First successful in vitro culture of autochthonous Leishmania sp. in Sri Lanka

Since the first autochthonous case of cutaneous leishmaniasis in Sri Lanka was reported in 1992 (1) attempts to culture the causative organisms have been unsuccessful. We report the first successful isolation of the local Leishmania sp. by in vitro culture, which would pave the way for species and strain indentification.     

Atypical mucocutaneous involvement with Leishmania donovani

Mucocutaneous leishmaniasis has rarely been reported from India. The usual causative organisms of this infection are Leishmania braziliensis and L. tropica. Another species, L. donovani, which usually causes visceral leishmaniasis, has recently been reported to cause mucocutaneous disease in a few patients from Sri Lanka. We report two patients who had undiagnosed chronic skin lesions for several years. Skin biopsies revealed Leishmania and the species was characterized as L. donovani in both patients. There was considerable improvement in the skin lesions following treatment with liposomal amphotericin B.     

Loa loa in a Sri Lankan expatriate from Nigeria

A worm was extracted from the subconjunctival space of the left eye in a 14-year old Sri Lankan girl, who returned to Sri Lanka in 1983 after spending six years in Nigeria. It was identified as a male Loa loa. A history of evanescent (Calabar) swellings was obtained. She also had significant eosinophilia. Microfilariae were not detected in the blood. This is the first case of Loa loa infection reported from Sri Lanka.     

Evaluation of a rapid whole blood immunochromatographic assay for the diagnosis of Plasmodium falciparum and Plasmodium vivax malaria

OBJECTIVE: Microscopic examination of blood smears is the 'gold standard' for malaria diagnosis, but is labour intensive and requires skilled operators. Plasmodium vivax malaria accounts for up to 70% of infections in Sri Lanka. The objective of this study was to determine the effectiveness of an immunochromatographic test which can detect both the species of Plasmodium, P. vivax and P. falciparum, present in Sri Lanka. DESIGN: Prospective study from May 2001 to March 2002. SETTING AND METHODS: All persons above 5 years of age who presented to the Malaria Research Station, Kataragama or the Anti-malaria Clinic, Kurunegala, with a history of fever were recruited to the study. Thick and thin blood smears were examined for malarial parasites. The rapid diagnostic test (RDT), ICT Malaria P.f/P.v (AMRAD ICT, Australia) was performed simultaneously by an independent investigator. The severity of clinical disease of all patients was evaluated. RESULTS: The study sample comprised 328 individuals of whom 126 (38%) were infected, 102 with P. vivax (31.1%) and 24 with P. falciparum (7.3%). The RDT was found to be highly sensitive (100%) and specific (100%) for the diagnosis of P. falciparum when compared with field microscopy. The sensitivity for the diagnosis of P. vivax malaria was only 70%. When P. vivax parasitaemia was greater than 5000 parasites/microL the RDT was 96.2% sensitive. A significant association was noted between the band intensity on the dipstick and both peripheral blood parasitaemia (p < 0.001) and clinical severity of disease with P. vivax (p = 0.011). CONCLUSIONS: The ICT Malaria P.f/P.v test can be used in Sri Lanka in the absence of microscopists.     

An observational study of staghorn calculi in south Sri Lanka

OBJECTIVES: To ascertain patient characteristics, management strategies and outcome of patients with staghorn calculi in southern Sri Lanka. METHODS: All patients with staghorn calculi seen at the urology unit in a teaching hospital during a period of eighteen months were included in this prospective study. Data in relation to patient demography, investigations, treatment and postoperative complications were collected. RESULTS: There were 60 patients with a mean age of 54 years. Eight (13%) of them were female. Urine pH was less than 7.0 in 52 (87%) patients. Urine culture was positive for bacteria in four (7%) patients. 58 patients underwent open surgery, and two patients were managed non-operatively. Seven (12%) patients developed postoperative complications. CONCLUSIONS: Staghorn calculi elsewhere are usually commoner in females and associated with alkaline urine. But in our study there was a clear male preponderance (M:F = 6.5:1), and urine pH was alkaline in 8 (13%) patients only. Hence the aetiological factors for staghorn calculi in Sri Lanka appear to be different. Although open surgical procedures which form the mainstay of treatment of staghom calculi in Sri Lanka can be performed safely and effectively, there is a necessity to provide minimal access surgical facilities.     

