Compliance with national snakebite treatment guidelines in rural Sri Lankan hospitals: a cluster randomized controlled trial of a brief educational intervention.

BACKGROUND: Snakebite is a global health problem that predominantly occurs in rural areas. In Sri Lanka, the majority of snakebite patients first present to smaller rural primary hospitals. Improving care delivered at rural hospitals has the potential to reduce morbidity and mortality from snakebites. OBJECTIVE: In this study, we evaluated whether an educational intervention would increase compliance with national snakebite treatment guidelines in primary hospitals. METHODS: The hospitals were randomized into educational intervention (n = 24) and control groups (n = 20). The intervention hospitals received a brief educational intervention based on Sri Lankan Medical Association (SLMA) guidelines on the management of snakebites. Control hospitals had free access to the guidelines but no additional promotion. Four outcomes were assessed: pre- and post-test knowledge at the completion of a one-day workshop of educational intervention (intervention group only); improvement in the quality of the patient's medical records; appropriateness of transfers to higher hospitals; and quality of overall management graded by a blinded expert. The data was collected over a period of 12 months. RESULTS: All case notes of snakebite hospital admissions were reviewed. There were 1021 cases in the intervention group hospitals and 1165 cases in the control hospitals. Four hospitals in the intervention group and three hospitals in the control group did not have snakebite admissions and were excluded from the cluster analysis. The absolute quality of care was high in both groups. Post-test knowledge was improved (p < 0.0001) following the intervention group's educational workshop. There was no statistical difference between the two groups in terms of clinical data documentation in hospital notes (scores, p = 0.58) or transfer appropriateness (p = 0.68)-both of which were significantly different from the guidelines. CONCLUSION: Education of primary hospital staff improved the immediate knowledge gained but did not improve record-keeping or the appropriateness of inter-hospital patient transfer. TRIAL REGISTRATION: The study was registered with Sri Lanka Medical Associations' clinical trial registry. Reg. No SLCTR -2013-023. Registered: 30/07/2013.

Thrombotic Microangiopathy Following Hypnale zara (Hump-Nosed Pit Viper) Envenoming: The First Known Case Report from Sri Lanka.

A 65-y-old previously healthy farmer developed thrombotic microangiopathy (TMA) comprising the triad of acute kidney injury, microangiopathic haemolysis, and thrombocytopenia after a proven Hypnale zara (hump-nosed pit viper) bite. He developed coagulopathy, which was treated with fresh frozen plasma, and underwent 8 cycles of hemodialysis. He is being followed up in the nephrology clinic for acute kidney injury. TMA caused by Hypnale hypnale, the commonest species of genus Hypnale, has previously been reported, but this is the first known case of TMA following a bite by H zara, the endemic species in Sri Lanka.

Intra-aural tick bite causing unilateral facial nerve palsy in 29 cases over 16 years in Kandy, Sri Lanka: is rickettsial aetiology possible?

BACKGROUND: Over the last two decades intra-aural tick infestation (otoacariasis) has been a common occurrence in the hilly central region in Sri Lanka. Very occasional detection of isolated unilateral facial nerve palsy associated with otoacariasis attributed to toxin damage of the nerve prompted us to study the clinico-epidemiology and aetio-pathology of the problem. METHODS: All cases having isolated unilateral facial nerve palsy associated with otoacariasis presented to, Ear Nose and Throat clinic at General Hospital Kandy, Sri Lanka from 2001 to 2016 were included in the study. The facial palsies were assessed with nerve conduction studies and, harvested ticks were identified. RESULTS: There were 29 patients with mean age of 46 years (range 22-76 years) with male to female ratio of 1:1.9. First 12 patients without specific treatment took 1-55 months for recovery and 4 had axonal degeneration. Last 5 patients were treated with doxycycline and recovered in 4 weeks. They had strong sero-conversion of immunofluorescence antibodies against spotted fever rickettsioses and the tick harvested from the last patient was PCR positive for rickettsial DNA. Identified ticks belonged to Dermacentor, Amblyomma, Rhipicephalus and Hyalomma species. CONCLUSIONS: On contrary to popular toxin theory, we were able to demonstrate treatable rickettsial aetio-pathology as the cause of otoacariasis associated lower motor facial palsy in Sri Lanka.

Microangiopathic Hemolytic Anemia Following Three Different Species of Hump-Nosed Pit Viper (Genus: Hypnale) Envenoming in Sri Lanka.

