A Case Report on Generalised Muscle Spasms After Ornamental Tarantula Bites That Responded Well to Intravenous Calcium Gluconate Treatment.

Here, we present a case of a 55-year-old male, who was admitted with a spider bite, which caused swelling of the hand and painful muscle spasms along with palpitations. The patient made a complete recovery after the administration of intravenous calcium gluconate, followed by oral calcium supplements. Although no specific treatment exists in Sri Lanka for spider bites, calcium supplements can be beneficial for Sri Lankan ornamental tarantula (Poecilotheria fasciata) bites.

Growth Failure and Primary Amenorrhea: Endocrine Dysfunction as a Late Presentation of Crohn's Disease.

Crohn's disease (CD) is a chronic inflammatory bowel disease involving entire gastrointestinal tract, most commonly affecting terminal ileum and colon. It usually presents with gastrointestinal symptoms like bloody diarrhea, fever and loss of weight. The clinical course of CD includes gastrointestinal complications like fistulas, abscesses and perianal disease. Inflammatory bowel diseases (IBD) are usually diagnosed during childhood and adolescence, majority during puberty and pubertal growth spurt. Various extraintestinal manifestations may be a presentation of CD that poses a diagnostic challenge. Growth failure is an important complication of IBD rather than a manifestation. Herein we present a case of a 16-year-old Sri Lankan girl presenting with growth failure and primary amenorrhea. She had minimal gastrointestinal symptoms. She also had microcytic anemia with marginally elevated inflammatory markers and hormonal profile. She underwent colonoscopy and was diagnosed to have Crohn's disease confirmed by ileal biopsy. On initiation of treatment with immunosuppressants, she attained menarche, although no improvement in height was observed.

Protein-Losing Enteropathy as the First Presentation of Systemic Lupus Erythematosus in a Resource-Limited Setting in Sri Lanka: A Case Report.

Protein-losing enteropathy (PLE) is one of the rare gastrointestinal manifestations of systemic lupus erythematosus (SLE), which can manifest several years before the diagnosis of SLE. PLE should be suspected in patients with hypoalbuminemia in the absence of urinary protein loss and normal liver functions without any other manifestations of malnutrition. Due to the non-specificity of the imaging and histological findings, it is difficult to diagnose PLE in resource-limited settings. Thus, it is underdiagnosed. We report the case of a 38-year-old Sri Lankan (South Asian) female who is a diagnosed patient with hypothyroidism and has presented with worsening generalized body swelling and ascites for two months. She had hypoalbuminemia without proteinuria. Thus, the clinical diagnosis of PLE was suspected. The diagnosis of SLE was suspected because of significant alopecia, high titer (1:1000) antinuclear antibody (ANA) positivity, and hypocomplementemia. Though confirmatory tests such as Tc-99 albumin scintigraphy and stool alpha-1 anti-trypsin were not available in our resource-limited setting, the diagnosis of the SLE-associated protein-losing enteropathy was made as the patient fulfilled the European Alliance of Associations for Rheumatology (EULAR) criteria for SLE and also by excluding all the other possible causes of PLE.

Assessment of Additional Risk Factors for Cardiovascular Disease and Awareness Among Adult Patients With Diabetes Mellitus: A Cross-Sectional Study From Northern Sri Lanka.

Introduction Cardiovascular diseases are the leading cause of death in people with type 2 diabetes. The assessment of additional risk factors for cardiovascular disease among diabetes patients and comparing current practices with the best practices can improve patient care. The aim of this study was to assess these additional risk factors and awareness of them among adult patients with diabetes mellitus. Materials and methods This cross-sectional study was conducted in the general medical wards at District General Hospital Kilinochchi from June 2021 through August 2021 and included 421 patients. The data were analyzed using SPSS version 28. Results Most patients (70.1%) were women, and their mean age was 57.4 years. Their lifestyle-related risk factors included being overweight (9%) or obese (2.1%), smoking (8.8%), consuming alcohol (2.4%), insufficient physical activity (23.5%), and not meeting the Sri Lankan dietary guidelines for the consumption of fruits and vegetable (75.3%). In addition, 3.3% were suffering from chronic kidney disease, 6.2% from micro-albuminuria, 49.4% from hypertension, and 67.7% from hypercholesterolemia. Further, 11.4% (CI: 8.6-11.7%) had uncontrolled diabetes, only 40.1% had low-density lipoprotein (LDL) levels within the target range, and only 16.2% had systolic blood pressure within the target range. Conclusions The findings presented here indicate the existence of significant gaps similar to those found in the literature regarding lifestyle modifications and recommended practices for reducing the risk of cardiovascular disease. As a result, it may be necessary to address physicians' inertia in regard to the implementation of best practices, and there is a clear need to educate patients during their visits to reinforce the importance of lifestyle modifications.

