Detection of pathogenic Leptospira with rapid extraction followed by recombinase polymerase amplification (RPA) and quantitative polymerase chain reaction (qPCR) assay-A comprehensive study from Sri Lanka.

Leptospirosis is the most widespread zoonosis in the world. The disease is more prevalent in tropical regions where the majority of developing countries are located. Leptospirosis is considered a protean manifestation zoonosis with severity of the disease ranging from a mild febrile illness to a severe and life-threatening illness. Clinical symptoms of leptospirosis overlap with other tropical febrile illnesses. Early, rapid, and definitive diagnosis is important for effective patient management. Since Polymerase Chain Reaction (PCR)-based assays are not readily available in most clinical settings, there is a need for an affordable, simple, and rapid diagnostic test. Quantitative PCR (qPCR) and Recombinase Polymerase Amplification (RPA) were implemented at the Faculty of Medicine, University of Kelaniya, and a prospective study to evaluate RPA for diagnosis of acute phase of leptospirosis was conducted. Results indicate that RPA and qPCR were positive in 81% (98/121) of the total positive and acute clinical samples. Of the 81 positive MAT confirmed patients 60 (74%) and 53 (65%) were positive with qPCR and RPA respectively. Retrospective evaluation revealed a high diagnostic accuracy (sensitivity-70% and specificity-87%) of RPA compared to MAT as the reference gold standard. Results further suggest that there is no significant difference between the two assays, qPCR and RPA-SwiftX (P = 0.40). Laboratory procedures for the extraction and detection by qPCR in the laboratory have been optimized to obtain results within 6 hours. However, the RPA-SwiftX method under field conditions took 35 minutes. The RPA-SwiftX method could replace the qPCR which shows similar sensitivity and specificity. Therefore, RPA established under the current study presents a powerful tool for the early and rapid diagnosis of leptospirosis at point-of-care.

Pre-clerkship procedural training in venipuncture: a prospective cohort study on skills acquisition and durability.

BACKGROUND: The effectiveness of simulation-based training for skill acquisition is widely recognized. However, the impact of simulation-based procedural training (SBPT) on pre-clerkship medical students and the retention of procedural skills learned through this modality are rarely investigated. METHODS: A prospective cohort study was conducted among pre-clerkship medical students. Learners underwent SBPT in venipuncture in the skills laboratory. Assessments were conducted at two main points: 1) immediate assessment following the training and 2) delayed assessment one year after training. Learner self-assessments, independent assessor assessments for procedural competency, and communication skills assessments were conducted in both instances. The students were assessed for their competency in performing venipuncture by an independent assessor immediately following the training in the simulated setting and one-year post-training in the clinical setting, using the Integrated Procedural Protocol Instrument (IPPI). The student's communication skills were assessed by standardized patients (SP) and actual patients in the simulated and clinical settings, respectively, using the Communication Assessment Tool (CAT). RESULTS: Fifty-five pre-clerkship medical students were recruited for the study. A significant increase was observed in self-confidence [mean: 2.89 SD (Standard Deviation) (0.69)] and self-perceived competency [mean: 2.42 SD (0.57)] in performing venipuncture, which further improved at the delayed assessment conducted in the clinical setting (p < 0.001). Similarly, the IPPI ratings showed an improvement [immediate assessment: mean: 2.25 SD (1.62); delayed assessment: mean: 2.78 SD (0.53); p < 0.01] in venipuncture skills when assessed by an independent assessor blinded to the study design. A significant difference (p < 0.01) was also observed in doctor-patient communication when evaluated by SPs [mean: 2.49 SD (0.57)] and patients [mean: 3.76 SD (0.74)]. CONCLUSION: Simulation-based venipuncture training enabled students to perform the procedure with confidence and technical accuracy. Improved rating scores received at a one-year interval denote the impact of clinical training on skills acquisition. The durability of skills learned via SBPT needs to be further investigated.

Procedural simulation in venipuncture for medical undergraduates and its transfer to the bedside: a cluster randomized study.