There are 3 species of hump-nosed pit vipers in Sri Lanka: Hypnale hypnale, Hypnale zara, and Hypnale nepa. The latter 2 are endemic to the country. Microangiopathic hemolytic anemia (MAHA) is a known complication of hump-nosed pit viper bites. It was previously documented as a complication of general viper bites and not species specific. We report a series of 3 patients who developed MAHA after being bitten by each species of hump-nosed pit viper. The first patient was bitten by H hypnale and developed a severe form of MAHA associated with acute kidney injury and thrombocytopenia falling into the category of thrombotic microangiopathy. The other 2 developed MAHA that resolved without any complications.

Prolonged Coagulopathy, Ecchymoses, and Microangiopathic Hemolytic Anemia Following Hump-Nosed Pit Viper (Hypnale hypnale) Bite in Sri Lanka.

A 74-year-old previously healthy woman was bitten by a hump-nosed pit viper (Hypnale hypnale) at dusk causing incoagulable blood lasting for 6 days. Further, she developed ecchymoses over her forearms, upper arms, hands, and lower back on day 4 after the snakebite, and microangiopathic hemolytic anemia (MAHA). Features of this nature are rare after hump-nosed pit viper bite.

A Pan-Dengue Virus Reverse Transcription-Insulated Isothermal PCR Assay Intended for Point-of-Need Diagnosis of Dengue Virus Infection by Use of the POCKIT Nucleic Acid Analyzer.

Dengue virus (DENV) infection is considered a major public health problem in developing tropical countries where the virus is endemic and continues to cause major disease outbreaks every year. Here, we describe the development of a novel, inexpensive, and user-friendly diagnostic assay based on a reverse transcription-insulated isothermal PCR (RT-iiPCR) method for the detection of all four serotypes of DENV in clinical samples. The diagnostic performance of the newly established pan-DENV RT-iiPCR assay targeting a conserved 3' untranslated region of the viral genome was evaluated. The limit of detection with a 95% confidence was estimated to be 10 copies of in vitro-transcribed (IVT) RNA. Sensitivity analysis using RNA prepared from 10-fold serial dilutions of tissue culture fluid containing DENVs suggested that the RT-iiPCR assay was comparable to the multiplex real-time quantitative RT-PCR (qRT-PCR) assay for DENV-1, -3, and -4 detection but 10-fold less sensitive for DENV-2 detection. Subsequently, plasma collected from patients suspected of dengue virus infection (n = 220) and individuals not suspected of dengue virus infection (n = 45) were tested by the RT-iiPCR and compared to original test results using a DENV NS1 antigen rapid test and the qRT-PCR. The diagnostic agreement of the pan-DENV RT-iiPCR, NS1 antigen rapid test, and qRT-PCR tests was 93.9%, 84.5%, and 97.4%, respectively, compared to the composite reference results. This new RT-iiPCR assay along with the portable POCKIT nucleic acid analyzer could provide a highly reliable, sensitive, and specific point-of-need diagnostic assay for the diagnosis of DENV in clinics and hospitals in developing countries.

First Reported Case of Fatal Stinging by the Large Carpenter Bee Xylocopa tranquebarica.

In the order Hymenoptera, bees, hornets, and wasps are well-known stinging insects whose envenoming can be fatal. Their stinging attacks are common in rural and forested areas of Sri Lanka. However, fatal stinging by the large-bodied carpenter bees is unreported. We report the first known case of a fatal sting by the large carpenter bee, Xylocopa tranquebarica, in a forested area in Puttalam (North Western Province) in the dry zone of Sri Lanka. A 59-year-old healthy male manual laborer accompanied by a fellow worker had been fixing a fence on a coconut estate bordering a forested area when a flying insect emerged from a dead tree trunk and stung him on his face. His coworker, who was watching the incident, killed the insect. The victim complained of immediate intense pain in the face and collapsed on the ground just after resuming work after 10 minutes of resting. He was found dead on admission to the hospital 90 minutes later. Autopsy showed normal coronary arteries and heart, but the lungs were slightly congested and contained secretions in the bronchi. Acute anaphylaxis was the most likely cause of death. This case presents the habitat, morphology, attack pattern, and the medical importance of large carpenter bees.

The effectiveness of radial extracorporeal shock wave therapy vs transcutaneous electrical nerve stimulation in the management of upper limb spasticity in chronic-post stroke hemiplegia-A randomized controlled trial.

