Journal/Magazine Articles
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This collection contains original research articles, review articles and case reports published in local and international peer reviewed journals by the staff members of the Faculty of Medicine
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Item Double-trouble: A rare case of co-infection with melioidosis and leptospirosis from Sri Lanka(Sage, 2023) Gunasena, J.B.; de Silva, S.T.Melioidosis and leptospirosis are two emerging tropical infections that share somewhat similar clinical manifestations but require different methods of management. A 59-year-old farmer presented to a tertiary care hospital with an acute febrile illness associated with arthralgia, myalgia and jaundice, complicated by oliguric acute kidney injury and pulmonary haemorrhage. Treatment was initiated for complicated leptospirosis but with poor response. Blood culture was positive for Burkholderia pseudomallei and microscopic agglutination test (MAT) for leptospirosis was positive at the highest titres of 1:2560, confirming a co-infection of leptospirosis and melioidosis. The patient made a complete recovery with therapeutic plasma exchange (TPE), intermittent haemodialysis and intravenous (IV) antibiotics. Similar environmental conditions harbour melioidosis and leptospirosis, making co-infection a very real possibility. Co-infection should be suspected in patients from endemic areas with water and soil exposure. Using two antibiotics to cover both pathogens effectively is prudent. IV penicillin with IV ceftazidime is one such effective combination.Item An unusual case of sepsis due to Salmonella enterica serovar Weltevreden, an emerging pathogen of non-typhoidal salmonellosis(Sage Publishing, 2021) Gunasena, J.B.; de Silva, S.T.ABSTRACT: Salmonella enterica serovar Weltevreden is identified as an emerging pathogen, especially in the South and Southeast Asian regions. A 45-year-old male presented with an acute febrile illness, disoriented and confused. Blood culture became positive for Salmonellae enterica serovar Weltevreden. The patient was started on intravenous Ceftriaxone. Despite aggressive management, he developed acute respiratory distress syndrome with septic shock, which required intubation and mechanical ventilation. On the 11th day of admission, he succumbed due to sepsis from peritonitis with bowel infarction. Severe sepsis due to S. Weltevreden is rare. Diabetes, malignancy, therapeutic immune suppression may predispose to invasive disease. Biochemical similarities to other Salmonella species may lead to S. Weltevreden being overlooked by clinicians. Isolates from around the world remain sensitive to most freely available antibiotics. Emergence of resistance to common antimicrobial agents could pose an obvious public health threat. KEYWORDS: Non typhoidal salmonella; Southeast Asia; antibiotic sensitivity; salmonella weltevreden; sepsis.Item The clinical utility of accurate NAFLD ultrasound grading: Results from a community-based, prospective cohort study(Elsevier Science Ireland Ltd, 2021) Niriella, M.A.; Ediriweera, D.S.; Kasturiratne, A.; Gunasekara, D.; de Silva, S.T.; Dassanayake, A.S.; de Silva, A.P.; Kato, N.; Pathmeswaran, A.; Wickremasinghe, A.R.; de Silva, H.J.OBJECTIVES: Despite its widespread use there is no consensus on ultrasound criteria to diagnose fatty liver. METHOD: In an ongoing, cohort-study, participants were initially screened in 2007 and reassessed in 2014 by interview, anthropometric measurements, liver ultrasonography, and blood tests. We evaluated utility of increased hepatic echogenicity alone (intermediate) compared to using additional criteria which included signal attenuation and/or vascular blunting along with increase of hepatic echogenicity (moderate-severe), to diagnose fatty liver in NAFLD. We made a comparison of the two radiologically defined groups, in order to choose a classification method for NAFLD, which may better predict baseline adverse metabolic traits (MT), and adverse metabolic and cardiovascular events (CVE) after 7-year of follow-up. RESULTS: Of 2985 recruited in 2007, 940 (31.5 %) had moderate-severe NAFLD, 595 (19.9 %) intermediate NAFLD, and 957 (32.1 %) were controls (no fatty liver). 