Hump-nosed pit viper (Hypnale hypnale and Hypnale zara) envenoming in Deniyaya, Sri Lanka: Epidemiological and clinical features from a prospective observational study.

Hypnale hypnale, Hypnale zara and Hypnale nepa are the three species of Hump nosed pit vipers that are implicated in human bites in Sri Lanka. H. zara and H. nepa are two endemic species to the country. The objective of the study was to characterize epidemiology and clinical features after different Hump nosed pit viper species bites. A prospective observational study was conducted in Base Hospital Deniyaya from 2013 to 2015. Hump nosed pit viper as the offending snake was identified when the victims brought live or dead specimens. Species identification of dead specimen was done by a herpetologist. Clinical details were recorded during the hospital stay. 83 Hump nosed pit viper bite patients (19-81 years) were studied. Fifty two dead specimens were identified as 39 of H. zara and 13 of H. hypnale by the herpetologist. No H. nepa was identified. Thirty one live snakes were identified as Hump nosed pit vipers and released in to the wild. Envenoming was reported throughout the year. Eighty (96.4%) were daytime bites. Hands (43.4%), feet (55.4%) and arms (1.2%) were affected sites. Sixty two (74.7%) were bitten in tea plantations. All had pain over bite site. Overall, sixty nine (83.1%) had local swelling, seven (8.4%) extensive limb swelling, nineteen (22.9%) haemorrhagic blisters, and seven (8.4%) regional lymphadenopathy. Four (4.8%) patients had incoagulable blood by 20WBCT. H. zara bites had 28.2% haemorrhagic blisters, 7.7% extensive limb swelling and 2.6% coagulopathy. H. hypnale bites had 7.7% each extensive limb swelling and coagulopathy and 23.1% haemorrhagic blisters. None developed elevated serum creatinine. Neurotoxicity was not noted. Hump nosed pit viper bites caused substantial morbidity. Risk factors included day time outdoor activities and occupation. Pain, extensive limb swelling, bite site swelling, haemorrhagic blisters, regional lymphadenopathy and coagulopathy were prominent clinical features. Nephrotoxicity and neurotoxicity were notably absent. Clinical features varied depending on the species implicated.

Sri Lankan green pit viper (Trimeresurus trigonocephalus) bites in Deniyaya: A clinico-epidemiological study.

Green pit viper (Trimeresurus trigonocephalus) is endemic to Sri Lanka and bites are reported from tropical rain forest and plantation areas. As scant data exists on clinico-epidemiological features of Sri Lankan green pit viper bite, objective of this study was to address this knowledge gap. A prospective observational study was conducted in Base Hospital Deniyaya from October 2013 to September 2015. Green pit viper as the offending snake was identified when the victims brought live or dead specimens. When the specimen was not available, green pit viper was identified by the victim pointing to preserved specimens and photographs of green pit viper and different similar appearing snakes. Clinical details were recorded during the hospital stay. Twenty four green pit viper bite patients (17-68 years) were studied. All cases were daytime bites despite green pit viper being a nocturnally active snake. Sixteen patients (67%) were bitten while they were working in tea plantation. Hands (42%), feet, (33%), forearms (8%), legs (8%), thighs (4%) and shoulders (4%) were the sites of bites. Thirteen (54%) had extensive limb swelling. Nine (38%) had local swelling and two had no swelling. Three (12.5%) developed haemorrhagic blisters. Four (17%) had regional lymphadenopathy. Two (8%) developed non clotting blood by the TWBCT. Green pit viper bites caused substantial morbidity. Risk factors included day time outdoor activities in bordering villages of tropical rain forests and occupation. Pain, extensive limb swelling and bite site swelling were prominent clinical features. However haemorrhagic blisters, regional lymphadenopathy and coagulopathy were reported. Nephrotoxicity and neurotoxicity were notably absent.

Revisiting lip shave: a solution for disorders of the vermilion border.