Simulation is accepted as an effective method of learning procedural skills. However, the translational outcomes of skills acquired through simulation still warrants investigation. We designed this study to assess if skills laboratory training in addition to bedside learning (intervention group [IG]) would provide better learning results than bedside learning alone (control group [CG]) in the context of venipuncture training. This prospective, cluster-randomized, single-blind study took place at the Faculty of Medicine, University of Kelaniya, Sri Lanka. Seventeen clusters of second-year medical students were randomly assigned to either IG or CG. The IG trained on venipuncture in the skills laboratory, receiving instruction after modified Payton's Four Step Method. Following the training, students of both IG and CG underwent bedside learning for one month. Afterward, students of both groups performed venipuncture on actual patients in a clinical setting. An independent, blinded assessor scored students' performance using the Integrated Procedural Protocol Instrument (IPPI) and a checklist. Patients assessed students' performance with the Communication Assessment Tool (CAT). Eight and nine clusters were randomized to the intervention and control groups, respectively. IG completed significantly more single steps of the procedure correctly (IG: 19.36 ± 3.87 for checklist items; CG: 15.57 ± 4.95; p < 0.001). IG also scored significantly better on IPPI ratings (median: IG: 27 (12) vs. CG: 21 (8); p < 0.001). Rated by patients, students' communication skills did not significantly differ between the two groups. Simulation-based venipuncture training enabled students to perform the procedure on actual patients with a higher technical accuracy than students who learned venipuncture at the bedside. Students were able to transfer the skills acquired through venipuncture training at the skill laboratory to the bedside.

Challenges in Learning Procedural Skills: Student Perspectives and Lessons Learned for Curricular Design.

Phenomenon: Developing foundational clinical procedural skills is essential to becoming a competent physician. Prior work has shown that medical students and interns lack confidence and competence in these skills. Thus, understanding the student's perspective on why these skills are more difficult to acquire is vital for developing and reforming medical curricula. Approach: This study explored procedural skills learning experiences of medical students with qualitative methods. Through purposive sampling, 52 medical students from the third, fourth, and final years were selected for inclusion. Data were collected using six audio-recorded, semi-structured focus group discussions. Transcripts were manually coded and analyzed using inductive content analysis. Findings: Students provided rich and insightful perspectives regarding their experiences in learning procedural skills that fell into three broad categories: 1) barriers to procedural learning, 2) reasons for learning, and 3) suggestions for better learning outcomes. Students described a range of barriers that stemmed from both patient and clinician interactions. Students were reluctant to make demands for their own benefit during clerkships. The most commonly expressed reason for wanting to learn procedural skills was the desire to be a competent and independent intern. The motivators suggested that students felt empathetic toward interns and visualized a successful internship as a learning goal. Participants suggested peer learning, improved teaching of procedural skills, assessments, and feedback to improve their learning. Insights: This study generated valuable information to promote critical reflection on the existing curriculum and pedagogical approaches to procedural skills development. Medical educators need to sensitize the clinical teachers to student perspectives and what students are really learning to make impactful changes to teaching and learning procedural skills. Students' self-advocacy skills and self-directed learning skills need to be developed for them to seek out learning opportunities and to promote life-long learning. Lessons from this study may also apply to curriculum design in general, especially in teaching clinical skills. Empowering the learner and embracing a learner-centered approach to teaching and learning procedural skills will benefit future clinicians and their patients.

Tender cervical lymphadenitis as a herald of multi-system inflammatory syndrome in COVID-19 infection of children and adolescents: a report of two cases.

