Explore the vast range of titles available.

Background Wasp stinging, a neglected tropical entity can have a myriad of local and systemic effects. We present a case of multi-organ injury following multiple wasp stings and a review of literature on the systemic manifestations of wasp stings. Case presentation A 48-year-old Sri Lankan male who suffered multiple wasp stings, developed an anaphylactic shock with respiratory failure, which was treated with adrenaline and mechanical ventilation. Within the next 2 days the patient developed acute fulminant hepatitis, stage III acute kidney injury, rhabdomyolysis, haemolysis and thrombocytopenia. The patient was treated in the intensive care unit with ionopressors and continuous renal replacement therapy (CRRT). Haemoadsorbant therapy was used in adjunct with CRRT. There was a gradual recovery of the organ functions over the 1st week. However, the patient succumbed to fungal sepsis on the 16th day despite treatment. We conducted a literature review to identify the various clinical manifestations of wasp stinging. Wasp venom contains enzymes, amines, peptides and other compounds. These proteins can cause type 1 hypersensitive reactions ranging from local skin irritation to anaphylactic shock. Furthermore, the toxins can cause direct organ injury or delayed hypersensitivity reactions. The commonly affected organs are the kidneys, liver, and muscles. The effect on the haematological system manifests as coagulopathy and/or cytopenia. The heart, nervous system, lungs, intestines and skin can be affected rarely. Treatment is mainly supportive. Conclusion In conclusion, wasp envenomation can result in multi-organ injury and attention should be paid in doing further research and establishing evidence-based treatment practices.

Background Uraemia causes a generalised encephalopathy as its most common neurological complication. Isolated brainstem uraemic encephalopathy is rare. We report a case of fatigable ptosis and complex ophthalmoplegia in brainstem uraemic encephalopathy. Case presentation A 22-year-old Sri Lankan man with end stage renal failure presented with acute onset diplopia and drooping of eyelids progressively worsening over one week. The patient had not complied with the prescribed renal replacement therapy which was planned to be initiated 5 months previously. On examination, his Glasgow coma scale score was 15/15, He had a fatigable asymmetrical bilateral ptosis. The ice-pack test was negative. There was a complex ophthalmoplegia with bilateral abduction failure and elevation failure of the right eye. The diplopia did not worsen with prolonged stare. The rest of the neurological examination was normal. Serum creatinine on admission was 21.81 mg/dl. The repetitive nerve stimulation did not show a decremental pattern. Magnetic resonance imaging (MRI) of the brain demonstrated diffuse midbrain and pontine oedema with T2 weighted/FLAIR hyperintensities. The patient was haemodialyzed on alternate days and his neurological deficits completely resolved by the end of the second week of dialysis. The follow up brain MRI done two weeks later demonstrated marked improvement of the brainstem oedema with residual T2 weighted/FLAIR hyperintensities in the midbrain. Conclusions Uraemia may rarely cause an isolated brainstem encephalopathy mimicking ocular myasthenia, which resolves with correction of the uraemia.

Background Severe leptospirosis often requires intensive care unit (ICU) treatment. The clinical phenotypes and outcomes of severe leptospirosis remain poorly characterised. We aimed to characterise the phenotypes and outcomes of patients with severe leptospirosis treated in the ICU. Methods We conducted a prospective cohort study at the Medical ICU of the National Hospital of Sri Lanka between January 2019 and January 2022 on adult patients with serologically or microbiologically confirmed leptospirosis. Clinical and laboratory data were recorded prospectively. Unsupervised two-step cluster analysis using six variables selected a priori (acute kidney injury, pulmonary haemorrhage, myocarditis, mechanical ventilation, renal replacement therapy, and hospital-acquired infections) was used to identify clinical phenotypes and to generate phenotypically distinct clusters of patients. Laboratory and biochemical parameters were compared across clusters. Kaplan–Meier survival analysis was used to compare mortality. The primary outcome was in-hospital mortality. Results One hundred and sixteen patients were included (mean age 43.9 years; males n  = 103, 88.8%). Among them, 99.1% ( n  = 115) developed acute kidney injury, 62.1% ( n  = 72) developed pulmonary haemorrhage, and 75.9% ( n  = 88) developed myocarditis. Mechanical ventilation and dialysis were required in 56.9% ( n  = 66) and 75% ( n  = 87), respectively. Mortality rate was 17.2% ( n  = 20). Cluster analysis identified four phenotypes: (1) multi-organ failure ( n  = 43) (mortality of 25.6%, n  = 11), (2) predominant respiratory failure ( n  = 20) (mortality of 35.0%, n  = 7), (3) predominant renal failure ( n  = 26) (mortality of 7.7%, n  = 2), and (4) intermediate severity ( n  = 27) (No mortality). Clusters with multi-organ and respiratory failure had higher hospital-acquired infection rates ( p  < 0.001) and a longer ICU stay ( p  < 0.001). Conclusions Critically ill patients with leptospirosis exhibit distinct clinical phenotypes with variable outcomes. Isolated pulmonary haemorrhage and multi-organ failure are associated with high mortality. These findings support the need for phenotype-based risk stratification, prognostication, and treatment. Clinical trial registration Not applicable.

