A Rare Presentation of Coinfection: Dengue Virus and Hepatitis A Virus.

Dengue fever caused by dengue virus is a common tropical infection transmitted by the mosquitos Aedes aegypti and Aedes albopictus. Four strains of the genus flavivirus is responsible for the epidemics of varying severity. Hepatitis A caused by hepatitis A virus is spread by faecal-oral route. The culprit virus is a hepatovirus. Coinfection with dengue virus and hepatitis A virus is rare and is a diagnostic as well as management challenge to the medical professional. We report a patient who presented to us with dengue virus and hepatitis A virus coinfection.

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.

Acute kidney injury following ingestion of plate developer (sodium metasilicate): a case report.

BACKGROUND: Plate developer is a chemical used in the printing industry and is a corrosive alkaline agent containing sodium metasilicate as the main substance. Plate developer poisoning is rare. Literature search revealed only a single case report of fatal sodium metasilicate poisoning (Z Rechtsmed 94(3):245-250, 1985). There are no reports of acute kidney injury related to ingestion of sodium metasilicate containing substances. CASE REPORT: A 52-year-old Sri Lankan male with a history of hypertension and affective disorder presented following ingestion of about 150 ml of plate developer solution. He developed severe upper airway obstruction due to laryngeal edema and underwent tracheostomy. While in the ward he developed features of acute kidney injury with high serum creatinine levels and persistent hyperkalemia which necessitated temporary haemodialysis. Because of the corrosive effect, he developed severe inflammation of the upper gastro intestinal tract with narrowing of esophagus and pyloric region, requiring feeding jejunostomy. He died while waiting for the surgery for pyloric stenosis. CONCLUSIONS: Acute kidney injury is a potential treatable complication of plate developer poisoning other than its complications related to corrosive effects. Regular monitoring of renal functions in such a patient would be useful for early recognition of acute kidney injury.

Comparison of risk factors, severity and outcome between lacunar and non-lacunar stroke in a tertiary care center in Sri Lanka: a descriptive study.

This study compares demography, risk factors and outcome of lacunar (LAC) and non-lacunar (non-LAC) strokes from the prospective hospital based stroke registry at Colombo South Teaching Hospital from 1st March 2012 to 30th June 2013. Data on admission, discharge and at 28 days after discharge were analysed. There were 229 ischaemic stroke (IS) patients. Average age was 65.7 years (SD 12.2, range 34-94) and 116 (50.7%) were males. LAC (n=130, 56.8%) were common than non-LAC (n=99, 43.2%). There were 75 (64.7%) males and 55 (48.7%) females in the LAC group (adjusted OR 2.1, 95% CI 1.08-4.29). Atrial fibrillation was less frequent among LAC stroke (OR 0.3, 95% CI 0.09-0.99). Hypertension, diabetes, smoking, dyslipidaemia did not differ in the two groups. Lower NIHSS (5.34 Vs 6.6, p= 0.053), higher GCS (14.7 Vs 13.3, p=0.001) were seen in LAC. Disability (MRS, Barthel index) on discharge, at 28 days and mortality during hospital stay and within 28 days was lower in the LAC group (p <0.001).

Efficacy of rivastigmine on activities of daily living in Sri Lankan patients with Alzheimer disease and on improving caregiver burden: a prospective study.

OBJECTIVE: This open label, parallel group, prospective cohort study investigated the efficacy of rivastigmine treatment on activities of daily living (ADL) in patients with mild to moderate Alzheimer's disease (AD) and the possible benefits of this therapy on caregiver stress levels. METHODS: Thirty eight consecutive patients with mild to moderate AD were recruited; 22 received rivastigmine 3-6 mg twice daily (treatment group) for 20 weeks. Sixteen patients who did not receive rivastigmine served as the control group. The 17-item ADL Index was used to assess ADL and to determine the presence of functional deterioration. Caregivers were evaluated with the Caregiver Stress Scale (CSS). Each patient was required to have a committed caregiver and all caregivers were interviewed and administered the ADL Index and the Caregiver Stress Scale (CSS) at the start of treatment (week 0) and at the end of 20 weeks of treatment (week 20). RESULTS: Patients in the control group showed a significant decline in ADL Index score at 20 weeks compared to rivastigmine-treated patients (difference in mean ADL Index score = 8.5; p < 0.001). At week 20, mean change from baseline scores for CSS total and individual domain scores were better for caregivers in the treatment group than those in the control group (CSS total mean difference = 19.2). CONCLUSION: We conclude that treatment of AD patients with rivastigmine for 20 weeks produces a significant improvement in patient ADL functioning, and lower levels of caregiver stress.