BACKGROUND: Post-COVID-19 multisystem inflammatory syndrome (MIS) has been increasingly recognized but fever with isolated tender cervical lymphadenitis as the initial presentation has been rarely reported. We present 2 female patients one a child and the other an adolescent. CASE PRESENTATION: Case 1 was a 13-year-old girl who presented with tender cervical lymphadenopathy and fever 3-weeks post-COVID-19, and then developed features of MIS 5 days later. Case 2, also female, was 18 years old. She had no history of COVID-19 infection or immunization but had a serologic diagnosis of COVID-19. She similarly presented with fever and tender cervical lymphadenopathy, and then progressed rapidly to develop features of MIS. Both patients responded well to treatment with immunosuppressants and intravenous immunoglobulin. CONCLUSION: Tender cervical lymphadenopathy could be the herald of multi-system inflammatory syndrome following COVID-19 infection among children and adolescents, which the clinicians must have a good suspicion about.

Molecular Characterization of Rickettsial Agents in Ticks (Acari: Ixodidae) from Sri Lanka.

Because the majority of spotted fever group rickettsiae are transmitted to humans by tick bites, it is important to understand which ticks might play a role in transmission of rickettsial pathogens in Sri Lanka. The purpose of our study was to conduct molecular surveillance of 847 ticks collected in different locations in central Sri Lanka to determine which were infected with Rickettsia and Anaplasmataceae. Molecular methods were used to identify the ticks and the agents detected. Most ticks (Amblyomma, Haemaphysalis, and Rhipicephalus) were collected by flagging, and lower number was collected from dogs, cattle, pigs, a pangolin, and tortoises. Five spotted fever genotypes were identified: a Rickettsia africae-like agent in Amblyomma larvae, Rhipicephalus massiliae and a related genotype identified in association with the tropical type of Rhipicephalus sanguineus from dogs and Rhipicephalus haemaphysaloides from dogs and cattle, and Candidatus R. kellyi and another novel genotype (SL94) in R. haemaphysaloides. Twenty-three ticks were positive for Anaplasmataceae, including one Anaplasma and two Ehrlichia genotypes. Because the sequence database for both ticks and rickettsial agents from Sri Lanka and southern India is not extensive, additional molecular characterization of the tick species of Sri Lanka and their rickettsial agents is required to understand their pathogenic potential more completely. However, several of the agents we identified in this survey may well be pathogenic for humans and domestic animals, and should be considered as a part of epidemiological surveillance and patient management.

Rickettsial illnesses, a leading cause of acute febrile illness.

Rickettsial illnesses, comprising mainly spotted fever group, typhus group and scrub typhus, are vector-borne re-emerging or newly emerging febrile illnesses where humans are an accidental dead-end host. They are a major cause of non-malarial febrile illnesses among returned travellers. They commonly present as an acute febrile illness and carry a characteristic entry wound (eschar) or a discrete erythematous maculo-popular rash based on the organism and the region. The illness severity is mainly dependent on the virulence of the rickettsial organism and delay in the diagnosis is known to cause severe illness with multi-organ involvement carrying high mortality. Almost all rickettsial infections respond to anti-rickettsial antibiotics such as doxycycline within 48-72 hours. Awareness of rickettsial illnesses and their various clinical presentations helps in early diagnosis and institution of appropriate treatment and hence prevent morbidity and mortality.

Predictive value of hepatic transaminases during febrile phase as a predictor of a severe form of Dengue: analysis of adult Dengue patients from a tertiary care setting of Sri Lanka.

OBJECTIVES: Dengue viral infection is an ongoing epidemic in Sri Lanka, causing significant mortality and morbidity. A descriptive-analytical study was carried out using serologically confirmed Dengue patients during a 6 month period. The relationship between the elevation of hepatic enzymes and severity of Dengue was assessed after stratifying recorded maximum AST/ALT (SGOT/SGPT) values 2-15 times elevated and by the phases of the illness. Sensitivity, specificity, predictive values, and ROC curves were assessed using maximum values for AST and ALT. RESULTS: Out of 255 patients, 107(42%) were females. The majority (52.9%) were in the 20-39 year age group. Only 19.6% had DHF. No statistically significant difference was noticed in the values of maximum transaminases during the febrile phase among DF and DHF patients. Higher sensitivity and low specificity with the 1-5 times elevation range was noticed, and a higher cut-off level of more than 5 times elevation showed low sensitivity and higher specificity. The combination of both transaminases cut-offs with age and sex also does not show clinically significant predictability of severe disease. The AST and ALT elevations are not showing discriminatory predictive value on dengue severity. As different serotypes cause different epidemics, it is important to carry out large-scale specific studies considering the serotypes.

