Comparing the 2009 and 1997 World Health Organization dengue case classifications in a large cohort of South Asian patients.

INTRODUCTION: Due to the shortcomings in the 1997-World Health Organisation (WHO) dengue case classification (DCC), a revised classification was proposed in 2009. This study was aimed to assess the clinical usefulness of the two classifications during a large dengue epidemic. METHODOLOGY: Clinical data of dengue patients admitted to selected units at National Hospital of Sri Lanka, Panadura Base Hospital and Nawaloka Hospital Colombo between June and August 2017 were collected prospectively. Cases were classified using the 1997 and 2009 WHO DCCs. RESULTS: 1,878 patients [adult = 1,573 (83.8%)] were studied. Based on 1997-WHO-DCC-DF (Dengue Fever): 1,316 (70.1%), DHF (Dengue Haemorrhagic Fever) -1: 468 (24.9%), DHF-2: 86 (4.6%) and DHF-3: 8 (0.4%). Based on 2009-WHO-DCC-Dengue with warning signs (WS): 1647 (87.7%), Dengue without WS: 231 (12.3%) and severe dengue (SD): 41 (2.18%). A total of 1,088 (82.7%) DF and 559 (99.5%) DHF patients developed WS. Of those without WS, 228 (17.3%) were DF patients and 3 (0.5%) were DHF patients. Three (0.23%) DF and 38 (6.76%) DHF patients had SD. All SD patients had WS. The level of agreement between the two systems of classification was poor (Kappa = - 0.035, p < 0.001). CONCLUSIONS: The 2009-WHO-DCC was more useful than 1997-WHO-DCC in predicting dengue disease severity as few DF patients also had SD. Furthermore, the presence of WS identified patients with SD. However, the 2009-WHO-DCC may not suit the resource limited countries as WS are non-specific, and lack of diagnostic tests can result in case overload.

Leptospirosis complicated with Guillain Barre syndrome, papillitis and thrombotic thrombocytopenic Purpura; a case report.

BACKGROUND: Leptospirosis is a zoonosis commonly prevalent in tropical countries. Clinical course of leptospirosis varies from mild to severe disease. Here we present a case of leptospirosis complicated with Guillain-Barre Syndrome (GBS), papillitis, and Thrombotic Thrombocytopenic Purpura(TTP). CASE PRESENTATION: A 21-year-old Asian male presented with fever, myalgia, oliguria and dyspnoea where he was managed as for leptospirosis complicated with pulmonary haemorrhages and acute renal failure. Leptospirosis was confirmed by Microscopic Agglutination Test(MAT) with a fourfold rise in antibody titre between acute and convalescent serum. The highest antibody titre was against Leptospira antigen serogroup Semaranga (strain Patoc) (1:1280) followed by serogroup Australis (strain Australis) (1:640) and serogroup Autumnalis (strain Bankgkinang) (1:320). Two weeks later he developed blindness, ascending weakness of lower limbs with global areflexia and an acute inflammatory demyelinating polyradiculopathy(AIDP) variant GBS was confirmed with nerve conduction studies. TTP complicated the picture several days later. He was initiated on plasmapheresis where clinical improvement was seen after 14 cycles. He had an incomplete neurological recovery with permanent vision loss but completely recovered from TTP. He also had permanent renal impairment. CONCLUSION: Leptospirosis should be suspected and treated empirically in the relevant clinical settings where it can present with an atypical clinical picture as in our case with an acute febrile illness followed by GBS as well as TTP.

Migratory polyarthritis as a paraneoplastic syndrome in a patient with diffuse large B cell lymphoma: a case report.

BACKGROUND: Diffuse large B cell lymphoma is the commonest histological subtype of non-Hodgkin lymphoma and typically presents as a rapidly enlarging lymph node mass and B symptoms. It is unusual for diffuse large B cell lymphoma to present as carcinomatous polyarthritis which is a type of paraneoplastic arthritis. CASE PRESENTATION: We present a case of a 45-year-old Asian man with diffuse large B cell lymphoma presenting with generalized lymphadenopathy, transient macular rash, and migratory polyarthritis involving both upper and lower limb small and large joints. Treatment of the lymphoma but not the routine anti-inflammatory agents resulted in complete resolution of the arthritis suggesting the paraneoplastic nature. CONCLUSIONS: Poor response to routine therapy for inflammatory arthritis should lead to early suspicion of paraneoplastic arthritis which will prompt investigation for an underlying malignancy. Suspicion of carcinomatous polyarthritis should be made in those with migratory polyarthritis and should be thoroughly investigated to exclude underlying malignancy.

