Histoplasmosis in Sri Lanka - a masquerader in a strange land: A Case Report

We present a patient with an oral mucosal ulcer who was diagnosed with disseminated histoplasmosis. This fungal infection is endemic in the United States, and thus may be not considered in the differential diagnosis of oral ulcers in Sri Lanka. Furthermore, it may mimic many common diseases found in Sri Lanka. It is therefore important to be aware of this entity, since it is potentially curable if diagnosed and treated early.</p

Sepsis with cerebral lupus…. or is it? A case report on Cryptococcaemia

We present a patient with SLE, with multiple comorbidities, whose blood cultures yielded Cryptococcus neoformans. Blood cultures became positive only after twelve days of hospital admission. The patient died within two days of starting Amphotericin B. Cryptococci are an important cause of infection in SLE. Only about 10% to 30% of those with cryptococcal disease have the organism isolated by blood cultures. Due to its non-specific clinical presentation, cryptococcal infection in SLE can be misdiagnosed as psychosis due to steroids, cerebral lupus and infections due to other non-fungal pathogens. This may lead to inappropriate therapy and delays in administration of antifungal agents. Therefore, cryptococcal infection should be considered when SLE patients present with sepsis irrespective of the presence of features of meningis

Exophiala jeanselmei causing subcutaneous phaeohyphomycosis in a healthy adult in Sri Lanka: A case report

Phaeohyphomycosis is a chronic infection caused by filamentous dematiaceous fungi and it embraces a wide range of clinical presentations. Subcutaneous phaeohyphomycosis is caused by traumatic implantation of aetiological fungi in subcutaneous tissue and is usually reported in agricultural workers in the tropics. Subcutaneous phaeohyphomycosis presents with various skin manifestations and is often misdiagnosed by clinicians. Exophiala sp is a common aetiological agent of post traumatic subcutaneous phaeohyphomycosis. We present a middle aged farmer who presented with a subcutaneous nodule in his dominant hand. This swelling was initially diagnosed as a ganglion but turned out to be an abscess caused by Exophiala jeanselmei and the patient was cured by complete surgical excision without antifungal therapy. This case report aims to contribute to knowledge on this uncommon entity, in order to help practitioners to correctly diagnose and treat subcutaneous phaeohyphomycosis. </p

Fusariosis in haematological malignancy – the skin is the clue… Experiences from the National Cancer Institute of Sri Lanka: a case report

We present two patients with haematological malignancies who developed skin lesions while neutropaenic and were subsequently diagnosed as having fusariosis. Although fusariosis is not as common as other fungal infections such as aspergillosis and candidiasis, it has to be considered in the diagnosis of immunocompromised patients who present with skin manifestations. Awareness of fusariosis, and early diagnosis and appropriate treatment is essential to reduce mortality. </p

Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies

Background: Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies. Methods: In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality. Findings: Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42\ub74% vs 44\ub72%; absolute difference \u20131\ub769 [\u20139\ub758 to 6\ub711] p=0\ub767; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5\u20138] vs 6 [5\u20138] cm H2O; p=0\ub70011). ICU mortality was higher in MICs than in HICs (30\ub75% vs 19\ub79%; p=0\ub70004; adjusted effect 16\ub741% [95% CI 9\ub752\u201323\ub752]; p&lt;0\ub70001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0\ub780 [95% CI 0\ub775\u20130\ub786]; p&lt;0\ub70001). Interpretation: Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status. Funding: No funding

A922 Sequential measurement of 1 hour creatinine clearance (1-CRCL) in critically ill patients at risk of acute kidney injury (AKI)

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Plasma leakage in dengue: a systematic review of prospective observational studies

Plasma leakage is a precursor to life-threatening complications of dengue, but this group is poorly defined and not often reported in literature. Patients with Dengue haemorrhagic fever (DHF) as defined in the 1997 World Health Organization classification are often reported, and they all have plasma leakage, but some patients with plasma leakage do not meet the definition of DHF. The study aims to estimate the frequency of plasma leakage and DHF (as a surrogate of plasma leakage) in dengue and its variations based on virus serotype, geography, patient gender and pre-existing immunity to dengue. PUBMED, Scopus, EMBASE, CINAHL and Web of Science were searched for prospective observational studies reporting on plasma leakage or DHF. Quality of data was assessed using the NIH quality assessment tool for cohort studies. Forty-three studies that recruited 15,794 confirmed dengue patients were eligible. Cumulative frequency of plasma leakage was 36.8% (15 studies, 1642/4462, 95% CI 35.4–38.2%), but surprisingly the estimated cumulative frequency of DHF was higher (45.7%, 32 studies, 4758/10417, 95% CI 44.7–46.6%), indicating that current medical literature over-reports DHF or under-reports plasma leakage. Therefore, a reliable estimate for the proportion of dengue patients developing plasma leakage cannot be derived from existing medical literature even after applying rigorous inclusion criteria to select homogenous studies. Plasma leakage is an important marker of “at-risk” dengue patients and standardizing its definition, diagnosis and reporting should be a priority in research and global policy

Rational use of ultrasonography with triaging of patients to detect dengue plasma leakage in resource limited settings: a prospective cohort study

Objectives: To compare the traditional haematocrit-based criteria (>20% rise above baseline) with ultrasonography for diagnosing plasma leakage in dengue fever and to identify clinical indicators for triaging patients in resource-limited settings when the demand for ultrasonography is high. Methods: The Colombo Dengue Study is a prospective observational cohort study recruiting dengue patients in the first three days of dengue fever, before plasma leakage. Serial haematocrit assessments and ultrasonography were performed in patients recruited from October 2017 to February 2020. Clinical signs/symptoms and laboratory investigation results independently associated with ultrasound detected plasma leakage were identified with a derivation cohort and confirmed in a validation cohort. Results: 129 of 426 patients had ultrasonography-confirmed plasma leakage while 146 had a haematocrit rise >20%. Those positive on ultrasonography were also likely to fulfil the haematocrit-based criteria (OR: 4.42, 95% CI: 2.85–6.86), but the two groups did not overlap fully. In the derivation cohort (n = 317), platelet count  51 IU/l and having abdominal pain in the first three days of fever were independent predictors of ultrasound-detected plasma leakage. In the validation cohort (n = 109), the combination of low platelet count and high aminotransferase level had better predictive capacity in terms of sensitivity and specificity. Conclusion: Dengue patients should be monitored with both serial haematocrit and ultrasonography whenever possible and plasma leakage should be diagnosed by either one of these criteria. If accessibility to scans is limited, platelet count, serum transaminase levels and presence of abdominal pain are useful to triage patients