BACKGROUND: Traditionally both rESWT and TENS are used in treating post-stroke upper limb spasticity over years and their effectiveness had been assessed disjointedly. However, these methods were not yet compared for superiority. OBJECTIVES: To compare rESWT vs TENS to assess their effectiveness in different parameters of stroke such as stroke type, gender, and the affected side. METHODS: The experimental group was treated with rESWT application to the middle of the muscle belly of Teres major, Brachialis, Flexor carpi ulnaris, and Flexor digitorum profundus muscles using 1500 shots per muscle, frequency of 5Hz, energy of 0.030 mJ/mm. The TENS was applied to the same muscles in the control group using 100 Hz for 15 minutes. Assessments were taken at the baseline (T0), immediately after first application (T1), and at the end of four-week protocol (T2). RESULTS: Patients 106 with a mean age of 63.87±7.052 years were equally divided into rESWT (53) and TENS (53) groups including 62 males, 44 females, 74 ischemic, 32 hemorrhagic, affecting 68 right, and 38 left. Statistical analysis has revealed significant differences at T1 and T2 in both groups. But at T2 compared to T0; the rESWT group has reduced spasticity 4.8 times (95% CI 1.956 to 2.195) while TENS reduced by 2.6 times (95% CI 1.351 to 1.668), improved voluntary control by 3.9 times (95% CI 2.314 to 2.667) and it was 3.2 times (95% CI 1.829 to 2.171) in TENS group. Improvement of the hand functions of the rESWT group was 3.8 times in FMA-UL (95% CI 19.549 to 22.602) and 5.5 times in ARAT (95% CI 22.453 to 24.792) while thrice (95% CI 14.587 to 17.488) and 4.1 times (95% CI 16.019 to 18.283) in TENS group respectively. CONCLUSION: The rESWT modality is superior compared to the TENS modality for treating chronic post-stroke spastic upper limb.

High efficacy of bolus methylprednisolone in severe leptospirosis: a descriptive study in Sri Lanka.

BACKGROUND: In 2008, an outbreak of leptospirosis caused high mortality in Sri Lanka. The General Hospital, Peradeniya recorded nine deaths in May, which prompted the medical staff to change the treatment protocol. Addition of intravenous methylprednisolone (MP) to the treatment regimen of severely ill patients was implemented on the basis of immune mediated pathogenesis of the disease to reduce mortality. METHODS: The day MP commenced (25 May 2008), the study period was divided into a 'pre-MP period' and an 'MP period'. A clinical score ranging from 0-6 was applied to assess the severity of the infection. A score ≥2 was considered severe. Thus, 62 patients received bolus MP 500 mg intravenously for 3 days, followed by oral 8 mg for 5 days (MP given). Ten patients to whom MP was withheld were included in the MP period severe group (n=72). The same score was applied to pre-MP periods and 60 cases were identified as the historical control group (pre-MP period severe). RESULTS: There were 78 and 149 cases of leptospirosis in the pre-MP period and MP period, respectively. Of these cases, 17 and 16 patients died, with case death rates of 21.8% and 10.7%, respectively; the difference was significant (p=0.025). The survival rate at score 4 in the MP period severe group was 100% (16 of 16), compared to 38% (5 of 13) in pre-MP period severe group; this difference was highly significant (p<0.001). Six patients who died despite MP therapy had a clinical score of 5 or 6; four were alcohol consumers, and two had heart disease and hypertension. CONCLUSION: MP may reduce mortality in patients with severe leptospirosis, except in cases with established multiple organ dysfunction and comorbidities. Therefore, early administration of MP seems advisable.

Melioidosis after a long silence in Sri Lanka: an environmental hazard and dilemma in diagnosis, with recovery and longitudinal follow-up for 13 years: a case report.

BACKGROUND: Melioidosis is a potentially fatal bacterial infection caused by Burkholderia pseudomallei. The existence of melioidosis in Sri Lanka was once unheard of, and entertaining it as a diagnosis in clinical practice was extremely rare. CASE PRESENTATION: In this case report, we describe the clinical, epidemiological, and longitudinal follow-up data of a 58-year-old previously healthy Sinhalese woman who presented to our hospital with protracted febrile illness of 5 weeks' duration, later developing multiple abscesses at different sites of the body. There was a significant delay in confirming the diagnosis of melioidosis by isolating B. pseudomallei from blood and pus cultures. The patient recovered fully with a prolonged course of antibiotics and has remained in good health over the last 13 years without recurrence. Despite being immunocompetent, she had contracted the infection by a brief contact with mud soil in a footpath. CONCLUSIONS: A high index of clinical suspicion along with laboratory support is needed to confirm the diagnosis of melioidosis. Treatment with sensitive antibiotics over a long duration is needed, and longitudinal follow-up is essential to detect recurrences. This case raised awareness and created renewed interest in studies of melioidosis in Sri Lanka.

