A rare case of insulinoma presenting with deep vein thrombosis, successfully treated with minimally invasive procedures including microwave ablation.

Summary: Treatment of insulinoma can be challenging, while surgical resection is considered the first line. When surgery is contraindicated or is refused, minimally invasive procedures such as selective arterial embolization, local ablative techniques including alcohol ablation, radiofrequency ablation and microwave ablation are being used of late. The world's first microwave ablation of insulinoma was performed in 2015, after which there have been only a handful of reported cases. A 78-year-old female presented with painful swelling of the left lower limb. She was drowsy and was previously misdiagnosed as epilepsy when she had similar episodes since 2 years ago. She had hypoglycaemia with high serum insulin and C-peptide, and mildly high adjusted calcium, serum prolactin. MRI did not show pituitary adenoma. Lower limb venous duplex scan showed left lower limb deep vein thrombosis for which she was treated with anticoagulation. CT of the abdomen showed a tumour measuring 1.8 cm, located in the antero-superior aspect of the body of the pancreas, with the superior surface being abutted by the splenic artery and the inferior surface being 3 mm above the pancreatic duct, suggestive of an insulinoma. Selective transcatheter arterial embolization of the pancreatic tumour was attempted but was abandoned due to multiple small feeding arteries. Microwave ablation of the tumour was performed successfully. Since there was a possibility of the ablation being compromised due to the heat sink at the splenic artery, 2 mL of 99% alcohol was injected into the rim of the tumour near the artery. She was subsequently normoglycaemic. She defaulted follow up for repeat imaging of pancreas and screening for MEN1 syndrome due to the impact of the COVID-19 pandemic. Minimally invasive procedures are preferred over surgery in selected patients with insulinoma, out of which microwave ablation could be preferentially recommended due to its efficacy and minimal complications. We report the first case of MWA performed in combination with AA in successfully treating insulinoma to our knowledge. This is also the first reported case of DVT associated with isolated insulinoma prior to intervention, though it is rarely reported in MEN1 syndrome. Learning points: Novel therapeutic minimally invasive procedures are successful in treating selected cases of insulinoma. Microwave ablation could be recommended preferentially over selective trans-arterial embolization, and radiofrequency ablation in treating insulinoma due to its efficacy and minimal complications. We report the first case of microwave ablation performed in combination with alcohol ablation in successfully treating insulinoma to our knowledge.

A Nonfunctioning Pituitary Macroadenoma Presenting as Cyclical Vomiting and Severe Hyponatremia in a Young Female.

INTRODUCTION: Recurrent vomiting is a commonly overlooked debilitating symptom which causes significant impact on the quality of life. There are several causes for vomiting, ranging from commonly known causes to rare causes. Nonfunctioning pituitary macroadenomas generally present with visual disturbances, headache, and symptoms due to anterior pituitary hormone deficiencies. This case report is about an atypical presentation of a nonfunctioning pituitary macroadenoma in which the patient presented with cyclical vomiting with severe hyponatremia. Case Report. A 23-year-old girl presented with four to five episodes of vomiting per day for two days duration. She had a history of similar episodes of vomiting since 2016, with each episode generally lasting for 4-5 days and occurring in every four to six months. All episodes exhibited similar symptomatology and she was free of symptoms in-between. Generalized body weakness, postural dizziness, reduced appetite, and secondary amenorrhea were other symptoms she has had since 2016. Examination findings showed a low body mass index (BMI) (16 kg/m2) with normal system examination. Investigations showed severe hyponatremia (110 mmol/L) with hypokalemia (3.2 mmol/L) and hypochloremia (74 mmol/L). Her urinary excretion of potassium, sodium, and serum osmolality was low. Urine osmolality was mildly elevated compared to serum osmolality. Blood urea was normal. Severe hyponatremia with minimal hyponatremic symptoms was suggestive of chronic hyponatremia, which was accentuated by ongoing vomiting and possible reduced intake of salt. Further investigations showed evidence of secondary hypoadrenalism, central hypothyroidism, hypogonadotropic hypogonadism, and mild hyperprolactinemia. Magnetic resonance imaging (MRI) revealed a pituitary macroadenoma with mass effect on the optic chiasma. Hydrocortisone and levothyroxine were started, and she underwent transsphenoidal resection of the pituitary tumor. She recovered from cyclical vomiting. CONCLUSION: There can be multiple overlapping aetiologies for every observed symptom, sign, and abnormal investigation finding. Therefore, aetiological diagnosis is challenging, especially in the presence of an atypical clinical presentation. Cyclical vomiting and severe hyponatremia are atypical presentations of nonfunctioning pituitary macroadenomas.