Chronic pain syndrome should be recognized as a separate clinical entity.

Chronic pain is a relatively new concept in our understanding of pain. It is rarely recognised or diagnosed as a separate clinical entity in Sri Lanka. Thus the extent of this problem is not known. The case histories of two patients with the chronic pain syndrome are presented, with a brief review of the theoretical aspects of chronic pain. Trends in the management of chronic pain are summarized. Unfortunately, organized treatment programmes for chronic pain are unavailable in Sri Lanka.     

Anti-tuberculosis drug inducd hepatitis - a Sri Lankan experience

OBJECTIVE: To assess the incidence of anti-tuberculosis (TB) drug induced hepatitis (AIH) in Sri Lankan patients, determine risk factors of AIH, and to address management options in AIH. DESIGN: A prospective study. SETTING: Chest Hospital, Welisara, Sri Lanka, from April 2001 to April 2002. PATIENTS: Seven hundred and eighty three patients with a confirmed diagnosis of TB and resident in the Colombo and Gampaha districts who presented to Chest Hospital, Welisara, Sri Lanka. METHODS: WHO recommended treatment was commenced in all cases. AIH was diagnosed when patients complained of decreased appetite with nausea or vomiting and elevated serum bilirubin (SB; >1.1 mg/dL) or elevated serum alanine transferase (ALT; > 3 times upper limit of normal). RESULTS: Of 783 enrolled patients, 74 (9.5%) developed AIH, the majority (58%) developing AIH within the first 2 weeks of the intensive phase of treatment. AIH was more common among patients over 60 years (p = 0.018), who developed pulmonary TB (p = 0.028), and in patients weighing 33-55 kg (p = 0.004). Age, weight and rifampicin overdosage were significant predictors of AIH. Of the 74 AIH patients, standard treatment was restarted in 60, treatment modified in six, two defaulted and six died. CONCLUSIONS: The incidence of AIH in Sri Lanka is 9.5% in treated patients. AIH was associated with age, low body weight and rifampicin overdosage.     

Paroxysmal kinesigenic dyskinesia

Paroxysmal kinesigenic dyskinesia (PKD) is a rare disorder characterised by brief and frequent attacks of abnormal involuntary movements induced by sudden movement. This disorder has not been reported previously in Sri Lanka. We studied six patients with respect to clinical presentation, aetiology, family history and response to treatment, and describe the Sri Lankan patterns of this illness. All the patients were males and the age at onset was from 11 to 22 years. The involuntary movements in all were dystonic and affected one or both sides, involving the face in the majority. All had difficulty in speaking during the attacks. One patient had an occasional attack during exercise. In all, the illness was sporadic, none had a family history of a similar illness and in none was it due to a secondary cause. The attacks usually lasted 10-60 seconds, and occurred up to 20 times a day. All patients responded well to anticonvulsants. PKD in Sri Lanka has a pattern similar to that described worldwide.     

Early catheter removal after transurethral resection of the prostate

INTRODUCTION: Post-operative care of transurethral resection of the prostate (TURP) includes prolonged bladder irrigation that places a heavy burden on the nursing staff and a substantial strain on the budget. There is a trend towards early catheter removal after TURP even to the extent of performing it as a day case. We explored the feasibility and limitations of early catheter removal after TURP in our unit. DESIGN: Prospective study. SETTING: Department of Urology, The National Hospital of Sri Lanka (NHSL), Colombo. PATIENTS AND METHODS: The study was in a tertiary referral centre (NHSL), on 65 patients with a mean age of 67.5 years who underwent TURP for mild to moderate enlargement of the prostate, less than 25 g, with lower urinary tract symptoms. Post-operative irrigation was maintained by diuretics at operation or a short term saline irrigation in the operating theatre. RESULTS: 17 patients developed clot retention in the ward that was managed by irrigation for 12 to 24 h. 62 patients who had clear or minimally blood-stained urine were tried without catheter after 24 h. Only two failed to pass urine. Patients without other complications were discharged from hospital after 1 or 2 successful voidings on the same day. There were no readmissions with complications. CONCLUSIONS: This study supports the feasibility of early catheter removal after a short irrigation period in TURP in the majority of patients with mild to moderate enlargement of the prostate without significantly increasing post-operative complications.     