Clinico-epidemiology of arthropod stings and bites in primary hospitals of North Western province of Sri Lanka.

OBJECTIVE: Arthropod stinging and bites are common environmental hazards in Sri Lanka. However, their medical importance has not been fully evaluated yet. This study aims to study the burden, epidemiology, and outcome of stings and bites in primary hospitals in the Kurunegala district in North Western Province (NWP) of Sri Lanka. METHODOLOGY: The study was conducted one year from 25th May 2013 to 25th May 2014. Details of all stings and bites admissions and their outcomes were retrospectively extracted from hospital records in all 44 primary hospitals in the district. RESULTS: There were 623 stings and bites with population incidence of 38/100,000 (95% CI 27-52). There were no deaths. Median age was 38 years (IQR: 19-53 years), and 351 (56%) were males. Most of stings and bites (75%) occurred in the daytime. Median time to hospital arrival was 55 minutes (IQR: 30 min to 2 h). The offending arthropods had been identified in 557 (89%) cases, of them, 357 (57%) were Hymenoptera (hornet and bees), 99 centipedes, 61 spiders and 40 scorpions. Local pain occurred in 346 (56%) cases - centipede 69 (70%), Scorpion 24 (60%), spider 36 (59%), Hymenoptera 187 (52%) and unidentified 30 (45%). Hymenoptera stings and spider bites occurred between 06 am to 12 noon, and scorpion stings and centipede bites mostly occurred between 06 pm to 12 midnight. Mild, moderate to severe anaphylaxis reactions occurred in 173 (28%) patients including 110 Hymenoptera stings - mild 39, moderate 62 and severe 9. From primary hospitals, 53(9%) cases had been transferred to tertiary care units for further management. Of them, 41 cases were Hymenoptera stings and 24 (58%) of them had mild, moderate to severe anaphylaxis. In the entire group, 27% severe cases received adrenaline. CONCLUSIONS: The primary hospitals in NW province of Sri Lanka manage large numbers of arthropod stings and bites. These include Hymenoptera (hornet and bee), centipedes, spiders, and scorpions. Pain, swellings and anaphylactic reactions were the most common adverse effects.

A prospective cohort study of the effectiveness of the primary hospital management of all snakebites in Kurunegala district of Sri Lanka.

INTRODUCTION: Sri Lanka records substantial numbers of snakebite annually. Primary rural hospitals are important contributors to health care. Health care planning requires a more detailed understanding of snakebite within this part of the health system. This study reports the management and epidemiology of all hospitalised snakebite in the Kurunegala district in Sri Lanka. METHODOLOGY: The district has 44 peripheral/primary hospitals and a tertiary care hospital-Teaching Hospital, Kurunegala (THK). This prospective study was conducted over one year. All hospitals received copies of the current national guidelines on snakebite management. Clinical and demographic details of all snakebite admissions to primary hospitals were recorded by field researchers and validated by comparing with scanned copies of the medical record. Management including hospital transfers was independently assessed against the national guidelines recommendation. Population rates were calculated and compared with estimates derived from recent community based surveys. RESULTS: There were 2186 admissions of snakebites and no deaths in primary hospitals. An additional 401 patients from the district were admitted directly to the teaching hospital, 2 deaths were recorded in this group. The population incidence of hospitalized snakebite was 158/100,000 which was significantly lower than community survey estimates of 499/100,000. However there was no significant difference between the incidence of envenomation of 126/100,000 in hospitalised patients and 184/100,000 in the community survey. The utilisation of antivenom was appropriate and consistent with guidelines. Seventy patients received antivenom. Anaphylactic reactions to antivenom occurred in 22 patients, treatment reactions was considered to be outside the guidelines in 5 patients. Transfers from the primary hospital occurred in 399(18%) patients but the majority (341) did not meet the guideline criteria. A snake was identified in 978 cases; venomous snakebites included 823 hump-nosed viper (Hypnalespp), 61 Russell's viper, 14 cobra, 13 common krait, 03 saw scaled viper. CONCLUSIONS: Primary hospitals received a significant number of snakebites that would be missed in surveys conducted in tertiary hospitals. Adherence to guidelines was good for the use of antivenom but not for hospital transfer or treatment of anaphylaxis. The large difference in snakebite incidence between community and hospital studies could possibly be due to non-envenomed patients not presenting. As the majority of snakebite management occurs in primary hospitals education and clinical support should be focused on that part of the health system.