Epidemiology and risk factors of patients with types of acute coronary syndrome presenting to a tertiary care hospital in Sri Lanka.

BACKGROUND: Acute Coronary Syndrome (ACS) is one of the leading causes of death worldwide and studies have shown higher mortality rates and premature death in South Asian countries. The occurrence and effect of risk factors differ by type ofACS.Epidemiological studies in the Sri Lankan population are limited. METHODS: This is a cross sectional descriptive study conducted at the Teaching Hospital Peradeniya, Sri Lanka among patients presenting with ACS. Data was collected by an interviewer administered structured questionnaire and epidemiological patterns and risk factors were analyzed. RESULTS: The sample of 300 patients had a mean age of 61.3+/- 12.6 and male sex showed higher association with all three type of ACS compared to female with a P value of 0.001. This study showed higher mean age of 62.2 ± 11.4 years amongst unstable angina (UA) patients and 61.9 ± 14.5 years amongst non ST elevation myocardial infarction (NSTEMI) patients compared to 59.2 ± 11.2 years for ST elevation myocardial infarction (STEMI) patients with no significant statistical difference (P = 0.246). Approximately 55.8% STEMI patients, 39.8% UA and 35.5% NSTEMI patients were smokers indicating a significant association between smoking and STEMI (P = 0.017). Nearly 54.5% STEMI, 35.4% UA and 32.7% NSTEMI patients consumed alcohol and there was a very strong association between alcohol consumption and STEMI (P = 0.006). Almost 51.8% NSTEMI patients, 47.8% UA patients and 29.9% STEMI patients had hypertension(HT) (P = 0.008) indicating significant association of HT with UA and NSTEMI. About 33.6% UA patients and 30.0% NSTEMI patients had DM whilst only 22.1% of STEMI patients had DM of no significance (p = 0.225). Around 15.0% patients with UA, 25.5% with NSTEMI and 11.7% with STEMI had dyslipidemia (P = 0.032). There was a very strong association between a past history of ACS or stable angina with NSTEMI and UA (P = 0.001). CONCLUSION: Smoking and alcohol abuse are significantly associated with STEMI.Patients with NSTEMI or Unstable Angina had higher rates of hypertension and were more likely to have a history of ACS or stable angina than STEMI patients. Patients with NSTEMI were more likely than patients with STEMI or UA to have dyslipidemia.

Analysis and identification of symptoms and risk factors in a cohort of chronic hypertensive patients in a tertiary care hospital in Sri Lanka.

BACKGROUND: Hypertension (HT) is identified as a highly prevalent cardiovascular risk factor and also as a separate disease entity, leading to significant mortality and morbidity. The rate of HT is increasing worldwide with a faster rate identified in developing countries. Thus, it is important to evaluate epidemiological patterns of chronic HT in a developing country like Sri Lanka. METHODOLOGY: This is a cross-sectional descriptive study conducted at the Teaching Hospital Peradeniya, Sri Lanka, to assess symptoms and risk factors among patients with chronic HT. RESULTS: In a cohort of 266 chronic hypertensives, the mean values for age of population, age of onset, and duration of HT, respectively, are 63, 45, and 8 years. At presentation, 24.8% were asymptomatic. The commonest presentation at diagnosis was dizziness accounting for 33.8% cases, followed by chest pain, headache, loss of consciousness, and shortness of breath accounting for 7.5%, 13.5%, 2.6%, and 4.5%, respectively. Approximately 36.5% of patients had a positive family history. Fathers of 7.1% patients, mothers of 19.2%, and both parents of 10.2% patients had HT. 38.7% of patients had one or more siblings with HT. 34.6% had diabetes mellitus. CONCLUSION: Symptoms of those with HT are mostly nonspecific and should be considered as possible warning signs prior to the development of sinister complications of the disease. Family history of HT with affected siblings, or one of the parents, was, observed in more than one-third of patients. Early screening and prevention of modifiable risk factors are important in these patients to prevent debilitating complications.

