The Diversity of Human Dirofilariasis in Western Sri Lanka.

BACKGROUND: Human dirofilariasis is an emerging zoonosis in many countries. Dirofilariasis caused by Dirofilaria repens may present with diverse clinical manifestations in humans due to aberrant localization of worm lesions causing diagnostic dilemmas. The aim of this retrospective study was to describe and update the demography and clinical spectrum of human dirofilariasis in western Sri Lanka. Nematode or nematode fragments isolated from excision biopsies that were confirmed as D. repens at the Department of Parasitology, Faculty of Medicine, University of Kelaniya, Sri Lanka, between 2012 and 2018 were included. Data on age, gender, and clinical details were obtained from case files. Identity of worms was established by morphometry and cuticle characteristics on wet-mount preparation. Specimens from unusual case presentations were further analyzed by PCR with specific primers for internal transcribed spacer region 2 (ITS2) of the ribosomal DNA. RESULTS: Sixteen nematode specimens isolated from subconjunctiva (n=2), subcutaneous (n=13) and intramuscular (n=1) locations were identified as D. repens by morphometry (average length 11.5 cm) and the characteristic longitudinal striations on cuticle visualized by microscopy. The age distribution of cases ranged from 1 to 65 years with a mean of 21.5. Females were more frequently affected (n=10, 62.5%) and worm locations were commonest in the orbital region (5/16) and scrotum (3/16). Imaging techniques were of use in detecting infections in deeper tissue levels. PCR analysis of DNA extracted from a worm in an intramuscular granuloma of the temporal region elicited the expected band at 484bp for D. repens. CONCLUSIONS: Human dirofilariasis is on an upward trend in incidence. Imaging techniques were of use in clinical diagnosis and molecular speciation in establishing the species identity in unusual case presentations. We suggest a more conservative approach in the management of human dirofilariasis and recommend a one health approach for control.

Extended spectrum beta lactamase producing organisms causing urinary tract infections in Sri Lanka and their antibiotic susceptibility pattern -A hospital based cross sectional study.

BACKGROUND: Extended Spectrum Beta- Lactamase producing organisms causing urinary tract infections (ESBL-UTI) are increasing in incidence and pose a major burden to health care. While ESBL producing Klebsiella species seem to account for most nosocomial outbreaks, ESBL-producing E. coli have been isolated from both hospitalized and non-hospitalized patients. Although 95-100% ESBL organisms are still considered sensitive to meropenem, rapid emergence of carbapenem resistance has been documented in many countries. The objective of this study was to evaluate urinary tract infections caused by ESBL producers and the antibiotic susceptibility patterns in Sri Lanka. METHODS: Patients with confirmed ESBL-UTI admitted to Professorial Medical Unit, Colombo North Teaching Hospital from January - June 2015 were recruited to the study. Their urine culture and antibiotic susceptibility reports were evaluated after obtaining informed written consent. RESULTS: Of 61 culture positive ESBL-UTIs, E. coli caused 53 (86.8%), followed by Klebsiella in 8 (13.1%).30 (49.1%) had a history of hospitalization within the past three months and included 6/8(75%) of Klebsiella UTI and 24/53(45.2%) of E.coli UTI. Antibiotic susceptibility of ESBL organisms were; Meropenem 58 (95%), Imipenem 45 (73.7%), Amikacin 37 (60.6%) and Nitrofurantoin 28(45.9%). In 3(4.9%), E.coli were resistant to Meropenem. These three patients had received multiple antibiotics including meropenem in the recent past for recurrent UTI. CONCLUSIONS: We observed a higher percentage of E. coli over Klebsiella as ESBL producing organisms suggesting most ESBL-UTIs to be community acquired, Carbapenems seem to remain as the first line therapy for majority of ESBL-UTIs in the local setting. However 4.9% prevalence of meropenem resistance is alarming compared to other countries. Although prior antibiotic utilization and hospitalization may contribute to emergence of ESBL producing Klebsiella and E.coli in Sri Lanka, high prevalence of community acquired ESBL-E. coli needs further investigations to identify potential causes . Being a third world country with a free health care system, observed alarming rate of carbapenem resistance is likely to add a significant burden to health budget. We feel that treatment of infections in general needs a careful approach adhering to recommended antibiotic guidelines in order to prevent emergence of multi drug resistant organisms.

Thyrotoxic crisis presenting with jaundice.

BACKGROUND: Thyrotoxic crisis is a medical emergency requiring early diagnosis and urgent management, which can be challenging due to its diverse clinical presentations. While common presentations include fever, sweating, palpitations, tremors and confusion, presence of jaundice is rare. CASE PRESENTATION: We report a 35-year-old male who presented with jaundice due to cholestasis along with other features of thyrotoxic crisis due to Graves' disease. He had a good clinical recovery with resolution of cholestasis following treatment for thyrotoxic crisis. CONCLUSION: Jaundice can be a rare manifestation of thyrotoxic crisis, and should be considered in the differential diagnosis when other clinical features of thyrotoxic crisis are present. However secondary causes of jaundice should be looked into and excluded.

