Possible complex regional pain syndrome following SARS-CoV-2 infection: Case report.

SARS-CoV-2 infection has various manifestations including neurological and musculoskeletal system involvement. COVID-19 infection causes peripheral nerve lesions including small fibre neuropathy. Complex regional pain syndrome is a debilitating neurological condition manifested by predominantly pain associated with other sensory, motor, autonomic and tropic involvement. Identification and early treatment of CRPS has better prognosis. Here, we report a 21-year-old woman presented with pain, hyperalgesia, and swelling of left upper and lower limb following SARS-CoV-2 infection managed as possible complex regional pain syndrome.

Neutrophil Lymphocyte Ratio as a Marker of In-Hospital Deterioration in COVID-19: Observations From a Resource Constraint Setting.

Introduction and Objectives: The study was conducted to assess the association of neutrophil lymphocyte ratio (NLR) in COVID-19 and to identify the cut-off value that predicts mortality, need of respiratory support and admission to high-dependency or intensive care. Methods: A retrospective observational study was conducted to collect demographic data, clinical variables, the neutrophil-lymphocyte ratio on-admission and the outcome of confirmed COVID-19 patients admitted to a tertiary care center in Sri Lanka. Results: There were 208 patients with a median age of 56 years (IQR 43-67) and 98 (47.1%) males. The median neutrophil count was 4.07 × 103/µL (IQR 2.97-6.79) and the median lymphocyte count was 1.74 × 103/µL (IQR 1.36-4.75). The calculated NLR ranged from 0.12 to 48.28 with a median value of 2.32 (IQR 1.37-4.76). A NLR value >3.6 predicted development of severe disease requiring respiratory support, transfer to a high-dependency or an intensive care unit and/or succumbing to the illness with a sensitivity 80% and specificity 80% (area under the curve 0.8, 95% CI 0.72-0.88, P < .0001). The adjusted odds ratio of NLR > 3.6 on predicting severe disease was 11.1, 95% CI 4.5- 27.0, P < .0001. Conclusions: A NLR > 3.6 is a useful variable to be included in risk prediction scores in Sri Lanka.

Survival after severe amitriptyline poisoning with prolonged ventricular tachycardia and cardiac arrest.

BACKGROUND: Tricyclic antidepressants (TCA) are becoming one of the most frequently used substances in self poisoning. Significant morbidity and mortality associated with TCA overdose are often related to and refractory hypotension. We report the first case of survival after severe amitriptyline poisoning, leading to prolonged cardiac arrest and ventricular tachycardia (VT), resuscitated with 3 h of uninterrupted cardiac massage and Direct current (DC) shocks. CASE PRESENTATION: A 25 year old girl presented with severe amitriptyline poisoning causing pulseless VT and prolonged cardiac arrest. After 3 h of uninterrupted external cardiac massage, together with nine DC shocks and intra venous bicarbonate injections the rhythm reverted to a nodal tachycardia, initial 2D echocardiogram showed left ventricular dysfunction, which recovered to normal after 2 weeks and the patient had a complete recovery subsequently. CONCLUSION: Our case highlights the importance of continued resuscitation in patients presenting with TCA poisoning and resistant arrhythmia, especially in young and otherwise healthy patients.

Non alcoholic fatty liver disease increases the mortality from acute coronary syndrome: an observational study from Sri Lanka.

BACKGROUND: Non alcoholic fatty liver disease is an independent risk factor for coronary artery disease. But its effect on acute coronary syndrome is not clear. We performed this study to identify the prevalence of NAFLD in patients with ACS admitted to a tertiary care center in Sri Lanka. We also described the association of NAFLD with the severity of ACS predicted by the GRACE score. METHODS: We performed a descriptive study including all consecutive patients with non-fatal ACS admitted to Colombo South Teaching Hospital from 01/02/2014 to 30/04/2014. Patients with excessive alcohol consumption, established cirrhosis and patients with identified risk factors for liver disease were excluded from the study. All patients underwent ultrasound scan of liver. RESULTS: There were 120 participants, 75 (62.5%) males and 45 (37.5%) females with acute coronary syndrome. Average age was 61.28 ± 11.83 years. NAFLD was seen in 56 (46.7%) patients with ACS. Patients with NAFLD had a higher GRACE score than patients without NAFLD (120.2 ± 26.9 Vs 92.3 ± 24.2, p < 0.001). Increased age and presence of NAFLD conferred a higher mortality risk from ACS as predicted by GRACE score. Patients with NAFLD had a higher predicted mortality during in-ward stay (adjusted OR 31.3, CI 2.2-439.8, p = 0.011) and at 6 months after discharge (adjusted OR 15.59, CI 1.6-130.6, p = 0.011). CONCLUSIONS: Patients with NAFLD have a higher predicted mortality from acute coronary syndrome and thus require aggressive treatment of CAD. It is important to consider this novel risk factor when risk stratifying patients with ACS.

