A Rapid and Satisfactory Outcome with Combined Immunosuppressive Therapy in Acquired Haemophilia A with Underlying Tuberculosis.

Acquired haemophilia A (AHA) is a rare disorder with an incidence of 1.5 cases per million per year in the United Kingdom. The incidence could be underestimated due to difficulty in diagnosis and also due to the fact that people with low titre inhibitor levels are asymptomatic. It is usually a disease affecting elderly but a disease peak in the younger population is known. The common underlying diseases are autoimmune disorders, malignancies, infections, and drugs. However, approximately 50% of the cases do not have a specific aetiology and about 10% will not have bleeding manifestations. Therefore, an isolated prolongation of APTT should be evaluated, especially prior to any haemostatic challenges. We report a case of a middle-aged man who presented with bleeding due to AHA associated with high inhibitory titres and active pulmonary tuberculosis. He was treated with both antituberculous and combined-aggressive immunosuppressive therapy which resulted in satisfactory disease remission.

Aseptic meningitis as the initial presentation of Leptospira borgpetersenii serovar Tarassovi: two case reports and a literature review.

BACKGROUND: Leptospirosis is a zoonotic illness caused by pathogenic spirochetes of the genus Leptospira. The disease spectrum ranges from a mild influenza-like presentation to a more serious Weil's syndrome. Leptospirosis rarely presents as a primary neurological syndrome. We report two cases of Leptospira borgpetersenii serovar Tarasssovi presenting as aseptic meningitis in Sri Lanka. CASE PRESENTATION: We describe case reports of two patients presenting as symptomatic aseptic meningitis due to neuroleptospirosis. Both patients had significant neurological involvement at presentation in the absence of common clinical features of leptospirosis. These patients were initially managed as bacterial or viral meningitis and leptospirosis was suspected due to a history of exposure to contaminated water. Subsequently, they were diagnosed to have neuroleptospirosis by positive Leptospira serology and both patients gained full recovery. CONCLUSION: Our report highlights the importance of considering leptospirosis as a differential diagnosis in patients with aseptic meningitis in endemic settings. Obtaining a detailed occupational and recreational history is helpful in diagnosing neuroleptospirosis promptly. We report the association of Leptospira borgpetersenii serovar (sv.) Tarassovi (strain bakeri) in causing aseptic meningitis, which has not been reported to the best of our knowledge.

A Descriptive Study on Sepsis: Causes, Outcomes, and Adherence to Guidelines on Patients with Sepsis at a Tertiary Care Hospital in Sri Lanka.

The global incidence of sepsis is increasing, and mortality remains high. The mortality is even higher in resource-poor countries where facilities and equipment are limited. The Surviving Sepsis Campaign (SSC) recommends an updated hour-1 bundle based on the evidence from the International Guidelines for Management of Sepsis and Septic Shock 2018. To reduce mortality from sepsis, compliance with the "bundle" is essential. Data from developing countries like Sri Lanka on the management of sepsis according to the SSC guidelines are not available. Hence, this study looks at the patient characteristics and management of septic patients at a tertiary care hospital in Sri Lanka. Patients admitted to the University Medical Unit of Colombo South Teaching Hospital from January to August 2019 fulfilling the inclusion criteria were included. The hour-1 sepsis bundle adherence, demographic data, and management were recorded. There were 387 patients: 163 males and 224 females. The age range was 15-95 with a mean age of 63. 83.7% were direct admissions while 16.3% were transfers from a peripheral hospital. The most common source of infection was urine (82 (21.2%)) followed by blood stream (105 (27.1%)) and skin and soft tissue (114 (29.5%)). One-hour SSC bundle compliance is as follows: administration of intravenous fluids: 42 (10.9%), blood cultures before antibiotics: 225 (58.1%), first dose antibiotic: 15 (3.9%), and arterial blood gas: 60 (15.5%). Staffing capacity did not make a difference to adherence to the bundle. The study mortality rate was 37 (9.6%). Binary logistic regression indicates that quick sequential organ failure assessment (qSOFA) score is a significant predictor of mortality (chi-square = 35.08, df = 3, and p = 0.001 (<0.05)) with an odds ratio (OR) of 7.529 (95% CI 3.597-14.323). The other predictors, age, sex, adherence to sepsis care bundle, and comorbidities, were not significant. In conclusion, mortality of sepsis is high and adherence to sepsis care bundle is poor in Sri Lanka even at a tertiary care hospital. Education and training of staff are needed to boost adherence. This will in turn improve quality of care and outcomes of septic patients in resource-poor countries.

Physical activity levels of patients prior to acute coronary syndrome - Experience at a tertiary care hospital in Sri Lanka.

OBJECTIVES: Physical inactivity is associated with high cardiovascular risk. The purpose of this study was to study physical activity levels of patients with acute coronary syndrome (ACS). METHODOLOGY: A total of 504 patients, from the Professorial Unit of the Colombo South Teaching Hospital completed the International Physical Activity Questionnaire (IPAQ). IPAQ is a validated questionnaire used internationally to objectively measure physical activity. Both the total volume and the number of sessions of activity are included in the IPAQ. Populations are divided into three levels based on physical activity levels: low, moderate and high activity. RESULTS: Out of 504 patients, 128 (25.1%) were highly active, 87 (17.1%) were minimally active and 289 (56.7%) were found be inactive. When considering mets per week 134 (26.3%) spent less than 1000mets/week. Physical activity levels of men and women were similar (p=0.06). There was a no significant association between body mass index (BMI) with total IPAQ score (p=0.11). There was no difference in the physical activity levels of patients presenting with different types of ACS: ST-Elevation Myocardial Infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI) or unstable angina (UA) (p=0.36). The activity levels did not affect the severity of ACS assessed by Thrombolysis In Myocardial Infarction (TIMI) scores. (NSTEMI/UA p=0.24, STEMI p=0.10). CONCLUSION: In Sri Lanka, a majority of patients with ACS were physically inactive. Physical inactivity is one of the remediable major risk factors of ACS and an active life style should be promoted.

Tricuspid Valve Endocarditis due to Streptococcus bovis in a Patient with Ventricular Septal Defect: A Rare Manifestation-Case Report and Review of the Literature.

Streptococcus bovis endocarditis has 18%-62% association with colonic neoplasms with multivalvular involvement and affects mainly elderly males leading to severe cardiac dysfunction, septic embolization, and neurological complications. The aortic valve is the commonest valve to be affected followed by aortic and mitral valves together. However, involvement of tricuspid valve is extremely rare. There are no reported cases of Streptococcus bovis endocarditis affecting the tricuspid valve in the presence of ventricular septal defect with left to right shunt. We report the case of a 25-year-old female with ventricular septal defect who was diagnosed to have tricuspid valve endocarditis caused by Streptococcus bovis. Her detailed colonoscopy, upper gastrointestinal endoscopy, liver biochemistry, and ultrasound scan of the abdomen were normal. She made a very good recovery with six weeks of intravenous antibiotics. This is the first case of tricuspid valve endocarditis caused by Streptococcus bovis in association with ventricular septal defect without any colonic lesions.