Vasoactive Intestinal Peptide-Secreting Pancreatic Neuroendocrine Tumor: A Case Report.

A 36-year-old female with chronic watery diarrhea and persistent hypokalemia for more than eight months duration eventually being diagnosed as vasoactive intestinal peptide tumor (VIPoma) clinically and histologically is presented here. The patient achieved complete recovery after starting octreotide, a somatostatin analog. She underwent a distal pancreatectomy along with the removal of the tumor at Teaching Hospital Jaffna for the permanent cure.

Depression, Disability, and Cognitive Impairment Among Elders With Medical Illnesses Attending Follow-Up Clinics at a Tertiary Care Hospital in Northern Sri Lanka.

INTRODUCTION: The rising proportion of the elderly is increasingly affected by non-communicable diseases. Despite an abundance of literature suggesting that elders with medical conditions are more vulnerable to depression, disability, and cognitive impairment, these tend to go unnoticed and unaddressed. This study describes the prevalence and correlates of depression, disability, and cognitive impairment among elders with medical illnesses attending follow-up clinics in a tertiary care hospital in northern Sri Lanka. METHODS: This descriptive cross-sectional study was carried out among 122 elders (≥60 years) attending medical clinics at Teaching Hospital Jaffna. Depression, disability, and cognitive impairment were assessed by the 15-item Geriatric Depression Scale, 12-item World Health Organization Disability Assessment Schedule 2.0, and Montreal Cognitive Assessment, respectively. Student's T-Test, ANOVA, and correlation coefficient were used in analyzing data using Statistical Package for Social Sciences 25 (SPSS-v25) (IBM, New York, United States). RESULTS: The mean age of the participants was 68.3 years (SD=5.70); 58 (47.5%) were males and 64 (52.5%) were females. Prevalence of depression was 44.3% (95% CI=35.5-53.1), while disability was 95.9% (95% CI=92.4-99.4) and cognitive impairment was 80.3% (95% CI=73.2-87.4). Depression was significantly associated with gender (p=0.013), marital status (p=0.019), and living arrangement (p<0.001). Cognitive impairment was significantly associated with education level (p=0.045), and disability was associated with education level (p=0.008) and marital status (p=0.027). Among the study participants, only 12 (9.8%) had previously sought professional help for depression, disability, or cognitive impairment. CONCLUSION: Depression, disability, and cognitive impairment are common among the elderly attending medical clinics in Teaching Hospital Jaffna, and are, in most cases, unaddressed.

A study on knowledge, attitude and practices towards the COVID-19 pandemic among the non-COVID-19 patients at Outpatient Department in a Teaching Hospital, Northern Sri Lanka.

