Improvement in the management of acutely poisoned patients using an electronic database, prospective audit and targeted educational intervention.

PROBLEM: The need to improve the clinical assessment and management of acutely poisoned patients presenting to an NHS hospital emergency department (ED). DESIGN: Creation of an electronic clinical toxicology database to prospectively collect all aspects of clinical information on poisoned-patient presentations. Systematic analysis of collated information to identify shortfalls in patient assessment and management. Bimonthly audit meetings, and design and implementation of educational interventions to address identified shortfalls. Ongoing audit to demonstrate continued improvement in patient care. BACKGROUND AND SETTING: ED in tertiary-level inner-city London teaching hospital. Study conducted by staff from the ED and clinical toxicology service. KEY MEASURES FOR IMPROVEMENT: Demonstration of overall reduction in the incidence of predefined shortfalls in patient assessment and management during 12-month study period. STRATEGIES FOR IMPROVEMENT: Targeted educational lectures and case-based clinical scenarios addressing identified deficiencies in the knowledge required to effectively manage poisoned patients. Weekly case-based anonymised feedback report sent electronically to staff involved in caring for poisoned patients. EFFECTS OF CHANGE: Implementation of targeted teaching of ED staff and regular electronic distribution of teaching cases. Between the first and second 6 months of the study, there was a significant increase in the proportion of presentations for which clinical management was graded as "good" (77.6% to 89.4%, p<0.0001) and a significant reduction in the proportion of "major" (9.9% to 5.8%, p = 0.012) and "minor" (12.6% to 4.8%, p<0.0001) shortfalls. LESSONS LEARNT: Systematic collection of clinical information, using a dedicated electronic database and subsequent review and audit of collated data by interested clinicians, enabled design and implementation of targeted educational interventions to address shortfalls in patient management. This process has led to significant improvements in the clinical care of acutely poisoned patients presenting to the ED.

Comparison of two commonly practiced atropinization regimens in acute organophosphorus and carbamate poisoning, doubling doses vs. ad hoc: a prospective observational study.

There is a wide variation and lack of evidence in current recommendations for atropine dosing schedules leading to subsequent variation in clinical practice. Therefore, we sought to examine the safety and effectiveness of a titrated vs. ad hoc atropine treatment regimen in a cohort of patients with acute cholinesterase inhibitor pesticide poisoning. A prospective cohort study was conducted in three district secondary referral hospitals in Sri Lanka using a structured data collection form that collected details of clinical symptoms and outcomes of cholinesterase inhibitor pesticide poisoning, atropine doses, and signs of atropinization. We compared two hospitals that used a titrated dosing protocol based on a structured monitoring sheet for atropine infusion with another hospital using an ad hoc regime. During the study, 272 symptomatic patients with anticholinesterase poisoning requiring atropine were admitted to the three hospitals. Outcomes of death and ventilation were analyzed for all patients, 226 patients were prospectively assessed for atropine toxicity. At baseline, patients in the titrated dose cohort had clinical signs consistent with greater toxicity. This in part may be due to ingestion of more toxic organophosphates. They received less pralidoxime and atropine, and were less likely to develop features of atropine toxicity, such as delirium (1% vs. 17%), hallucinations (1% vs. 35%), or either (1% vs. 35%) and need for patient restraint (3% vs. 48%) compared with the ad hoc dose regime. After adjusting for the pesticides ingested, there was no difference in mortality and ventilatory rates between protocols. Ad hoc high dose atropine regimens are associated with more frequent atropine toxicity without any obvious improvement in patient outcome compared with doses titrated to clinical effect. Atropine doses should be titrated against response and toxicity. Further education and the use of a structured monitoring sheet may assist in more appropriate atropine use in anticholinesterase pesticide poisoning.

Severe hypokalaemic metabolic alkalosis following ingestion of gaviscon.

