Is oral penicillin an effective chemoprophylaxis against leptospirosis? A placebo controlled field study in the Kandy District, Sri Lanka.

Leptospirosis poses a severe threat to the lives of farmers in Sri Lanka, thus, development of an effective chemoprophylaxis is deemed essential. We tested oral penicillin as chemoprophylaxis against leptospirosis in high transmission areas in central Sri Lanka in October 2005. Eight hundred active farmers were randomly assigned to take either oral penicillin (500 mg bid) or a similar looking placebo over a month during active farming season. The primary study point was the incidence of serologically confirmed leptospirosis. Data were available for 602 subjects of whom 319 (152 taking penicillin and 167 taking placebo) had good compliance, shown by tablet count. Of 5 subjects hospitalized with fever, 3 had serological evidence of leptospirosis, all of whom belonged to the placebo group. Therefore, oral penicillin may be effective chemoprophylaxis against leptospirosis.

Routine antibiotic therapy in the management of the local inflammatory swelling in venomous snakebites: results of a placebo-controlled study.

OBJECTIVE: To evaluate the value of routine antibiotic therapy in the management of the local swelling of patients with venomous snakebites. METHODS: A prospective, placebo-controlled study at the General Hospital, Anuradhapura, Sri Lanka where 144 patients with envenoming and local swelling in the leg were allocated to receive either antibiotics (Group A = test group) or placebo (Group B = controls). Benzyl penicillin 2 mega units intravenously 6 hourly and metronidazole 500 mg by intravenous infusion 8 hourly for 5 days from the first day of the bite were given to Group A. Ethical committee approval was obtained from the Committee of General Hospital, Anuradhapura. MAIN OUTCOME MEASURES: Circumference difference between the affected limb and the normal limb, length of the swelling measured in centimetres, and the physical characteristics of the local swelling of both groups were compared. RESULTS: Group A had 69 patients and the Group B 75. The mean circumference difference (MCD) of the leg between the groups showed no significant difference for 4 days (P > 0.05), except at the site of the bite on the third day when the Group B showed a significant improvement (p = 0.02). There was no significant difference in the length of the local swelling or the score of physical characteristics between the two groups (P > 0.05). The proportions of recovery of the local swelling on the fourth and fifth day had no significant difference between the groups (P > 0.05). CONCLUSION: The routine use of antibiotics (penicillin and metronidazole) does not seem to be of value in reducing the local inflammatory swelling in venomous snakebite.

Survey on the management of dengue infection in Sri Lanka: opinions of physicians and pediatricians.

The management of dengue infection is variable and clinicians often adopt their own methods based on clinical experience. Hence, there is a lack of uniformity in the practice and management of dengue fever (DF) and dengue hemorrhagic fever (DHF) in Sri Lanka. The objectives were to describe the opinions of clinicians regarding certain management issues of, and their clinical experiences in DF/DHF. A self-administered questionnaire survey of 50 consultant physicians and pediatricians that were currently practicing in Government Hospitals was conducted. Their cumulative experience was based on managing approximately 15,119 patients for a period of three years in 15 districts of the island. The WHO guidelines were used by only 16(45%) physicians and 6(40%) pediatricians in the management of DF/DHF Most of the clinicians did not agree on the value of steroids and antibiotics. However, the majority was in favor of platelet and plasma transfusions, although most had no fixed policy on fluid management. In the experience, clinicians observed the recurrence of dengue, post-viral fatigue syndrome, and many other complications. A conclusion was made that a national policy and guidelines should be created to suit the local context, based on the evidence and experiences of clinicians managing dengue infection.

Epidemiology, clinical features, laboratory investigations and early diagnosis of dengue fever in adults: a descriptive study in Sri Lanka.

