Chathuranga Lakmal Fonseka

Background: Healthcare systems in these low- and middle-income settings remain severely constrained by a reliance on single acute-phase diagnostic testing for leptospirosis. To evaluate the impact of serial diagnostic testing for leptospirosis in an endemic tropical setting on the diagnostic yield and its relationship with the disease severity. Methods: In this prospective observational cohort study, 354 patients meeting the 2013 CDC clinical case definition for suspected leptospirosis were recruited from four hospitals in Southern Sri Lanka (March-September 2024). Quantitative PCR (qPCR) and microscopic agglutination testing(MAT) were performed on acute-phase samples, with repeat testing at discharge and one-month follow-up. Patients were classified using a four-tier framework based on combined qPCR and MAT results.Findings: Of 354 patients, 190(53·7%) were Confirmed, 72(20·3%) Probable, 64(18·1%) Possible, and 28(7·9%) Negative. Confirmed cases increased from 42·4% with acute-phase testing alone to 63·6% after discharge sampling and 74·0% with post-discharge follow-up. Among 63 patients initially negative by both qPCR and MAT who attended follow-up, 32 (50·8%) seroconverted. Among them, 10 (17·5%) were first detected at the discharge sample and 47 (82·4%) required post-discharge follow-up. Of the 93 patients with dual-replicate qPCR positivity, 71 (76·3%) never developed a reactive MAT titre at any timepoint; conversely, 71(37·4%) Confirmed had negative qPCR and were identified by MAT criteria. Severe disease showed lower qPCR positivity (26·5% vs. 67·6%; p<0·001) but higher acute MAT positivity (51·0% vs. 23·5%; p=0·005) than mild disease.Interpretation: Single acute-phase testing substantially underestimates leptospirosis. Serial qPCR and MAT testing significantly improves diagnostic confirmation and supports routine follow-up serology to improve diagnosis and management in endemic settings.

Background: During the 2024–2025 Chikungunya virus (CHIKV) resurgence in Sri Lanka, atypical neurological manifestations (neuro-CHIKV) emerged. We aimed to define the clinical, diagnostic, and longitudinal profiles of these patients. Methods: This descriptive case series at National Hospital Galle (April–September 2025) evaluated 11 adults (median age 59; five >60 years) presenting with neurological symptoms and serologically confirmed CHIKV infection. Results: Central nervous system (CNS) involvement predominated (n=9). Acute presentations (≤7 days) included encephalitis (n=4) and meningoencephalitis (n=1) and delayed presentations (≥7 days) featured late-onset encephalitis (n=3), acute disseminated encephalomyelitis (n=1), and peripheral syndromes (Guillain-Barré variant, Bell's palsy). Reduced consciousness affected 7 out of 9 CNS cases, occasionally compounded by acute kidney/liver injury or profound hyponatremia. Diagnostically, 30% exhibited atypical cerebrospinal fluid profiles (hypoglycorrhachia or hyperproteinorrhachia without pleocytosis) mimicking bacterial meningitis. Neuroimaging revealed variety of radiological findings such as non-haemorrhagic acute necrotizing encephalopathy, a spinal cord "H-sign" and isolated bilateral caudate/putamina hyperintensities. Early systemic corticosteroids (≤7 days, n=4) correlated with favourable functional recovery, whereas delayed initiation yielded negligible responses in 2 out of 3 patients. Overall mortality was 18.2% (n=2), and 62.5% of survivors exhibited persistent non-severe neurological or rheumatological sequelae at three months. Conclusion: Neuro-CHIKV poses a high-mortality diagnostic challenge due to atypical clinical, biochemical and neuroradiological presentations. Early immunomodulation with therapeutic options such as steroids was associated with favourable neurological recovery and warrants prospective evaluation.