INTRODUCTION: Uncommon metabolic abnormalities in the emergency department could be a result of drug overdose due to uncommon agents. CASE REPORT: A 35-year-old male presented to the emergency department with a Glasgow Coma Scale (GCS) of 3/15 and a normal pulse rate and blood pressure. Subsequent questioning after recovery revealed he had ingested 2 L of Gaviscon over the preceding 48 hours. He had normal haematology, liver, and renal function during admission. The electrocardiogram showed T wave inversion in the inferior leads on admission. Arterial blood gas on air was: pH 7.54, HCO3 50 mmol/L (50 meq/L), Chloride 66 mmol/L, anion gap was 19, pO2 11 kPa (82.5 mmHg), and pCO2 8 kPa (60 mmHg). Serum sodium was 127 mmol/L and serum potassium was 1.6 mmol/L. His GCS improved within one hour of admission with supportive care, and his serum potassium and bicarbonate improved within 24 hours. He subsequently made a full recovery. Discussion. Bicarbonate ingestion in the form of Gaviscon(R) and vomiting made this patient alkalotic, and simple supportive care provided effective management with a complete recovery. CONCLUSION: This case illustrates how a severe metabolic alkalosis can result from a significant ingestion of Gaviscon, and that such presentations can give rise to diagnostic dilemma.

A randomized controlled trial of fresh frozen plasma for coagulopathy in Russell's viper (Daboia russelii) envenoming.

Essentials Russell's viper envenoming is a major health issue in South Asia and causes coagulopathy. We studied the effect of fresh frozen plasma and two antivenom doses on correcting coagulopathy. Fresh frozen plasma did not hasten recovery of coagulopathy. Low-dose antivenom did not worsen coagulopathy. SUMMARY: Background Russell's viper (Daboia russelii) envenoming is a major health issue in South Asia and causes venom-induced consumption coagulopathy (VICC). Objectives To investigate the effects of fresh frozen plasma (FFP) and two antivenom doses in correcting VICC. Methods We undertook an open-label randomized controlled trial in patients with VICC at two Sri Lankan hospitals. Patients with suspected Russell's viper bites and coagulopathy were randomly allocated (1 : 1) to high-dose antivenom (20 vials) or low-dose antivenom (10 vials) plus 4 U of FFP. The primary outcome was the proportion of patients with an International Normalized Ratio (INR) of < 2 at 6 h after antivenom administration. Secondary outcomes included anaphylaxis, major hemorrhage, death, and clotting factor recovery. Results From 214 eligible patients, 141 were randomized: 71 to high-dose antivenom, and 70 to low-dose antivenom/FFP; five had no post-antivenom blood tests. The groups were similar except for a delay of 1 h in antivenom administration for FFP patients. Six hours after antivenom administration, 23 of 69 (33%) patients allocated to high-dose antivenom had an INR of < 2, as compared with 28 of 67 (42%) allocated to low-dose antivenom/FFP (absolute difference 8%; 95% confidence interval - 8% to 25%). Fifteen patients allocated to FFP did not receive it. Severe anaphylaxis occurred equally frequently in each group. One patient given FFP developed transfusion-related acute lung injury. Three deaths occurred in low-dose antivenom/FFP patients, including one intracranial hemorrhage. There was no difference in recovery rates of INR or fibrinogen, but there was more rapid initial recovery of factor V and FX in FFP patients. Conclusion FFP after antivenom administration in patients with Russell's viper bites did not hasten recovery of coagulopathy. Low-dose antivenom/FFP did not worsen VICC, suggesting that low-dose antivenom is sufficient.

Is socioeconomic position associated with risk of attempted suicide in rural Sri Lanka? A cross-sectional study of 165†000 individuals.

BACKGROUND: Lower socioeconomic position (SEP) is associated with an increased risk of suicidal behaviour in high-income countries, but this association is unclear in low-income and middle-income countries. METHODS: We investigated the association of SEP with attempted suicide in a cross-sectional survey of 165 233 Sri Lankans. SEP data were collected at the household (assets, social standing (highest occupation of a household member), foreign employment and young (≤40 years) female-headed households) and individual level (education and occupation). Respondent-reported data on suicide attempts in the past year were recorded. Random-effects logistic regression models, accounting for clustering, were used to investigate the association of SEP with attempted suicide. RESULTS: Households reported 398 attempted suicides in the preceding year (239 per 100 000). Fewer assets (OR 3.2, 95% CI 2.4 to 4.4) and having a daily wage labourer (ie, insecure/low-income job; OR 2.3, 95% CI 1.6 to 3.2) as the highest occupation increased the risk of an attempted suicide within households. At an individual level, daily wage labourers were at an increased risk of attempted suicide compared with farmers. The strongest associations were with low levels of education (OR 4.6, 95% CI 2.5 to 8.4), with a stronger association in men than women. CONCLUSIONS: We found that indicators of lower SEP are associated with increased risk of attempted suicide in rural Sri Lanka. Longitudinal studies with objective measures of suicide attempts are needed to confirm this association. TRIAL REGISTRATION NUMBER: NCT01146496; Pre-results.