Actinic keratosis, leukoplakia, carcinoma in situ, and superficially invasive carcinomas of the lower lip are caused mainly by the cumulative effects of exposure of the vermilion of the lower lip to ultraviolet radiation. Current treatments all have limitations: cryosurgery or electrosurgery is suitable to treat only focal lesions; topical chemotherapy, which is an option for diffuse actinic damage, yields unreliable results; and laser treatment fails to rejuvenate the vermilion. However, "lip shave", which involves full-thickness excision of the damaged vermilion and reconstruction with an advancement labial mucosal flap, will produce a fresh mucosal lining to the vermilion border. We describe our experience of the technique and evaluate the functional and aesthetic outcomes in 20 patients treated between January 2011 and January 2016. The follow-up period ranged from 24 to 60 months. Three-quarters of the patients had dysplasia or superficially invasive malignancy. Resected lesions were about 63mm long, 13.7mm wide, and 3.9mm deep. No patients had recurrence or secondary lesions during follow up, functional disturbance was minimal, and the cosmetic outcome pleasing. Lip shave can efficiently reconstruct the vermilion of the lower lip with minimum deformity.

Bee and wasp stings in Deniyaya; a series of 322 cases.

OBJECTIVES: To describe wasp and bee species that sting humans, analyse risk factors and clinical features. METHODS: A prospective observational study was conducted on patients presenting to Base Hospital Deniyaya with suspected bee and wasp stings from 2011 to 2013. Data were gathered using a questionnaire and specimens of offending insects collected for identification. When the insect specimen was unavailable, identification was made by the victim selecting (without prompting) from several dead specimens presented by the first author. RESULTS: There were 322 patients (mean age: 42.5 years, SD: 15.1, 173 [53.7%] males). Insects were brought by 55 (17%) and 267 (83%) were identified using specimens. All occurred during day-time, 142 (44.1%) during August and September, and 200 victims (62%) were tea plantation workers. Majority (78.9%) reported a localized painful self-limiting swelling without systemic features and 15 (4.6%) developed anaphylactic shock. None died. Five specimens were available from those in anaphylactic shock (four Apis dorsata, one Ropalidia marginata). Vespa tropica stinging caused a characteristic skin lesion. Of the 55 specimens, 46 (83.6%) were Apis dorsata (Giant honey-bee, ''Bambara''), 8 (14.5%) Vespa tropica (Greater banded hornet, ''Debara'') and one Ropalidia marginata (Paper wasp, ''Kaladuruwa''). CONCLUSIONS: Only three hymenoptera species stings were reported. Risk factors included day-time outdoor activities, occupation (tea plantation workers) and period of year. The latter may be due to pollen season when the insects are found in abundance. Only 4.6% of the patients developed anaphylactic shock. Vespa tropica stings led to a unique skin lesion.

Silent rupture of aortic aneurysm mimicking lung malignancy.

Extra-pulmonary diseases may mimic pulmonary lesions on chest radiography. We report a case of a silent rupture of an atherosclerotic thoracic aortic aneurysm with peripheral thrombus formation, that closely mimicked a complicated lung malignancy.

Efficacy of low dose dexamethasone in severe thrombocytopenia caused by dengue fever: a placebo controlled study.

BACKGROUND: The use of corticosteroids in the management of thrombocytopenia in dengue fever remains untested. OBJECTIVES: To test whether intravenous low dose dexamethasone is efficacious in increasing platelet count in acute severe thrombocytopenia in dengue infection. METHODS: We undertook a placebo controlled study at the Teaching Hospital, Peradeniya, Sri Lanka in July 2004. Patients with thrombocytopenia (platelet count <50x10(9)/l) were allocated to the treatment and placebo groups using the sealed envelop method. The treatment group received an initial intravenous dose of 4 mg dexamethasone, followed by 2 mg doses every 8 h for 24 h, and the placebo group received normal saline. The primary outcome was the degree of mean platelet count rise. RESULTS: Each group comprised 100 patients and their baseline data and other variables (headaches, nausea, flush, temperature, pulse, blood pressure, haematocrit, white cell count and haemoglobin) were similar. The primary outcome--mean platelet count (x10(9)/l)--increased steadily in both groups from day 1 to 4 and showed no significant difference between the two groups (p>0.05): day 1, 35 vs 35 (p = 0.70); day 2, 47 vs 43 (p = 0.19); day 3, 64 vs 59 (p = 0.31); day 4, 72 vs 78 (p = 0.55). Analysis of variance (ANOVA) statistics showed a significant linear association of mean platelet counts by days in either group (p<0.001). Regression analysis identified the day of the illness and patient age as the independent predictors of platelet count change. CONCLUSION: At a low dose regimen, dexamethasone was not effective in achieving a higher rise of platelet count in dengue infection.