Cold cellulitis. An unusual presentation of cutaneous leishmaniasis

We describe a case of cutaneous leishmaniasis, which presented as what we call "cold cellulitis". This may be differentiated from classical cellulitis/erysipelas by 1. Lesser local reaction like pain and tenderness 2. No systemic symptoms 3. No leucocytosis 4. Negative bacteriological and serological assay for bacterial cellulitis/erysipelas, 5. Longer course of illness and 6. Failure to respond to antibiotics. However, awareness of this type and frequent skin smears or skin biopsy will settle the right diagnosis. A review of different leishmanial presentations is given for comparison.     

Thalassaemia control in developing countries--the Sri Lankan perspective

Beta thalassaemia is a Mendelian recessive disorder. The economic and social cost of the disease is high due to patients' life long need for monthly blood transfusions and treatment with desferrioxamine, an iron chelating agent. Wider availability of cheaper drugs is on the horizon. If there is no concomitant reduction in the number of new thalassaemia major births, there will be a cumulative increase in numbers requiring treatment. The frequency and severity, and the economic and social costs of thalassaemia, support the case for the introduction of a carrier screening and counselling program in Sri Lanka. A three-pronged plan emphasising professional, political and public education in outlined.     

Rhinosporidiosis presenting as recurrent nasal polyps

Rhinosporidiosis is a chronic granulomatous disease of the mucous membrane, predominantly of the nose and nasopharynx. It is uncommon in Malaysia but has been seen in immigrant workers from endemic areas like India and Sri Lanka. A case seen in Johor is reported here to highlight the need of awareness among clinicians at a time where there is increasing numbers of immigrant workers in our country. The causative organism of this disease is Rhinosporidium seeberi, which is found in stagnant waters. Sporangia and endospores of R. seeberi are seen in the granulomatous polypoidal lesions. The patients commonly present with epistaxis and nasal blockage. Complete excision is the treatment of choice for this disease. Recurrences are common despite anti-microbial treatment.     

Audit of stroke care at the Institute of Neurology,National Hospital of Sri Lanka, 1994-1997

OBJECTIVE: To audit the process of stroke care. DESIGN: Retrospective case record evaluation using an audit package designed by the Royal College of Physicians of London. SETTING: Institute of Neurology, National Hospital of Sri Lanka, Colombo. PATIENTS: 263 patients with stroke admitted over a period of 3 years. MEASUREMENTS: Documentation of 60 audit items related to 13 aspects of stroke care. RESULTS: The process of care was considered 'very good' for only 11 (18.3%), and 'good' for only 9 (15%) of the audit items. Care was 'average' for 5 (8.3%), 'poor' for 9 (15%) and 'very poor' for 26 (43.3%) of the items. CONCLUSIONS: Stroke care was suboptimal in many aspects. Care related to rehabilitation oriented neurological assessments, initiation of secondary preventive measures, rehabilitation planning and discharge planning were especially deficient. Competing interests: none declared. Some of the data reported in this paper have been presented at the Annual Scientific Sessions of the Sri Lanka Medical Association, 1998.     

Hyperhomocysteinaemia in Sri Lankan patients with coronary artery disease

OBJECTIVE: To determine the association between hyperhomocysteinaemia and coronary artery disease (CAD) in a sample of Sri Lankans. DESIGN: A case control study. SETTING: Asiri Hospital, Kirula Road, Colombo 5, Sri Lanka. SUBJECTS: 105 patients with coronary artery disease and 112 controls. METHOD: Fasting serum homocysteine levels were measured in 105 patients diagnosed as having CAD and in 112 unmatched controls. All patients admitted with clinical, electrocardiographical, biochemical or echocardiographical evidence of CAD were included in the study. Controls were selected from subjects admitted for health screening. RESULTS: 105 patients with CAD and 112 controls (unmatched for age and sex) were studied. A serum homocysteine level in excess of 18.2 mumol/l was considered high. Confounding effects of other conventional risk factors for CAD were controlled using multivariate logical regression analysis. CONCLUSION: Hyperhomocysteinaemia is significantly associated with CAD. Multivariate logistic regression analysis indicated that the association between hyperhomocysteinaemia and CAD was confounded by other risk factors. However, statistical analysis revealed a significant independent association between hyperhomocysteinaemia and CAD (adjusted odds ratio = 2.881).     

