Relationship between asymptomatic anicteric hepatitis and asymptomatic myositis in a cohort of adult Sri Lankan dengue patients admitted to a medical unit of a tertiary referral centre

Objective: To study the relationship between asymptomatic anicteric hepatitis and asymptomatic myositis in a cohort of adult Sri Lankan dengue patients admitted to a medical unit of a tertiary care centre. Methods: Case notes of 88 consecutive confirmed dengue patients admitted to the principal authors unit at Sri Jayewardenapura Teaching Hospital, Kotte, Sri Lanka from January 2012 to June 2012 were retrospectively analyzed to obtain the required information. Clinical criteria defined for suspected dengue fever were a confirmed viral infection with a platelet count less than 100000/cumm3 during the epidemic. Results: Age ranged from 13 to 64 years with a mean age of 28.6+/- 8.62 SD. Sex distribution was male: female = 56:32 (6:4). An elevated AST level (>37u/l) and elevated ALT level (>40 u/l) were found in 95% and 90.9% of the instances respectively. AST levels were above ALT levels in 86.2% of the instances. Elevated CPK levels were seen in 87.5% patients. There was no linear relationship between asymptomatic transaminitis and elevated CPK levels. Hypocalcaemia was noted in 72% as described in the literature, without any relationship to either tramsaminitis or myositis. Conclusions: Immunological mechanisms resulting in anicteric hepatitis and asymptomatic myositis in dengue seem to differ. Elevation in AST and ALT levels seem to differ from other viral infections mimicking what is seen in acute alcoholic liver disease. The role of hypocalcaemia was uncertain.

Demographic and clinical profile of adult Sri Lankans having hepatocellular carcinoma admitted to medical units of a tertiary referral center; 4 years experience

Objective: To study the demographic and clinical profile of adult Sri Lankans having hepatocellular carcinoma. Methods: Clinical notes of 42 patients having hepatoma admitted to medical units at Sri Jayawardenepura General Hospital, Kotte, Sri Lanka from January 2008 to January 2012 were retrospectively analyzed to obtain the required data. Results: The age range was 43-91 years with a mean age of 65.5+/- 11.1 SD. Sex distribution was male: female; 38:4 (9:1). 90.5% were alcoholics. 57.1% had established liver disease at the time of diagnosis. 27.7% of patients with undiagnosed liver disease at presentation had radiological evidence of cirrhosis. On presentation ascites, abdominal pain, hepatic encephalopathy, anorexia and weight loss were found in 38.1%, 19%, 19%, 16.7% and 14.7% respectively. Uni-focal tumors were found in 61.9%. Secondaries were seen in 11.9%. The detectable sites were lymph nodes, bones, lungs, and the inferior vena cava extending into the right atrium. Hepatitis B and C infection were not seen. The available curative therapeutic modalities were minimal. Conclusions:A marked male dominance was seen. Alcohol etiology was the dominant cause. Hepatoma may be the first presentation in undiagnosed liver disease. In all patients the diagnosis had been made at an advanced stage of the tumor thus resulting in a poor prognosis. We recommend that ultrasound scanning of the abdomen and alpha-feto protein estimation to be done at every six months interval in chronic liver disease patients

The clinical profile of adult Sri Lankans having microscopic colitis not otherwise specified (NOS) admitted to a medical unit of a tertiary care hospital

Objective: To study the clinical profile of adult Sri Lankans having microscopic colitis not otherwise specified (NOS) admitted to a medical unit of a tertiary care hospital. Method: Case notes of 83 consecutive patients admitted to Sri Jayawardenepura General Hospital, histologically diagnosed as having microscopic colitis from January 2008 to January 2012 were retrospectively analyzed. Results: Age range was 21-84 years, mean age 51.1+/- 17.4 SD years. Sex distribution male: female 48:35 (1.3:1). Presentation had been a watery diarrhea, abdominal pain, weight loss, asthenia and bleeding per rectum in 55.4%, 42.2%, 40.9%, 38.1% and 2.4% of the instances respectively. 71.1% had no major associated background problems. Hypertension, diabetes mellitus, bronchial asthma was present in 21.7%, 8.0% and 7.2% of the instances respectively. The salient histological feature was infiltration of plasmacytes and lymphocytes beyond lamina propria without other specific features of colitides. Rectum, sigmoid, transverse colon, ascending colon, descending colon, ceacum were histologically involved in 89.2%, 86.7%, 68.7%, 65.1%, 60.2%, 38.1% of the instances respectively. Pancolitis was seen in 25.3%. Inflammatory markers (ESR and/or C-RP) were elevated in 20.8% where they have been done. Neutrophilia was noted in 13.3%. Non steroidal anti inflammatory drugs and proton pump inhibitors have been prescribed in 6.0% and 4.8% instances respectively where information was available. Conclusions: Microscopic colitis not specified otherwise seem to be an ill defined colitis which could represent low grade immunological reaction to an unidentified intra-luminal antigen causing therapeutic dilemmas. Further studies are needed for better categorization and to define the outcome

Demographic and clinical profile of enteric fever admitted to a medical unit of a tertiary referral centre in Sri Lanka

Objectives: To study the demographics and clinical features of enteric fever patients admitted to a medical unit of a tertiary referral centre in Sri Lanka Method: Clinical notes of 114 patients diagnosed as having enteric fever admitted to the principal author’s unit at Sri Jayawardenepura General Hospital, Kotte, Sri Lanka from January 2011 to June 2012 were retrospectively analyzed to obtain the required data. Results: Age range was 12-82 years with a mean age of 35+/- 14.0 SD. Sex distribution male: female =78:36 (2:1). Fever, abdominal pain, diarrhea, headache and constipation were present in 100%, 36.0%, 26.4%, 9.6% and 9.0% of instances respectively. Paratyphoid and typhoid serology were positive in 48.2%and 51.1% respectively. Anicteric hepatitis was found in 73.7%. Inflammatory markers (ESR and/or C-RP) were elevated only in 42.1%.Thrombocytopenia (<150,000mm) was found in 25.1%. Abdominal ultrasound showed hepatic, splenic and gall bladder involvement in 31.8%, 27.3% and 10.1% of instances respectively. Blood cultures were positive only in 47.2%. Ceftriaxone resistance was seen in 3.5%. Acute transverse myelitis was seen in one patient. The classically described ‘step ladder’ fever pattern, doughy abdomen and rose spots were not observed. Conclusion: A male dominance was noted. Hepatobilliary involvement was asymptomatic. Response to antibiotics and a falling Salmonella antibody titre confirmed diagnosis in culture negative patients. Pretreatment with antibiotics in the community could have influenced the clinical picture, serology and culture positivity.