A study on the knowledge and attitudes on advanced life support among medical students and medical officers in a tertiary care hospital in Sri Lanka.

BACKGROUND: Advanced life support (ALS) and cardio pulmonary resuscitation, provided at the right time is essential for improving mortality in medical emergencies. Accurate knowledge and skills on this regard, in all medical personals is an essential part of medical education and it should be up to date with varying protocols. The aim of this study is to assess the knowledge and attitudes among the undergraduate medical students and medical officers in the Teaching Hospital Peradeniya and provide suggestions to improve the training programme on ALS. METHODS: A standardized self-administered questionnaire regarding knowledge and attitudes on ALS was filled by 4th and final year medical students, and medical officers, and the data was analyzed. RESULTS: There were 411 eligible candidates and of them 130 (31.6 %) were 4th year medical students, 221 (53.8 %) were final year medical students and 60 (14.6 %) were medical officers. Of the medical officers, only 15.8 % indicated that the internship training was adequate to handle an emergency confidently. Approximately 45 % of the medical officers and 34.6 % of the final year medical students were confident of saving lives with their current ALS knowledge. However, only 22 % of 4th year medical students were confident in saving the life of a patient. CONCLUSIONS: Overall, just over 10 % of participants demonstrated inadequate ALS knowledge scores. A significantly higher proportion of final year medical students had good knowledge, compared to medical officers and 4th year students. Only one-third of participants were confident in saving a life with their current ALS knowledge. Nearly all participants thought that the ALS course should be reevaluated frequently.

A study on paracetamol cardiotoxicity.

BACKGROUND: Sri Lanka has a high suicide rate, with more than 40 % of poisoning admissions due to overdose of drugs with Paracetamol being the commonest. Data regarding cardiotoxicity to paracetamol is very minimal though hepatotoxicity following poisoning is well studied. Paracetamol cardiotoxicity has rarely been clinically significant and may have well been overlooked. The possibility that paracetamol overdose might be directly cardiotoxic has been the subject of a few reports. Unexplained deaths and electrocardiographic changes associated with paracetamol poisoning have also been reported in which cardiac origin cannot be clearly ruled out. Although some studies state that paracetamol poisoning has no direct cardiotoxic effect, electrocardiographic changes due to metabolic derangement of hepatotoxicity have been shown in certain studies. Thus, we conducted this study to assess in detail the cardiotoxic effect of paracetamol poisoning. METHODS: This is a cross sectional descriptive study done on those with confirmed paracetamol poisoning. Serum paracetamol levels, Electrocardiogram, Echocardiogram, troponin I, and other basic investigations were done. RESULTS: Paracetamol ingestion is more common among teenagers and the young population in Sri Lanka. Although several cases of paracetamol poisoning induced cardiotoxicity has been described in the past, this study demonstrated no electrocardiographic, echocardiographic or cardiac biomarkers changes of myocardial toxicity. CONCLUSION: Though literature review support cardiotoxicity following paracetamol poisoning, our study does not provide enough evidence for this. Continuous cardiac monitoring, serial troponin and echocaediogram assessment would be voluble adjunct in its management. Further experiments and research in this subject would be useful with a larger number of samples to further evaluate this important problem.

A case of treatable hypertension: fibromuscular dysplasia of renal arteries.

BACKGROUND: Renovascular hypertension accounts for 51-52% of all cases of hypertension in the general population, but plays a major role in treatable causes for hypertension in the young. This entity consists of renal vascular atherosclerosis (90%), commonly seen among the elderly population, and renal fibro muscular dysplasia (FMD) (10%), predominantly seen in the young. The prevalence of clinically significant renal artery fibromuscular dysplasia is 0.4%. CASE PRESENTATION: We present a case of treatable young hypertension in a 29 year old female, who was diagnosed with renovascular hypertension due to fibromuscular dysplasia of the left renal artery. Computed tomographic angiogram revealed significant stenosis of the left main renal artery. Diethylene triamine penta acetic acid renogram showed a small left kidney due to renal artery stenosis. She underwent left sided nephrectomy, and histology revealed features of FMD, after which she achieved full recovery with normalization of blood pressure, and did not require antihypertensive drug treatment. CONCLUSIONS: Fibromuscular dysplasia causing renal artery stenosis, though a rare cause of renovascular hypertension, is essential to be considered in young hypertensives, even in the absence of family history of hypertension. A high index of suspicion is necessary in early diagnosis and prompt treatment, which can result in rapid and complete recovery.