Expression of Nitric Oxide Synthase and Nitric Oxide Levels in Peripheral Blood Cells and Oxidized Low-Density Lipoprotein Levels in Saliva as Early Markers of Severe Dengue.

BACKGROUND: Severe dengue (SD), experienced by only a fraction of dengue patients, can be lethal. Due to the lack of early markers that can predict the evolution of SD, all dengue patients have to be monitored under hospital care. We discovered early oxidative stress markers of SD to identify patients who can benefit from early intervention before the symptoms appear. METHODS: The expression of inducible nitric oxide synthase (iNOS) in peripheral blood cells (PBC), nitric oxide (NO), and oxidized low-density lipoprotein (oxLDL) levels in plasma and saliva collected at early stages of dengue infection from 20 nonsevere dengue fever (DF) patients and 20 patients who later developed SD were analyzed in a retrospective nested case-control study. RESULTS: The expression of iNOS is significantly (P < 0.05) lower in patients who developed SD than in DF patients at admission within 4 days from fever onset. Median plasma NO concentration within 4 days from fever onset is also significantly (P < 0.05) lower in patients who developed SD (17.9 ± 1.6 µmol/L) than DF (23.0 ± 2.1 µmol/L). Median oxLDL levels in plasma within 3 days from fever onset is significantly (P < 0.05) lower in patients who developed SD (509.4 ± 224.1 ng/mL) than DF (740.0 ± 300.0 ng/mL). Median salivary oxLDL levels are also significantly (P < 0.05) lower in patients who developed SD (0.8 ± 0.5 ng/mL) than DF (3.6 ± 2.6 ng/mL) within 4 days from fever onset. CONCLUSIONS: These findings suggest that the expression of iNOS (73% sensitivity, 86% specificity) and plasma NO (96% sensitivity, 61% specificity at 22.3 µmol/L; P < 0.05) may serve as early markers of SD within 3 days from fever onset. Salivary oxLDL levels may serve as early noninvasive markers of SD with a sensitivity and specificity, respectively, of 57% and 91% at 0.9 ng/mL; 76% and 55% at 2.3 ng/mL; and 100% and 50% at 4.6 ng/mL (P < 0.05) within 4 days from fever onset.

Descriptive Investigation of Strongyloidiasis Infection and Characterization of Strongyloides stercoralis Using Morphological and Molecular-Based Methods.

Strongyloidiasis is caused by the nematode Strongyloides stercoralis which has the unique ability to reproduce and complete its entire life cycle within the human host through its autoinfection cycle. Diagnosis of this infection is important because of its potential to cause fatal hyperinfection syndrome or disseminated infections in those with defective cellular immunity. Parasitological methods based on faecal microscopy and culture often fail to detect low-intensity infections. A multiplex polymerase chain reaction (PCR) assay was developed for the detection of S. stercoralis, Ascaris lumbricoides, and Enterobius vermicularis by designing primers specific for the ITS1 region of ribosomal DNA of S. stercoralis and A. lumbricoides and 18S region of rRNA of E. vermicularis. A 61-year-old patient presented with chronic gastrointestinal and respiratory symptoms and weight loss with a stool microscopy positive for helminth larvae. Stool cultures with the Harada-Mori technique yielded L3 larvae which were identified as S. stercoralis based on morphology. The multiplex PCR performed on DNA extracted from stool elicited the expected band at 129 bp on gel electrophoresis of the PCR yield providing molecular evidence of intestinal strongyloidiasis. The patient's gastrointestinal symptoms improved with a six-day course of albendazole (400 mg twice daily). Negative posttreatment stool microscopy, culture, and PCR confirmed successful clearance of infection. Molecular-based PCR assay is a promising tool to diagnose and assess the therapeutic efficacy of anthelmintics in intestinal helminthiases such as strongyloidiasis.

