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.

Study of dirofilariasis in a selected area in the Western Province.

INTRODUCTION: Human dirofilariasis is a zoonotic infection caused by the filarial worm, Dirofilaria (Nochtiella) repens, whose primary host is the dog. This infection is on the increase over the past decade in Sri Lanka and the prevalence of canine dirofilariasis in the country is also believed to be high. We present here a study on public awareness of dirofilariasis and the prevalence of this infection in dogs in Negombo, an urban area that has a high domestic canine population. OBJECTIVE: To assess the awareness of dirofilariasis infection among residents and study the prevalence of this infection in domestic dogs in Negombo. DESIGN: Prospective study. SETTING: Department of Parasitology, Faculty of Medicine, University of Colombo, Colombo 8, Sri Lanka. METHODS: A descriptive cross-sectional study within the city of Negombo during September and November 2003 using a pre-tested, interviewer-administered questionnaire with cluster sampling was done. Two hundred seventy adults, including 132 dog owners, were included in the study. Data analysis was done using the Epilnfo programme. The prevalence of canine dirofilariasis was studied in a group of 65 dogs over the age of 1 year. They were selected by cluster sampling with random choice of the streets within the study area. Stained thick blood films, made following an earlobe-prick at any time during the day, were microscopically examined for the presence of microfilariae. RESULTS: Forty nine of the respondents (18%) were aware of the existence of canine dirofilariasis while human dirofilariasis was known only to 6%. Awareness was related to the level of education. Knowledge of canine filariasis was better among pet owners (32/132) when compared to others (18/138; p < 0.05). Veterinary surgeons were acknowledged as the source of information by 38% of those who were aware of the disease. Forty five per cent (n = 29) of the dogs screened were positive for microfilariae. Out of these 18 and two dogs were infected with D repens. and B. ceylonensis, respectively, while nine others were co-infected with the two parasites. CONCLUSIONS: The knowledge of dirofilariasis is extremely poor in the study area. The high prevalence of filarial infections in dogs highlights the importance of improving the public awareness of this disease, especially among the dog owners. Proper management of this condition in dogs-the reservoirs of infection for human dirofilariasis, is important for the control of this zoonotic infection.

A preliminary study of the hospital-admitted older patients in a Sri Lankan tertiary care hospital.

OBJECTIVE: To provide reasons for admission, comorbidities, physical and psychosocial characteristics, and outcome of older patients admitted to hospital in Sri Lanka, and to assess adequacy of routine assessment. DESIGN: Descriptive study. SETTING: University Medical Unit, National Hospital of Sri Lanka during 10 weeks commencing August 2003. PATIENTS: All > or = 65 years admitted to the unit, excluding transfers for specialised management and direct admissions by consultants or clinics; 75 men and 75 women. MEASUREMENTS: Vision, hearing and speech, tests for tendency to fall, basic activities of daily living (BADL), mood and cognition, body mass index and waist circumference. RESULTS: Seventy three per cent and 40% had cognitive dysfunction and depression., 20% required assistance in > or = 5/9 BADL, 23% had unprovoked falls within past year, and 57% had a tendency to fall, 34% had < or =6/60 vision. CONCLUSIONS: Falls, depression, cognitive dysfunction and severe visual impairment were present in substantial proportions, unidentified by routine assessment of older patients.