Coeliac artery and splenic artery thrombosis complicated with splenic infarction 7 days following the first dose of Oxford vaccination, causal relationship or coincidence?

The novel coronavirus SARS-CoV-2 became a global pandemic in late 2019, and is still ongoing in 2021 causing significant morbidity and mortality. The advent of vaccinations heralded the turning of the tide. The Oxford jab, a vector-based vaccine was favoured due to its low cost and ease of storage. However, its potential association with thromboembolic adverse events resulted in controversy and disrupted its roll-out and use. The aetiopathogenesis of these thromboembolic events and its association with the Oxford vaccine are still speculative and uncertain, more so in the background of SARS-CoV-2 infection being highly thrombogenic in its own right. This paper presents a case of an otherwise healthy 50-year-old Caucasian man who developed acute abdominal pain 7 days following the first dose of Oxford vaccine and was found to have coeliac and splenic artery thrombosis complicated with splenic infarction.

Rituximab induced acute thrombocytopenia in a patient with systemic lupus erythematosus: a case report.

BACKGROUND: Rituximab is a novel chimeric monoclonal antibody that has established itself as a potent therapeutic option for autoimmune medical conditions, including systemic lupus erythematosus, owing to its mechanism of action targeting CD20 cells. Rituximab is also known to cause a spectrum of side effects including hematological abnormalities. Acute isolated thrombocytopenia following rituximab is an uncommon occurrence and, when seen, occurs in the presence of underlying hematological malignancies. Its occurrence in autoimmune diseases is rare. Despite this, acute isolated thrombocytopenia in the backdrop of systemic lupus erythematosus is undocumented. CASE PRESENTATION: A young 36-year-old South Asian female with systemic lupus erythematosus with class IV lupus nephritis poorly responding to standard therapy was initiated on rituximab. Ten days later, she presented with mucocutaneous bleeding and ecchymotic skin lesions. Isolated severe thrombocytopenia was noted with a platelet count of 5 × 109/L (150-450). Anticipating life-threatening bleeding, she was given intravenous immunoglobulin, methyl prednisolone, and platelet transfusion considering a spectrum of initial differential diagnosis. Rituximab was also withheld. Though extensively investigated, most investigations were negative. A platelet destructive process was suspected as bone marrow biopsy showed adequate megakaryocytes. Weighing the risk versus benefit, following recovery, she was reinitiated on rituximab. Within 4 days, she presented again with similar symptoms and severe isolated thrombocytopenia was noted. Rituximab-induced acute thrombocytopenia was considered the working clinical diagnosis. CASE DISCUSSION AND CONCLUSION: Rituximab can cause a spectrum of hematological abnormalities, including isolated acute thrombocytopenia. Its occurrence in autoimmune conditions is rare, and its manifestation in systemic lupus erythematosus is undocumented. Its exact etiology is still disputed. Usually considered benign, the platelet numbers tend to show improvement with cessation of therapy. However, in the presence of mucocutaneous bleeding in our patient, we took an aggressive approach to management. Though evidence for corrective therapy is anecdotal, it could be justified on the basis of averting potential catastrophic hemorrhagic manifestations. The spectrum of autoimmune disease that potentially predisposes rituximab to cause thrombocytopenia should be extended to include systemic lupus erythematosus.

The eye in dengue fever, a rarely appreciated aspect of dengue expanded syndrome: a case report.