Secondary bacteraemia in adult patients with prolonged dengue fever.

INTRODUCTION: Although dengue management guidelines do not advice on use of antibiotics in dengue shock syndrome, unrecognised bactraemia is likely to contribute to morbidity and mortality. OBJECTIVES: To assess the occurance of secondary bacteraemia in adult patients with prolonged dengue fever. METHODS: A prospective study was conducted recruiting patients with confirmed acute dengue infection who had prolonged fever (>5 days). Two sets of blood cultures were taken in such patients prior to institution of antibiotic therapy. Demographic, clinical, haematological and biochemical parameters were recorded. Development of ascites and pleural effusions were detected using ultrasonography. RESULTS: Fourty patients (52.5% males) with a mean age of 29.8 years (SD 13.6) were studied. The average duration of fever was 7.9 days (SD 1.8). Ten patients (25%) had bacterial isolates in their blood cultures; Staphylococcus aureus (n=2), coliforms (n=3), pseudomonas (n=1) and 4 had mixed growths. The culture positive group had severe body aches at admission and higher fever, third space fluid accumulation, a significant drop in platelets and a higher CRP. CONCLUSIONS: A quarter of dengue patients with prolonged fever had a bacterial isolate. Culture positive patients appeared more ill with body aches and had higher degrees of fever during the latter part of the illness. Increased vascular permeability may predispose to bacterial seepage into blood. Although white cell count is not helpful in detecting bacteraemia, low platelet count and elevation of CRP seem to be helpful.

Rickettsioses in the central hills of Sri Lanka: serological evidence of increasing burden of spotted fever group.

OBJECTIVES: To study the epidemiology, clinical features, and changing pattern of rickettsial infections on the western slopes of the hilly Central Province of Sri Lanka over 6 years. METHODS: All patients with rickettsial infections who presented to the Teaching Hospital, Peradeniya were studied prospectively from January 2002 to December 2007. An immunofluorescent antibody assay (IFA) was used to confirm the diagnosis. RESULTS: Of the 371 clinical cases of rickettsial infection, 122 underwent IFA to confirm the diagnosis. Species-specific IgG antibodies were positive in 105/122 (86.1%) cases: 43/105 (40.9%) to Rickettsia conorii and 6/105 (5.7%) to Orientia tsutsugamushi, with mixed antibody reactivity to more than one antigen in 56/105 (53.3%) cases, including Rickettsia typhi in 27/105 (25.7%). Among those with mixed IgG reactivity, IgM assays were used to detect pathogens responsible for acute infections. Finally, a total of 55 spotted fever group (SFG) infections, seven scrub typhus infections, and one case of murine typhus were identified. Of the 105 positive cases, 53 (50.5%) were male and 52 (49.5%) were female, and the mean age was 40 years (range 11-83 years). In the SFG patients, 13/55 (24%) had severe vasculitis with fern leaf type skin necrosis and 17/55 (31%) had arthritis. Three patients (5%) had an altered level of consciousness. A patient with scrub typhus had transient deafness. None of the 105 patients had an eschar. CONCLUSIONS: It appears that SFG rickettsioses are on the rise in the hilly Central Province of Sri Lanka, whilst murine typhus and scrub typhus are present at a lower rate.

Timing, predictors, and progress of third space fluid accumulation during preliminary phase fluid resuscitation in adult patients with dengue.

BACKGROUND: Fluid leakage remains the hallmark of dengue hemorrhagic fever (DHF). The applicability of currently recommended predictors of DHF for adults with dengue is questionable as these are based on studies conducted in children. METHODS: One hundred and two adults with dengue were prospectively followed up to investigate whether home-based or hospital-based early phase fluid resuscitation has an impact on clinical and hematological parameters used for the diagnosis of early or critical phase fluid leakage. RESULTS: In the majority of subjects, third space fluid accumulation (TSFA) was detected on the fifth and sixth days of infection. The quantity and quality of fluids administered played no role in TSFA. A reduction in systolic blood pressure appeared to be more helpful than a reduction in pulse pressure in predicting fluid leakage. TSFA occurred with lower percentage rises in packed cell volume (PCV) than stated in the current recommendations. A rapid reduction in platelets, progressive reduction in white blood cells, percentage rises in Haemoglobin (Hb), and PCV, and rises in aspartate aminotransferase and alanine aminotransferase were observed in patients with TSFA and therefore with the development of severe illness. CONCLUSIONS: Clinicians should be aware of the limitations of currently recommended predictors of DHF in adult patients who are receiving fluid resuscitation.

