Different Outcomes of "Silent Hypoxia" in Patients with COVID-19 Pneumonia: A Case Series and Literature Review.

COVID-19 has been declared a pandemic since March 2020 and it has been responsible for millions of deaths worldwide. The SARS-CoV-2 causes a spectrum of diseases mainly affecting the respiratory system. It can also complicate other systems causing thromboembolic phenomena and myocardial ischaemia. An entity of hypoxia has been described in these patients which show no clinical signs and symptoms of respiratory distress despite being extremely hypoxic. This is called silent or happy hypoxia. The exact mechanism for this is not known. We report 4 cases which had similar presentations of silent hypoxia but had different course of illness and different outcomes. All 4 patients did not show any signs of respiratory distress, but had oxygen saturation less than 82%. 3 of them needed intensive care unit support for oxygen therapy and subsequently needed noninvasive ventilation. Only one required invasive ventilation. The fourth patient did not require intensive care support. The patient who required invasive ventilation succumbed due to severe COVID pneumonia whereas the other 3 patients were discharged from the hospital. Silent hypoxemia can go undetected in COVID-19 patients particularly in the time of a pandemic. This case series highlights the importance of meticulous clinical examination including oxygen saturation measurements in suspected or confirmed patients with COVID-19. The course of illness can be different in different populations, and this needs further clinical evidence.

Guillain-Barré syndrome with associated unilateral ptosis without ophthalmoplegia - a rare presentation: a case report and review of the literature.

BACKGROUND: Guillain-Barré syndrome is an acute inflammatory polyradiculoneuropathy. Nearly half of patients with Guillain-Barré syndrome have cranial nerve involvement. However, isolated bilateral ptosis without ophthalmoplegia is a rare manifestation, and isolated unilateral ptosis without ophthalmoplegia in Guillain-Barré syndrome has not previously been reported in the literature. Furthermore, only few cases of Guillain-Barré syndrome with cranial nerve enhancement visualized by gadolinium-enhanced magnetic resonance imaging have previously been reported. We describe the first reported case of unilateral ptosis without ophthalmoplegia in Guillain-Barré syndrome and associated multiple cranial nerve enhancement seen by gadolinium-enhanced magnetic resonance imaging. CASE PRESENTATION: Our patient was a 55-year-old Sinhalese man who was admitted to a tertiary care hospital in Sri Lanka with acute-onset progressive weakness in the lower limbs followed by the upper limbs. He had bilateral symmetrical flaccid quadriparesis with absent reflexes and flexor plantar response. Left-sided isolated partial ptosis without associated ophthalmoplegia was noted with normal pupils. The patient's neurological examination was otherwise normal. A nerve conduction study showed a severe demyelinating type of polyneuropathy. No decremental response to repetitive nerve stimulation was observed, and the result of a single-muscle-fiber electromyogram was negative. A diagnosis of Guillain-Barré syndrome was made, and the patient was treated with intravenous immunoglobulin. His condition gradually deteriorated over the next few days, and he became quadriplegic despite the completion of immunoglobulin therapy. Later he developed multiple cranial nerve palsies, including bi-lateral lower motor neuron type facial nerve palsy, and he required mechanical ventilation. By this time, he had complete left-sided ptosis with a normal right eye. He never developed ophthalmoplegia or ataxia. Magnetic resonance imaging of the brain showed contrast enhancement in the intracranial part of multiple cranial nerve roots and basal leptomeninges. He gradually improved with plasmaparesis, and ptosis was the first to improve. CONCLUSIONS: Even though Guillain-Barré syndrome was recognized a century ago, there are still many unanswered questions about it and its florid presentation. Large-scale studies are needed for better understanding of its pathophysiology and prototypes and to find answers for still-unanswered questions. The clinician must have a high index of suspicion and be familiar with mimics and prototypes to diagnose Guillain-Barré syndrome accurately without delay.

A case of delayed neurological manifestation following carbon monoxide poisoning in Sri Lanka: epidemiology of exposure and literature review.

