A Nonfunctioning Pituitary Macroadenoma Presenting as Cyclical Vomiting and Severe Hyponatremia in a Young Female.

INTRODUCTION: Recurrent vomiting is a commonly overlooked debilitating symptom which causes significant impact on the quality of life. There are several causes for vomiting, ranging from commonly known causes to rare causes. Nonfunctioning pituitary macroadenomas generally present with visual disturbances, headache, and symptoms due to anterior pituitary hormone deficiencies. This case report is about an atypical presentation of a nonfunctioning pituitary macroadenoma in which the patient presented with cyclical vomiting with severe hyponatremia. Case Report. A 23-year-old girl presented with four to five episodes of vomiting per day for two days duration. She had a history of similar episodes of vomiting since 2016, with each episode generally lasting for 4-5 days and occurring in every four to six months. All episodes exhibited similar symptomatology and she was free of symptoms in-between. Generalized body weakness, postural dizziness, reduced appetite, and secondary amenorrhea were other symptoms she has had since 2016. Examination findings showed a low body mass index (BMI) (16 kg/m2) with normal system examination. Investigations showed severe hyponatremia (110 mmol/L) with hypokalemia (3.2 mmol/L) and hypochloremia (74 mmol/L). Her urinary excretion of potassium, sodium, and serum osmolality was low. Urine osmolality was mildly elevated compared to serum osmolality. Blood urea was normal. Severe hyponatremia with minimal hyponatremic symptoms was suggestive of chronic hyponatremia, which was accentuated by ongoing vomiting and possible reduced intake of salt. Further investigations showed evidence of secondary hypoadrenalism, central hypothyroidism, hypogonadotropic hypogonadism, and mild hyperprolactinemia. Magnetic resonance imaging (MRI) revealed a pituitary macroadenoma with mass effect on the optic chiasma. Hydrocortisone and levothyroxine were started, and she underwent transsphenoidal resection of the pituitary tumor. She recovered from cyclical vomiting. CONCLUSION: There can be multiple overlapping aetiologies for every observed symptom, sign, and abnormal investigation finding. Therefore, aetiological diagnosis is challenging, especially in the presence of an atypical clinical presentation. Cyclical vomiting and severe hyponatremia are atypical presentations of nonfunctioning pituitary macroadenomas.

Severe Sepsis with Multiorgan Failure due to Melioidosis: A Lesson to Learn.

INTRODUCTION: Melioidosis is a bacterial infection caused by a Gram-negative bacillus Burkholderia pseudomallei, prevalent in Southeast Asia and Northern Australia. Sri Lanka is situated in the endemic belt of melioidosis. Melioidosis has a wide spectrum of clinical presentations and results in high mortality rates in severe infection. Case Report. We report a 54-year-old previously healthy Sri Lankan farmer who presented with septicemia following a cut injury to the right leg while working in a paddy field. Initially, he had mild wound sepsis, and later, his condition deteriorated rapidly. The patient required organ support later for cardiovascular instability, acute liver failure, acute kidney injury, acute respiratory distress syndrome, and coagulopathy. The patient's blood culture was negative on the admission day, and the repeated blood culture taken at the ICU was contaminated with a commensal flora initially and later isolated Burkholderia pseudomallei. Although wound swab culture taken on the first day isolated an organism, it took six days to identify it as Burkholderia pseudomallei. The patient succumbed to severe melioidosis leading to a severe sepsis and multiorgan failure in spite of treatment with meropenem. CONCLUSION: This case report highlights the importance of considering melioidosis as a differential diagnosis when a patient comes with risk factors for melioidosis.

Core Prescribing Indicators and the Most Commonly Prescribed Medicines in a Tertiary Health Care Setting in a Developing Country.