Differential expression of microRNA, miR-150 and enhancer of zeste homolog 2 (EZH2) in peripheral blood cells as early prognostic markers of severe forms of dengue.

BACKGROUND: Dengue presents a wide clinical spectrum. Most patients recover following a self-limiting non-severe clinical course. A small proportion of patients progress to severe disease, mostly characterized by plasma leakage with or without hemorrhage. Early symptoms of severe dengue (SD) are similar to those of non-severe dengue fever (DF). Severe symptoms manifest after 3-5 days of fever, which can be life threatening due to lack of proper medications and inability to distinguish severe cases during the early stages. Early prediction of SD in patients with no warning signs who may later develop severe infection is very important for proper disease management to alleviate related complications and mortality. microRNA are small non-coding RNA molecules that regulate post-transcriptional gene expression. Due to the remarkable stability and the role of microRNA in gene expression, altered expression of microRNA was evaluated to explore clinically relevant prognostic markers of severe dengue. METHODS: The relative expression of microRNA hsa-let-7e (let-7e), hsa-miR-30b-5p (miR-30b), hsa-miR-30e-3p (miR-30e), hsa-miR-33a (miR-33a), and hsa-miR-150-5p (miR-150) and several putative target genes in peripheral blood cells (PBC) collected from 20 DF and 20 SD positive patients within 4 days from fever onset was evaluated by quantitative reverse transcription PCR (qRT-PCR). RESULTS: miR-150 showed significant (P < 0.01) up regulation in PBC of SD patients compared to DF patients during the acute phase of infection. Expression of enhancer of zeste homolog 2 (EZH2) was significantly (P < 0.01) down regulated indicating that genes involved in epigenetic regulation are also differentially expressed in SD patients during the early stage of infection. CONCLUSIONS: Differential expression of microRNA miR-150 and the putative target gene EZH2 may serve as reliable biomarkers of disease severity during early stages of dengue infection.

Rickettsia conorii O antigen is the target of bactericidal Weil-Felix antibodies.

Rickettsial diseases have long been diagnosed with serum antibodies cross-reactive against Proteus vulgaris (Weil-Felix reaction). Although Weil-Felix antibodies are associated with the development of immunity, their rickettsial target and contribution to disease pathogenesis are not established. Here, we developed a transposon for insertional mutagenesis of Rickettsia conorii, isolating variants defective for replication in cultured cells and in spotted fever pathogenesis. Mutations in the polysaccharide synthesis operon (pso) abolish lipopolysaccharide O-antigen synthesis and Weil-Felix serology and alter outer-membrane protein assembly. Unlike wild-type R. conorii, pso mutants cannot elicit bactericidal antibodies that bind O antigen. The pso operon is conserved among rickettsial pathogens, suggesting that bactericidal antibodies targeting O antigen may generate universal immunity that could be exploited to develop vaccines against rickettsial diseases.

A preliminary survey of filarial parasites in dogs and cats in Sri Lanka.

