Arjuna Medagama

Background: Dengue haemorrhagic fever (DHF) remains a major cause of morbidity in tropical countries, with progression to shock contributing substantially to mortality. Early plasma leakage with organ hypoperfusion may represent a critical therapeutic window for intervention. This study evaluates whether dextran-40 is superior to normal saline in preventing dengue shock during the early leakage phase of DHF.Methods: The Dextran in the Early Leakage Phase of Dengue Prevents Shock (DELPODS) study is a multicenter, double-blind, randomised, parallel-group phase III superiority trial conducted in Sri Lanka. Adults aged ≥18 years with confirmed dengue fever and evidence of early plasma leakage with organ hypoperfusion are randomised to receive either intravenous dextran-40 (5 mL/kg; maximum 250 mL) or 0.9% normal saline at an equivalent dose infused over 2 hours. Patients with advanced plasma leakage, established shock, pregnancy, acute kidney injury, advanced chronic kidney disease, severe heart failure, severe liver disease, or dextran hypersensitivity are excluded. The planned sample size is 218 participants.Outcomes: The primary outcome is the incidence of shock within 48 hours of randomisation. Secondary outcomes include maintenance of haemodynamic stability, time to haemodynamic instability, need for additional fluid therapy, clinical outcomes at discharge, and safety outcomes including fluid overload, acute kidney injury, and hypersensitivity reactions.Ethics and Registration: Ethical approval was obtained from the Ethics Review Committee of the Faculty of Medical & Allied Sciences, Rajarata University of Sri Lanka (22 June 2022). The trial is registered with the Sri Lanka Clinical Trial Registry (SLCTR/2022/003; U1111-1272-4389).

Acute Disseminated Encephalomyelitis (ADEM) complicating pregnancy is a rare occurrence, posing challenges to the management due to maternal and fetal risks including fetal loss, fetal anomalies, intrauterine fetal growth restriction (FGR) and preterm labour. We report a case of a 21-year-old primiparous woman who was diagnosed with ADEM during the second trimester. She was treated with high dose intravenous (IV) steroids as well as IV immunoglobulin. She made complete neurological recovery within two months, but there were fetal complications including oligohydramnios, intrauterine growth restriction and low birth weight. The baby was delivered via elective caesarean section due to suspicious cardiotocograph and abnormal fetal doppler studies indicative of compromised fetal circulation. The baby was given special baby care unit (SBCU) care. However, both the mother and baby were safely discharged following six days of special neonatal care. This is the first reported case of ADEM in pregnancy in Sri Lanka, and highlights the challenges in management.

Varicella zoster virus is a Deoxyribonucleic acid (DNA) virus exclusively affecting humans. Reactivation of varicella zoster virus causes herpes zoster with vesicular eruptions in a restricted dermatomal distribution. Peripheral motor neuropathy is a very rare complication of varicella zoster virus. A 57-year-old previously well Sri Lankan female presented with acute onset painful weakness of the left upper limb with a preceding history of a febrile illness. Subsequently she developed vesicular eruptions in the dermatomal distribution of cervical 5, 6, and 7. Electromyography was suggestive of acute denervation of cervical 5, 6, and 7 myotomes. Diagnosis of zoster-associated brachial plexopathy was made, and the patient was treated with acyclovir, steroids, and analgesics. She made a good recovery. Brachial plexus neuritis due to varicella zoster infection should be considered in an acute monoparesis of a limb as it is a treatable and reversible condition

Background. Dengue is endemic in most parts of the tropics with a significant mortality of 1–5%. Although individual case reports and case series have been published, large-scale case controls studies are few. The objective of this study was to find clinical and laboratory predictors of mortality in dengue. Methods. Hospital case record based case control study was performed. Results. Twenty fatalities with 80 controls were analyzed. Clinical parameters of postural dizziness (OR 3.2; 95% CI 1.1–8.9), bleeding (OR 31.9; 95% CI 6.08–167.34), presence of plasma leakage (OR 64.6; 95% CI 7.45–560.5), abdominal tenderness (OR 2.24; 95% CI 0.79–6.38), and signs of cardiorespiratory instability at admission increased the risk of dying from dengue. Altered consciousness was exclusively seen in 20% of cases. Laboratory parameters of elevated CRP (OR 1.652; 95% CI 1.28–2.14), AST, or ALT > 500 IU/L (OR 52.5; 95% CI 12.52–220.1) and acute kidney injury (AKI) (OR 103.5; 95% CI 13.26–807.78) during hospital stay increased the odds of dying. Need for assisted ventilation and multiorgan dysfunction (MOD) were exclusively seen in the cases. Multivariate logistic regression revealed bleeding at admission, AKI, and elevated hepatic transaminase >500 IU/L to be independent predictors of mortality. Conclusions. This case control study revealed that mortality from dengue could be predicted using clinical parameters at admission and low cost routine laboratory investigations.