BACKGROUND: Severe Acute Respiratory Syndrome Coronavirus -2 (SARS-CoV-2) has infected millions of people all over the world and Sri Lanka is not an exception for the impact of Coronavirus Disease (COVID-19). As there are no effective therapeutic agents at present and newly developed vaccines are not freely available for many countries, preventive measures such as handwashing, social distancing, and respiratory etiquette are key to control of spread. The effective implementation of these measures depends on public knowledge and attitude towards COVID-19 and adherence to key practices. METHODS: This is a cross-sectional study conducted among 500 non-COVID-19 patients who attended the Outpatient Department (OPD) of the Teaching Hospital Jaffna, Sri Lanka. Knowledge, attitude and practices (KAP) was assessed through a self-administered questionnaire and analysis was performed by using SPSS 26. RESULTS: The majority were females (67.8%) and the mean age of the participants was 36.9 (range: 15-85). Most of the participants were homemakers. Two hundred and twenty-two patients (44.4%: 40.1-48.8) showed a suboptimal knowledge score regarding COVID-19. The males, age above 65, were significantly associated with low knowledge score (P < 0.05). Similarly, a significant proportion (36.4%: 32.3-40.7) showed a suboptimal attitude score but the majority of the participants have adopted positive behaviours such as frequently washing hands (88.4%) and wearing masks in appropriate places (91.6%). The major sources for information regarding COVID-19 among the participants were the news media (54.0%) followed by social media (23.2%). CONCLUSION: As a significant proportion of the participants showed a poor knowledge score and gaps in specific aspects related to COVID-19, the primary care physicians have a significant role to play to improve community knowledge by educating specific groups such as the males and elderly by using appropriate news media and social media platforms.

Kounis Syndrome and Multiorgan Failure Following Multiple Wasp Stings.

Wasp and bee stings are common in Sri Lanka, and systemic envenomation causes a spectrum of clinical manifestations that includes simple local allergic reaction to life-threatening multiple organ injury or failure. However, wasp toxin-induced acute myocardial infarction is very rare in the literature. Here, we describe a pregnant lady with mass wasp stings who developed toxin-induced acute myocardial infarction with multiorgan injury. The treating physician should anticipate the complications of massive envenomation following multiple wasp stings.

Immunoglobulin A Nephropathy with Erythrocytosis: An Unusual Association.

Immunoglobulin A (IgA) nephropathy is the commonest type of glomerular nephritis worldwide and is one of the leading causes of chronic kidney disease. Erythrocytosis is known to be associated with IgA nephropathy and other renal manifestations. We report a case of a 35-year-old male with grade 3 hypertensive retinopathy, erythrocytosis, and heavy proteinuria with an impaired renal function who was diagnosed as a case of erythrocytosis with IgA nephropathy and secondary focal segmental glomerulosclerosis. An extensive evaluation and prompt interventions significantly improved the outcome in this patient.

Shoulder pad and macroglossia: "two signs of AL amyloidosis".

"Shoulder pad" sign resulting from deposition of amyloid in the periarticular soft tissue is rare but it is pathognomonic for immunoglobulin amyloidosis (AL). Although the detection remains a challenge, it gives a strong clue leading to prompt diagnosis.

Unusual Manifestations of Dengue Fever: A Review on Expanded Dengue Syndrome.

Dengue infection may manifest as dengue fever (DF), dengue hemorrhagic fever (DHF), and dengue shock syndrome (DSS). The World Health Organization (WHO) came up with the term "expanded dengue syndrome" (EDS) to designate cases which do not fall into either DHF or DSS, with unusual manifestations in other organs such as the cardiovascular system, the nervous system, the kidneys, the gut, and the hematological system, which have been increasingly reported and called EDS. Furthermore, EDS is becoming widespread globally with unusual features and increased severity. There are increasing reports of under-recognized and infrequent manifestations with severe organ involvement. This review gives knowledge of expanded dengue syndrome which helps to catch the diagnosis of dengue early, particularly during the ongoing epidemics and escaping from further series of unnecessary investigations.

Dengue Hemorrhagic Fever Complicated With Hemophagocytic Lymphohistiocytosis in an Adult With Diabetic Ketoacidosis.

Dengue infection can cause a wide spectrum of presentations extending from simple self-limiting febrile illness to severe dengue, including dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS). Dengue associated hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening condition characterized by the uncontrolled activation of macrophages and T cells, eliciting clusters of symptoms and signs and abnormal biochemical parameters. Herein we report a 28-year-old Sri Lankan female with no past medical history who presented with dengue hemorrhagic fever and diabetic ketoacidosis complicated with hemophagocytic lymphohistiocytosis. She was treated with a three-day course of intravenous methylprednisolone in addition to standard care for diabetic ketoacidosis and dengue hemorrhagic fever. She made an uneventful recovery.