Background: Dengue fever is a severe public health challenge in Sri Lanka, where reliance on manual outbreak identification often delays targeted responses. We developed a real-time geospatial framework using routine hospital notification data to rapidly identify geographic clusters for proactive vector control. Methods: This spatial epidemiological study analyzed 2,119 suspected and confirmed dengue notifications from Galle District from October 2023 to December 2024. Patient addresses were precisely geocoded. The Density-Based Spatial Clustering of Applications with Noise (DBSCAN) algorithm defined micro-clusters (≥2 cases) and hotspots (≥3 cases) within 200-meter grids over 14-day intervals. Spatial distribution was compared against key environmental indices. An interactive ArcGIS web application was deployed to share bi-weekly hotspot maps with health authorities, allowing prompt preventive measures. Findings: The analyzed cohort had a median age of 28 years(57% male). Densely populated coastal administrative divisions, primarily Galle Four Gravets and Habaraduwa, reported the highest continuous disease burdens, each exceeding 250 cases. Furthermore, high case densities positively correlated with increased urbanization, elevated land surface temperatures, high environmental moisture, and dense urban vegetation. The automated DBSCAN framework successfully pinpointed emerging street-level clusters and persistent hotspots, revealing distinct disease transmission peaks immediately following monsoonal rains. This mapping highlighted that localized microclimates heavily sustain the local disease spread and directly influence outbreak trajectories. Interpretation: Integrating spatial clustering algorithms with routine disease notifications creates a highly proactive surveillance tool. This automated mapping directly empowers local health officers to efficiently deploy vector control resources to localized hotspots, optimizing rapid outbreak mitigation in endemic tropical regions.

Decompression sickness (DCS) is a life‐threatening clinical condition that occurs following an uncontrolled rapid ascent after a deep dive, leading to the formation of gas bubbles in the blood occurring due to the rapid decline in environmental pressure. We report the case of a 32‐year‐old male who presented with bilateral lower limb numbness eight hours following a diving session. He was diagnosed with neurological DCS and transported 365 km to the Naval Hospital, Eastern Command where he received hyperbaric oxygen treatment and made a full recovery. This individual developed DCS after repetitive dives within a week despite having planned ascents with advice from a diving instructor. He switched between different rented diving computers; consequently, these devices lacked cumulative dive history to indicate minimum surface time required for sufficient nitrogen gas washout. Both the diver and instructors had a suboptimal assessment of the cumulative dive exposure and worked with a false reassurance of having planned ascents under supervision. In addition, this report highlights critical delays in the diagnosis of DCS and complexities involved in accessing the country’s only hyperbaric treatment facility. It also emphasizes the need for empowering diving centers and medical professionals for early identification and facilitating access to prompt treatment.

Objective: The purpose of this study is to explore physicians’ knowledge, attitudes, and perceptions toward antibiograms and identify perceived barriers and facilitators to their implementation in a low-resource setting in Sri Lanka. Design: A qualitative study utilizing semi-structured interviews and thematic analysis. Setting: A public tertiary care hospital in southern Sri Lanka. Participants: Thirty physicians working in pediatric and adult medical wards were purposively sampled and interviewed between June and August 2023. Results: Most physicians had limited prior knowledge or experience with antibiograms. However, after receiving a brief explanation, 29 out of 30 participants expressed strong support for implementing antibiograms, citing potential benefits such as improved antibiotic prescribing, reduced antimicrobial resistance (AMR), and enhanced patient outcomes. Approximately one-third of participants expressed concerns about feasibility due to time constraints, limited laboratory infrastructure, and personnel shortages. Participants recommended delivering antibiogram training through small-group sessions led by a multidisciplinary team. Thematic analysis identified three core themes: (1) limited baseline knowledge of antibiograms, (2) perceived clinical value and enthusiasm for implementation, and (3) barriers related to healthcare system constraints. Conclusions: Physicians in this LMIC setting demonstrated high interest in using antibiograms to guide empiric antibiotic therapy and address AMR. Despite logistical and infrastructural challenges, tailored training and stakeholder engagement may facilitate the successful development and use of antibiograms in similar resource-limited settings.

Background: Dengue fever is an endemic infectious disease in tropical countries including Sri Lanka with a seasonal transmission. Expanded dengue syndrome consists of unusual manifestations of dengue involving the liver, heart, kidney, and central nervous system. Dengue encephalitis is a rare neurological manifestation of expanded dengue syndrome which can lead to significant morbidity and mortality. Among patients with dengue encephalitis, rapid deterioration without plasma leakage and preceding neurological symptoms and signs is an unusual presentation. Case Presentation: We report an 18‐year‐old previously healthy male, who presented with fever for three days with mild frontal headache without other preceding neurological signs who succumbed following rapid deterioration and generalized tonic‐clonic seizures complicated with status epilepticus despite optimal medical management. He did not have features of plasma leakage clinically and through focused ultrasound and did not have rising pack cell volume. He was positive for dengue NS1, IgM, and RT‐PCR for dengue Serotype 3 with histopathological findings of the brain revealing dengue encephalitis. Conclusions: Dengue encephalitis can lead to sudden and unexpected mortality associated with status epilepticus with or without signs of dengue hemorrhagic fever. It is a rare manifestation seen in dengue expanded syndrome and can cause sudden death without warning symptoms and signs. The initial presentation may have little warning signs without obvious neurological signs; hence, it is imperative to be vigilant on atypical but potentially lethal presentations of dengue fever.