Prevalence of dementia in a semi-urban population in Sri Lanka: report from a regional survey.

BACKGROUND: The prevalence of dementia in Sri Lanka, which has a rapidly ageing population, is unknown. OBJECTIVE: This study aimed to determine the prevalence of Alzheimer's disease (AD) and other dementias in a semi-urban elderly Sinhala-speaking population in Ragama, Sri Lanka. METHODS: The study was conducted in two phases. Phase I: After informed consent 703 subjects aged > or =65 years from the study area (population 15 828) were screened for cognitive impairment using the Sinhalese Mini Mental State Examination. Subjects scoring < or =17 were regarded as suspected dementia cases. Phase II: All subjects who screened positive in phase I were included in phase II for detailed evaluation for dementia according DSM IV and NINCDS-ADRDA criteria which included structured neuropsychiatric assessment, laboratory investigations, an axial CT scan of the brain and an informant interview. RESULTS: In the study sample, 61% were female and 86% were between 65-75 years. 42 subjects screened positive in phase I. Of these, 28 subjects were diagnosed as having dementia, giving an overall prevalence rate of 3.98% (95% Confidence Intervals (CI) =2.6-5.7%). Of these, 20 (71.4%) had probable AD, four had vascular dementia (14.3%), two had mixed (vascular and AD) dementia (7.1%), one had Lewy body dementia, and one had dementia due to syphilis. Greater age, illiteracy and female gender were associated with higher prevalence of dementia. CONCLUSION: Comparison with other community studies performed in North India suggests that dementia prevalence is higher in Sri Lanka. This may be due to regional differences in disease incidence.

Multiple-dose activated charcoal for treatment of yellow oleander poisoning: a single-blind, randomised, placebo-controlled trial.

BACKGROUND: Deliberate self-poisoning with yellow oleander seeds is common in Sri Lanka and is associated with severe cardiac toxicity and a mortality rate of about 10%. Specialised treatment with antidigoxin Fab fragments and temporary cardiac pacing is expensive and not widely available. Multiple-dose activated charcoal binds cardiac glycosides in the gut lumen and promotes their elimination. We aimed to assess the efficacy of multiple-dose activated charcoal in the treatment of patients with yellow-oleander poisoning. METHODS: On admission, participants received one dose of activated charcoal and were then randomly assigned either 50 g of activated charcoal every 6 h for 3 days or sterile water as placebo. A standard treatment protocol was used in all patients. We monitored cardiac rhythm and did 12-lead electocardiographs as needed. Death was the primary endpoint, and secondary endpoints were life-threatening cardiac arrhythmias, dose of atropine used, need for cardiac pacing, admission to intensive care, and number of days in hospital. Analysis was by intention to treat. FINDINGS: 201 patients received multiple-dose activated charcoal and 200 placebo. There were fewer deaths in the treatment group (five [2.5%] vs 16 [8%]; percentage difference 5.5%; 95% CI 0.6-10.3; p=0.025), and we noted difference in favour of the treatment group for all secondary endpoints, apart from number of days in hospital. The drug was safe and well tolerated. INTERPRETATION: Multiple-dose activated charcoal is effective in reducing deaths and life-threatening cardiac arrhythmias after yellow oleander poisoning and should be considered in all patients. Use of activated charcoal could reduce the cost of treatment.

Self-limiting cerebellar ataxia following organophosphate poisoning.

Deliberate self-harm by ingestion of organophosphate insecticides is a common health problem in Sri Lanka. The poisoning results in an initial life-threatening cholinergic crisis and several intermediate and late neurological and psychiatric manifestations. A patient who developed self-limiting cerebellar signs 8 days after ingestion of dimethoate, an organophosphorous insecticide, is reported on.

Yellow oleander poisoning in Sri Lanka: outcome in a secondary care hospital.

