Double-trouble: A rare case of co-infection with melioidosis and leptospirosis from Sri Lanka.

Melioidosis and leptospirosis are two emerging tropical infections that share somewhat similar clinical manifestations but require different methods of management. A 59-year-old farmer presented to a tertiary care hospital with an acute febrile illness associated with arthralgia, myalgia and jaundice, complicated by oliguric acute kidney injury and pulmonary haemorrhage. Treatment was initiated for complicated leptospirosis but with poor response. Blood culture was positive for Burkholderia pseudomallei and microscopic agglutination test (MAT) for leptospirosis was positive at the highest titres of 1:2560, confirming a co-infection of leptospirosis and melioidosis. The patient made a complete recovery with therapeutic plasma exchange (TPE), intermittent haemodialysis and intravenous (IV) antibiotics. Similar environmental conditions harbour melioidosis and leptospirosis, making co-infection a very real possibility. Co-infection should be suspected in patients from endemic areas with water and soil exposure. Using two antibiotics to cover both pathogens effectively is prudent. IV penicillin with IV ceftazidime is one such effective combination.

Validation of the World Health Organization/ International Society of Hypertension (WHO/ISH) cardiovascular risk predictions in Sri Lankans based on findings from a prospective cohort study.

INTRODUCTION AND OBJECTIVES: There are no cardiovascular (CV) risk prediction models for Sri Lankans. Different risk prediction models not validated for Sri Lankans are being used to predict CV risk of Sri Lankans. We validated the WHO/ISH (SEAR-B) risk prediction charts prospectively in a population-based cohort of Sri Lankans. METHOD: We selected 40-64 year-old participants from the Ragama Medical Officer of Health (MOH) area in 2007 by stratified random sampling and followed them up for 10 years. Ten-year risk predictions of a fatal/non-fatal cardiovascular event (CVE) in 2007 were calculated using WHO/ISH (SEAR-B) charts with and without cholesterol. The CVEs that occurred from 2007-2017 were ascertained. Risk predictions in 2007 were validated against observed CVEs in 2017. RESULTS: Of 2517 participants, the mean age was 53.7 year (SD: 6.7) and 1132 (45%) were males. Using WHO/ISH chart with cholesterol, the percentages of subjects with a 10-year CV risk <10%, 10-19%, 20%-29%, 30-39%, ≥40% were 80.7%, 9.9%, 3.8%, 2.5% and 3.1%, respectively. 142 non-fatal and 73 fatal CVEs were observed during follow-up. Among the cohort, 9.4% were predicted of having a CV risk ≥20% and 8.6% CVEs were observed in the risk category. CVEs were within the predictions of WHO/ISH charts with and without cholesterol in both high (≥20%) and low(<20%) risk males, but only in low(<20%) risk females. The predictions of WHO/ISH charts, with-and without-cholesterol were in agreement in 81% of subjects (ĸ = 0.429; p<0.001). CONCLUSIONS: WHO/ISH (SEAR B) risk prediction charts with-and without-cholesterol may be used in Sri Lanka. Risk charts are more predictive in males than in females and for lower-risk categories. The predictions when stratifying into 2 categories, low risk (<20%) and high risk (≥20%), are more appropriate in clinical practice.

Lean non-alcoholic fatty liver disease (lean NAFLD): characteristics, metabolic outcomes and risk factors from a 7-year prospective, community cohort study from Sri Lanka.

INTRODUCTION: While patients with non-alcoholic fatty liver disease (NAFLD) are mostly overweight or obese, some are lean. METHODS: In a community-based follow-up study (baseline and follow-up surveys performed in 2007 and 2014), we investigated and compared the clinical characteristics, body composition, metabolic associations and outcomes, and other risk factors among individuals with lean (BMI < 23 kg/m2) NAFLD, non-lean (BMI ≥ 23 kg/m2) NAFLD and those without NAFLD. To investigate associations of selected genetic variants, we performed a case-control study between lean NAFLD cases and lean non-NAFLD controls. RESULTS: Of the 2985 participants in 2007, 120 (4.0%) had lean NAFLD and 816 (27.3%) had non-lean NAFLD. 1206 (40.4%) had no evidence of NAFLD (non-NAFLD). Compared to non-lean NAFLD, lean NAFLD was commoner among males (p < 0.001), and had a lower prevalence of hypertension (p < 0.001) and central obesity (WC < 90 cm for males, < 80 cm for females) (p < 0.001) without prominent differences in the prevalence of other metabolic comorbidities at baseline survey. Of 2142 individuals deemed as either NAFLD or non-NAFLD in 2007, 704 NAFLD individuals [84 lean NAFLD, 620 non-lean NAFLD] and 834 individuals with non-NAFLD in 2007 presented for follow-up in 2014. There was no difference in the occurrence of incident metabolic comorbidities between lean NAFLD and non-lean NAFLD. Of 294 individuals who were non-NAFLD in 2007 and lean in both 2007 and 2014, 84 (28.6%) had developed lean NAFLD, giving an annual incidence of 4.1%. Logistic regression identified the presence of diabetes at baseline, increase in weight from baseline to follow-up and a higher educational level as independent risk factors for the development of incident lean NAFLD. NAFLD association of PNPLA3 rs738409 was more pronounced among lean individuals (one-tailed p < 0.05) compared to the whole cohort sample. CONCLUSION: Although lean NAFLD constitutes a small proportion of NAFLD, the risk of developing incident metabolic comorbidities is similar to that of non-lean NAFLD. A PNPLA3 variant showed association with lean NAFLD in the studied population. Therefore, lean NAFLD also warrants careful evaluation and follow-up.

Tuberculous monoarthritis of the wrist in a patient with systemic lupus erythematosus: a case report.

BACKGROUND: Unusual forms of tuberculosis are common among immune-suppressed patients, leading to challenges in diagnosis and management. We present a Sri Lankan patient with systemic lupus erythematosis, investigated for chronic wrist pain with low inflammatory markers and without systemic symptoms, who was subsequently diagnosed to have tuberculosis of the joint. CASE PRESENTATION: A 31-year-old woman with systemic lupus erythematosis in remission was evaluated for chronic left wrist pain without significant examination findings on presentation. She did not have any constitutional symptoms. Basic investigations did not reveal any significant abnormalities. She was treated with increasing immunosuppression as for lupus related arthritis. Subsequently she developed a wrist effusion with high inflammatory markers, and was treated as septic arthritis. Synovial biopsy features suggested tuberculosis. The patient's symptoms improved with surgical intervention and anti-tuberculosis treatment. CONCLUSION: Tuberculosis should be considered in patients with systemic arthritis with unusual symptoms. Delayed diagnosis along with continuing immunosuppression can lead to extensive tissue damage. Clinically detectable effusions should be analyzed along with synovial biopsy in order to exclude concurrent infections. Radiography of the joint has poor sensitivity to detect early joint damage, but changes may be evident early on magnetic resonance imaging, sothis should be considered in patients with unusual features.