Should all patients with unexplained anaemia be screened for chronic lead poisoning?

The global prevalence of lead poisoning is declining. However, the prevalence of lead poisoning in patients with either microcytic or normocytic anaemia is unknown. Blood samples from anaemic patients residing in south-east London without an obvious cause for anaemia had their blood lead concentration (BLC) analysed. A batch of 988 samples was analysed for BLC using atomic absorption spectroscopy. Median haemoglobin was 10.3 g/dL (range: 4.2-10.9) in females, 10.6 g/dL (range: 5.2-11.4) in males and 10.7 g/dL (range: 6.7-10.9) in children. Median BLC was 2.63 microg/dL (0.21-24.0 microg/dL; 95th centile 7.54 microg/dL). Fifteen samples (1.5%) had a BLC > 10.0 microg/dL, five samples (1%) > 15.0 microg/dL and one sample (0.1%) > 20.0 micrg/L. In the 106 children, median BLC was 2.34 microg/dL (0.5-14.5 microg/dL; 95th centile 6.12 microg/ dL). Only one child (14.5 microg/L) had a BLC > 10.0 pg/dL. There was a poor correlation between haemoglobin and BLC (r2 = 0.08). Routine screening for lead poisoning cannot be justified in all patients with unexplained anaemia, unless there is a history or clinical features to suggest lead toxicity. Additionally, we have shown that in this former high-risk area for lead exposure, there is a low point prevalence of significant lead poisoning, even in an anaemic population.

Epidemiology, clinical features, laboratory investigations and early diagnosis of dengue fever in adults: a descriptive study in Sri Lanka.

A descriptive observational study was conducted to identify the epidemiology, clinical features, laboratory investigations and markers for early diagnosis of acute dengue virus infection in adults. We enrolled 404 patients over a period of two years, beginning from 2001, at the Teaching Hospital Peradeniya, Sri Lanka. Based on serology, 239 patients were grouped as: IgM 43 (18%), IgG and IgM 140 (58%), and IgG 28 (12%). The clinically diagnosed group without serology numbered 165 patients. Most of the parameters between groups showed a similar pattern: mean age of 30 years, mean duration of fever 7 days (range 1-19 days). Mean total white blood cell and platelet counts started to fall from the second day of fever, with the lowest counts on the 5th to 7th days. Packed cell volume (PCV) showed minimum fluctuation. One hundred and sixty (88%) patients showed elevated liver enzymes (ALT and AST), with 122 of them having a two-fold increase. Three patients died, and complications such as myocarditis, large effusions, encephalopathy, acute renal failure, acute liver failure and diarrhea were observed. These results suggest that a combination of clinical picture, thrombocytopenia, leukopenia and elevated liver enzymes could be used as markers for early diagnosis of dengue infection. Furthermore, evidence-based guidelines should be developed for managing dengue infection in adults.

Routine antibiotic therapy in the management of the local inflammatory swelling in venomous snakebites: results of a placebo-controlled study.

OBJECTIVE: To evaluate the value of routine antibiotic therapy in the management of the local swelling of patients with venomous snakebites. METHODS: A prospective, placebo-controlled study at the General Hospital, Anuradhapura, Sri Lanka where 144 patients with envenoming and local swelling in the leg were allocated to receive either antibiotics (Group A = test group) or placebo (Group B = controls). Benzyl penicillin 2 mega units intravenously 6 hourly and metronidazole 500 mg by intravenous infusion 8 hourly for 5 days from the first day of the bite were given to Group A. Ethical committee approval was obtained from the Committee of General Hospital, Anuradhapura. MAIN OUTCOME MEASURES: Circumference difference between the affected limb and the normal limb, length of the swelling measured in centimetres, and the physical characteristics of the local swelling of both groups were compared. RESULTS: Group A had 69 patients and the Group B 75. The mean circumference difference (MCD) of the leg between the groups showed no significant difference for 4 days (P > 0.05), except at the site of the bite on the third day when the Group B showed a significant improvement (p = 0.02). There was no significant difference in the length of the local swelling or the score of physical characteristics between the two groups (P > 0.05). The proportions of recovery of the local swelling on the fourth and fifth day had no significant difference between the groups (P > 0.05). CONCLUSION: The routine use of antibiotics (penicillin and metronidazole) does not seem to be of value in reducing the local inflammatory swelling in venomous snakebite.