Cardiac toxicity after self-poisoning from ingestion of yellow oleander seeds is common in Sri Lanka. We studied all patients with yellow oleander poisoning (YOP) admitted to a secondary care hospital in north central Sri Lanka from May to August 1999, with the objective of determining the outcome of management using currently available treatment. Patients with bradyarrhythmias were treated with intravenous boluses of atropine and intravenous infusions of isoprenaline. Temporary cardiac pacing was done for those not responding to drug therapy. During the study period 168 patients with YOP were admitted to the hospital (male:female = 55:113). There were six deaths (2.4%), four had third-degree heart block and two died of undetermined causes. They died soon after delayed admission to the hospital before any definitive treatment could be instituted. Of the remaining 162 patients, 90 (55.6%) patients required treatment, and 80 were treated with only atropine and/or isoprenaline while 10 required cardiac pacing in addition. Twenty-five (14.8%) patients had arrhythmias that were considered life threatening (second-degree heart block type II, third-degree heart block and nodal bradycardia). All patients who were treated made a complete recovery. Only a small proportion of patients (17%) admitted with YOP developed life-threatening cardiac arrhythmias. Treatment with atropine and isoprenaline was safe and adequate in most cases.

Safety of subcutaneous adrenaline as prophylaxis against acute adverse reactions to anti-venom serum in snakebite.

OBJECTIVES: To study the safety of low dose subcutaneous adrenaline given as prophylaxis against acute adverse reactions to anti-venom serum (AVS) in patients bitten by snakes. METHODS: Patients admitted with snakebite envenoming who satisfied inclusion criteria were given 0.25 ml of 1:1000 adrenaline subcutaneously immediately before administration of AVS. They were observed for adverse effects, and pulse and blood pressure (BP) were monitored. RESULTS: 51 patients [35 males, mean age 34.8 years (SD 14)] were included in the study. Adverse reactions to AVS occurred in 15 (29.4%) patients. There was one death from suspected cerebral haemorrhage, and 3 (5.9%) patients developed small haematomas at the subcutaneous injection site. There were no significant changes in mean pulse or BP following administration of subcutaneous adrenaline. CONCLUSIONS: Low dose subcutaneous adrenaline did not cause significant changes in pulse rate or BP. Although the death was unlikely to be directly related to subcutaneous adrenaline, we suggest further studies on the safety of this prophylactic treatment before its routine use.

Mini Mental State Examination in Sinhalese: a sensitive test to screen for dementia in Sri Lanka.

BACKGROUND: Although the Sri Lankan population is ageing rapidly, dementia has not been systematically investigated here. The Mini Mental State Examination (MMSE) is a brief global instrument used to assess cognitive abilities in the elderly. OBJECTIVE: This study aimed to develop and validate a Sinhalese translation of the MMSE, which could be used as a screening instrument to detect impaired cognition in an epidemiological investigation of dementia in Sri Lanka. METHODS: Due to the high literacy rate in the country, the MMSE was translated and modified slightly without having to make major changes to the original version. 380 randomly selected subjects over 65 years in a semi-urban area were screened with the translated version of the MMSE. The cut-off score for cognitive impairment was taken as 17. Of the 380 subjects screened, 33 scored < or = 17, and were thus considered cases of suspected dementia. All 33 who scored < or = 17 and 24 randomly selected subjects who scored>17 on the MMSE, thus considered cognitively normal, underwent a brief clinical examination and neuropsychological assessment with the more comprehensive neuropsychiatric test battery, Cambridge Cognitive Score (CAMCOG), to determine the presence of dementia. RESULTS: Evaluated against the performance at the CAMCOG, the sensitivity and specificity of the translated MMSE were 93.5% and 84.6% respectively. CONCLUSION: Therefore, the Sinhalese translation of the MMSE described here is a sensitive instrument to screen for dementia in Sri Lanka.

Parasuicide by self-injection of an organophosphate insecticide.

Parasuicide by ingestion of organophosphate (OP) insecticides is common in Sri Lanka, but the use of the parateral route to self administer the poison is extremely rare. We report a patient who deliberately injected herself intramuscularly with an OP compound with suicidal intent. The clinical manifestations of OP poisoning were unpredictable and posed a therapeutic problem.

Stroke subtypes in Sri Lanka--a hospital based study.