BACKGROUND: Dengue fever is a mosquito-borne illness prevalent mainly in the tropics. It is feared for causing the dengue hemorrhagic spectrum of the disease leading to significant morbidity and mortality. Its rarer manifestations are categorized as the expanded dengue syndrome, and though being recognized, they are not fully appreciated and understood. The involvement of the eye in dengue fever is one such phenomenon. CASE PRESENTATION: A 27-year-old South-Asian woman presented on day 2 of dengue fever, without capillary leakage, for further management. Despite developing hepatitis, she had an otherwise uncomplicated progression of the illness because she did not develop capillary leakage. On day 8 of the illness, she had the lowest platelet count and developed bilateral blurred vision. Examination revealed that only gross movements were detected in the left eye, and the right eye had a visual acuity of 6/9. She was diagnosed with foveolitis in the right eye and central serous chorioretinopathy in the left eye, along with hemorrhages in both eyes. These were confirmed by funduscopy, fluorescein angiography, optical coherence tomography, and macular scans. She received systemic and intravitreal steroids and was assessed regularly. After 6 months of observation, her visual acuity was 6/6 in the right eye and 6/9 in the left eye, which remained the same thereafter. DISCUSSION: The exact mechanism of eye involvement in dengue viral infection is poorly understood. Multiple causes have been suspected and include viral factors, immune mediation, capillary leakage, stress, and hemorrhage. Eye involvement is classically seen at the lowest platelet count and when the count begins to rise. Though symptoms are nonpathognomonic, blurring of vision is the commonest complaint, but the range of presentation is extensive and variable. Ophthalmological assessment and funduscopy are very useful in addition to advanced assessments. There is no clear consensus on management; suggestions range from conservative care to aggressive steroid therapy with immune modulation and even ophthalmological intervention. Recovery can be full or partial with a variable time scale. CONCLUSION: The extensive spectrum of possible visual symptoms should prompt the clinician to suspect any visual complaint as potential dengue eye involvement. Guided studies and screening are needed to better understand the true incidence of eye involvement in dengue fever.

Inflammation in ST- elevation myocardial infarction: risk factors, patterns of presentation and association with clinical picture and outcome, an observational study conducted at the Institute of Cardiology-National Hospital of Sri Lanka.

BACKGROUND: Inflammation in myocardial infarction has a complex immunogenic origin and is suspected to be closely involved in its aetio-pathogenesis as well as outcome. In this study the objective was to further elucidate the clinical correlations of inflammation using clinical parameters and basic inflammatory markers and how it correlates with patient risk parameters, imaging findings and outcome. METHODS: An observational descriptive cross sectional study was carried out at the Institute of Cardiology, National Hospital of Sri Lanka, where consenting patients presenting for further management of ST- elevation myocardial infarction were recruited. Venous blood samples were collected on admission to assess C-reactive protein levels and on a timed manner to asses Troponin I levels as well as on subsequent days to performs whole blood analysis. Patients underwent 6 hourly axillary temperature assessment. All patients underwent 2D transthoracic echocardiographic analysis via biplane Simpson's method to ascertain ejection fraction as well. RESULTS: Eighty eight subjects were recruited into the study. Fever was noted in 20.5% (n = 18). Fever was usually intermittent and seen commonly between day 1 and 3 post-acute myocardial infarction. Haematological abnormalities indicative of inflammation were also observed as whole blood analysis demonstrated predominant leukocytosis and elevated C-reactive protein levels. Significant correlation was noted between presence of leukocytosis (P = 0.033) and fever as well as with the presence of diabetes mellitus (P = 0.005). Development of acute heart failure also showed significant correlation with leukocytosis (P = 0.002). Correlation was also observed between LV dysfunction and elevated C-reactive protein and Troponin I levels with P values of P = 0.023 and P = 0.011 (P < 0.05) respectively. CONCLUSIONS: Inflammation is appreciated following acute myocardial infarction. Biochemical evidence of inflammation is commonly seen. Clinical manifestation as fever however is seen less often. Patient factors correlate poorly with inflammation but diabetes mellitus may have a contributory role. Whole blood analysis derangement is a simple test that correlates well with inflammation as well as presence of fever and development of heart failure. Inflammation also correlated with left ventricular dysfunction and may thus have an impact on clinical morbidity and mortality. Delineating associates of inflammation will hopefully help improve therapy of myocardial infarction.

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.

Lucio's phenomenon, an uncommon occurrence among leprosy patients in Sri Lanka.