Human brugian filariasis has re-emerged in Sri Lanka after a quiescent period of four decades. This study investigated the prevalence of canine and feline filarial parasites in three localities with human sub-periodic brugian filariasis, in order to determine their potential reservoir status. All reachable dogs and cats, both stray and domestic, within a 350m radius of an index case of brugian filariasis in three locations (Madampe, Wattala and Weliweriya) were screened for microfilariae using Giemsa stained thick blood smears. A representative sample of canine and feline blood samples positive for Brugia spp. microfilariae by microscopy, from each of the three locations, were further analyzed by PCR with specific primers for internal transcribed spacer region 2 (ITS2) of the ribosomal DNA. A total of 250 dogs and 134 cats were screened. The overall microfilaraemia rates were high among both dogs (68.8%) and cats (47.8%). The prevalence of microfilaraemia was significantly higher among dogs than cats (p<0.05). Two filarial species were identified based on morphology of microfilariae: Dirofilaria (Nochtiella) repens (dogs, 54.4% and cats, 34.3%) and Brugia spp. (dogs, 51.6% and cats, 30.6%). PCR analysis of canine (n = 53) and feline (n = 24) samples elicited bands in the region of 615bp, which confirmed Brugia malayi infection. Co-infection with D.(N.) repens was detected by PCR with an additional band at 484bp, in 36 canine and 17 feline samples. Overall microfilaraemia rates of dogs (81.8%) and cats (75%) in Madampe (rural) were significantly higher than in urbanized Wattala (dogs, 62.4% and cats, 26.0%) (p<0.05). High rates of zoonotic filarial infections strongly implicate dogs and cats as potential reservoirs for human dirofilariasis and brugian filariasis in Sri Lanka.

Morbidity management and disability prevention for lymphatic filariasis in Sri Lanka: Current status and future prospects.

BACKGROUND: Sri Lanka was acknowledged to have eliminated lymphatic filariasis (LF) as a public health problem in 2016, largely due to its success in Mass Drug Administration (MDA) to interrupt disease transmission. Analysis of the Strengths, Weaknesses, Opportunities and Threats (SWOT) of the national Morbidity Management and Disability Prevention (MMDP) program, the other pillar of the LF control program, was carried out with the objective of evaluating it and providing recommendations to optimize the use of available resources. METHODOLOGY: A situation analysis of the MMDP activities provided by the state health sector was carried out using published records, in-depth interviews with key informants of the Anti Filariasis Campaign, site-visits to filariasis clinics with informal discussions with clinic workforce and personal communications to identify strengths and weaknesses; and opportunities to overcome weaknesses and perceived threats to the program were explored. The principal strength of the MMDP program was the filariasis clinics operational in most endemic districts of Sri Lanka, providing free health care and health education to clinic attendees. The weaknesses identified were the low accessibility of clinics, incomplete coverage of the endemic region and lack of facilities for rehabilitation. The perceived threats were diversion of staff and resources for control of other vector-borne infections, under-utilization of clinics and non-compliance with recommended treatment. Enhanced high level commitment for MMDP, wider publicity and referral systems, integration of MMDP with other disease management services and collaboration with welfare organizations and research groups were identified as opportunities to overcome weaknesses and challenges. CONCLUSIONS: The recommended basic package of MMDP was functional in most of the LF-endemic region. The highlighted weaknesses and challenges, unless addressed, may threaten program sustainability. The identified opportunities for improvement of the programme could ensure better attainment of the goal of the MMDP program, namely access to basic care for all affected by lymphatic filarial disease.

Human infection with sub-periodic Brugia spp. in Gampaha District, Sri Lanka: a threat to filariasis elimination status?