Antivenom for snakebite envenoming in Sri Lanka: the need for geographically specific antivenom and improved efficacy.

Sri Lanka is a tropical developing island nation that endures significant economic and medical burden as a result of snakebite envenomation, having not only a high prevalence of envenomations, but also one of the highest incidence rates (200 snakebites/100,000 people/year) of venomous snakebite in the world (Kasturiratne et al., 2005). Ironically, the very snakes responsible for this human morbidity and mortality are a valuable biomedical and ecological national resource, despite the medical and economic consequences of envenomation. Currently, no snake antivenom is produced using venoms from native Sri Lankan snakes as immunogens, and there is a true need for an efficacious Sri Lanka, poly-specific snake antivenom. An approach to fulfilling this need via combining the scientific, technological and economical resources from Costa Rica and the United States with the knowledge and talent of Sri Lankan official governmental agencies, legal counsels, environmental, medical and veterinary academic institutions, and religious and cultural leaders has been initiated, coordinated and funded by Animal Venom Research International (AVRI), a nonprofit charity. This bridging of nations and the cooperative pooling of their resources represents a potential avenue for antivenom development in a developing country that suffers the consequences of few specific resources for the medical management of venomous snakebite. The desired final outcome of such an endeavor for Sri Lanka is, most importantly, improved medical outcomes for snakebite patients, with enhanced and expanded science and technology relating to snake venoms and antivenoms, and the collateral benefits of reduced economic cost for the country.

Peripheral burning sensation: a novel clinical marker of poor prognosis and higher plasma-paraquat concentrations in paraquat poisoning.

INTRODUCTION: Self-poisoning with paraquat has a case fatality ratio (CFR) over 65% in Sri Lanka. Plasma-paraquat concentration is the best prognostic indicator for patient outcome but is not readily available. Alternative surrogate clinical markers could be useful in management and determining prognosis. Anecdotal reports by medical and research staff suggested that patients who complained of burning sensation of the body had a poor prognosis and a prospective study was initiated. METHODS: This was a prospective observational study in three hospitals in Sri Lanka. We collected demographic data, presence or absence of burning sensation, and major outcome, and determined the plasma-paraquat concentration within 24 h post-ingestion. RESULTS: There were 179 patients with deliberate self-ingestion of paraquat over 30 months. Burning sensation was reported in 84 patients (48%), which was initiated at a median of 1 day (range 1-3 days) post-ingestion. Of the patients who had burning, 61 died [CFR = 72.62%; 95% confidence interval (CI) = 62-81]. Of the 91 patients who had no peripheral burning, 23 died (CFR = 25.27%, 95% CI = 18.15-35.9). Presence of peripheral burning sensation was associated with a significantly higher risk of death (odds ratio = 7.8, 95% CI = 3.9-15, p < 0.0001). Patients who complained of peripheral burning died at a median of 36 h (interquartile range = 30.5-88) following ingestion whereas those who had no peripheral burning died at a median of 50.5 h (interquartile range = 16.75-80). The difference was not significant (p > 0.05). Median admission plasma-paraquat concentration in patients with peripheral burning (2.67 microg/mL, 95% CI = 0.84-14.2) was significantly higher than in the patients with no peripheral burning (0.022 microg/mL, 95% CI = 0.005-0.78; p < 0.001). Peripheral burning has a sensitivity of 0.72 (95% CI = 0.6-8) and specificity of 0.74 (95% CI = 0.64-0.08) and a positive predictive value of 0.73 (95% CI = 0.6-0.8). DISCUSSION: It is possible that this symptom may help discriminate between patients who have poor chance of survival and those who may potentially benefit from interventions. The mechanism is not clear but could either include a direct concentration-related effect or be a marker of oxidative stress. CONCLUSION: Presence of burning sensation is associated with high plasma-paraquat concentrations and is strongly predictive of death.

Acute ischemic strokes due to bites by Daboia russelii in Sri Lanka - first authenticated case series.