BACKGROUND: Lucio's phenomenon is a rare manifestation of untreated leprosy which is seen almost exclusively in regions surrounding the Gulf of Mexico. Its occurrence elsewhere though documented is considered uncommon. We present a case of Lucio's phenomenon in a previously undiagnosed leprosy patient who presented to us with its classical skin manifestations. CASE PRESENTATION: A 64 year old South Asian (Sri Lankan) male with a history of chronic obstructive airway disease presented to us with fever and cough. He had a generalized smooth and shiny skin with ulcerating skin lesions afflicting the digits of the fingers. The lesions progressed to involve the extremities of the body and healed with crusting. Based on the clinical and investigational findings Tuberculosis and common vasculitic conditions were suspected and excluded. The unusual skin manifestations prompted a biopsy, and wade fite stained revealed Mycobacterium bacilli. In context of the clinical picture and histological findings, Lucio's phenomenon was suspected. A clinical diagnosis of Lucio's phenomenon occurring in the backdrop of lepromatous leprosy was made. CONCLUSION: Though leprosy is still a prevalent disease, it has manifestations that are not easily recognized or fully appreciated. Regional patterns of atypical manifestations should not limit better understanding of rarer manifestations as it will aid in clinching an early diagnosis and instituting prompt treatment, thereby reducing morbidity and mortality.

Complete heart block in dengue complicating management of shock due to both bleeding and leakage: a case report.

BACKGROUND: The spread of Dengue virus infection is reaching pandemic proportions. Dengue is usually dreaded for causing shock due to capillary leakage. However the clinical spectrum of dengue is vast and the newly incorporated expanded dengue syndrome introduces a wide range of presentations that are rarely observed and appreciated but nevertheless have the potential to cause significant morbidity and even mortality. Cardiac involvement in dengue is one such example. CASE PRESENTATION: A 26 year old South-Asian female presented in a state of haemodynamic shock with a history of fever and use of non-steroidal anti inflammatory drugs. Dengue was suspected clinically and later confirmed. Following stabilization and while still in the febrile phase the patient developed bradycardia with dynamic electrocardiogram changes which evolved into complete heart block. However there was no circulatory compromise. Clinical picture was further complicated by the development of dengue haemorhaghic fever and cautious fluid resuscitation was carried out in correlation to clinical and haematological parameters. Impaired coagulation profile necessitated administration of activated factor seven on the backdrop of low platelets and bleeding. Cardiac pacing could be avoided due to maintenance of vitals within acceptable parameters. CONCLUSION: Expanded dengue syndrome should be given greater appreciation as not all may be benign. Cardiovascular system involvement in dengue has the potential to cause significant morbidity and mortality. Careful interpretation of clinical parameters will help in the institution of the appropriate management and help avoid unnecessary invasive interventions. Screening of dengue patients with timely electrocardiographs would be useful to detect cardiac involvement. Guidance on managing atypical manifestations of dengue expanded syndrome should available to help clinicians dictate treatment.

Tropical pyomyositis as a presenting feature of subclinical leukemia: a case report.

INTRODUCTION: Pyomyositis, though classically considered a tropical disease, has a variable geographic prevalence. Among the predisposing risk factors, immunodeficiency plays an important role. Pyomyositis has a tendency to mimic more commonly considered diseases, and a lack of familiarity with it is a cause of delayed diagnosis. CASE PRESENTATION: A 53-year-old South Asian man with newly diagnosed type 2 diabetes mellitus was referred to our medical unit in an advanced stage of the disease, which was complicated by sepsis and acute kidney injury. Failure of the referring unit to provide prompt treatment, as well as their delay in coming to a diagnosis, led to the patient's complicated state. Antibiotic therapy was initiated, and clinical stabilization was achieved with supportive measures. Following the patient's recovery from sepsis, his persistent leukopenia and anemia was suggestive of an underlying immunodeficiency, and a subsequent bone marrow biopsy revealed acute myeloid leukemia, M2 variant. Multi-disciplinary care was initiated by the medical, surgical and oncological teams. CONCLUSION: Awareness of tropical pyomyositis is lacking. Common predisposing behaviors and conditions should always be sought and investigated. Immunosuppressive state is an important predisposing factor in the pathogenesis of pyomyositis. Early antibiotic treatment is pivotal in management, and surgical intervention, when relevant, should not be delayed. Identifying one cause should not halt the search for others, as pyomyositis may herald underlying sinister diseases.

Inoperable inflammatory myofibroblastic tumour of the para-nasal sinuses and orbit with recurrence responding to methotrexate and prednisolone: a case report.