First-year success in a nursing baccalaureate plan of study: A descriptive research study.

BACKGROUND: Predicting students' aptitude for post-secondary success remains a widely studied topic. This descriptive study explored demographic variables contributing to success in quantitative courses required by the nursing degree plan. Identification of an "at risk" student profile may inform interventions with which to support attainment of an academic degree. OBJECTIVE: The purpose of this study was to examine the associations between demographic characteristics and successful completion of baccalaureate nursing courses thought to enhance quantitative reasoning skills: first-year math, first-year chemistry, and second-year pathopharmacology nursing. METHODS: This retrospective analysis accessed 4521 academic records of students who took these three courses at a United States university sometime between Fall 2008 and Fall 2015. De-identified student data included course grades, gender, full-time study, income, marital status, first generation, secondary school (also known as high school) location, dual credit, and high school and university grade point averages. Descriptive statistical analysis was conducted to describe the important features of the data. RESULTS: Of the 4521 records, 2556 undergraduates (57%) passed the courses in which they were enrolled. Among successful students, females outnumbered males (66%), ages ranged from 20 to 24 years, 86% were classified as low income, 54% fit the designation of first generation, and 12% earned dual credit (university credit during secondary school). Our data demonstrate a positive relationship between dual credit and success, with the strongest correlation (0.62) noted for students in pathopharmacology. CONCLUSION: In the baccalaureate-nursing plan of study, courses thought to enhance students' quantitative reasoning skills remain difficult for some to successfully complete. We conclude that the more successful students tend to be older, have a higher income, and a higher high school grade point average, while those less successful are directly out of high school and have not earned dual credit.

Pattern of dengue virus infections in adult patients from Sri Lanka.

Background: Sri Lanka experienced its largest dengue epidemic in 2017. This study describes the disease pattern of adult dengue patients from two hospitals in Sri Lanka. Methods: Demographic, clinical and investigation findings of adult dengue patients admitted to the two hospitals from June to August 2017 were collected and analysed. Results: A total of 1167 patients (777 males [66.2%], mean age 32.9 y) were studied. There were 775 (66.4%) patients with dengue fever (DF), 334 (28.6%) with dengue haemorrhagic fever grade I, 54 (4.6%) with DHF grade II and 4 (0.3%) with DHF grade III. DHF was significantly associated with abdominal symptoms/signs and bleeding manifestations (p<0.001). A considerable variation in time of onset of the critical phase was noted (day 3, 11.9%; day 4-5, 63.1%; day 6, 16.2%; day ≥7, 8.7%). Significantly lower platelet and white blood cell counts and elevated transaminase levels were found in DHF than DF (p<0.001). Other complications included myocarditis (two patients) and mild renal impairment (three patients). None had neurological manifestations. Conclusions: We found abdominal symptoms/signs, low platelet and white blood cell counts and high transaminase to be associated with DHF. The onset of the critical phase was variable and difficult to predict. Compiling data from various regions would help to understand disease patterns, which in turn would help in formulating evidence-based management guidelines and the allocation of limited health care resources.

Medullary nephrocalcinosis, distal renal tubular acidosis and polycythaemia in a patient with nephrotic syndrome.