Revisiting clinico-epidemiological pattern of human rickettsial infections in the central region of Sri Lanka: a hospital based descriptive study.

BACKGROUND: This study revisits the clinico-epidemiology and serological patterns of rickettsioses in the central region of Sri Lanka and highlights the need of advanced diagnostics for precise identification of species responsible for rickettsioses. METHODS: The patients treated for rickettsioses between November 2009 and October 2011 were recruited for the study from Teaching Hospital, Peradeniya. Clinical characteristics and serology results were used for diagnosis. RESULTS: Study included 210 patients (mean age 44 years ± 3.2) and of them 188 (90%) had positive IgG and/or IgM sero-reactivity for spotted fever group (SFG). Of them, 134 had IgG titre ≥1/256 for SFG and presented with fever and skin rash. They also had headache [n = 119 (89%)], myalgia [n = 103 (77%)], arthralgia [n = 89 (66%)] of large joints, conjunctival injections [n = 83 (62%)], thrombocytopenia (n = 78.58%), anaemia (n = 14.10%), leukocytosis [n = 35 (26%)], leucopenia [n = 17 (13%)], elevated aspartate transaminase [n = 69 (52%)] and alanine transaminase [n = 73 (55%)]. CONCLUSIONS: Predominance of SFG rickettsioses are reiterated, possibly transmitted by ticks. Joint disease is common with occasional fern leaf skin necrosis. Changing socio-economic conditions, vegetations, contact with domestic and wild animals, abundance of vectors would have contributed for emergence and sustenance of SFG in the region. Further research is needed to identify the causative agents and the mode of transmission.

Hematological and plasma biochemical parameters in a wild population of Naja naja (Linnaeus, 1758) in Sri Lanka.

BACKGROUND: Hematological studies of any animal species comprise an important diagnostic method in veterinary medicine and an essential tool for the conservation of species. In Sri Lanka, this essential technique has been ignored in studies of many species including reptiles. The aim of the present work was to establish a reference range of hematological values and morphological characterization of wild spectacled cobras (Naja naja) in Sri Lanka in order to provide a diagnostic tool in the assessment of health condition in reptiles and to diagnose diseases in wild populations. METHODS: Blood samples were collected from the ventral caudal vein of 30 wild-caught Naja naja (18 males and 12 females). Hematological analyses were performed using manual standard methods. RESULTS: Several hematological parameters were examined and their mean values were: red blood cell count 0.581 ± 0.035 × 106/µL in males; 0.4950 ± 0.0408 × 106/µL in females; white blood cell count 12.45 ± 1.32 × 103/µL in males; 11.98 ± 1.62 × 103/µL in females; PCV (%) in males was 30.11 ± 1.93 and in females was 23.41 ± 1.67; hemoglobin (g/dL) was 7.6 ± 0.89 in males and 6.62 ± 1.49 in females; plasma protein (g/dL) was 5.11 ± 0.75 in males and 3.25 ± 0.74 in females; whereas cholesterol (mg/mL) was 4.09 ± 0.12 in males and 3.78 ± 0.42 in females. There were no significant differences in hematological parameters between the two genders except for erythrocyte count, thrombocyte count, hematocrit, hemoglobin, plasma protein, percentage of azurophil and heterophil. Intracellular parasites were not found in any of the studied specimens. CONCLUSION: Hematological and plasma biochemical parameters indicated a difference between geographically isolated populations and some values were significantly different between the two genders. These hematological results provide a reference range for Sri Lankan population of adult Naja naja.

Efficacy of intravenous hydrocortisone administered 2-4 h prior to antivenom as prophylaxis against adverse drug reactions to snake antivenom in Sri Lanka: An open labelled randomized controlled trial.