BACKGROUND: Inflammatory myofibroblastic tumour is a rare neoplasm with a potential to behave in a malignant manner. It can occur anywhere in the body, however involvement of the head, especially the para-nasal sinuses is rare. CASE PRESENTATION: A 33-year-old South Asian male presented with coryzal symptoms including a persistent cough with an asymmetrical swelling of the left side of the face. Imaging revealed a mass lesion involving the para-nasal sinuses eroding into the orbit. Histology and the clinical picture were compatible with inflammatory myofibroblastic tumour. As curative excision of the tumour was not feasible, medical management was offered. Despite early features of remission to glucocorticoids, tapering resulted in recurrence. Hence combination therapy with glucocorticoids and methotrexate was commenced with dramatic reduction of tumour burden and the patient has been in remission to date. CONCLUSION: Inflammatory myofibroblastic tumour has the potential to behave in a malignant manner. Medical management with chemotherapy, glucocorticoids and non-steroidal anti-inflammatory drugs though effective, do not have a uniform response pattern. Surgically unresectable inflammatory myofibroblastic tumour above neck should be treated aggressively with combination regimens. Combination of prednisolone with methotrexate has been shown to have good outcome.

Lead toxicity among traffic wardens: a high risk group exposed to atmospheric lead, is it still a cause for concern?

BACKGROUND: Traffic policemen are identified to be at a higher risk of exposure to air pollution and its contaminants such as lead. A study done prior to the introduction of unleaded petroleum in Sri Lanka revealed a mean blood lead level of 53.07 µg/dL, which was well above the Center for Disease Control defined acceptable safe levels. This study aimed to determine whether unleading of fuel has made an impact on the blood lead levels of traffic police working in an urban area with high traffic density. METHOD: A cross-sectional survey of 168 traffic police personnel working within Colombo city limits of Sri Lanka, a high traffic density area, was conducted. Blood lead levels of participants were measured using nitric acid, perchloric acid ashing method and atomic absorption spectrophotometry. An interviewer administered questionnaire was used for a targeted history and examination. RESULTS AND DISCUSSION: Mean age of the sample population was 37 years. Thirty eight percent had detectable levels of lead in blood and 24.4% of the study sample had blood lead levels above Centre for disease control defined safe limits. Sample mean was 4.82 µg/dL (95% CI 3.58-6.04), and this is a 91% overall reduction when compared to data prior to unleading. Neither symptoms nor signs of classic lead toxicity showed significant correlation with toxic lead levels. CONCLUSION: Lead poisoning though still present in the high risk traffic warden population shows a considerable reduction following unleading. The need to have a low threshold to suspect lead poisoning is highlighted by the non-specific nature of the symptoms and signs of lead poisoning and its lack of association even in those found to have elevated lead levels. Further studies are required to elucidate a cause for the prevalence of lead poisoning despite cessation of using lead as an additive in petroleum.

Necrotizing fasciitis--a diagnostic dilemma: two case reports.

INTRODUCTION: Necrotizing soft tissue infections can affect various tissue planes. Although predisposing etiologies are many, they mostly center on impaired immunity occurring directly or indirectly and loss of integrity of protective barriers which predispose to infection. The nonspecific presentation may delay diagnosis and favor high mortality. CASE PRESENTATION: Two case vignettes are presented. The first patient, a 44-year-old healthy South Asian man with a history of repeated minor traumatic injury presented to a primary health care center with a swollen left lower limb. He was treated with antibiotics with an initial diagnosis of cellulitis. Because he deteriorated rapidly and additionally developed intestinal obstruction, he was transferred to our hospital which is a tertiary health care center for further evaluation and management. Prompt clinical diagnosis of necrotizing soft tissue infection was made and confirmed on magnetic resonance imaging as necrotizing fasciitis. Urgent debridement was done, but the already spread infection resulted in rapid clinical deterioration with resultant mortality. The second patient was a 35-year-old South Asian woman with systemic lupus erythematous receiving immunosuppressive therapy who developed left lower limb pain and fever. Medical attention was sought late as she came to the hospital after 4 days. Her condition deteriorated rapidly as she developed septic shock and died within 2 days. CONCLUSIONS: Necrotizing fasciitis can be fatal when not recognized and without early intervention. Clinicians and surgeons alike should have a greater level of suspicion and appreciation for this uncommon yet lethal infection.