Irrational prescribing is common, especially in developing countries. It is important to identify the magnitude of irrational use, to take necessary steps to promote rational prescribing. We identified core prescribing indicators and commonly prescribed medicines at ward settings (IW) and outpatients' clinics (OPC) in a tertiary care hospital in Sri Lanka. A descriptive cross-sectional study was carried out at IW and OPC settings. Prescriptions were obtained from 5 major specialties (Clinical Medicine (CM), Gynaecology and Obstetrics (GO), Paediatrics, Psychiatry, and Surgery). The WHO core prescribing indicators were used to describe the pattern of prescribing, and the most commonly prescribed medicines were identified. A total of 1,318 prescriptions were analyzed. The five most commonly prescribed medicines were paracetamol (31.0%), omeprazole (20.6%), folic acid (18.3%), atorvastatin (16.2%), and salbutamol (15.3%). The average number of medicines per encounter was 4.8 ± 3.6 (IW: 5.7 ± 4; OPC: 3.8 ± 2.8; p < 0.001), with the highest IW (7.8 ± 4.2) and OPC (7.8 ± 2.7) values were from CM, being significantly higher than all other disciplines (p < 0.05). Percentage encounters with an antibiotic or an injection was 26.4% and 30.1%, respectively, with IW being significantly higher than OPC (p < 0.001). Percentage of medicines prescribed by generic name and from the essential medicine list (EML) was 90.1% and 91.1%, respectively, with no significant IW and OPC difference. In conclusion, a high degree of polypharmacy was noted. The use of injectable medicines, prescribing from the EML, and generic name prescribing was satisfactory; however, overall rational prescribing needs further improvement. Further investigation into the degree of rational prescribing associating it with clinical information will be important.

Management, characteristics and outcomes of patients with acute coronary syndrome in Sri Lanka.

BACKGROUND: Ischaemic heart disease is the leading cause of in-hospital mortality in Sri Lanka. Acute Coronary Syndrome Sri Lanka Audit Project (ACSSLAP) is the first national clinical-audit project that evaluated patient characteristics, clinical outcomes and care provided by state-sector hospitals. METHODS: ACSSLAP prospectively evaluated acute care, in-hospital care and discharge plans provided by all state-sector hospitals managing patients with ACS. Data were collected from 30 consecutive patients from each hospital during 2-4 weeks window. Local and international recommendations were used as audit standards. RESULTS: Data from 87/98 (88.7%) hospitals recruited 2177 patients, with 2116 confirmed as having ACS. Mean age was 61.4±11.8 years (range 20-95) and 58.7% (n=1242) were males. There were 813 (38.4%) patients with unstable angina, 695 (32.8%) with non-ST-elevation myocardial infarction (NSTEMI) and 608 (28.7%) with ST-elevation myocardial infarction (STEMI). Both STEMI (69.9%) and NSTEMI (61.4%) were more in males (P<0.001). Aspirin, clopidogrel and statins were given to over 90% in acute setting and on discharge. In STEMI, 407 (66.9%) were reperfused; 384 (63.2%) were given fibrinolytics and only 23 (3.8%) underwent primary percutaneous coronary intervention (PCI). Only 42.3 % had thrombolysis in <30 min and 62.5% had PCI in <90 min. On discharge, beta-blockers and ACE inhibitors/angiotensin II receptor blockers were given to only 50.7% and 69.2%, respectively and only 17.6% had coronary interventions planned. CONCLUSIONS: In patients with ACS, aspirin, clopidogrel and statin use met audit standards in acute setting and on discharge. Vast majority of patients with STEMI underwent fibrinolyisis than PCI, due to limited resources. Primary PCI, planned coronary interventions and timely thrombolysis need improvement in Sri Lanka.

The "e-Generation": The Technological Usage and Experiences of Medical Students from a Developing Country.

BACKGROUND: The medical community is increasingly using Portable Electronic Devices (PEDs). We evaluated usage of PEDs and medical apps among medical students from Sri Lanka. METHODS: This descriptive cross-sectional study was conducted at Faculty of Medicine, University of Colombo. Medical students from 2nd to 5th year were invited for the study. A self-administered questionnaire was used to collect details of PEDs availability, accessibility, and usage, perceived advantages/barriers of PEDs, and availability, accessibility, and usage of medical apps. RESULTS: Sample size was 505 (response rate, 61.8%). Mean age was 23.2 ± 1.3 years and majority were females (60.4%, n = 305). Majority (87.5%, n = 442) of students owned a PED. Nonaffordability was the most common reason for having not owning a PED (46%). Nonaffordability and lack of knowledge were key determinants of the usage of PEDs and medical "apps." Doubts about reliability and lack of knowledge regarding reliable electronic sources of information were other significant barriers. CONCLUSIONS: Our results show that a significant majority of students owned a PED, a higher percentage than what is reported elsewhere. Considering barriers identified, it is important for institutions to promote usage of PEDs and medical apps by providing financial support, training, and knowledge to build confidence in technology.