The prevention of adverse drug reactions to antivenom serum poses a formidable challenge in the management of snakebite. Hydrocortisone is being used concurrently with antivenom in order to prevent these adverse drug reactions without a proven benefit. However, all previous studies seemed to ignore the testing of effectiveness of hydrocortisone therapy during its pharmacological effects, which come hours later. On this principle, we aimed to test the effectiveness of intravenous hydrocortisone given 2 h or more prior to the commencement of antivenom therapy to reduce adverse drug reactions to antivenom. In an open-labelled randomized controlled trial, patients with a history of snakebite were randomly assigned to receive either 500 mg intravenous hydrocortisone bolus given 2 h or more prior to antivenom therapy (Group A) or at the time of antivenom therapy (Group B). The primary endpoint was the reduction of adverse drug reactions to antivenom of any grade of severity within the first 48 h. This trial has been registered with the "Sri Lanka Clinical Trials Registry", number SLCTR/2010/005. A total of 236 patients were randomized to group A or Group B. In the group A, 38 participants received hydrocortisone 2 h before administration of antivenom whilst 33 received hydrocortisone less than 2 h before administration of antivenom. In the Group B, 84 participants received hydrocortisone at the time of antivenom therapy. In Group A (n, 38), and Group B (n, 84), 15 patients (39%) and 29 patients (35%) developed reactions respectively and the difference is not significant (p = 0.598). Moreover, hydrocortisone therapy did not significantly reduce the occurrence of antievnom reactions of any grade of severity. Further, it didn't delay the occurrence of antivenom reactions in patients who received hydrocortisone either more than 2 h or less than 2 h before the antivenom as opposed to the control group (group B). Intravenous hydrocortisone shows no difference in the timing, rate or severity of adverse drug reactions to antivenom when administered simultaneously and up to 4 h prior to antivenom.

Trends of fluid requirement in dengue fever and dengue haemorrhagic fever: a single centre experience in Sri Lanka.

BACKGROUND: Meticulous fluid management is the mainstay of treatment in dengue fever that is currently governed by consensus guidelines rather than by strong research evidence. To examine this issue we audited the fluid requirement of a cohort of adult patients with dengue fever (DF) and dengue haemorrhagic fever (DHF) in a tertiary care clinical setting. RESULTS: This retrospective cohort study was conducted from July 2012 to January 2013 in Teaching Hospital, Peradeniya, Sri Lanka. Adult patients with confirmed dengue infection managed according to the national and WHO guidelines were included. Their fluid requirement was audited once data collection was over in both DF and DHF groups. Out of 302 patients, 209 (69%) had serological confirmation of dengue infection, comprising 62 (30%) patients gone into critical phase of DHF. Mean age of the DHF group was 30 years (range 12-63 years) and included more males (n = 42, 68%, p < 0.05). Their mean duration of fever on admission and total duration of fever were 4 days and 6 days respectively. DHF group had high incidence of vomiting, abdominal pain and flushing, lowest platelet counts and highest haematocrit values compared to DF group. In DHF group, the mean total daily requirements of fluid from 2(nd) to 7(th) day were 2123, 2733, 2846, 2981, 3139 and 3154 milliliters respectively to maintain a safe haematocrit value and the vital parameters. However, in DF group the fluid requirement was lowest on 3(rd) day (2158 milliliters). DHF group had significantly high fluid requirement on 5(th) -7(th) day compared to DF group (p < 0.05). CONCLUSIONS: Patients in critical phase of DHF required a higher volume of fluids from the 3(rd) day of fever and again on 5(th) to 7(th) day of fever. Despite being an audit, these finding could be useful in future updates of guidelines and designing research.

Clinico-epidemiology of stings and envenoming of Hottentotta tamulus (Scorpiones: Buthidae), the Indian red scorpion from Jaffna Peninsula in northern Sri Lanka.