Sensory neuronopathy complicating systemic lupus erythematosus: a case report.

INTRODUCTION: Systemic lupus erythematosus is a multi-system connective tissue disorder. Peripheral neuropathy is a known and underestimated complication in systemic lupus erythematosus. Ganglionopathy manifests when neuronal cell bodies in the dorsal root ganglion are involved. Autoimmune disorders are a known etiology, with systemic lupus erythematosus being a rare cause. CASE PRESENTATION: A 32-year-old South Asian woman presented with oral ulceration involving her lips following initiation of treatment for a febrile illness associated with dysuria. She had a history of progressively worsening numbness over a period of 4 months involving both the upper and lower limbs symmetrically while sparing the trunk. Her vibration sense was impaired, and her reflexes were diminished. For the past 4 years, she had had a bilateral, symmetrical, non-deforming arthritis involving the upper and lower limbs. Her anti-nuclear antibody and anti-double-stranded deoxyribonucleic acid status were positive. Although her anti-Ro antibodies were positive, she did not have clinical features suggestive of Sjögren syndrome. Nerve conduction studies revealed sensory neuronopathy. A diagnosis of systemic lupus erythematosus complicated by sensory neuronopathy was made. Treatment with intravenous immunoglobulin resulted in clinical and electrophysiological improvement. CONCLUSION: Peripheral neuropathy in systemic lupus erythematosus can, by itself, be a disabling feature. Nerve conduction studies should be considered when relevant. Neuropathy in systemic lupus erythematosus should be given greater recognition, and rarer forms of presentation should be entertained in the differential diagnosis when the clinical picture is atypical. Intravenous immunoglobulin may have role in treatment of sensory neuronopathy in systemic lupus erythematosus.

Polyarteritis nodosa complicated by posterior reversible encephalopathy syndrome: a case report.

BACKGROUND: Posterior reversible encephalopathy syndrome is a presentation which is diagnosed clinico-radiologically. The primary aetiological processes leading to posterior reversible encephalopathy syndrome are many, which include autoimmune conditions. Polyarteritis nodosa as an aetiological factor for posterior reversible encephalopathy syndrome is rare. We present a case of polyarteritis nodosa complicated by posterior reversible encephalopathy syndrome. CASE PRESENTATION: A 26-year-old South-Asian female presented with left sided focal seizures with secondary generalization and visual disturbance for 2 days duration. She had a prior history of arthralgia and weight loss with no medically explainable cause for young onset hypertension. Examination revealed a right claw hand with a palpable vasculitic type of rash involving both the palmar surfaces. Symptoms responded to management with anti-hypertensives and anti-epileptics. Whole blood count, iron studies, erythrocyte sedimentation rate and C-reactive protein values portrayed an ongoing chronic inflammatory process. Serological studies such as Anti-nuclear antibody, Anti -double stranded deoxyribonucleic acid, Anti-neutrophil cytoplasmic antibody and Anti-cyclic citrulinated peptide were negative. Magnetic resonance imaging revealed high signal intensity on T2 in both occipital lobes. Skin biopsy of the palm revealed moderate vessel vasculitis. Renal imaging revealed structurally abnormal kidneys with micro aneurysms in the right renal vasculature. Repeat magnetic resonance imaging of the brain two months later showed marked improvement. A diagnosis of polyarteritis nodosa with posterior reversible encephalopathy syndrome was made. CONCLUSIONS: Posterior reversible encephalopathy syndrome should not be missed. Investigations for an aetio-pathological cause should be considered including the rarer associations like polyarteritis nodosa.

A case of paroxysmal atrial fibrillation following low voltage electrocution.

BACKGROUND: Electrical injury may result in arrhythmias, however atrial fibrillation following low voltage electrocution is not a common occurrence. CASE PRESENTATION: A 70-year-old South-Asian woman with no prior history of cardiovascular disease presented following an accidental low voltage electrocution with loss of consciousness. On initial assessment she was found to be in atrial fibrillation with a moderate to rapid ventricular rate. Troponin I and 2D echo were normal. Transient rise in markers of muscle damage were noted. The arrhythmia resolved spontaneously without active intervention. CONCLUSION: Loss of consciousness and the path of electrical conduction involving the heart may herald cardiac involvement following electrocution. Low voltage electrocution may cause cardiac insult. Conservative management may suffice in management of atrial fibrillation without cardiovascular compromise.