AIM: Data on stroke subtypes in Sri Lanka are limited, mainly due to the unavailability of brain imaging facilities in most government hospitals. In two leading private hospitals in Colombo, a high proportion of stroke patients have computerised tomography (CT) scanning. Hence we studied stroke patients admitted to these two hospitals to determine the stroke subtypes. METHODS: A prospective study of 103 consecutive first ever stroke patients who were under the care of the first author during the period 15 May 1995 to 30 August 1996 were studied. Diagnosis of stroke was made according to the WHO definition, and transient ischaemic attacks (TIA) were not included. The pathological subtype was confirmed by CT scan in 99 patients. RESULTS: The age of the patients ranged from 37 to 94 years (mean 64.5). 87 patients were over the age of 50 years. The proportion of pathological subtypes confirmed by CT scanning was cerebral infarction (CI) 74.7%, intracerebral haemorrhage (ICH) 19.1% and subarachnoid haemorrhage (SAH) 62.2%. Of the infarcts 31 (42%) were cortical, 30 (41%) lacunar, 12 (16%) cerebellar and brainstem, and 1 (1.3%) was a border zone infarct. CONCLUSION: Direct comparisons with stroke subtypes seen in other countries are not valid due to differences in methodology. In developed countries in the West cerebral infarcts account for about 80% of all first ever strokes and of these 13 to 21% are lacunar strokes. Countries in the East (e.g. Japan and Hong Kong) have reported a higher proportion of haemorrhages (27% of first ever strokes in Hong Kong). In Sri Lanka the proportion of stroke subtypes seem to be intermediate between these countries in the West and East. Lacunar strokes are commoner in Sri Lanka than in other countries.

Use of antivenom serum in snake bite: a prospective study of hospital practice in the Gampaha district.

OBJECTIVE: To record current practices in hospital management of snake bite, especially with regard to use of antivenom serum (AVS). METHODS: Management of all snake bite victims admitted to the four main hospitals of the Gampaha district was prospectively studied during a 5-month period. A pretested data collection sheet was used. Relevant information was obtained from patients, accompanying persons, medical staff and hospital records. RESULTS: 466 patients (M:F = 7:3; 402 adults and 64 children) were admitted following snake bite during the study. The offending snake was identified in 357 (76.6%) cases [172 (36.9%) by examining the dead snake, 185 by identification of the snake in a photograph]. 273 (76.5%) of the 357 admissions were due to hump nosed viper bite. AVS was given to 184 (39.5%) patients, including 99 (36.3%) with hump nosed viper bite. A sensitivity test of AVS was used in all 184 patients. Premedication with hydrocortisone and/or antihistamines before AVS infusion was given to 89 patients. Acute adverse reactions to AVS occurred in 102 (55.4%) patients given AVS. There was no significant difference in the rate of reactions whether premedication was given or not. CONCLUSION: Precise identification of the offending snake was not possible in many instances. Practices that are of no benefit in the treatment of snake bite are still widely used. Acute adverse reactions to AVS are common, and neither hydrocortisone nor antihistamines seem to be of benefit as prophylaxis. Evidence based management guidelines, especially with regard to AVS therapy, are urgently required.

Juvenile myoclonic epilepsy: a study in Sri Lanka.

Juvenile myoclonic epilepsy (JME) has a distinct clinical profile. Often JME is not recognized, with the result that proper treatment is not instituted, leading to poor control of seizures. This study is an attempt to identify the factors that contribute to the delay in diagnosing this condition. During a period of 3 years 40 patients (21 females) with JME were identified and all were included in a prospective follow-up study. The age range was 12-58 years. Twenty-seven patients (67%) had already seen at least one specialist; however, diagnosis had not been made despite the presence of characteristic features. The duration of delay in diagnosis varied from months to years with a mean of 11 years. Myoclonic jerks were the most characteristic feature, but only six volunteered this information spontaneously. The response to treatment with sodium valproate was excellent, although only three were taking it when first seen. As a result of treatment with other drugs all patients were having recurrent seizures. The main reasons for the delay in diagnosis found in our study were that the physicians were unaware of the condition, the occurrence of myoclonic jerks were overlooked either because the patients were not directly questioned about them or because the patients did not volunteer the information.