Profuse Sweating and Hot Flashes: An Unusual Presentation of Post-Dengue Fatigue Syndrome.

The dengue virus is a mosquito-borne flavivirus that causes dengue fever (DF), dengue hemorrhagic fever, and dengue shock syndrome. DF is characterized by fever, headache, arthralgia, retro-orbital pain, and skin rashes. However, some patients with DF develop post-dengue fatigue syndrome (PDFS) following their initial febrile episode. Fatigue is common during the febrile episode of DF; however, PDFS is defined as the presence of a stubborn sense of tiredness that results in a decreased capacity for physical and mental work. PDFS carries a spectrum of musculoskeletal and neurological features. Following the recovery of DF, vasomotor symptoms such as hot flashes, excess sweating, and mood changes are rare. We present the first reported case of PDFS in a young woman in Sri Lanka.

Rhabdomyolysis and acute kidney injury associated with thiocyclam hydrogen oxalate (Evisect) poisoning.

Thiocyclam hydrogen oxalate (Brand name: Evisect) is an insecticide with anti-cholinergic and cholinergic properties. Although there are few case reports and a case series of human toxicity of nereistoxin analogue insecticide such as cartap hydrochloride poisoning published in the literature, poisoning with thiocyclam hydrogen oxalate (Evisect), an another analogue of nereistoxin with its own molecular formula is only heard in animals, such as Nubian goats. Herein, we report a patient presented with rhabdomyolysis and acute kidney injury without significant symptoms of acute cholinergic syndrome following self-ingestion of thiocyclam hydrogen oxalate (Evisect) and he made an uneventful recovery with prompt supportive care.

Hemophagocytic Lymphohistiocytosis: An Unusual Presentation of Scrub Typhus.

Scrub typhus is an important etiological cause for acute undifferentiated febrile illness in the Asia-Pacific region, including Sri Lanka. It is a mite-borne disease caused by Orientia tsutsugamushi. Hemophagocytic lymphohistiocytosis (HLH) is a rapidly progressive and potentially life-threatening hyperinflammatory syndrome rarely associated with scrub typhus. We herein describe a rare case of scrub typhus complicated by hemophagocytic lymphohistiocytosis in a 40-year-old previously healthy woman who presented with a history of an acute febrile illness. Following the observation of acute deterioration of hematological parameters despite the nature of the febrile illness, the rare association of hemophagocytic lymphohistiocytosis was considered, and this disease association was confirmed by fulfilling six out of eight of the diagnostic criteria of haemophagocytic lymphohistiocytosis. The patient made an uneventful recovery following treatment for the precipitating illness and with supportive care.

Acute unilateral anterior uveitis following zoledronic acid infusion: A case report.

Bisphosphonates are widely used to treat several clinical conditions. Zoledronic acid is one of this class, commonly used for the treatment and prevention of osteoporosis, hypercalcemia of malignancy, Paget's disease, and multiple myeloma. A variety of ocular side effects associated with bisphosphonates therapy has been reported but are uncommon and readily treatable. Most of these ocular inflammatory conditions are associated with other bisphosphonates such as pamidronate but rarely reported with zoledronic acid. Acute anterior uveitis associated with zoledronic acid is rare. We describe a 75-year-old female who presented with features of acute unilateral non-granulomatous anterior uveitis which developed within 24 h following the first dose of intravenous infusion of zoledronic acid administered to treat post-menopausal osteoporosis. She was treated with topical steroids and made an uneventful recovery in 2 weeks.

Dengue fever complicated with acute liver failure: A case report of expanded dengue syndrome and literature review.

Dengue is the most common arboviral disease, the presentation of which ranges from asymptomatic illness to dengue shock syndrome. Liver is the most common organ affected in dengue, and liver involvement is asymptomatic in majority. Dengue fever is a rare, but a leading cause for acute liver failure in endemic regions. Here, we report a case of a 34-year-old male ethanol user (16 units per week), presented with typical features of dengue infection, which was confirmed serologically, complicated with acute liver failure without clinical, radiological or laboratory evidence of plasma leakage. He was managed with intravenous fresh frozen plasma and N-acetyl cysteine along with other recommended supportive therapies for acute hepatic failure. He made an uneventful recovery.