BACKGROUND: Post-mass drug administration (MDA) surveillance during the lymphatic filariasis (LF) elimination program in Sri Lanka, revealed the re-emergence of brugian filariasis after four decades. This study was done with the objectives of investigating the epidemiology and age-specific vulnerability to infection. Surveillance was done using night blood smears (NBS) and the Brugia rapid test (BRT), to detect microfilaria (MF) and anti-Brugia IgG4 antibodies in blood samples collected from an age-stratified population enrolled from two high-risk study areas (SA)s, Pubudugama and Wedamulla in the Gampaha District. The periodicity of the re-emergent Brugia spp. was characterized by quantitative estimation of MF in blood collected periodically over 24 h using nucleopore-membrane filtration method. RESULTS: Of 994 participants [Pubudugama 467 (47.9%) and Wedamulla 527 (53%)] screened by NBS, two and zero cases were positive for MF at Pubudugama (MF rate, 0.43) and Wedamulla (MF rate, 0), respectively, with an overall MF rate of 0.2. Of the two MF positives, one participant had a W. bancrofti while the other had a Brugia spp. infection. Of 984 valid BRT test readings [Pubudugama (n = 461) and Wedamulla (n = 523)], two and seven were positive for anti-brugia antibodies by BRT at Pubudugama (antibody rate 0.43) and Wedamulla (antibody rate 1.34), respectively, with an overall antibody rate of 0.91. Both MF positives detected from SAs and two of three other Brugia spp. MF positives detected at routine surveillance by the National Anti-Filariasis Campaign (AFC) tested negative by the BRT. Association of Brugia spp. infections with age were not evident due to the low case numbers. MF was observed in the peripheral circulation throughout the day (subperiodic) with peak counts occurring at 21 h indicating nocturnal sub-periodicity. CONCLUSIONS: There is the low-level persistence of bancroftian filariasis and re-emergence of brugian filariasis in the Gampaha District, Sri Lanka. The periodicity pattern of the re-emergent Brugia spp. suggests a zoonotic origin, which causes concern as MDA may not be an effective strategy for control. The importance of continuing surveillance is emphasized in countries that have reached LF elimination targets to sustain programmatic gains.

Widespread subcutaneous necrosis in spotted fever group Rickettsioses from the coastal belt of Sri Lanka- a case report.

BACKGROUND: Spotted fever group rickettsioses (SFGR) transmitted mostly by ticks are increasingly discovered around the World and some of them are either re-emerging or emerging in Sri Lanka. Accidental human infections caused by these vector borne zoonotic diseases generally give rise to nonspecific acute febrile illnesses which can be complicated by multi organ involvement carrying high morbidity and mortality. Nonspecific clinical features and non-availability of early diagnostic facilities are known to result in delay in the diagnosis of rickettsial infections. Therefore, awareness of their prevalence and more importantly their clinical features would be help in the early diagnosis and institution of appropriate therapy. CASE PRESENTATION: A 39-year-old otherwise healthy female presented with an acute febrile illness complicated by severe small joint and large joint arthritis, jaundice, acute kidney injury and disseminated intravascular coagulation (DIC) mimicking palindromic rheumatism or severe sepsis. She later developed a widespread fern-leaf pattern necrotic skin rash with evidence of vasculitis on the palms and soles, aiding the clinical diagnosis of SFGR. She had very high antibody titres against R. conorii antigen confirming the diagnosis and recovered completely with anti-rickettsial therapy. CONCLUSION: We feel that clinicians should be aware of the unusual clinical presentations such as purpura fulminans and 'fern-leaf' pattern necrotic skin rash of SFGR infection. Such knowledge would not only benefit those who practice in tropics with limited diagnostic facilities but also would improve the management of acute febrile illness in returning travelers who visit endemic areas.

Sporadic cases of adult measles: a research article.

BACKGROUND: Measles caused by a paramyxovirus, characterized by fever, malaise, cough, coryza conjunctivitis, a maculopapular rash is known to result in pneumonia, encephalitis and death. Fatal cases of measles in Sri Lanka are rare after implementation of the National Immunization Programme in 1984. Thereafter 0.1% case fatality rate was observed during October 1999-June 2000 which is a very low figure compared to other regional countries. Immunization guidelines were further revised in 2001, 2011 and in 2012 when additional immunization was recommended to age group 4-21 years; who are likely to have inadequate immunization, in order to achieve elimination of Measles by 2020. However, in 2013-2014, 4690 cases were reported and the majority were children less than 1 year of age. The occurrence in adults is hard to retrieve in published epidemiological reports, however had been 38% (out of 1008 patients) in the 3rd quarter of 2013. During this outbreak 73/101 (72%) reported from the North Central Province of Sri Lanka had been more than 12 years of age with 50% being more than 29 years. 14 Sri lankan adult patients [median age 32 years (range 25-48)] who presented sporadically from June 2014 to March 2016, with confirmed measles infection were enrolled retrospectively after informed consent. Details with regards to their clinical presentation, immunization and other relevant areas were collected using an interviewer administered questionnaire or using patient management records. RESULTS: The patients presented with high fever, headache, severe body aches, sore throat, dry cough, intense tearing, red eyes and posterior cervical lymphadenopathy over 3-5 days duration. Later they developed discrete maculopapular rash helping the diagnosis. They had a variable degree of leucopenia, lymphocytosis, thrombocytopenia and derangements in the liver functions mimicking any other acute febrile illnesses such as dengue, chikungunya, leptospirosis or Zika virus infection. CONCLUSION: At least a 3-5 day delay in the diagnosis was observed (even after the appearance of the rash in some patients), due to non-awareness of its occurrence, unfamiliarity of measles in adults, non-specific nature of the illness and non-availability of rapid diagnostics, risking transmission to the immune-compromised or non-immune staff or patients. Identification of the source of infection in these sporadic adult cases and their virologic surveillance and molecular epidemiology will be important to interrupt the transmission and to achieve the targeted elimination of measles from Sri Lanka by 2020.