Background/aim: Type 2 diabetes mellitus (T2DM) is closely associated with atherosclerotic cardiovascular diseases (ASCVD). The objective of this study was to describe the degree of ASCVD risk factor control and their association with carotid intima-media thickness (CIMT) in T2DM patients followed up at a diabetes clinic in Southern, Sri Lanka. Materials and methods: A crosssectional study was conducted to examine the association between CIMT and nonalcoholic fatty liver disease (NAFLD)in 300 T2DM patients. Both CIMT and its associations with modifiable cardiometabolic risk factors were examined using ultrasonography. The recommended optimal targets for risk factors were defined as glycated hemoglobin (HbA1C) < 7 %, absence of NAFLD, albumin-to-creatinine ratio (ACR) < 30 mg, triglyceride (TG) < 150 mg/dL, low-density lipoprotein cholesterol (LDL-C) < 100 mg/dL, high-density lipoprotein cholesterol (HDL-C) in men > 40 and in women > 50 mg/dL, systolic blood pressure (SBP) < 130 mmHg, and diastolic blood pressure (DBP) < 80 mmHg. Results: SBP, DBP, LDL-C, TG, HDL-C, HbA1C, and ACR were optimally controlled in 59.3%, 75.0%, 46.7%, 84.3%, 46.0%, 33.0%, and 18.7% of patients, respectively. Notably, nearly half of the study subjects did not have NAFLD. Only three patients (1%) had achieved all therapeutic targets. There were statistically significant differences in CIMT between optimally controlled TG and suboptimally controlled TG group (p = 0.027) and between the groups with and without NAFLD (p = 0.045) when adjusted for age and duration of diabetes. CIMT showed significant and positive associations with LDL-C (p = 0.024), TG (p = 0.026), and NAFLD (p = 0.005). Among these, the presence of NAFLD had the highest odds of having higher CIMT when compared to LDL-C and TG. Conclusion: The majority of patients have not achieved the recommended targets for ASCVD risk factors and are at high risk of ASCVD. It is therefore necessary to identify the reasons for not achieving the treatment targets in order to reduce the ASCVD burden by controlling LDL-C, TG, and NAFLD.

Background: Leptospirosis is a tropical disease associated with life threatening complications. Identifying clinical and investigation-based parameters that predict mortality and morbidity is vital to provide optimal supportive care Methods: We conducted an observational study in an endemic setting, in the southern Sri Lanka. Consecutive patients having complicated leptospirosis were recruited over 18 months. Clinical, investigational and treatment data were collected and the predictors of mortality were analysed. Results: Out of 88 patients having complicated leptospirosis, 89% were male. Mean age was 47yrs (±16.0). Among the total major complications 94.3% had acute kidney injury, 38.6% pulmonary haemorrhages, 12.5% fulminant hepatic failure, 60.2% hemodynamic instability and 33% myocarditis. An acute significant reduction of haemoglobin (Hb) was observed in 79.4% of patients with pulmonary haemorrhage. The mean of the highest haemoglobin reduction in patients with pulmonary haemorrhage was 3.1g/dL. The presence of pulmonary haemorrhage (PH) and hemodynamic instability within first 48 hours of admission significantly predicted mortality (p<0.05) in severe leptospirosis. Additionally, within first 48 hours of admission, elevated SGOT (AST), presence of atrial fibrillation, presence of significant haemoglobin reduction, higher number of inotropes used, prolonged shock, invasive ventilation and admission to ICU significantly predicted mortality. Out of major complications during the first week after admission, pulmonary haemorrhage and fulminant hepatic failure (FHF) combination had significant adjusted odds of mortality (OR = 6.5 and 4.8, p<0.05). Six patients with severe respiratory failure due to PH underwent ECMO and four survived. The overall mortality in complicated leptospirosis was 17%. In PH and FHF, the mortality rate was higher reaching 35.4% and 54.5%, respectively. Conclusions: Within first 48 hours of admission, major complications such as pulmonary haemorrhage and haemodynamic instability and other parameters such as atrial fibrillation, acute haemoglobin reduction, elevated SGOT level could be used as early parameters predictive of mortality in severe leptospirosis. PH and FHF during the first week of admission in leptospirosis are associated with high morbidity and mortality requiring prolonged ICU care and hospitalisation. Above parameters could be used as parameters indicating severity for triaging and intensifying treatment. Using ECMO is a plausible treatment option in patients with severe pulmonary haemorrhage.