Vitamin D status among postmenopausal osteoporotic women: a hospital based cross-sectional study from Northern Sri Lanka.

BACKGROUND: Vitamin D deficiency is common among post-menopausal women and it is important to treat vitamin D deficiency to prevent falls and fractures in patients with osteoporosis. Few studies examined the prevalence of vitamin D deficiency in general population of Sri Lanka but no studies to date done among post-menopausal women with osteoporosis in Sri Lanka. This is the first study in Sri Lanka of such kind conducted to evaluate the serum vitamin D levels among postmenopausal women. METHODS: Cross-sectional study was conducted at the Endocrine Unit, Teaching Hospital Jaffna from January to December 2018. During this period 105 postmenopausal women who registered for bone density assessment were recruited to the study. Data collection was done by investigators and blood sample was taken from each participant by registered nurses and total 25-Hydroxy Vitamin D level (25(OH)-Vit D) was measured by competitive immunoassay with enhanced chemiluminiscence technique, levels were categorized and analysis was done using SPSS 26. RESULTS: Mean age of 105 postmenopausal women was 67.7 with minimum 33 and maximum 84 years. Mean total 25(OH)-Vit D was 27.5 (range11.7-52.5 ng/mL). 25(OH)-Vit D levels were adequate in only 36.2% (95%CI: 27-45), 44% had insufficient levels and deficiency was present in 19% (95%CI: 12-27) of postmenopausal women. Among total study participants 20% were vegetarian, 53, 76.2 and 64.8% were consuming milk, fish and egg respectively and 71.4% reported adequate level of sun exposure (> 30 min/day). Commonly reported vitamin D deficiency symptoms include paraesthesia (57.1%), bone-pain (55.2%), easy fatigability (54.3%), malaise (51.4%), muscle cramps (43.8%) and proximal myopathy (40.0%). Nevertheless, comparison of musculoskeletal symptoms between group with sufficient level and group with insufficient and deficient level showed no significant difference (P > 0.05). Among 71 participants (66.7%) who completed bone density assessment, 38% (95%CI: 27-49) showed osteoporosis. Vertebral Z score showed a significant correlation with 25(OH)-Vit D level (r-0.252, P-0.03). CONCLUSION: Prevalence of vitamin D deficiency is relatively high among the post-menopausal women with a provisional diagnosis of osteoporosis. It is essential to consider vitamin D supplementation when initiating treatment for osteoporosis. Hence, Vitamin D testing is desirable in decision making to treat or not to treat.

An unusual case of remitting seronegative symmetrical synovitis with pitting edema: Case report and literature review.

Remitting seronegative symmetrical synovitis with pitting edema is a rare but well-recognized clinical entity that is easily overlooked due to lack of clinical vigilance. It is classically described as an acute onset of symmetrical tenosynovitis of both upper and lower extremities with pitting edema, mostly noted in elderly population. Young patients with other rheumatological diseases and unilateral involvement had also been reported, but symmetrical remitting seronegative symmetrical synovitis with pitting edema in a young patient is a rare observation. We hereby report a case of a remitting seronegative symmetrical synovitis with pitting edema in a young male affected by no rheumatological diseases in the past, typically fulfilling the diagnostic criteria and well responded to low-dose steroid therapy. The salient features of the present case in terms of age, remitting seronegative symmetrical synovitis with pitting edema possibly related to undifferentiated arthropathy, reactive arthritis, or diabetes mellitus.

Cheilitis: An unusual presentation of Mucocutaneous Leishmaniasis.

The Mucocutaneous Leishmaniasis (MCL) involving lip is extremely uncommon. A clinical diagnosis of Leishmaniasis of the lips is often challenging to the treating clinician and may result in delayed diagnosis as this case illustrates. MCL should be considered in the differential diagnosis of lip lesions in a Leishmania endemic area.