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.

Essential thrombocythemia: an uncommon cause of digital gangrene.

We describe a case of essential thrombocythemia (ET), presenting as digital gangrene. ET is a rare myeloproliferative disorder characterised by a persistently elevated platelet count which commonly presents with haemorrhagic manifestations. Thrombosis occurs less frequently and digital gangrene is an uncommon presentation.

Intestinal helminthiasis and abdominal symptoms in adults.

In a study to test the association between soil transmitted intestinal helminthiasis and abdominal symptoms in a non-paediatric age group, 242 randomly selected patients (137 males, 105 females, median age 45 years) were asked specific questions pertaining to abdominal symptoms at the time of admission to the adult medical wards. Stool examination on all patients revealed a round worm prevalence rate of 21%. A larger proportion of stool positive female patients were symptomatic than stool negative females (68% vs 30%, p = 0.04). There was no significant difference in symptoms between stool positive and stool negative male patients (34.6% vs 31%, p = 0.91). The results suggested an association between intestinal nematode infection and abdominal symptoms in females but not in males.

Counterimmunoelectrophoresis in the rapid diagnosis of bacterial meningitis.

Cerebrospinal fluid from patients with clinically diagnosed meningitis was tested for meningococcal, pneumococcal, streptococcal Group B and Haemophilus influenzae antigens by counterimmunoelectrophoresis. Antigens were rapidly identified and the results compared favourably with that of bacteriological culture. In the case of pneumococcal meningitis counterimmunoelectrophoresis proved to be more sensitive than culture. The procedure was shown to be sensitive, specific, rapid and easily performed.