BACKGROUND: Carbon monoxide poisoning is a common emergency worldwide, which carries high morbidity and mortality. Some patients who recover from the insult of acute carbon monoxide toxicity may later develop delayed neuropsychiatric sequelae (DNS) after a lucid period in the form of cognitive impairments, a broad spectrum of neurological deficits and affective disorders. Here, we present the first case of DNS following carbon monoxide poisoning in Sri Lanka and epidemiology of the exposure of nine (9) more victims. CASE PRESENTATION: A 55-year-old patient and nine other people developed effects of carbon monoxide poisoning in two different occasions after sleeping few hours in the same room in their work place in Sri Lanka. These patients developed spectrum of symptoms with the acute carbon monoxide poisoning. However, one patient developed neurological deterioration pertaining to delayed neuropsychiatric sequelae (DNS) after 1 month of lucid interval. His MRI scan of the brain showed diffuse high signal intensity involving subcortical white matter, globus pallidus on FLAIR and T2W images. These areas showed high signals in DWI images with no significant changes appreciated on ADC map. There was no abnormal contrast enhancement appreciated in the above areas. EEG showed generalized slow waves. He gradually deteriorated over next 2 weeks, exhibited athetoid movements of his feet and hands and went into rigid akinetic mute state. He could not response to any stimulation and even displayed decorticated-like posture and died. Others had normal MRI brain finding at 8 weeks of acute toxicity and all were neurologically normal after 1 year. CONCLUSION: Though, it is uncommon in a tropical country like Sri Lanka, clinicians should have high degree of suspicion with the correct circumstances, as it is a challenge for the emergency physicians, even in countries with higher rate of CO poisoning. The exact mechanisms of acute and delayed toxicity, preventive methods and the suggested treatments are yet to be elucidated and this needs further attention and studies.

Infective myositis, an uncommon presentation of melioidosis: a case report and review of the literature.

BACKGROUND: Melioidosis is considered endemic in certain areas of the world. Musculoskeletal and soft tissue involvement are relatively uncommon presentations in melioidosis. We present a case of infective myositis in a patient with melioidosis in Sri Lanka, which is not considered an endemic country. Even though multiple cases of melioidosis have been reported with an increasing number in Sri Lanka, infective myositis secondary to melioidosis was not reported previously. CASE PRESENTATION: A 60-year-old Sinhalese man with diabetes presented with fever of 4 months' duration and a limp with a painful lump on the right side of the upper thigh of 2 months' duration. He had been treated in a local hospital for community-acquired pneumonia 3 weeks prior to this admission, for which he had received intravenous meropenem and teicoplanin with intensive care unit admission. He had a 0.5-cm × 0.5-cm tender lump over the right vastus lateralis muscle, and contrast-enhanced computed tomography of the area showed an ill-defined, heterogeneously enhancing, hypodense area involving the vastus lateralis, vastus intermedius, and quadratus femoris, suggestive of infective myositis but without abscess formation. Histopathology of the muscle biopsied from the vastus lateralis showed suppurative inflammation of subcutaneous fat with connective tissue necrosis and muscle infiltrated by lymphocytes. These features are suggestive of infective myositis possibly due to melioidosis. Although the result of a culture taken from the muscle biopsy was negative, the patient's antibody titer was strongly positive for melioidosis. He did not show any other areas with infected foci. He was treated with intravenous meropenem for 2 weeks and responded well. He was discharged with trimethoprim-sulfamethoxazole for 6 months as a maintenance therapy. CONCLUSION: Melioidosis is commonly an undiagnosed disease that has a wide variety of clinical presentations. Myositis in melioidosis is uncommon, and careful evaluation is mandatory to avoid misdiagnosis of this treatable but fatal disease. The clinician should have a high index of clinical suspicion, and further clinical and epidemiological studies are needed to determine the true burden of the disease.

Incidence and effects of Varicella Zoster Virus infection on academic activities of medical undergraduates--a five-year follow-up study from Sri Lanka.

BACKGROUND: The adult population in Sri Lanka is having high level of susceptibility for Varicella Zoster Virus (VZV) infection. Among medical undergraduates, 47% are VZV seronegative. The purpose of the present study was to determine the incidence of VZV infection in medical undergraduates in Sri Lanka, and to describe the effects of VZV infection on their academic activities. METHODS: A retrospective cohort of medical undergraduates' susceptible for VZV infection was selected from the University of Peradeniya, Sri Lanka. Data on the incidence of VZV infection (Chickenpox) during their undergraduate period was collected using a self-administered structured questionnaire. A second questionnaire was administered to collect data on the details of VZV infection and the impact of it on their academic activities. VZV incidence rate was calculated as the number of infections per 1,000 person years of exposure. Descriptive statistics were used to describe the impact of VZV infection on academic activities. RESULTS: Out of the 172 susceptible cohort, 153 medical undergraduates were followed up. 47 students reported VZV infection during the follow up period and 43 of them participated in the study. The cumulative incidence of VZV infection during the period of five and half years of medical training was 30.7%. Incidence density of VZV infection among medical undergraduates in this cohort was 65.1 per 1,000 person years of follow-up. A total of 377 working days were lost by 43 students due to the VZV infection, averaging 8.8 days per undergraduate. Total academic losses for the study cohort were; 205 lectures, 17 practicals, 13 dissection sessions, 11 tutorials, 124 days of clinical training and 107 days of professorial clinical appointments. According to their perception they lost 1,927 study hours due to the illness (Median 50 hours per undergraduate). CONCLUSIONS: The incidence of VZV infection among Sri Lankan medical undergraduates is very high and the impact of this infection on academic activities causes severe disruption of their undergraduate life. VZV immunization for susceptible new entrant medical undergraduates is recommended.