A Rare Case of Double Pyramidal Lobe of the Thyroid Gland.

The pyramidal lobe is an anatomical component of the thyroid gland seen in up to 65% of individuals. It represents the distal, nondegenerate part of the thyroglossal duct. The double pyramidal lobe is a very rare occurrence, and this is the first reported case in Sri Lanka. A 40-year-old woman presented a long-standing goiter. Her evaluation revealed a benign multinodular goiter with a dominant right colloid nodule and background thyroiditis. She was euthyroid and had no compressive symptoms. Considering cosmesis, the patient opted for total thyroidectomy during which two pyramidal lobes were identified. The rest of the thyroid gland and the parathyroids had no anomalies. After an uneventful postoperative stay, she was discharged later. This is a very rare case where the patient had two separate pyramidal lobes; a phenomenon documented in less than 10 cases around the world. In addition to embryology, the pyramidal lobe has significance in clinical practice. It can be associated with benign and malignant disease of the thyroid; focal and diffuse. Incomplete removal may result in recurrence of the disease in the remaining thyroid tissue of the pyramidal lobe. Therefore, active inspection of the lobe including its anatomy during thyroid surgery and complete excision when indicated is of paramount importance.

A rare case of melioidosis presenting as myositis in Sri Lanka.

BACKGROUND: Melioidosis caused by Burkholderia pseudomallei is an emerging infection in Sri Lanka with a high case fatality rate. The disease usually manifests as pneumonia, however multisystem involvement is common. Myositis is an extremely rare occurrence and this is the only documented case where the initial presentation of melioidosis has been myositis and later complicated to myonecrosis. CASE PRESENTATION: A 45-year-old gentleman with pre-existing diabetes presented with a tender, right thigh lump for 1 week duration without any history of trauma or infection. Investigations revealed neutrophil leukocytosis, high erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels whilst ultrasonography showed focal myositis of right quadriceps. The patient went into sepsis amidst antibacterial treatment which warranted urgent surgery. At surgery, a large intramuscular abscess with myonecrosis was observed within vastus medialis which was completely drained and pus was taken for culture which eventually isolated Burkholderia pseudomallei. Melioidosis was diagnosed and intravenous meropenem was prescribed for 3 weeks. Following complete recovery, the patient was discharged on doxycycline and trimethoprim sulfamethoxazole for 3 months. CONCLUSIONS: Melioidosis, an endemic disease in south east Asia and northern Australia, is an emerging infection in Sri Lanka. Myositis is a rare presentation of the disease that can lead to myonecrosis and abscess formation which can cause rapid disease escalation and sepsis. Early surgical intervention may be life-saving in such cases where antibiotic therapy alone may not suffice.

Clinical and epidemiological characteristics of cutaneous leishmaniasis in Sri Lanka.

BACKGROUND: Leishmaniasis, a vector borne tropical/subtropical disease caused by the protozoan Leishmania is transmitted to humans by sandfly vectors Phlebotomus and Lutzomyia. The principal form found in Sri Lanka is cutaneous leishmaniasis (CL) and is caused by Leishmania donovani. A rising trend in disease prevalence has been observed recently in Sri Lanka and the island is in fact the newest endemic focus in South Asia. Determining the prevalence of smear positivity among clinically suspected CL patients, identifying risk factors and specific clinical presentations of CL in order to implement preventive and early treatment strategies were the objectives of this study. METHODS: A sample of 509 clinically suspected cases of CL referred to the Department of Parasitology from all across Sri Lanka between 2005 and 2015 was selected consecutively. Diagnosis was confirmed by microscopic visualization of the Leishmania amastigote from the slit skin smear. A structured questionnaire was used to identify exposure related risk factors and a clinical examination was performed to identify lesion characteristics. RESULTS: Out of 509 clinical cases, 41.5% (n = 211) were smear positive. The study population ranged from ages 1 to 80 years (mean age = 34.76) and the most affected age group was 40-49. Of the smear positives, 58.85% were males. Majority (47.86%) were from the North Western region (Kurunegala) of the country and were exposed to scrub jungles. Sand fly exposure (p = 0.04) and positive contact history (p = 0.005) were significant risk factors for smear positivity. Erythema (p = 0.02), lack of pruritus (p = 0.02) and scaly appearance (p = 0.003) were significant lesion characteristics in smear positivity. Lesions were commonly found in the exposed areas and the commonest morphological type was papulo-nodular. CONCLUSIONS: An increasing trend in the spread of cutaneous leishmaniasis from endemic to non-endemic areas has become evident. Positive contact history and sandfly exposure were significant risk factors for smear positivity which may indicate the possibility of human reservoir hosts in infection transmission. Lack of pruritus, scaly appearance and erythema were highly significant lesion characteristics associated with Leishmania positive smears which can be used for the clinical diagnosis of CL.

Seroprevalence of toxoplasmosis and risk factors of Toxoplasma gondii infection among pregnant women in Sri Lanka: a cross sectional study.

BACKGROUND: Toxoplasma gondii is an intracellular protozoan infecting humans and animals. Infection in adults usually causes mild disease but greater importance lies in preventing transplacental transmission which can cause major foetal anomalies and is vital to identify infection in pregnancy. Research on this regard in Sri Lanka is scarce and would be beneficial in developing antenatal care strategies for improved foetal outcome. METHODS: A random sample of 536 pregnant women attending antenatal care in Teaching Hospital Peradeniya from 2010 to 2013 was recruited for this study. Blood samples were tested for Toxoplasma gondii IgG and IgM antibodies from the participants by using a commercial ELISA kit with a cut-off OD value of >1 and a structured questionnaire was used to identify the exposure to risk. Bivariate analysis using the Chi Square test was used to calculate associations between documented risk factors and seropositivity and a p value of <0.05 was taken as significant. RESULTS: Among the participants 160 (29.9%) were positive for T. gondii IgG antibodies and 2 (0.37%) were IgM positive. The seroprevalence in the first, second and third trimesters were 30.4%, 30.6% and 26.1% respectively. Of the risk factors studied, preparation and selling raw meat (p = 0.05) and household gardening (p = 0.01) were significant whereas the presence of domesticated cats and dogs, eating locally produced meat or dairy products did not show significant associations. CONCLUSIONS: Seroprevalence of T. gondii present among pregnant women attending antenatal care in Peradeniya was 29.9% indicating high level of transmission among the study population. However 70.1% of the study population were seronegative and were susceptible to primary acute infection during pregnancy and possible foetal anomalies. Therefore implementing health education especially on the aforementioned risk factors is recommended.