Background Osler’s nodes, Janeway lesions and splinter haemorrhages are cutaneous manifestations of infective endocarditis. They occur due to vascular occlusion by septic emboli and a resulting localized vasculitis. They are usually bilateral. We report a case of unilateral Osler’s nodes, Janeway lesions and splinter haemorrhages due to an ipsilateral surgical arterio-venous fistula infection. Case presentation A fifty-two-year-old Sri Lankan female with end stage kidney disease presented with fever for five days with blurred vision, pain and redness of the right eye. She had a left brachio-cephalic arterio-venous fistula (AVF) created one month back. She complained of a foul-smelling discharge from the surgical site for past three days. Redness of the right eye with a hypopyon was noted. AVF site over the left cubital fossa was infected with a purulent discharge. Osler’s nodes, Janeway lesions and splinter haemorrhages were noted in the distal fingers, thenar and hypothenar eminences of the left hand. Right hand and both feet were normal. No cardiac murmurs were heard. Blood cultures, vitreous sample cultures and pus cultures from the fistula site were all positive for methicillin sensitive Staphylococcus aureus . Infective endocarditis was excluded by a trans-oesophageal echocardiogram. She was treated with IV flucloxacillin and surgical excision of the AVF. Conclusion Infections of AVF can result in septic emboli formation which can have both anterograde arterial embolization and retrograde venous embolization. Arterial embolization can result in unilateral Osler’s nodes, Janeway lesions and splinter haemorrhages. Venous embolization can cause metastatic infections in the systemic and pulmonary circulations.

Background Leptospirosis, a spirochaete infection, can lead to Leptospirosis Pulmonary Haemorrhage Syndrome (LPHS), which requires intensive care admission and has a high mortality. Although data on short-term outcomes are available, the long-term respiratory sequelae of LPHS survivors are not known. We aimed to identify the post-discharge pulmonary functions and functional limitations in survivors of LPHS. Methods We conducted a prospective cohort study from January to December 2022 at the Medical Intensive Care Unit (ICU) of the National Hospital of Sri Lanka to assess the sequential changes in the spirometry parameters in patients who survived LPHS. The Forced Vital Capacity (FVC) and Forced Expiratory Volume in 1 s (FEV1) were measured on the day of discharge from the ICU (D0), 7th day after discharge (D7) and 28th day after discharge (D28). The predicted lung volume was calculated using the gender, age and height as per standard protocol. Physical and functional role limitations were assessed on D28 using the modified Medical Outcomes Study Questionnaire Short Form 36 Health Survey (SF-36). Results Twenty-one patients with a mean age of 44 years (SD 16.07) were enrolled for the study. The majority were male patients ( n  = 19, 90.5%). Leptospirosis was serologically confirmed in all individuals. Seventeen (81%) patients had reduced FEV1 and FVC on D0, indicating a restrictive lung abnormality. FVC and FEV1 improved during the first 7 days ( p  < 0.01) but did not change significantly afterwards. Only seven individuals (33.3%) achieved a normal FVC (exceeding 80% of the predicted volume) at D28. However, 19 (90.5%) individuals achieved a normal FEV1 (exceeding 80% of predicted volume) by D28. In our study, administering corticosteroids during ICU stay did not impact lung recovery in FVC ( p  = 0.521) or FEV1 ( p  = 0.798). The participants did not have significant physical, functional, and role limitations at D28. Conclusions The spirometry measurements of individuals diagnosed with LPHS significantly improved during the first 7 days. Most survivors did not have a functional impairment despite the FVC not recovering to normal by D28.