2148 (71.9 %) attended follow-up in 2014; they included 708 who had moderate-severe NAFLD, 446 intermediate NAFLD and 674 controls, at baseline (in 2007). At baseline, adverse anthropometric indices and MTs were significantly higher in both moderate-severe NAFLD and intermediate NAFLD compared to controls, except for low HDL. They were commoner in moderate-severe NAFLD than in intermediate NAFLD. After seven years, the odds of developing new-onset metabolic traits and CVEs were significantly higher compared to controls only in moderate-severe NAFLD. CONCLUSIONS: Only moderate-severe NAFLD predicted risk of incident adverse MTs and CVEs. However, both moderate-severe and intermediate NAFLD were associated with higher prevalence of adverse anthropometric and metabolic traits, thereby identifying individuals who need medical intervention even among those with milder degrees of fatty liver. We therefore recommend using increased hepatic echogenicity, and not only the more stringent criteria (which include signal attenuation and/or vascular blunting), for the diagnosis of fatty liver in individuals with NAFLD. KEYWORDS: Cardiovascular events; Fatty liver; NAFLD; Outcomes; Ultrasonography; Ultrasound criteria.Item Metabolic syndrome, but not non-alcoholic fatty liver disease, increases 10-year mortality: A prospective, community-cohort study(Wiley-Blackwell, 2020) Niriella, M.A.; Kasturiratne, A.; Beddage, T.U.; Withanage, S. A.; Goonatilleke, D.C.; Abeysinghe, C.P.; de Mel, R.T.; Balapitiya, T.L.; de Silva, S.T.; Pathmeswaran, A.; Wickremasinghe, A.R.; Kato, N.; de Silva, H.J.BACKGROUND:Data on outcomes of non-alcoholic fatty liver disease (NAFLD) from South Asia are lacking. We compared mortality, among those with- and without-NAFLD, after 10-years follow-up among urban, adult Sri Lankans.METHOD:Participants (aged 35-64 years), selected by age-stratified random sampling, were screened by structured-interview in 2007. Anthropometric measurements, liver ultrasonography and biochemical/serological tests were done. NAFLD was diagnosed on ultrasound criteria, safe-alcohol consumption (Asian-standards) and absence of hepatitis B/C. Subjects without NAFLD were those without any ultrasound criteria of fatty liver, safe-alcohol consumption and absence of hepatitis B/C. The cohort was re-evaluated to assess mortality in 2017. Participants or their households were contacted by telephone/post, and deaths confirmed by home-visits and death certificate review. Cox-regression was used to determine predictors of all-cause mortality (ACM) and cardiovascular mortality (CVM) in those with- and without-NAFLD.RESULTS:2724 (91.2%) of 2985 original participants were contacted (851-with NAFLD and 1072-without NAFLD). Overall there were 169 (6.2%) deaths [41-deaths among NAFLD (17-cardiovascular; 9-cancer-related; 4-liver-specific; 11-other) and 79-deaths among no-NAFLD (28-cardiovascular; 17-cancer-related; 1-liver-specific; 33-other)]. Metabolic syndrome (MetS), low-education level, higher age and male-gender independently predicted ACM. MetS, increasing age and male-gender independently predicted CVM. NAFLD did not predict either ACM or CVM. In those with NAFLD, MetS and age >55-years were independently associated with ACM, while MetS and male-gender were associated with CVM.CONCLUSION:In this community-based study, increasing age, male-gender and MetS, but not NAFLD, predicted 10-year ACM and CVM. Among those with NAFLD, only those metabolically abnormal were at a higher risk for mortality.Item Lean non-alcoholic fatty liver disease (lean NAFLD): characteristics, metabolic outcomes and risk factors from a 7-year prospective, community cohort study from Sri Lanka(Springer, 2019) Niriella, M.A.; Kasturiratne, A.; Pathmeswaran, A.; de Silva, S.T.; Perera, K. R.; Subasinghe, S.K.C.E.; Kodisinghe, S.K.; Piyaratna, T.A.C.L.; Vithiya, K.; Dassanayake, A.S.; de Silva, A.P.; Wickremasinghe, A.R.; Takeuchi, F.; Kato, N.; de Silva, H.J.INTRODUCTION: While patients with non-alcoholic fatty liver disease (NAFLD) are mostly overweight or obese, some are lean. METHODS: In a community-based follow-up study (baseline and follow-up surveys performed in 2007 and 2014), we investigated and compared the clinical characteristics, body composition, metabolic associations and outcomes, and other risk factors among individuals with lean (BMI < 23 kg/m2) NAFLD, non-lean (BMI ≥ 23 kg/m2) NAFLD and those without NAFLD. To investigate associations of selected genetic variants, we performed a case-control study between lean NAFLD cases and lean non-NAFLD controls.RESULTS: Of the 2985 participants in 2007, 120 (4.0%) had lean NAFLD and 816 (27.3%) had non-lean NAFLD. 