A case series of spotted fever rickettsiosis with neurological manifestations in Sri Lanka.

BACKGROUND: Spotted fever group (SFG) rickettsial infections are increasingly detected in Sri Lanka. We describe 17 patients with SFG who developed neurological manifestations. METHODS: The cases were studied prospectively from 2008 at the Teaching Hospital, Peradeniya. An immunofluorescent antibody assay (IFA) was used to confirm the diagnosis. RESULTS: All had an IFA IgG titer ranging from 1/64 to 1/4096 and a positive IFA IgM titer against Rickettsia conorii antigen; in 10 (59%) cases the IgG titers were ≥ 1/256 (definitive cases). The median age of the patients was 62 years (range 26-82 years); 10 were male and seven female. The median duration of fever was 12 days (range 4-35 days). Neurological manifestations on admission were drowsiness or confusion in 14 (82%) and a semi-comatose state in three (18%). Rigidity of the limbs occurred in 14 (82%), bradykinesia and resting tremors in 12 (71%), which persisted after defervescence, neck stiffness in seven (42%), weakness of the limbs in five (29%), deafness in two (12%), and stupor in three (18%). Electroencephalograms in three (18%) showed generalized slow waves. Cerebrospinal fluid examination showed a cellular reaction, predominantly lymphocytes, in three cases. Two patients died (fatality rate 12%). CONCLUSION: We have documented for the first time the neurological features of SFG rickettsioses in the Central Province, Sri Lanka. These were predominantly extrapyramidal features in patients of older age.

Repeated dengue shock syndrome and 'dengue myocarditis' responding dramatically to a single dose of methyl prednisolone.

The place of steroids in the management of severe forms of dengue is unclear. A retrospective observational study showed the benefits of a single dose of intravenous methyl prednisolone in a highly selected group of patients who developed severe dengue during the febrile phase of infection. We report the case of a 14-year-old boy with dengue who developed three episodes of severe hemodynamic compromise while having high fever, 'myocarditis', third space fluid accumulation, progressive reduction in urine output, and altered mentation, who made a dramatic recovery following a single dose of intravenous methyl prednisolone. Results justify a well powered randomized controlled trial to evaluate the efficacy of this treatment in severe dengue.

Evidence of acute rickettsioses among patients presumed to have chikungunya fever during the chikungunya outbreak in Sri Lanka.

BACKGROUND: Chikungunya fever (CGF) and rickettsioses are known to cause acute onset febrile illnesses associated with severe arthritis. Rickettsial arthritis is curable with the use of appropriate anti-rickettsial antibiotics, however the arthritis of CGF tends to have a prolonged course leading to protracted disability. The aim of this study was to investigate the contribution of CGF and rickettsioses to cases of fever and arthritis during a presumed CGF outbreak in Sri Lanka. METHODS: Fifty-eight consecutive patients with presumed CGF were further investigated to determine the occurrence of rickettsioses among them, and to identify differences in clinical, hematological, and biochemical parameters between the two diseases. RESULTS: Nearly a third of the patients had serological evidence of rickettsioses accounting for their illness. The presence of a late onset major joint arthropathy sparing the small joints of the hands and feet, and the occurrence of a late onset discrete maculopapular rash over the trunk and extremities, suggested rickettsioses over CGF. White blood cell count, erythrocyte sedimentation rate, C-reactive protein, and liver function tests were not helpful in differentiating rickettsioses from CGF. Patients with rickettsioses and arthritis who received an empirical course of doxycycline recovered faster than those who did not receive specific treatment. CONCLUSIONS: The establishment of rapid diagnostic methods able to differentiate the etiological agents of fever and arthritis, such as CGF and rickettsioses, would be beneficial in endemic settings.

Contribution of rickettsioses in Sri Lankan patients with fever who responded to empirical doxycycline treatment.

Twenty-eight febrile Sri Lankan patients with undiagnosed fever for 7 days after hospital admission, who responded to empirical treatment with doxycycline, were retrospectively investigated using microimmunofluorescence assay to verify whether they had rickettsial infection. Eleven (39%) patients were confirmed as having spotted fever group rickettsioses and 10 (36%) as having Orientia tsutsugamushi. Seven were negative for all tests. This suggests that greater use of doxycycline appears justified for patients with undiagnosed fever in settings where rickettsial diseases are endemic or re-emerging with inadequate diagnostic facilities.

Scrub typhus mimicking enteric fever; a report of three patients.

We report three patients who presented with fever and late onset diarrhoea mimicking enteric fever. All three patients were diagnosed with an Orientia tsutsugamushi infection and responded dramatically to doxycycline treatment. Clinicians practicing in rickettsial disease endemic areas should be made aware of similar clinical presentations in order to prevent morbidity and mortality associated with rickettsioses.