UNLABELLED: Bites due to Russell's Viper (Daboia russelii) are common in Sri Lanka. Commonest haematological manifestation is consumptive coagulopathy and bleeding. Commonest neurological manifestations are ptosis, ophthalmoplegia and rarely respiratory failure which are due to presynaptic inhibition of neuromuscular transmission. There are no authenticated reports of acute ischemic strokes following bites by D. russelii. We report the first authenticated case series of ischemic strokes following bites by D. russelii in Sri Lanka. METHODS: This was a prospective observational study of all atypical neurological manifestations following bites by D. russelii admitted to a hospital in Sri Lanka. We documented clinical features of all atypical neurological manifestations of D. russelii bites and recorded the findings of brain imaging. RESULTS: During a period of 18 months, at one centre, 9 patients out of an estimated 500 victims of D. russelii bites were found to have Computerized Tomographic evidence of single or multiple ischemic (non-haemorrhagic) strokes of medium to large vessel territories of the brain. These patients had either low Glasgow coma scale or hemiparesis within minutes to 4 days following bites. One patient died and another had gross neurological deficit, while others had mild or no neurological deficit at three months. DISCUSSION: This report confirms that ischemic strokes can occur following envenoming by D. russelii. Involvement of multiple medium to large vessel territories and absence of watershed infarctions points to prothrombotic properties of the venom as the putative mechanism.

Validity of the Weil-Felix test in the diagnosis of acute rickettsial infections in Sri Lanka.

The diagnosis of rickettsial infections in developing countries is based on clinical features and a positive Weil-Felix test (WFT), as tests such as indirect immunofluorescent antibody (IFA) assays are not available for routine use. We estimated the sensitivity of the WFT in Sri Lanka using IFA testing as the gold standard. The WFT demonstrated low sensitivity (33%) in diagnosing acute rickettsial infections and low specificity, with a positive titre of 1:320 seen in 54% of healthy volunteers and 62% of non-rickettsial fever patients. Therefore, the use of the WFT should be discouraged in the diagnosis of acute rickettsial infections.

Epidemiology, clinical profile and management issues of cobra (Naja naja) bites in Sri Lanka: first authenticated case series.

In Sri Lanka, the Spectacled cobra (Naja naja) inflicts fatal bites. This hospital-based prospective study describes 25 cases of proven cobra bites, including 10 (40%) males and 15 (60%) females with a median age of 36 years (range 13-70 years). In 22 cases (88%) bites occurred in the daytime and in 13 cases (52%) they occurred at the victim's home compound. The site of the bite was the upper limb in 10 cases (40%), and 12 patients (48%) had applied a tourniquet. There were 5 dry bites (20%), 20 local reactions (80%), 9 cases of neurotoxicity (36%) and 3 cases of coagulopathy (12%). Eight patients (32%) had severe local necrosis-five underwent desloughing and skin grafting and two (including one of the above) had fasciotomy and compartmental decompression of the upper limb. Two patients died (case fatality rate 8%; 95% CI 0.98-26.03) due to rapidly spreading necrosis of the upper limb. Four patients (16%; 95% CI 4.53-36.08) developed respiratory paralysis; their median time from bite to assisted ventilation was 2h (range 2-5h) and the median duration of ventilation was 24h (range 18-24h). Envenomed patients received Indian polyvalent antivenom. The findings highlight the magnitude of local necrosis, respiratory paralysis and antivenom failure in Spectacled cobra bite in Sri Lanka. Coagulopathy requires verification with robust laboratory tests.

Auditory event-related potential changes in chronic occupational exposure to organophosphate pesticides.

OBJECTIVE: To determine whether chronic occupational exposure to organophosphates (OP) pesticides leads to cognitive impairment using event-related potentials (ERPs). METHODS: ERPs of 38 vegetable farmers applying OP pesticides and 35 controls were recorded using an auditory oddball paradigm. The N1, P2, N2 and P300 ERP components and the number of counting errors were compared between the groups. RESULTS: The farmers made significantly more counting errors than controls in the oddball task. The mixed model ANOVA of component latencies revealed a significant componentxgroup interaction, suggesting farmers had a greater delay in later ERP components. Intergroup comparisons of individual components showed significant delays in N2 and P300 latencies. Subsequent ANCOVA showed significant P300 delay even after adjusting for the latency of the preceding component, N2. Intergroup differences of P300 amplitudes were not significant, although there was limited evidence of a difference in scalp topography. CONCLUSION: Our findings indicate that chronic low-level occupational exposure to OP pesticides is associated with progressively increasing delay in successive ERP components, particularly P300. SIGNIFICANCE: Chronic exposure to OP pesticides may delay the neurophysiological processes underlying early stages of selective attention and late stages of sensory information processing that include stimulus evaluation and updating of working memory.

