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.

Screening for gestational diabetes mellitus: the Sri Lankan experience.

OBJECTIVE: To evaluate tests used for screening and confirmation of gestational diabetes mellitus (GDM) in Sri Lanka. METHODS FIELD BASED: Consecutive pregnant women in Homagama DDHS area (n = 853), were assessed for risk factors and subjected to random and postprandial urinary Benedict's and Dipstick tests, fasting and 2 hour post 75 g glucose capillary blood glucose (FBG and 2hBG) which were validated against 75 g oral glucose tolerance test (OGTT) performed at 24-28 weeks (WHO criteria). HOSPITAL BASED: Retrospective analysis of consecutive high-risk women (n = 999) and prospective study of randomly selected GDM women (n = 66) to assess predictive value of the OGTT. RESULTS FIELD BASED: Sensitivity and specificity respectively of random urine Benedict's, 10%, 99.2%; postprandial urine Benedict's, 52.2%, 94.5%; postprandial urine Dipstick, 68.7%, 90%; capillary FBG threshold 4.1 mmol/l, 62.6%, 73%; capillary 2hBG threshold 7.2 mmol/l, 98.5%, 95.2%; risk factors, 93.1%, 22.2%. HOSPITAL BASED: OGTT-11.6% lag curves, 16.3% abnormal, FPG accuracy at 4.7mmol/l; predictive value of 2 hPG > or = 8.9 mmol/l for insulin treatment-sensitivity 97.2%, specificity 71.4%. CONCLUSIONS: Current practice of random urine testing in community screening for gestational diabetes is unreliable, and glucose specific postprandial urine test improves sensitivity. FPG is unsuitable for screening, the 2 hour post 75 g blood glucose at a threshold of > 7.2 mmol/l is sensitive and specific. In laboratory confirmation using 75 g OGTT the fasting plasma glucose has low predictive value, 2 hour test performed alone is liable to false positives and 2 hour glucose > 8.9 mmol/l following a peak at 1 hour suggests the need for insulin treatment.

Pregnancy following renal transplantation in Sri Lanka.

OBJECTIVE: To assess the outcome and complications of pregnancy following renal transplantation in Sri Lanka. METHODS: Ten pregnancies following transplantation managed between January 1993 and July 1999 by the University Obstetrics and Gynaecology Unit, De Soysa Hospital for Women, Colombo were reviewed. RESULTS: Five women had planned pregnancy with an average duration from transplantation to conception of 2.3 (+/- 0.2) years; five had an unplanned pregnancy within 12 months of transplantation. All were treated with immunosuppressives, with none developing rejection. In the planned pregnancy group, 3 developed pregnancy induced hypertension and 3 impaired glucose tolerance. All delivered mature healthy babies with an average birth weight of 2.6 (+/- 0.3) kg. In the unplanned group, 1 developed cholestatic jaundice and delivered a growth retarded baby at 36 weeks. Another developed severe pulmonary oedema at 34 weeks (due to a past myocardial infarction) resulting in a fresh stillbirth. Two others has mid-trimester foetal deaths complicating severe diabetes mellitus. The conception at 3 months after transplantation developed diabetes mellitus and pregnancy induced hypertension, and delivered a live growth retarded baby. None had deterioration of renal function. CONCLUSION: Although a successful outcome is possible with stringent pre-pregnancy selection, maternal morbidity and foetal wastage can be high in those without.