BACKGROUND: Medullary nephrocalcinosis and distal renal tubular acidosis are closely associated and each can lead to the other. These clinical entities are rare in patients with nephrotic syndrome and polycythaemia is an unusual finding in such patients. We describe the presence of medullary nephrocalcinosis, distal renal tubular acidosis and polycythaemia in a patient with nephrotic syndrome due to minimal change disease. Proposed mechanisms of polycythaemia in patients with nephrotic syndrome and distal renal tubular acidosis include, increased erythropoietin production and secretion of interleukin 8 which in turn stimulate erythropoiesis. CASE PRESENTATION: A 22 year old Sri Lankan Sinhala male with nephrotic syndrome due to minimal change disease was investigated for incidentally detected polycythaemia. Investigations revealed the presence of renal tubular acidosis type I and medullary nephrocalcinosis. Despite extensive investigation, a definite cause for polycythaemia was not found in this patient. Treatment with potassium and bicarbonate supplementation with potassium citrate led to correction of acidosis thereby avoiding the progression of nephrocalcinosis and harmful effects of chronic acidosis. CONCLUSION: The constellation of clinical and biochemical findings in this patient is unique but the pathogenesis of erythrocytosis is not clearly explained. The proposed mechanisms for erythrocytosis in other patients with proteinuria include increased erythropoietin secretion due to renal hypoxia and increased secretion of interleukin 8 from the kidney. This case illustrates that there may exist hitherto unknown connections between tubular and glomerular dysfunction in patients with nephrotic syndrome.

Cytomegalovirus associated transverse myelitis in an immunocompetent host with DNA detection in cerebrospinal fluid; a case report.

BACKGROUND: Cytomegalovirus associated transverse myelitis among immunocompetent adults has been rarely reported. We report a patient presenting with clinical myelitis followed by previously unreported finding of cytomegalovirus deoxyribonucleic acid in cerebrospinal fluid. CASE REPORT: A forty year old immunocompetent male presented with acute onset progressive bilateral lower limb weakness. His spinal magnetic resonance imaging findings, cerebrospinal fluid analysis and clinical picture were compatible with transverse myelitis. Polymerase chain reaction of the cerebrospinal fluid for cytomegalovirus was positive while other infectious agents were not detected by serology or polymerase chain reaction. He was treated with intravenous ganciclovir with partial clinical response. CONCLUSION: Viral genome detection in the cerebrospinal fluid was performed but negative in five out of ten reported cases of cytomegalovirus associated transverse myelitis in the immunocompetent host. In previous cases the inability to isolate the virus in cerebrospinal fluid was considered favouring an immunological mechanism leading to pathogenesis rather than direct viral toxicity but this case is against that theory. This case highlights the fact that Cytomegalovirus should be considered as an aetiological agent in patients with transverse myelitis and that the virus may cause serious infections in immunocompetent host. Therefore this report is of importance to neurologists and physicians in general.

Cold autoimmune haemolytic anaemia secondary to Epstein Barr virus infection presenting with peripheral gangrene; case report.

A sixty year old male presented with dark urine, symptomatic anaemia and peripheral gangrene following cold exposure. Investigations revealed that he had haemolysis and serological evidence of recent Epstein Barr virus infection. Although acrocyanosis is commonly associated with cold agglutinin disease, gangrene is a rare complication. Management of secondary cold agglutinin disease is mainly supportive.

Epstein-Barr virus co-infection in a patient with dengue fever presenting with post-infectious cerebellitis: a case report.

INTRODUCTION: Post-infectious cerebellitis is an acute form of inflammatory encephalitis mainly limited to the cerebellum. It is commonly found in children, especially after viral infections such as Epstein-Barr virus. Post-infectious cerebellitis presents with acute onset dysarthria and ataxia. To the best of our knowledge, this is the first case report of post-infectious cerebellitis in a patient with both dengue and Epstein-Barr viral infection confirmed on serology. CASE PRESENTATION: A 43-year-old Sri Lankan Sinhala man presented with an acute febrile illness associated with thrombocytopenia. While being managed as uncomplicated dengue fever, our patient developed dysarthria, ataxia and cerebellar signs. Our patient's infectious disease screen was positive for both dengue and Epstein-Barr specific immunoglobulin M. A cerebrospinal fluid analysis was suggestive of viral meningoencephalitis while cerebrospinal fluid serology was positive for dengue immunoglobulin G. T2-weighted magnetic resonance images were consistent with post-viral cerebellitis. The patient was given full supportive care and he made an uneventful complete recovery. CONCLUSION: There have been no previously reported cases of post-infectious cerebellitis associated with both Epstein-Barr and dengue viral infections confirmed by serology. Our patient's clinical features and findings on the imaging studies were consistent with post-viral cerebellitis. This report highlights the need to screen for other possible more common etiologies of a particular presentation before coming to a specific diagnosis based on initial findings. Uncomplicated cases of cerebellitis can be successfully managed with appropriate supportive measures with good prognosis, as in this case.