri Lanka. The information available at present (2017) about G6PD deficiency prevalence and variants of the G6PD gene among Sri Lankans is very sparse. There are no past reports on hemolytic crisis in a G6PD deficient person presenting mimicking leptospirosis. CASE PRESENTATION: A middle-aged Sri Lankan man presented on the third day of illness complaining of fever, head ache, arthralgia, myalgia, abdominal pain, vomiting, passing dark urine and reduced of urine volume. He gave a history of possible exposure to leptospirosis. He was pale, icteric and his liver was palpable 1 cm below costal margin and there were no other remarkable findings upon physical examination. He had neutrophilic leucocytosis. Leptospirosis was diagnosed. During the second assessment we noticed he was very pale and his urine sample pointed towards hemoglobinuria. Further questioning revealed he had consumed leaves of Acalypha indica as a vegetable. Acute hemolysis in a G6PD deficient patient following Acalypha indica ingestion was diagnosed. Blood transfusions were given to correct his anemia. Later, Brewer's test and quantitative assay of G6PD levels confirmed the diagnosis of G6PD deficiency. CONCLUSIONS: A hemolytic crisis following oxidative stresses in G6PD deficient patients can present mimicking leptospirosis. Further investigations may reveal why the great majority of cases of acute hemolysis in G6PD deficient person following Acalypha indica ingestion are from Sri Lanka.