Genotypic characterization of Orientia tsutsugamushi from patients in two geographical locations in Sri Lanka.

BACKGROUND: To date more than 20 antigenically distinct strains of Orientia tsutsugamushi (OT) reported within the tsutsugamushi triangle that cause an undifferentiated acute febrile illness in humans. Genotypic characterization of OT in different geographic regions or within the same country, is important in order to establish effective diagnostics, clinical management and to develop effective vaccines. Genetic and antigenic characterization of OT causing human disease in OT-endemic regions is not known for Sri Lanka. METHODS: Adult patients and children who were admitted with an acute febrile illness and presumed to having acute scrub typhus based on presence of an eschar and other supporting clinical features were recruited. Eschar biopsies and buffy coat samples collected from patients who were confirmed having OT by IFA were further studied by real time PCR (Orientia 47 kD) and nested PCR (Orientia 56 kD) amplification. DNA sequences were obtained for 56 kD gene amplicons and phylogenetic comparisons were analyzed using currently available data in GenBank [Neucleotide substitution per 100 residues, 1000 Bootstrap Trials]. RESULTS: Twenty eschar biopsies (Location1,19, Location 2,1) and eight buffy coat samples (Location1,6, Location2,2) examined by real time PCR revealed Orientia amplicons in 16 samples. DNA sequences were obtained for the 56 kD gene amplicons in 12 eschars and 4 buffy coat samples. The genotypes of the Location1 samples revealed that, 7 exhibiting close homology with JP1 [distantly related to UT177 Thai (Karp related)], five had close homology with Kato strain, two had close homology with JGv and JG AF [Distantly related to Kawasaki M63383] and one had close homology with Gilliam strain. The Location 2 strain was closely related to Kuroki-Boryong L04956, the genotype which is distributed in far eastern Asia. Similar to other patients in the cohort this patient also had never travelled out of Sri Lanka. CONCLUSIONS: We observed all three main OT genotypes in Sri Lanka, and the majority fell into Thai Karp related clade. These results demonstrate great antigenic diversity of OT in the studied areas of Sri Lanka.

Surveillance for transmission of lymphatic filariasis in Colombo and Gampaha districts of Sri Lanka following mass drug administration.

BACKGROUND: Sri Lanka was recently declared by WHO to have eliminated lymphatic filariasis as a public health problem, after conclusion of annual mass drug administration. Our aim was to assess the lymphatic filariasis situation, following mass drug administration. METHODS: Surveillance was done in two districts of the Western Province in two consecutive phases (2009-2010 and 2013-2015), by examining 2461 thick night blood smears and performing 250 dipstick tests on children for antibodies to Brugia malayi. RESULTS AND CONCLUSIONS: Decline in bancroftian microfilaraemia (microfilaria rate 0.32% to zero) supports elimination, but re-emergence of brugian filariasisis (antibody rate, 1.6%; one microfilaria positive) is a cause for concern.