A descriptive observational study was conducted to identify the epidemiology, clinical features, laboratory investigations and markers for early diagnosis of acute dengue virus infection in adults. We enrolled 404 patients over a period of two years, beginning from 2001, at the Teaching Hospital Peradeniya, Sri Lanka. Based on serology, 239 patients were grouped as: IgM 43 (18%), IgG and IgM 140 (58%), and IgG 28 (12%). The clinically diagnosed group without serology numbered 165 patients. Most of the parameters between groups showed a similar pattern: mean age of 30 years, mean duration of fever 7 days (range 1-19 days). Mean total white blood cell and platelet counts started to fall from the second day of fever, with the lowest counts on the 5th to 7th days. Packed cell volume (PCV) showed minimum fluctuation. One hundred and sixty (88%) patients showed elevated liver enzymes (ALT and AST), with 122 of them having a two-fold increase. Three patients died, and complications such as myocarditis, large effusions, encephalopathy, acute renal failure, acute liver failure and diarrhea were observed. These results suggest that a combination of clinical picture, thrombocytopenia, leukopenia and elevated liver enzymes could be used as markers for early diagnosis of dengue infection. Furthermore, evidence-based guidelines should be developed for managing dengue infection in adults.

Epidemiology and clinical picture of the Russell's viper (Daboia russelii russelii) bite in Anuradhapura, Sri Lanka: a prospective study of 336 patients.

Russell's viper (Daboia russelii russelii) bite is associated with a high incidence of morbidity and mortality in Sri Lanka. Hence, this study enrolled all consecutive Russell's viper bite admissions to the 'Unit A' of General Hospital, Anuradhapura, over a two year period from January 1996, to describe the epidemiology, clinical picture, treatment and outcome. There were 336 cases which showed the following results. The male: female ratio was 5:1; 75% of patients were below the age of 40 years. Biting occurred mainly in paddy fields 41%, and on footpaths 29% at dusk or dawn. Envenoming manifested in 310 (92%) of patients as follows: local swelling 92%, local necrosis 8.9%, coagulopathy 77%, neurotoxicity 78%, nephrotoxicity 18%, cardiac effects 3-12% and myotoxicity 14%. Coagulopathy appeared within 30 minutes to 12 hours after the bite and was corrected within 1 hour to 48 hours (mode 20 hours). Neurotoxicity recovered spontaneously in 1 to 5 days (mode 3 days): however, eight patients needed mechanical ventilation. Thirteen (4%) of patients were managed with peritoneal dialysis because of hyperkalemia caused by a hypercatabolic state (7) and acute renal failure (6). The mortality rate of the series was 2.6% (9 patients). Rural dry zone paddy farmers are the common victims of Russell's viper bite in Sri Lanka and its' envenoming leads to diverse clinical manifestations. Therefore, practically feasible preventive measures should be developed to minimize the incidence of bite and an evidence based management guideline should be developed for hospital practice.

Severe systemic effects of Merrem's hump-nosed viper bite.

OBJECTIVE: To report unpredictable severe systemic effects of hump-nosed viper envenomation. SETTING: Medical unit, General hospital, Anuradhapura. METHODS: The clinical outcome of seven patients bitten by Merrem's hump-nosed viper were monitored until recovery or death. Limited autopsies were performed on the latter. Offending snakes were positively identified by medical officers and in one instance by a herpetologist. CONCLUSION: Merrem's hump-nosed viper bites, caused an array of potentially fatal systemic manifestations. One patient developed neurological effects, severe Raynaud's syndrome leading to ascending gangrene of distal limbs and adult repiratory distress syndrome (ARDS), in addition to the known complications of severe renal cortical necrosis and haemostatic dysfunction. Two patients who developed acute renal failure and prolonged coagulopathy recovered completely. The combination of extensive renal cortical necrosis, disseminated intravascular coagulation, and ARDS proved fatal in three.

Acute pulmonary embolism in a patient with nephrotic syndrome.

Pulmonary embolism is a rare complication of nephrotic syndrome. We report the case history of a 30 year old man who presented with nephrotic syndrome and became acutely dyspnoeic with cyanosis and peripheral circulatory failure while on treatment. The clinical and ECG findings were strongly suggestive of acute pulmonary embolism.