Protein-Losing Enteropathy as the First Presentation of Systemic Lupus Erythematosus in a Resource-Limited Setting in Sri Lanka: A Case Report.

Protein-losing enteropathy (PLE) is one of the rare gastrointestinal manifestations of systemic lupus erythematosus (SLE), which can manifest several years before the diagnosis of SLE. PLE should be suspected in patients with hypoalbuminemia in the absence of urinary protein loss and normal liver functions without any other manifestations of malnutrition. Due to the non-specificity of the imaging and histological findings, it is difficult to diagnose PLE in resource-limited settings. Thus, it is underdiagnosed. We report the case of a 38-year-old Sri Lankan (South Asian) female who is a diagnosed patient with hypothyroidism and has presented with worsening generalized body swelling and ascites for two months. She had hypoalbuminemia without proteinuria. Thus, the clinical diagnosis of PLE was suspected. The diagnosis of SLE was suspected because of significant alopecia, high titer (1:1000) antinuclear antibody (ANA) positivity, and hypocomplementemia. Though confirmatory tests such as Tc-99 albumin scintigraphy and stool alpha-1 anti-trypsin were not available in our resource-limited setting, the diagnosis of the SLE-associated protein-losing enteropathy was made as the patient fulfilled the European Alliance of Associations for Rheumatology (EULAR) criteria for SLE and also by excluding all the other possible causes of PLE.

A feasibility trial of pulmonary rehabilitation for patients with COPD in a low resource setting: Jaffna, Sri Lanka.

BACKGROUND: Pulmonary rehabilitation is recommended for most patients with chronic obstructive pulmonary disease (COPD). Accordingly, the aim of this study was to explore the feasibility of devising a pulmonary rehabilitation program for patients with COPD in a low resource setting (Jaffna, Sri Lanka) and to observe its effects. METHODS: Non-randomized controlled feasibility trial of ambulatory patients with COPD attending the pulmonary outpatient clinic of the Jaffna Teaching Hospital, Northern Province, Sri Lanka. Age-matched patients were allocated alternatively to an intervention group or to a control group. Twice weekly, for six weeks, patients in the intervention group attended pulmonary rehabilitation sessions consisting of supervised stretching, aerobic and strengthening exercises, and patient-education. Before and at the conclusion of the study, all patients performed incremental shuttle walking test (ISWT), 6-min walk test (6MWT) and completed the Medical Research Council (MRC) dyspnea scale, COPD assessment test (CAT), chronic COPD questionnaire (CCQ), and hospital anxiety depression scale (HADS). RESULTS: 204 patients with COPD (94% males) were identified at screening; 136 (66.7%) were eligible for pulmonary rehabilitation and 96 patients (47%) consented to participate. Of these, 54 patients (53 males) eventually participated in the study (42 patients were discouraged to participate by family members or friends); 40 patients (20 in the rehabilitation group and 20 patients in the control group) completed the study. Baseline characteristics of the intervention group and the control group were similar. 95% of patients in the intervention group adhered to regular home training exercises (self-reported diary). At post assessment, only the intervention group experienced clinically-meaningful improvements in symptoms and exercise capacity. CONCLUSION: A simple and clinically beneficial pulmonary rehabilitation program for patients with COPD can be effectively implemented in a low resource setting. However, there is a need for educating patients and the local community on the benefits of pulmonary rehabilitation to enhance uptake. Retrospective Trial Registration date and number: 16/04/2021, ISRCTN10069208.

Development and validation of a set of patient reported outcome measures to assess effectiveness of asthma prophylaxis.

BACKGROUND: In the local setting, asthma control is assessed by symptoms and signs elicited by clinicians because of the limited availability of spirometry. Hence, we intended to develop a patient reported outcome measure (PROM) with more holistic interpretation that could also serve as a tool to measure the asthma control in resource limited settings. Therefore, this study was carried out in Northern Sri Lanka to develop and validate the Asthma Control PROM (AC-PROM) Tamil to measure the effectiveness of asthma prophylaxis based on symptoms, exacerbation and limitation of activity which could also serve as an easy measure of asthma control to the provider. METHODS: The AC-PROM Tamil was developed in 3 steps: item generation, item reduction and psychometric evaluation. Items were generated through thematic analysis from focus group discussions among patients with asthma. Items were converted to an interviewer administered questionnaire in Tamil in the format of 5-point Likert scale. Item reduction was done by two rounds of online Delphi surveys among 10 experts and an exploratory factor analysis among 200 patients with asthma. The face and content validity were assessed by a panel of experts during Delphi survey and patients during the pre-test of the tool. Criterion validity of the tool was assessed against the forced expiratory volume in one second of 187 patients with asthma. The cut-off value to assess the asthma control was determined by receiver operating characteristic curve. Reliability was verified by Cronbach's alpha coefficient. RESULTS: From thematic analysis of focus group discussions 10 items were generated. One item was removed during Delphi survey. Exploratory factor analysis indicated removal of another item with 8 items categorised into two factors. Cronbach's alpha coefficient of factors 1 and 2 were 0.821 and 0.903 respectively, indicating good reliability. Observations made by experts and responses made by patients were incorporated to improve the clarity and relevance of the items. Criterion validity was demonstrated by significant correlation between the AC-PROM Tamil and forced expiratory volume in one second (r = 0.66, p = 0.001). The cut-off value of the AC-PROM Tamil to detect asthma control was 28.5 with 79% (95% CI 71.3-86.9) sensitivity and 71% (95% CI 61.9-79.6) specificity. The AC-PROM Tamil showed moderate accuracy (the area under the receiver operating characteristic curve = 0.796; 95% CI 0.73-0.86). Response rate of the AC-PROM Tamil was 100% and time taken to complete was 3-4 min. CONCLUSION: The AC-PROM Tamil is a simple, feasible and reasonably accurate tool to assesses the effectiveness of asthma prophylaxis, particularly in resource limited settings.

Etoricoxib- induced pleural effusion: A case for rational use of analgesics.

Pleural effusion caused by drug is an uncommon event in clinical practice. Etoricoxib induced pleural effusion is an extremely rare. We describe a patient with pleural effusion as an adverse drug reaction of etoricoxib.

Microscopic haematuria: A rare presentation of typhoid fever.

Typhoid fever can cause a number of renal manifestations heretofore dubbed 'nephrotyphoid'. Haematuria in the absence of renal impairment is extremely rare among typhoid patients. We report a case of an adult who presented with a prolonged febrile illness and microscopic haematuria. Blood culture confirmed the diagnosis of typhoid and the patient was treated successfully with ceftriaxone.