Uncommon triggers of insulin autoimmune syndrome: a case report.

BACKGROUND: Insulin autoantibody syndrome (IAS), or Hirata disease, is caused by high concentrations of insulin autoantibodies, which result in spontaneous, mainly post-prandial, hypoglycemic episodes. We report a case of a previously healthy 67-year-old man presenting with recurrent fasting hypoglycemia culminating in a diagnosis of insulin autoimmune syndrome linked to omeprazole and probably spices, namely, coriander, and ginger. CASE PRESENTATION: A previously healthy 67-year-old Sinhalese man presented with recurrent syncopal attacks for 3 months, which were found to be hypoglycemic episodes. He experienced mainly fasting hypoglycemic attacks, at a frequency gradually increasing to daily attacks. His cardiovascular, respiratory, abdominal, and neurologic examinations were normal. He was found to have insulin levels > 6000 mU/L and a post-polyethylene glycol insulin recovery of less than 9.5%. Contrast-enhanced computed tomography of the pancreas was normal. The diagnosis of insulin autoantibody syndrome was confirmed by testing for the insulin autoantibody level, yielding a level of > 300 U/mL. With regard to a possible trigger, he had a history of omeprazole intake for 2 weeks, 4 weeks prior to the onset of symptoms. He also consumed an herbal supplement containing coriander and ginger extracts daily for a period of 1 year, approximately 2 years prior to the onset of hypoglycemic attacks. He was commenced on prednisolone 30 mg daily, and hypoglycemic episodes responded dramatically, and thus he was tapered off corticosteroids. CONCLUSION: Omeprazole-induced insulin autoantibody syndrome is likely in this patient; however, the known hypoglycemic effects of coriander and ginger make it worthwhile to consider a possible association with insulin autoantibody syndrome. In addition, this case report highlights the need to consider insulin autoantibody syndrome even in patients presenting with fasting hypoglycemic attacks.

Vibrio vulnificus pneumonia with multiorgan failure: a case report and review of the literature.

BACKGROUND: Vibrio vulnificus is a gram-negative bacterium causing three clinical syndromes namely, gastrointestinal symptoms, skin sepsis and primary sepsis. Primary sepsis exhibits mortality rates exceeding 50%, particularly in the immunocompromised. Vibrio vulnificus is transmitted via consumption of contaminated seafood and contaminated seawater skin exposure. We describe a rare case of an immunocompetent male presenting with an atypical Vibrio vulnificus infection, culminating in severe pneumonia requiring intensive care. CASE PRESENTATION: A 46 year old Indian male dockyard worker, a non-smoker and teetotaler, of Indian origin presented to the emergency treatment unit of a tertiary care hospital in Sri Lanka, with fever, productive cough with yellow sputum, pleuritic chest pain and tachypnea for five days. He had no gastrointestinal or skin manifestations. His respiratory rate was 38 breaths/min, pulse rate was 120 bpm, blood pressure was 107/75 mmHg and pulse oximetry was 85% on air. Chest X-ray revealed consolidation of the left lung. Empiric intravenous Piperacillin-tazobactam and Clarithromycin were commenced after obtaining blood and sputum cultures. Over the next 24 h, his oxygen requirement rose and as he required vasopressor support, he was admitted to the intensive care unit. He was intubated and bronchoscopy was performed on day two, which demonstrated thick secretions from left upper bronchial segments. His antibiotics were changed to intravenous ceftriaxone and doxycycline following a positive blood culture report of Vibrio vulnificus. He was ventilated for ten days and his intensive care stay was complicated with a non-oliguric acute kidney injury, with serum creatinine rising up to 8.67 mg/dL (0.81-0.44 mg/dL). He developed mild thrombocytopenia with platelets dropping to 115 × 103 /uL (150-450 × 103/uL) which resolved spontaneously. Vasopressors were weaned off by day eight and the patient was extubated on day ten. He was discharged from intensive care on day twelve and made a full recovery. CONCLUSIONS: Pneumonia itself is an atypical manifestation of Vibrio vulnificus and furthermore, this patient was immunocompetent and did not exhibit the classical gastro-intestinal and skin manifestations. This case highlights the occurrence of atypical Vibrio sp. infections in patients with high exposure risks and the need for early supportive and appropriate antibiotic therapies.

Estimation of the basic reproduction number (R0) for the novel coronavirus disease in Sri Lanka.

BACKGROUND: The basic reproduction number (R0) is the number of cases directly caused by an infected individual throughout his infectious period. R0 is used to determine the ability of a disease to spread within a given population. The reproduction number (R) represents the transmissibility of a disease. OBJECTIVES: We aimed to calculate the R0 of Coronavirus disease-2019 (COVID-19) in Sri Lanka and to describe the variation of R, with its implications to the prevention and control of the disease. METHODS: Data was obtained from daily situation reports of the Epidemiology Unit, Sri Lanka and a compartmental model was used to calculate the R0 using estimated model parameters. This value was corroborated by using two more methods, the exponential growth rate method and maximum likelihood method to obtain a better estimate for R0. The variation of R was illustrated using a Bayesian statistical inference-based method. RESULTS: The R0 calculated by the first model was 1.02 [confidence interval (CI) of 0.75-1.29] with a root mean squared error of 7.72. The exponential growth rate method and the maximum likelihood estimation method yielded an R0 of 0.93 (CI of 0.77-1.10) and a R0 of 1.23 (CI of 0.94-1.57) respectively. The variation of R ranged from 0.69 to 2.20. CONCLUSION: The estimated R0 for COVID-19 in Sri Lanka, calculated by three different methods, falls between 0.93 and 1.23, and the transmissibility R has reduced, indicating that measures implemented have achieved a good control of disease.

Is it appropriate to use WHO Multicentre Growth Reference Study standards to assess the growth parameters of Sri Lankan babies? A single-centre cross-sectional study.

OBJECTIVE: To compare the anthropometric measurements of newborns in a tertiary care hospital in Sri Lanka, with WHO standards. METHODS: Birth weight, length and occipitofrontal circumference (OFC) of 400 consecutive, term newborns of healthy mothers were measured in a tertiary care hospital. RESULTS: 400 subjects were approached and seven were excluded, concluding the study population to 184 boys and 209 females. Medians of birth weight, length and OFC were 3000 g, 49.95 cm and 34.15 cm of males and IQRs were 555.00, 2.70 and 1.70, respectively. For females, the medians of birth weight, length and OFC were 2900 g, 48.9 cm and 34.00 cm with IQRs of 450.00, 2.70 and 1.50, respectively. The two-tailed t-test revealed that median weights of males (t=9.632) and females (t=12.04) and OFC of males (t=3.98) were significantly lower than the WHO medians. There was a significant association of birth weight, with mother's prepregnancy weight, in males (ß coefficient=12.629 with 95% CI 6.275 to 18.982) and females (ß coefficient=5.880, 95% CI 1.434 to 10.325). Significant associations of length (ß coefficient=0.046, 95% CI 0.012 to 0.080) and OFC (ß coefficient=0.033, 95% CI 0.014 to 0.053) with mother's prepregnancy weight in males and length (ß coefficient=0.084, 95% CI 0.022 to 0.145) and weight (ß coefficient=10.780, 95% CI 0.93 to 20.629) with maternal age in females were found. Furthermore, birth weight in males was significantly associated with maternal height (ß coefficient=10.899, 95% CI 0.552 to 21.247). Education level, ethnicity and parity showed no significant associations with above parameters. CONCLUSION: The median weights of both sexes and OFC in males were significantly lower than the WHO standards. Island-wide studies are indicated to evaluate the appropriateness of applying WHO standards to Sri Lankan newborns.