Clozapine induced pancytopenia leading to severe sepsis: an unusual early complication.

BACKGROUND: Clozapine is a second generation antipsychotic used to treat resistant schizophrenia and other psychotic illnesses. Leucopenia or agranulocytosis is a rare side effect of this drug. Pancytopenia is an extremely rare side effect of clozapine and literature review showed only one such case in where the pancytopenia developed several months after starting clozapine together with other antipsychotic drugs. CASE PRESENTATION: A 26-year-old Sri Lankan male was admitted with fever for 3 days. Apart from generalized body aches there were no other significant symptoms. His blood counts showed pancytopenia. He was being treated for a resistant schizophrenia and clozapine was started only 4 weeks before. Common causes for pancytopenia were excluded, and a diagnosis of clozapine induced pancytopenia was made. He was managed in the intensive care unit with broad spectrum antibiotics, antifungals and granulocyte colony stimulating factors. He made a complete recovery after 4 weeks. CONCLUSION: This is a rare and probably the first reported case of early onset clozapine induced pancytopenia complicated by severe sepsis recovering completely.

Myocarditis causing severe heart failure--an unusual early manifestation of leptospirosis: a case report.

BACKGROUND: Leptospirosis is the most widespread zoonosis in the world. Cardiac involvement is a frequent complication of leptospirosis although significant left ventricular dysfunction is rare. We report a case of fatal leptospira myocarditis leading to cardiogenic shock on the second day of illness. This early occurrence of myocarditis is not previously reported. CASE PRESENTATION: A 36-yr-old previously healthy Sri Lankan male who takes care of a horse presented to the medical casualty ward with a one day history of fever, arthralgia and severe myalgia. He developed hypotension on the second day of illness. Electrocardiogram showed sinus tachycardia with ST segment depression in lateral leads which evolved in to rapid atrial fibrillation in the subsequent days. 2D echocardiogram showed dilated cardiac chambers with severe global hypokinesia and an ejection fraction of 20%. His renal and liver functions were within normal limits. He developed multi organ dysfunction syndrome and refractory shock, later in the course of illness. Leptospirosis was confirmed by positive leptospira IgM and negative IgG. Patient died on the fifth day of illness despite optimal medical treatment with intravenous penicillin, meropenem, levofloxacin, inotropes and supportive care in the intensive care unit. CONCLUSIONS: We describe a rare and unusual early complication of leptospirosis which has not been reported before. It is important to bear in mind that leptospirosis could present as myocarditis during the early phase of illness.

Ventricular trigeminy in a patient with serologically confirmed dengue haemorrhagic fever.

BACKGROUND: Cardiac arrhythmias occur during the acute stage of Dengue Haemorrhagic Fever. Dengue myocarditis is the most likely cause of the arrhythmias. CASE PRESENTATION: We report a 55-year-old patient with Dengue Haemorrhagic Fever presenting with transient ventricular trigeminy which has not been reported before. CONCLUSION: Among many other known cardiac arrhythmia seen in DHF, ventricular trigeminy is also a possibility. Clinicians should be aware of this cardiac rhythm abnormality that can occur in dengue patients.

Electrocardiogram artifact caused by rigors mimicking narrow complex tachycardia: a case report.

BACKGROUND: The electrocardiogram (ECG) is useful in the diagnosis of cardiac and non-cardiac conditions. Rigors due to shivering can cause electrocardiogram artifacts mimicking various cardiac rhythm abnormalities. CASE PRESENTATION: We describe an 80-year-old Sri Lankan man with an abnormal electrocardiogram mimicking narrow complex tachycardia during the immediate post-operative period. Electrocardiogram changes caused by muscle tremor during rigors could mimic a narrow complex tachycardia. CONCLUSIONS: Identification of muscle tremor as a cause of electrocardiogram artifact can avoid unnecessary pharmacological and non-pharmacological intervention to prevent arrhythmias.