Introduction Myocardial dissection is a rare complication of ischaemic heart disease. It occurs when a haematoma forms within the cardiac muscle, either due to an endocardial rupture or rupture of an intra-myocardial vessel. Higher ventricular wall tension and reduced myocardial tensile strength increase the risk of dissection. We describe a young male who developed a myocardial dissection following an ST elevation infarction. We explore the possible pathophysiological connection between myocardial dissection and his amphetamine use. Case presentation A 37-year-old Sri Lankan patient presented with progressively worsening heart failure for two weeks. One month before the presentation, he had developed an ischaemic chest pain, for which he had not sought medical advice. He was abusing inhalational heroin, crystal methamphetamines and cigarette smoke daily for five years. On examination, the patient had a blood pressure of 90/60 mmHg and a pulse rate of 110 beats per minute. The cardiac apex was deviated. The jugular venous pressure was elevated, bilateral pitting ankle and pulmonary oedema were present. The ECG had Q-ST elevations in the lateral leads. Serum troponin was elevated. A transthoracic echocardiogram revealed a poorly functioning dilated left ventricle with a mass within the myocardial apex. Cardiac MRI established that the mass was an intra-myocardial haematoma. A coronary angiogram demonstrated a critical plaque stenosis at the mid left-anterior-descending artery with poor distal flow. The patient did not have HIV or infective endocarditis. We treated the patient with diuretics and guideline-directed medical therapy for heart failure with reduced ejection fraction. We did not attempt surgical repair as the dissection was non-expanding, and the patient was at a high risk of operative complications. Conclusions Myocardial dissection with aneurysm formation is a rare complication of ischaemic heart disease. Methamphetamines enhance the risk of myocardial dissection by inducing myocardial inflammation, causing a dilated cardiomyopathy and increasing the left ventricular pressures.

Background The case fatality rate of untreated dengue is 20%; it can be reduced to less than 1% with optimal management. The leading causes of death in dengue patients are shock, bleeding, and acute liver injury. We describe the clinical features of patients who died of dengue and discuss the therapeutic challenges and pitfalls of complicated dengue. Methods This retrospective study was done in the intensive care unit (MICU) of the National Hospital of Sri Lanka over 30 months between 2021 and 2023. All patients who died of serologically confirmed dengue were incorporated. Results Of the 1722 ICU admissions, 44 (2.6%) patients were treated for dengue—of them, 11 (25.0%) died. Two patients were excluded as their deaths were not directly linked to dengue. Six were females. The average age was 40.2 years. The leading causes of death included shock ( n  = 5), acute liver failure ( n  = 6), intracranial bleeding ( n  = 2), and pulmonary embolism ( n  = 1). Patient 1 had concomitant leakage and bleeding, which did not respond to fluids or blood products. He developed fluid overload and acute liver failure (ALF) and died of multiorgan dysfunction. Patients 2–5 were in shock for a prolonged period due to leakage ± bleeding. Patients 2–5 developed ALF and lactic acidosis followed by multiorgan dysfunction. Patient 8 developed acute hepatitis and ALF without preceding shock. The patient was treated with immunosuppressants for myasthenia gravis. Patients 6 and 7 experienced intracranial bleeding. Patient 9 died of pulmonary embolism after prolonged ventilation for dengue encephalitis. Conclusions Prolonged shock, fluid overload and acute liver failure were common causes of dengue related deaths, in our study. Fluid overload occurred when vigorous crystalloid resuscitation was continued in patients who were poorly responding. A prompt switch to colloids or blood could have prevented overload. Patients who were in shock for a prolonged period become unresponsive to fluid resuscitation. How to manage dengue in patients who take anti-inflammatory drugs, immunomodulators, or antiplatelets is not known. Balancing the bleeding risk of dengue in patients predisposed to bleeding or thrombosis is a challenge.