Dengue fever and dengue hemorrhagic fever incidence is increasing in Sri Lanka, especially among the young population. Uncommon presentations of this common illness make diagnostic dilemmas and can delay standard treatment which leads to unfavorable outcomes. An 18-year-old Sri Lankan Sinhalese boy presented with a history of 1 day of fever and an episode of seizure followed by left-side hemiparesis. He was diagnosed to have dengue complicated by dengue hemorrhagic fever and recovered with minimal residual weakness. He presented with neurological symptoms; cerebrospinal fluid analysis, electroencephalogram, and magnetic resonance imaging showed evidence of encephalitis. Positive dengue antigen and antibody in serum and cerebrospinal fluid with the exclusion of other possible etiologies confirmed parainfectious dengue encephalitis. He was started on sodium valproate 200 mg 8 hourly and made a slow neurological recovery with mild residual weakness (grade 4+ power) in his left upper limb at 2 months with intensive supervised physiotherapy. Standard national guideline-based management of dengue illness has significantly reduced its mortality rates in Sri Lanka. However, uncommon presentations of a common illness often cause diagnostic dilemmas. Hence, reporting of these presentations and knowing the epidemiologic patterns of the disease help physicians to arrive at the correct diagnosis even though they do not have sophisticated serological investigations. Overall, this can improve the quality of health care and reduce mortalities, especially in a resource-poor setup.

South Asians have high prevalence of diabetes, increased cardiovascular risk and low levels of physical activity (PA). Reasons for low levels of PA have not previously been explored among Asians living within their endogenous environment. This qualitative study was performed to explore the contextual reasons that limited PA among type 2 diabetic patients living in a rural community. Purposeful sampling recruited 40 participants with long standing type 2 diabetes for this qualitative study. Semi-structered questions utilising in-depth interviews were used to collect data on PA patterns, barriers to PA and factors that would facilitate PA. The interviews were digitally recorded and transcribed. Data were analyzed using a framework approach. The sample consisted of 11 males and 29 females. Mean age was 55.4 (SD 8.9) years. The mean duration of diabetes in the study population was 8.5 (SD 6.8) years. Inability to differentitate household and daily activities from PA emerged as a recurring theme. Most did not have a clear understanding of the type or duration of PA that they should perform. Health related issues, lifestyle and time management, envronmental and social factors like social embarrassment, prioritizing household activities over PA were important factors that limited PA. Most stated that the concept of exercising was alien to their culture and lifestyle. Culturally appropriate programmes that strengthen health education and empower communities to overcome socio-economic barriers that limit PA should be implemented to better manage diabetes among rural Sri Lankan diabetic patients.

Background Physical inactivity is the fourth leading risk factor for mortality worldwide and a leading risk factor for type 2 diabetes and cardiovascular disease. Medical undergraduates are a group of young adults expected to have a sound knowledge of the benefits of physical activity (PA) and have an active lifestyle. Objective To quantifyPA levels among medical undergraduates of a Sri Lankan university and to determine the socio-demographic correlates of physical inactivity. Methods Medical undergraduates in their third, fourth and fifth years of study were recruited for this quantitative, descriptive, cross-sectional study using a self-administered questionnaire. Results A total of 421 students were recruited. Overall 41% were physically inactive. Females (47%) were more inactive than males (34%). The total mean weekly metabolic equivalent (MET)-minutes was 1468.2±1873. Males (1676.2±1629) had a higher mean weekly MET minutes than females (1319±20102), p=0.05. 88% owned a portable internet device such as a smartphone or tablet. Students using health-related apps on their devices had significantly higherPA (p=0.01) and lower body mass index (BMI) (p=0.04), than those who did not. Binary logistic regression revealed physical inactivity to be significantly associated with gender (p=0.01), not using a health-promoting app on their portable device (p=0.01) and the year of study (p=0.03). Conclusion Physical inactivity is a significant problem among medical undergraduates. The use of health applications was associated with a higher PA and lower BMI. The reasons for inactivity and the discrepancy in activity levels between males and females needs to be explored in greater detail.

Star fruit (Averrhoa carambola) is commonly consumed as a herbal remedy for various ailments in tropical countries. However, the dangers associated with consumption of star fruit are not commonly known. Although star fruit induced oxalate nephrotoxicity in those with existing renal impairment is well documented, reports on its effect on those with normal renal function are infrequent. We report two unique clinical presentation patterns of star fruit nephrotoxicity following consumption of the fruit as a remedy for diabetes mellitus—the first, in a patient with normal renal function and the second case which we believe is the first reported case of chronic kidney disease (CKD) due to prolonged and excessive consumption of star fruits. The first patient is a 56-year-old female diabetic patient who had normal renal function prior to developing acute kidney injury (AKI) after consuming large amount of star fruit juice at once. The second patient, a 60-year-old male, also diabetic presented with acute on chronic renal failure following ingestion of a significant number of star fruits in a short duration with a background history of regular star fruit consumption over the past 2–3 years. Both had histologically confirmed oxalate induced renal injury. The former had histological features of acute tubulo-interstitial disease whilst the latter had acute-on-chronic interstitial disease; neither had histological evidence of diabetic nephropathy. Both recovered over 2 weeks without the need for haemodialysis. These cases illustrate the importance of obtaining the patient’s detailed history with respect to ingestion of herbs, traditional medication and health foods such as star fruits especially in AKI or CKD of unknown cause.