Background: Leptospirosis is a tropical disease associated with life threatening complications. Identifying clinical and investigation-based parameters that predict mortality and morbidity is vital to provide optimal supportive care. Methods: We conducted a prospective observational study in an endemic setting, in the southern Sri Lanka. Consecutive patients having complicated leptospirosis were recruited over 18 months. Clinical, investigational and treatment data were collected and the predictors of mortality were analysed. Results: Out of 88 patients having complicated leptospirosis, 89% were male. Mean age was 47yrs ( + 16.0). Among the total, 94.3% had acute kidney injury, 38.6% had pulmonary haemorrhages, 12.5% had fulminant hepatic failure, 60.2% had hemodynamic instability and 33% had myocarditis. An acute significant reduction of haemoglobin (Hb) was observed in 79.4% of patients with pulmonary haemorrhage. The mean Hb reduction of patients with pulmonary haemorrhage was 3.1g/dl. The presence of pulmonary haemorrhage (PH) and hemodynamic instability within first 48 hours of admission significantly predicted mortality(p<0.05) in severe Leptospirosis. Additionally, within first 48 hours of admission, elevated SGOT, presence of atrial fibrillation, presence of significant haemoglobin reduction, higher number of inotropes used, prolonged shock, invasive ventilation and admission to ICU significantly predicted morality. Out of organ complications in the first week of illness, pulmonary haemorrhage and fulminant hepatic failure (FHF) combination had significant adjusted odds of mortality (OR=6.5 and 4.8, p<0.05). Six patients with severe respiratory failure due to PH underwent ECMO and four survived. The overall mortality in complicated leptospirosis was 17%. In PH and FHF, the mortality rate was higher reaching 35.4% and 54.5%, respectively. Conclusions: Within first 48 hours of admission, organ complications such as pulmonary haemorrhage and haemodynamic instability and other parameters such as atrial fibrillation, acute haemoglobin reduction, elevated SGOT level could be used as early parameters predictive of mortality in severe Leptospirosis. PH and FHF within the first week of admission in leptospirosis are associated with high morbidity and mortality requiring prolonged ICU care and hospitalisation. Above parameters could be used as parameters indicating severity for triaging and intensifying treatment. Using ECMO is a plausible treatment option in patients with severe pulmonary haemorrhage. Author summary: Leptospirosis is a tropical infectious disease predominantly affecting the lower socioeconomic groups in Sri Lanka. It is associated with significant morbidity and mortality, especially in an endemic setting. Hence, it is vital to identify clinical and biochemical parameters that can predict mortality for triaging and for escalation of care. We observed that pulmonary haemorrhage, myocarditis, hemodynamic instability and hepatic dysfunction are frequent complications of leptospirosis in southern Sri Lanka. Additionally, we identified that mortality was associated with the presence of two major complications of leptospirosis: pulmonary haemorrhage and haemodynamic instability. Therefore, early detection of these two complications along with other parameters that predict mortality such as elevated SGOT levels on admission, acute haemoglobin reduction, atrial fibrillation, prolonged shock and need for invasive ventilation would assist to recognise critically ill patients. Within the first week of admission, PH and development of FHF predicted mortality. One-third our population had acute kidney injury in isolation and they had lesser mortality. Other organ complications were almost always detected in combination and were associated with a higher mortality. Pulmonary haemorrhage was detected in one-third of patients and the majority warranted intensive care. Other than usual treatment modalities, ECMO (Extracorporeal Membrane Oxygenation) was used in six patients with critical respiratory failure due to pulmonary haemorrhage, where four survived. Out of the total group of complicated leptospirosis, in excess of one-third required intensive care treatment and 17% succumbed. Additionally, we mapped the leptospirosis prevalence rate in Galle district, and observed that severe cases are detected in specific localities. These features are helpful in early detection of severe disease and proactive management for those who are having predictors of mortality.