Is fresh frozen plasma effective for thrombocytopenia in adults with dengue fever? A prospective randomised double blind controlled study.

RATIONALE: Thrombocytopenia is a common problem which causes concern and complications in dengue fever. If proven effective, intravenous fresh frozen plasma is a simple and widely available therapeutic option to manage thrombocytopenia. OBJECTIVE: To test the efficacy of fresh frozen plasma (FFP) on thrombocytopenia in patients with dengue fever. DESIGN: 109 serologically confirmed dengue patients with platelet counts <40 000/mm3 were randomised into two groups. Group A (treatment) comprised 53 patients and group B (control) 56 patients. Group A received an intravenous infusion of 3 units (600 ml) of FFP over 90 minutes. Group B received an intravenous infusion of an equal volume of isotonic saline over the same period. The primary outcome measure was the difference between pre- and post-interventional platelet counts at 12, 24 and 48 hours. RESULTS: Following Intervention, the mean platelet count was significantly higher in Group Athan in Group B at 12 hours (p=0.04; t-test). The mean platelet counts continued to be higher in Group A than in Group B at 24 and 48 hours post-intervention, but the differences were not statistically significant. CONCLUSIONS: In dengue patients with thrombocytopenia, infusion of 600 ml FFP may contribute to a significant increase in platelet count in the first 12 hours, but not thereafter.

An outbreak of Aspergillus meningitis following spinal anaesthesia for caesarean section in Sri Lanka: a post-tsunami effect?

An outbreak of Aspergillus fumigatus meningitis occurred in 5 women following spinal anaesthesia, performed between 21 June and 17 July 2005 for caesarean section, in Colombo, Sri Lanka. The patients' median age was 27 years. Different teams in 2 maternity hospitals gave spinal anaesthesia. Mean incubation period was 11.2 days. Fever, headache and nuchal rigidity were common presentations. Remittent fever continued despite broad-spectrum intravenous antibiotics. Papilloedema, lateral rectus palsy, cerebral infarction and haemorrhage developed later. Three patients died. Cerebrospinal fluid pleocytosis with low glucose yielded negative PCR for fungi. Fungal cultures subsequently grew Aspergillus fumigatus. A post-mortem of the first patient confirmed Aspergillus meningitis, followed by treatment with amphotericin B and voriconazole, that saved the lives of others. Visual and hearing impairment in one and complete recovery in the other were observed a year after treatment. Examination of unused plastic syringes, needles, cannulae, and ampoules of anaesthetic agents confirmed that 43 syringes from three different manufactures were contaminated with Aspergillus fumigatus. The stores for drugs and devices of the Ministry of Health were examined and found to be full of tsunami donations, while regular procurements of the Ministry were kept in a poorly maintained humid warehouse. Inadequate space for tsunami donations was identified as the most plausible explanation for sub-optimal storage. Withdrawal and incineration of all unused syringes controlled the outbreak. The survival of those aggressively treated for Aspergillus meningitis suggests in hindsight that the availability of diagnostic tests and specific treatment, and early recognition of the outbreak could have saved the lives of victims who died. Early life-threatening side-effects and permanent long term sequelae of antifungal medication stress the need to be cautious with empirical treatment in immuno-competent low-risk individuals.

Acute myocardial infarction in a patient with Russell's viper bite.

We describe a previously healthy patient who developed and acute anterolateral Q wave myocardial infarction after a Russell's viper bite. Severe chest pain persisted despite intravenous morphine and polyspecific antivenom therapy. The pain subsided with intravenous heparin. The patient recovered.

Intravenous immunoglobulin in the treatment of snake bite envenoming: a pilot study.

The standard treatment for snake bite envenoming is with snake antivenon (AVS). Reports to date on the efficacy of AVS have been equivocal. Some studies have shown a beneficial effect on the coagulopathy, while its effect on neurotoxicity is questionable. AVS therapy is also associated with a high incidence of reactions. We conducted a pilot study to compare the standard AVS therapy, with AVS plus intravenous immunoglobulin (IVIG), in the treatment of snake bite evenoming. Our study indicates that the addition of IVIG to the standard AVS regimen, eliminates the need to repeat AVS for envenoming associated with coagulopathy.