B12 deficiency with neurological manifestations in the absence of anaemia.

BACKGROUND: Vitamin B12 deficiency is often diagnosed with hematological manifestations of megaloblastic macrocytic anemia, which is usually the initial presentation. Neurological symptoms are often considered to be late manifestations and usually occur after the onset of anemia. Sub acute combined cord degeneration, which is a rare cause of myelopathy is however the commonest neurological manifestation of vitamin B12 deficiency. CASE PRESENTATION: We present a case of a 66 year old Sinhalese Sri Lankan female, who is a strict vegetarian, presenting with one month's history suggestive of Sub-acute combined cord degeneration in the absence of haematological manifestations of anaemia. Her Serum B12 levels were significantly low, after which she was treated with hydroxycobalamine supplementation, showing marked clinical improvement of symptoms, with normalization of serum B12 levels. Hence, the diagnosis of vitamin B12 deficiency was confirmed retrospectively. CONCLUSION: Vitamin B12 deficiency could rarely present with neurological manifestations in the absence of anaemia. Therefore a high index of suspicion is necessary for the early diagnosis and prompt treatment in order to reverse neurological manifestations, as the response to treatment is inversely proportionate to the severity and duration of the disease.

Spinal intradural metastasis from scapular Ewing sarcoma.

BACKGROUND: Ewing sarcoma is a primary bone neoplasm, which is a high grade aggressive small round blue cell tumour, and is currently recognized as a part of the Ewing family of tumours. It is the most lethal bone tumor, and is a rare malignant bone tumor accounting for 10% of all primary bone tumors, and 6% of malignant bone tumors. It has an average annual incidence of 3 per 1 million, found almost exclusively in Caucasians. It commonly occurs in long bones and pelvis but rarely involves the scapula. 85% of cases have metastasis within 2 years of diagnosis, rarely involving the meninges. CASE PRESENTATION: We report a case of a 25 year old Sinhalese Sri Lankan female, presenting with a 1 day history of bilateral lower limb weakness and urinary incontinence. She had a sensory level with flaccid paralysis of lower limbs and a painless bony lump in the left dorsal scapula. Investigations showed scapular primary Ewing sarcoma giving rise to spinal intradural metastasis. For the best of our knowledge this is the first reported case of a scapular Ewing sarcoma with spinal intradural metastasis presenting with lower limb paralysis. CONCLUSION: Intradural spinal metastasis of Ewing sarcoma presenting with lower limb weakness, without a history of pain, though rarely, can be the first presentation, and can rapidly progress to brainstem involvement and death.

Fibrocalculous pancreatic diabetes: a case report.

BACKGROUND: Diabetes is now becoming a major cause of morbidity and mortality in both developing and developed countries. Even though type 1 and type 2 are the commonest, diabetes mellitus due to secondary causes have been identified. Fibrocalculous Pancreatic Diabetes is a unique entity wherein pancreatic calcification and chronic inflammation lead to exocrine and endocrine failure of the pancreas. This form of non-alcoholic pancreatopathy is exclusively seen among the young, with a male preponderance and commonly in tropical countries where malnutrition and poverty go hand in hand. Whereas, interestingly this case has a late presentation in a female, unlike in other reported cases. For the best of our knowledge this is the first such documented case reported in Sri Lanka. CASE PRESENTATION: A 57 year old non-alcoholic Sinhalese female from Sri Lanka, presented with a history of chronic pancreatitis of nine years duration, after which she had developed severe Insulin Dependent Diabetes Mellitus. Imaging of the abdomen showed typical pancreatic calcifications, and this presentation accords with the criteria for Fibrocalculous pancreatic diabetes. CONCLUSION: This case report demonstrates a rare form of secondary diabetes in a middle aged female, without a childhood history of abdominal pain suggestive of pancreatitis, indicating late onset disease. Therefore a high index of suspicion is necessary even though the diagnostic criteria indicates the presence of childhood onset of disease.