Electrocardiographic and echocardiographic manifestations of cardiac involvement in leptospirosis.

BACKGROUND: Cardiac involvement is known to occur in leptospirosis, however, data on the significance of electrocardiographic and echocardiographic findings is very limited. METHODS: Electrocardiographic and echocardiographic changes were studied in serologically confirmed patients with leptospirosis. RESULTS: Of 22 patients, 45% (10) had cardiac symptoms; 59% (13) had abnormalities on the ECG; 90% (9/10) of patients with cardiac symptoms had at least one electrocardiographic abnormality. Echocardiographic abnormalities were seen in 41% (9). Clinical and echocardiographic evidence of myocarditis was seen in two patients, but left ventricular function was preserved. CONCLUSIONS: Echocardiographic changes may be useful in identifying patients with myocarditis in leptospirosis, especially in symptomatic patients.

Cardiac involvement in leptospirosis.

Leptospirosis is a neglected global disease with significant morbidity and mortality. Cardiac complications such as chest pain, arrhythmias, pulmonary oedema and refractory shock have been reported in patients with severe disease. However, the frequency and extent of cardiac involvement in leptospirosis, are under-reported and poorly understood. Multiple factors may contribute to clinical manifestations that suggest cardiac involvement, causing diagnostic confusion. A variety of electrocardiographic changes occur in leptospirosis, with atrial fibrillation, atrioventricular conduction blocks and non-specific ventricular repolarization abnormalities being the most common. Electrolyte abnormalities are likely to contribute to electrocardiographic changes; direct effects on Na(+)-K(+)-Cl(-) transporters in the renal tubules have been postulated. Echocardiographic evidence of myocardial dysfunction has not been adequately demonstrated. The diagnostic value of cardiac biomarkers is unknown. Histopathological changes in the myocardium have been clearly shown, with myocardial inflammation and vasculitis present in postmortem studies. Nonetheless, the pathophysiology of cardiac involvement in leptospirosis is poorly understood. Cardiac involvement, demonstrated electrocardiographically or clinically, tends to predict poor outcome. No specific therapies are available to prevent or treat cardiac involvement in leptospirosis; current management is based on correction of deranged homeostasis and supportive therapy. Evidence suggests that direct myocardial damage occurs in patients with severe leptospirosis, and further studies are recommended to elucidate its pathophysiology, clinical features and contribution to overall prognosis, and to identify appropriate diagnostic investigations and specific therapies.

Final-year medical students' perceptions regarding the curriculum in public health.

BACKGROUND: The Faculty of Medicine, University of Colombo, has an integrated curriculum in which teaching of public health takes place through a series of modules which span the full five-year study programme. AIM: To assess final year medical student perceptions regarding the public health curriculum and to identify factors which influence this. MATERIALS AND METHODS: The study was cross sectional. Convenience sampling was utilized on final-year students of the Faculty of Medicine, University of Colombo, Sri Lanka. A self-administered 4-point Likert scale questionnaire covered general opinion on public healthcare and perceptions about the curriculum. Data were analyzed using descriptive statistics and Chi-square tests. RESULTS: One hundred and eighty four students (94%) participated in the study. Eighty-two percent (148) viewed public health as an important field. Only 9% (16) were interested in a career in public health. A significant association was found between choosing public health as career and the following: perception of public health as an important field; holding a good opinion about public health prior to commencement of the course; having found the field-based experience enjoyable and beneficial to the community; and feeling competent to work in the community at the end of the course (P < 0.01). With regard to teaching methods, group activities and discussion-centered activities were identified positively (153, 83% and 125, 68% respectively). The majority of students indicated that they were not stimulated to read more on the subject or regularly revise what they have learnt, both during the introductory public health programme and during the final year. CONCLUSIONS: The curriculum has been able to create a positive opinion about public health. However, students lack enthusiasm to learn independently. Experiential, group-centered teaching activities and a constructivist approach may be more effective in promoting independent learning. Perceptions are important and should aid in structuring the curricula.