An attempt to measure burden of disease using disability adjusted life years for Sri Lanka

INTRODUCTION: Disability adjusted life years (DALY) is a measure of burden of disease (BOD) that assesses the years of healthy life lost due to disease or illness. OBJECTIVE: The main objective of the study was to develop a draft measure of the BOD in Sri Lanka, using DALY. METHODS: Computation was done for 100 disease categories identified to reflect the disease pattern in Sri Lanka. Factors that were considered for the calculation of DALY were incidence, degree of disability, duration of the illness and age of onset. RESULTS: Injuries, ischaemic heart disease, asthma, disease of the pulmonary circulation and burns contribute to 55% of BOD in Sri Lanka. CONCLUSION: The highest burden was due to non-communicable diseases, as their duration and degree of disability are high. Diseases such as malaria, which are short term illnesses with low disability, although affecting large numbers, did not give a high value for DALY.     

Stroke subtypes in Sri Lanka--a hospital based study

AIM: Data on stroke subtypes in Sri Lanka are limited, mainly due to the unavailability of brain imaging facilities in most government hospitals. In two leading private hospitals in Colombo, a high proportion of stroke patients have computerised tomography (CT) scanning. Hence we studied stroke patients admitted to these two hospitals to determine the stroke subtypes. METHODS: A prospective study of 103 consecutive first ever stroke patients who were under the care of the first author during the period 15 May 1995 to 30 August 1996 were studied. Diagnosis of stroke was made according to the WHO definition, and transient ischaemic attacks (TIA) were not included. The pathological subtype was confirmed by CT scan in 99 patients. RESULTS: The age of the patients ranged from 37 to 94 years (mean 64.5). 87 patients were over the age of 50 years. The proportion of pathological subtypes confirmed by CT scanning was cerebral infarction (CI) 74.7%, intracerebral haemorrhage (ICH) 19.1% and subarachnoid haemorrhage (SAH) 62.2%. Of the infarcts 31 (42%) were cortical, 30 (41%) lacunar, 12 (16%) cerebellar and brainstem, and 1 (1.3%) was a border zone infarct. CONCLUSION: Direct comparisons with stroke subtypes seen in other countries are not valid due to differences in methodology. In developed countries in the West cerebral infarcts account for about 80% of all first ever strokes and of these 13 to 21% are lacunar strokes. Countries in the East (e.g. Japan and Hong Kong) have reported a higher proportion of haemorrhages (27% of first ever strokes in Hong Kong). In Sri Lanka the proportion of stroke subtypes seem to be intermediate between these countries in the West and East. Lacunar strokes are commoner in Sri Lanka than in other countries.     

PCR detection and typing of human papilloma virus DNA in squamous carcinoma of the cervix in a cohort of Sri Lankan women

OBJECTIVE: To determine the prevalence of human papilloma virus (HPV) types 16 and 18 in squamous carcinomas of the cervix in Sri Lanka. DESIGN: Case control study. SETTING: One gynaecological unit at the Cancer Institute, Maharagama, Sri Lanka. PATIENTS: 15 patients with squamous carcinoma of the cervix, and 15 age matched controls with histologically normal cervices. MEASUREMENTS: DNA was extracted from paraffin embedded cervical biopsies. Polymerase chain reaction was performed on extracted DNA employing primers specific for HPV types 16 and 18. RESULTS: HPV 16 DNA was detected in 11 out of 15 cervical cancer biopsies (73.3%), in comparison with 3 out of 15 normal controls (20%). HPV 18 was detected in 3 out of 15 cervical cancer biopsies, but not in a single control biopsy. CONCLUSION: Despite the limited number of cases in this cohort, this study supports the strong association between HPV 16 and squamous cancer of the cervix.     

Banding of oesophageal varices using locally improvised materials

Bleeding from oesophageal varices is the commonest cause of significant upper gastrointestinal bleeding in Sri Lanka. Endoscopic band ligation is an effective method in the management of varices. But the cost of banding equipment is high, unaffordable for a majority of our patients. We have devised a cheap method to carry out banding of varices. Banding of varices using this technique was carried out in 235 patients. In the patients who were followed up, there was a reduction in the size of varices across all grades of varices. No complications due to banding were noted, and only 10 patients developed re-bleeding. Since the initial experience on efficacy and safety of this technique is encouraging, we believe that its widespread adoption in Sri Lanka would be cost effective and life-saving.