Central nervous system (CNS) hemorrhage is a serious complication of intravenous thrombolysis. Tenecteplase, a fibrin‐specific thrombolytic agent, has a lower risk of hemorrhage than other agents. We report the first documented case of simultaneous intracranial and spinal hemorrhage following intravenous administration of tenecteplase. A 55 year old Sri Lankan woman presented with ischemic chest pain and was diagnosed with an acute inferior ST‐elevation myocardial infarction (STEMI). She was treated with oral aspirin, clopidogrel, atorvastatin, intravenous enoxaparin, tenecteplase (30 mg), and subcutaneous enoxaparin. Two hours after successful thrombolysis, she developed acute paraparesis with a sensory level at the fourth thoracic segment. A CT angiogram ruled out aortic dissection, but an MRI spine revealed a posterior extradural hemorrhage extending from the C4 to S1 vertebrae, and long segment of T2‐weighted hyperintensity of the spinal cord with prominent gray matter involvement, consistent with compressive myelopathy. There was no evidence of pre‐existing arteriovenous malformations, cavernoma, or coagulopathy. Additionally, a non‐contrast CT of the brain performed due to headache revealed an intracranial hemorrhage in the left frontal lobe, although this was not associated with focal neurological deficits. Antiplatelet therapy and enoxaparin were discontinued. The patient developed cardiogenic shock and died 8 days later. In conclusion, tenecteplase can result in concurrent CNS hemorrhages even in the absence of vascular anomalies or coagulation defects. Clinicians should remain vigilant for both cranial and spinal hemorrhagic complications even with fibrin‐specific agents like tenecteplase. Key Clinical Message Tenecteplase, despite its favorable safety profile, can cause simultaneous intracranial and spinal hemorrhages. Clinicians should remain vigilant for neurological symptoms post‐thrombolysis and consider early imaging to identify rare but catastrophic bleeding complications.

Objective To study the change in trend of antenatal mental health and associated factors among a cohort of pregnant women during the second wave of COVID-19 using Hospital Anxiety and Depression Scale (HADS). Previous study using the same scale, during the first wave reported a higher prevalence of anxiety and depression. Results A descriptive cross-sectional study was carried out at the two large maternity hospitals in Colombo, Sri Lanka: Castle Street Hospital for Women (CSHW) and De Soysa Hospital for Women (DSHW). Consecutively recruited 311 women were studied. Out of which, 272 (87.5%) were having uncomplicated pregnancies at the time of the survey and 106 (34.1%) were either anxious, depressed, or both. Prevalence of anxiety was 17.0% and depression 27.0%. Overall, continuing COVID-19 pandemic increased antenatal anxiety and depression. The trend was to aggravate depression more intensively compared to anxiety in this cohort of women studied. Special support is needed for pregnant mothers during infectious epidemics taking more attention to antenatal depression.

Drainage of a pleural effusion is done either by inserting an intercostal tube or by aspirating pleural fluid using a syringe. The latter is a time-consuming and labour-intensive procedure. The serious complications of pleural aspiration are the development of a pneumothorax and re-expansion pulmonary oedema. We describe an observation made during a pleural aspiration in a patient who was on positive pressure ventilation. We explain the physiological basis for the observation, the safety of the procedure and its potential to reduce complications by reviewing the literature. A 56-year-old Sri Lankan female patient with end-stage kidney disease presented with fluid overload and bilateral pleural effusions. She was found to have concurrent COVID pneumonia. The patient was on bilevel positive airway pressure, non-invasive ventilation when pleural aspiration was done. The pleural fluid drained completely without the need for aspiration, once the cannula was inserted into the pleural space. One litre of fluid drained in 15 min without the patient developing symptoms or complications. Positive pressure ventilation leads to a supra-atmospheric (positive) pressure in the pleural cavity. This leads to a persistent positive pressure gradient throughout the procedure, leading to complete drainage of pleural fluid. Pleural fluid drainage in mechanically ventilated patients has been proven to be safe, implying the safety of positive pressure ventilation in pleural fluid aspiration and drainage. It further has the potential to reduce the incidence of post-aspiration pneumothorax by reducing the pressure fluctuations at the visceral pleura. Re-expansion pulmonary oedema is associated with a higher negative pleural pressure during aspiration, and the use of positive pressure ventilation can theoretically prevent re-expansion pulmonary oedema. Positive pressure ventilation can reduce the re-accumulation of the effusion as well. We suggest utilizing positive pressure ventilation to assist pleural aspiration in suitable patients.