In recent years, stings of a lethal scorpion species were recorded from Jaffna Peninsula in the northern dry zone of Sri Lanka. This species was identified as Hottentotta tamulus (Scorpiones: Buthidae) which is the Indian red scorpion commonly found in Maharashtra, India. The Teaching Hospital, Jaffna recorded 84 H. tamulus stings over a year in 2012 and of them, 23 cases provided offending scorpions (proven cases). Three localities in Jaffna were recorded as hotspots of scorpion stings namely Palali, Achchuvali and Karainagar. Of the proven cases, 13 (57%) and 10 (43%) were males and females respectively and had a mean age of 30 years (SD ± 20 years). Among them, 5 (22%) were children below 12 years. In 13 (57%) patients stings occurred inside their houses including two children (40%). Six (26%) stings occurred at night when the victims were in sleep. Median time taken to arrive at the hospital from the time of stinging was 58 min (range 8-550 min). Signs of over activation of autonomic nervous system predominated the clinical picture-tachycardia in 14 (61%), high blood pressure in 11 (48%), excessive sweating in 9 (39%), excessive salivation in 5 (22%), hypotension in 4 (17%) and piloerection in 3 (13%). Children showed higher predilection to develop tachycardia - 4 (80%) and excessive salivation - 3 (60%). Priapism was not observed and 17 (74%) patients have developed intense pain at the site of sting. The commonest ECG change was tachycardia (73%) and occasional T wave inversion. Prazosin as a treatment was given to 22 (96%) patients. All patients made recovery and 13 (57%) patients left the hospital within two days. In future, there is a potential risk of spreading this species to elsewhere in the country and may disturb the ecological balance.

Cutaneous manifestations of spotted fever rickettsial infections in the Central Province of Sri Lanka: a descriptive study.

BACKGROUND: Characteristic skin lesions play a key role in clinical diagnosis of spotted fever group rickettsioses and this study describes these cutaneous manifestations along with basic histological features. METHODS AND FINDINGS: Study was conducted at Medical Unit, Teaching Hospital, Peradeniya, from November 2009 to October 2011, where a prospective data base of all rickettsial infections is maintained. Confirmation of diagnosis was made when IgM and IgG immunofluorescent antibody titre of 1/32 and >1/256 respectively. Of the 210 clinical cases, 134 had cutoff antibody titers for Rickettsia conorii antigen for confirmation. All these 134 patients had fever and skin rash, and of them 132(98%) had discrete maculopapular rash while eight (6%) had fern leaf type skin necrosis. Eight patients (6%) had healed tick bite marks. Average size of a skin lesion was 5 mm and rash involved 52% of body surface, distributed mainly in limbs and back of the chest. Generally the facial and leg skin was slightly oedematous particularly in old aged patients. Sixteen patients (12%) had pain and swelling of ankle joints where swelling extended to feet and leg. Biopsies from skin rash of six patients showed evidence of cutaneous vasculitis and of them, 247 bp region of the 17-kDa spotted fever group specific protein antigen was amplified using PCR. CONCLUSIONS: A discrete maculopapular rash and occasional variations such as fern leaf shape necrosis and arthritis are found in spotted fever group. Histology found vasculitis as the pathology of these lesions.

Revisiting Russell's viper (Daboia russelii) bite in Sri Lanka: is abdominal pain an early feature of systemic envenoming?

The Russell's viper (Daboia russelii) is responsible for 30-40% of all snakebites and the most number of life-threatening bites of any snake in Sri Lanka. The clinical profile of Russell's viper bite includes local swelling, coagulopathy, renal dysfunction and neuromuscular paralysis, based on which the syndromic diagnostic tools have been developed. The currently available Indian polyvalent antivenom is not very effective in treating Russell's viper bite patients in Sri Lanka and the decision regarding antivenom therapy is primarily driven by clinical and laboratory evidence of envenoming. The non-availability of early predictors of Russell's viper systemic envenoming is responsible for considerable delay in commencing antivenom. The objective of this study is to evaluate abdominal pain as an early feature of systemic envenoming following Russell's viper bites. We evaluated the clinical profile of Russell's viper bite patients admitted to a tertiary care centre in Sri Lanka. Fifty-five patients were proven Russell's viper bite victims who produced the biting snake, while one hundred and fifty-four were suspected to have been bitten by the same snake species. Coagulopathy (159, 76.1%), renal dysfunction (39, 18.7%), neuromuscular paralysis (146, 69.9%) and local envenoming (192, 91.9%) were seen in the victims, ranging from mono-systemic involvement to various combinations. Abdominal pain was present in 79.5% of these patients, appearing 5 minutes to 4 hours after the bite. The severity of the abdominal pain, assessed using a scoring system, correlated well with the severity of the coagulopathy (p<0.001) and the neurotoxicity (p<0.001). Its diagnostic validity to predict systemic envenoming is - Sensitivity 81.6%, Specificity 82.4%, Positive predictive value 91.2%. Thus, abdominal pain is an early clinical feature of systemic Russell's viper bite envenoming in Sri Lanka. However, it is best to judge abdominal pain together with other clinical manifestations on decision making.