Emerging epidemic of fatal human self-poisoning with a washing powder in Southern Sri Lanka: a prospective observational study.

INTRODUCTION: Self-poisoning is a public health problem in Sri Lanka. A new laundry detergent consisting of a sachet each of 1.2 g of potassium permanganate and 12.5 g of oxalic acid has become a popular agent among the youth for self-poisoning. METHOD: Prospective clinical data and major outcomes were recorded in all patients admitted to a referring and a referral hospital. Serial biochemistry was performed in 20 patients. Postmortem examinations were performed in some patients. RESULTS: There were 115 patients. The majority developed symptoms of the gastrointestinal tract within the first 24 h. There were 18 deaths. Ingestion of oxalic acid was associated with a case fatality ratio of 25.4% (95% CI = 14-39), while ingestion of both potassium permanganate and oxalic acid was associated with a case fatality ratio of 9.8% (95% CI = 3.2-21). Ingestion of more than one sachet was associated with a significantly higher risk of death (risk ratio = 13.26, 95% CI = 3.2-54, p < 0.05). Majority of the deaths occurred within an hour since ingestion. Postmortem examinations revealed mucosal ulceration in the majority of deaths. DISCUSSION: This case series brings to light an emerging epidemic of fatal self-poisoning in Sri Lanka from a compound that is not regulated. As deaths occur soon after ingestion, medical management of these patients is bound to be difficult. CONCLUSION: This case series highlights a fatal mode of self-poisoning that could be controlled through regulation of the manufacture and sale of the product.

Laryngeal edema and metabolic acidosis after Omnicide ingestion.

INTRODUCTION: Glutaraldehyde and quaternary ammonium compounds are widely used as disinfectants and sterilizing agents. Glutaraldehyde is irritating to the eyes and upper respiratory tract, and has been associated with occupational asthma. Acute oral ingestion of a concentrated solution has not been previously reported in humans. CASE REPORT: A 19-year-old woman presented after deliberate ingestion of a biocide containing glutaraldehyde and a quaternary ammonium compound. She developed respiratory distress and severe metabolic acidosis 10 hours after admission. Marked laryngeal edema was noted when she was being intubated. She eventually improved following supportive care and was discharged alive after 9 hospital days. DISCUSSION: There are no reports of acute ingestions of both glutaraldehyde and quaternary ammonium compounds. As both these substances are known to cause metabolic acidosis, localized edema, erosion and sensitization of both the respiratory and alimentary tract. The clinical effect may be additive or synergistic. CONCLUSIONS: Omnicide ingestion should be closely monitored for metabolic acidosis and laryngeal edema which may progress to upper airway obstruction requiring urgent airway stabilization.

Emerging rickettsial infections in Sri Lanka: the pattern in the hilly Central Province.

OBJECTIVES: To identify different rickettsial infections using a specific immunofluorescent technique in patients clinically diagnosed as 'typhus fever' in the Central Province of Sri Lanka, and to define the clinical picture, assess the severity of infection and to determine the pattern of geographical distribution of the infections of the hospital-based patients. METHODS: A specific indirect immunofluorescent antibody technique was used on the sera of two groups of patients in laboratories in Japan and Thailand. RESULTS: We serodiagnosed infections with Orientia tsutsugamushi, Rickettsia typhi and spotted fever group in 56 of 118 clinically investigated patients. There were eight infections with O. tsutsugamushi, two with R. typhi and 10 spotted fever group patients with IgM antibodies suggestive of acute infection. Nineteen patients had antibodies against these three rickettsial species, suggestive of past exposure, co-infection or cross-reactivity of antigens. Discrete, erythematous maculopapular rash was common to all three types of infection except for five patients who had no rash. Five patients positive for spotted fever antibodies developed fern-leaf type skin necrosis with severe illness. Duration of the febrile period ranged from 4 to 23 days with defervescence occurring after specific antibiotic treatment. CONCLUSIONS: The study has shown the presence of different types of rickettsial infections in the Central Province of Sri Lanka. The characterization of the clinical picture and the severity of infection provide useful information for the proper management of the patients in the future.