Isolated Lupus-Associated Protein-Losing Enteropathy in a Resource-Limited Centre.

Systemic lupus erythematosus (SLE) is a relatively common autoimmune disease with recently reported cases of lupus-associated protein-losing enteropathy (LUPLE) as an unusual manifestation. It is a well-recognized clinical entity predominantly affecting middle-aged Asian females. LUPLE is diagnosed by exclusion of possible causes for hypoalbuminemia in a patient with positive anti-nuclear antibody (ANA). LUPLE as the first manifestation of SLE is rare but it is a well-recognized complication secondary to SLE. We report a case of a 39-year-old Sri Lankan lady who was investigated for generalized body swelling, pleural effusions, ascites and pericardial effusions due to hypoalbuminemia. Her ANA was positive with speckled pattern and intestinal biopsy samples revealed evidences of chronic inflammatory cell infiltrates in laminapropria. Her investigations were not suggestive of liver diseases, albuminuria or malnutrition. We excluded all possible etiologies for protein-losing enteropathy although gold standard tests to confirm it was not available in our center. In conclusion, LUPLE should be considered as an etiology for all the unexplained protein-losing enteropathies. We suggest to treat LUPLE with prednisolone, hydroxychloroquine (HCQ) followed by steroid-sparing agents such as azathioprine. Prognosis was excellent following appropriate treatment.

Bilateral rectus sheath haematoma complicating dengue virus infection in a patient on warfarin for mechanical aortic valve replacement: a case report.

BACKGROUND: The management of Dengue virus infection can be challenging. Varied presentations and numerous complications intrinsic to dengue by itself increase the complexity of treatment and potential mortality. When burdened with the presence of additional comorbidities and the need to continue compulsory medications, clear stepwise definitive guidance is lacking and patients tend to have more complex complications and outcomes calling to question the clinical decisions that may have been taken. The use and continuation of warfarin in dengue virus infection is one such example. CASE PRESENTATION: We report a 65 year old South Asian female who presented with dengue fever. She had a history bronchial asthma, a prior abdominal surgery, and was on warfarin and maintained a therapeutically appropriate internationalized normalized ratio for a mechanical aortic valve replacement. Though preemptive decision to stop warfarin was taken with decreasing platelet counts, her clinical course was complicated with the development of bilateral rectus sheath haematoma's requiring resuscitation with blood transfusions. CONCLUSION: Though management of dengue viral fever has seen drastic evolution with recent updated guidance, clinical scenarios seen in the course of the illness still pose challenges to the managing physician. The need to continue obligatory anticoagulation which may seem counterintuitive during a complex disease such as dengue virus infection must be considered after understanding the potential risks versus that of its benefits. Though case by case decisions maybe warranted, a clear protocol would be very helpful in making clinical decisions, as the correct preemptive decision may potentially avert catastrophic and unpredictable bleeding events.

Organizing pneumonia as the first manifestation of anti-synthetase syndrome.

BACKGROUND: Anti-synthetase syndrome associated interstitial lung disease can occur either simultaneously, before, or after the development of polymyositis/dermatomyositis. Histology of interstitial lung disease can be nonspecific interstitial pneumonia, usual interstitial pneumonia, diffuse alveolar damage, organizing pneumonia. Organizing pneumonia associated anti-synthetase syndrome is a rare finding especially as the first manifestation. CASE PRESENTATION: We report a 41 year old male patient who presented with organizing pneumonia and 2 years following the onset, developed polymyositis with anti-JO-1 antibody positivity. CONCLUSION: It is important to screen patients with organizing pneumonia for anti-synthetase syndrome which can be manifested later.

A rare case of self-injection of elemental mercury.

BACKGROUND: Self-injection of elemental mercury is a rare finding especially in healthy people who are mentally sound. Early detection and removal of mercury from the body by chelation and physical removal of a stored injected site is required to prevent long term toxicity. CASE PRESENTATION: A 15 year old previously healthy girl presented with an acute febrile illness with a generalized maculopapular skin rash for 3 days with a preceding history of self-injection of mercury to both her forearms. This was an imitating experimental act influenced by a movie and she was mentally sound. Very high whole blood mercury levels, x-rays of the forearms and histology confirmed mercury poisoning. CONCLUSION: Self-injection of elemental mercury can also occur in mentally sound people and rapid diagnosis and decontamination is required. This also signifies the importance of imposing limitations for visual media which could misguide minors and lead those to imitate and cause serious self-harm.

Challenges faced by visually disabled people in use of medicines, self-adopted coping strategies and medicine-related mishaps.

BACKGROUND: Difficulties faced by visually disabled people when using medicines, self-adopted coping strategies, and medicine-related mishaps have been under-explored locally and internationally. The objective of this study was to gain insight regarding this long-neglected issue. METHODS: A descriptive cross-sectional study, using an interviewer administered questionnaire on 63 visually disabled adults was carried out at a vocational training centre and a school for visually disabled students in Sri Lanka. RESULTS: Among 63 participants, 71% wanted to be independent in medicine use and 79% in spite of difficulties had self-administered medicines. They had difficulty in locating medicines (25.39%), identifying medicines and medicine containers (17.46%), and administering liquid medications (25.39%). These difficulties led to inaccurate dosing (14.28%), missed doses (39.68%), and discontinuation of treatment prematurely (28.57%). Self-adopted coping strategies to overcome these difficulties included using different sized and shaped containers, tying medicines to the attire, and dipping their finger into a measuring cup while measuring liquid medicines. Mishaps related to medicines such as taking vinegar instead of gripe mixture and, putting ear drops into eyes were disclosed. CONCLUSIONS: There were many challenges for visually disabled people in taking medicines and some self-adopted coping strategies were inadequate to overcome these.