1206 (40.4%) had no evidence of NAFLD (non-NAFLD). Compared to non-lean NAFLD, lean NAFLD was commoner among males (p < 0.001), and had a lower prevalence of hypertension (p < 0.001) and central obesity (WC < 90 cm for males, < 80 cm for females) (p < 0.001) without prominent differences in the prevalence of other metabolic comorbidities at baseline survey. Of 2142 individuals deemed as either NAFLD or non-NAFLD in 2007, 704 NAFLD individuals [84 lean NAFLD, 620 non-lean NAFLD] and 834 individuals with non-NAFLD in 2007 presented for follow-up in 2014. There was no difference in the occurrence of incident metabolic comorbidities between lean NAFLD and non-lean NAFLD. Of 294 individuals who were non-NAFLD in 2007 and lean in both 2007 and 2014, 84 (28.6%) had developed lean NAFLD, giving an annual incidence of 4.1%. Logistic regression identified the presence of diabetes at baseline, increase in weight from baseline to follow-up and a higher educational level as independent risk factors for the development of incident lean NAFLD. NAFLD association of PNPLA3 rs738409 was more pronounced among lean individuals (one-tailed p < 0.05) compared to the whole cohort sample. CONCLUSION: Although lean NAFLD constitutes a small proportion of NAFLD, the risk of developing incident metabolic comorbidities is similar to that of non-lean NAFLD. A PNPLA3 variant showed association with lean NAFLD in the studied population. Therefore, lean NAFLD also warrants careful evaluation and follow-up.Item Septicaemia caused by Elizabethkingia-sp in a 'healthy' Sri Lankan man(London : Sage, 2018) Sebastiampillai, B.S.; Luke, N.V.; de Silva, S.T.; Premaratna, R.Item Frequency, pattern and short-term outcome of chronic renal dysfunction in patients with cirrhosis: a prospective study using HRS and ADQI-IAC criteria(Lippincott Williams And Wilkins, 2014) de Silva, S.T.; Perera, R.P.; Niriella, M.A.; Pathmeswaran, A.; de Silva, H.J.BACKGROUND: Diagnostic criteria of hepatorenal syndrome type 2 (HRS2) fail to detect milder degrees of chronic renal dysfunction (CRD) in cirrhosis and exclude patients with pre-existing kidney disease. Definitions addressing this have been proposed by Working Party of the Acute Dialysis Quality Initiative and International Ascites Club (ADQI-IAC). AIMS: We studied the frequency, pattern and short-term outcome of CRD in patients with cirrhosis, using both HRS2 and ADQI-IAC criteria. PATIENTS AND METHODS: Consecutive patients with cirrhosis and stable serum creatinine for 3 months or more attending outpatient clinics in Colombo North Teaching Hospital (Ragama, Sri Lanka) were prospectively recruited and followed up. RESULTS: Of 277 patients with cirrhosis and stable serum creatinine, 23 (8.3%) fulfilled criteria for HRS2, and 65/277 (23.5%) had estimated glomerular filtration rate (eGFR) less than 60 ml/min/1.73 m [ADQI-IAC definition of chronic kidney disease (CKD)]. This included the 23 patients with HRS2 and an additional 42/65 (64.6%) who did not fulfil diagnostic criteria for HRS2 (non-HRS2 CKD). In all, 58/277 (20.9%) died during follow-up [mean 9.8 months (SD 4.5)]. This included 12/23 (52.2%) with HRS2 and 14/42 (33.3%) with non-HRS2 CKD. On the basis of multiple regression model, Child-Turcotte-Pugh class and CRD were significantly associated with death. After correcting for Child-Turcotte-Pugh class, both HRS2 (odds ratio 4.56, 95% confidence interval 1.79-11.53) and non-HRS2 CKD (odds ratio 2.19, 95% confidence interval 1.02-4.68) were independently associated with death. CONCLUSION: Compared with HRS2 criteria, eGFR less than 60 ml/min/1.73 m detected almost twice the number of cirrhotics with CRD. Patients with eGFR less than 60 ml/min/1.73 m who did not fulfil criteria for HRS2 also had significant short-term mortality. ADQI-IAC criteria thus appear to be a more useful definition of CRD in cirrhotics.Item Mycotic aneurysm of the descending aorta due to Aspergillus species(Sri Lanka Medical Association, 2010) Mettananda, K.C.D.; de Silva, S.T.; Premawardhena, A.P.Mycotic aneurysms of the aorta are rare, and carry a poor prognosis unless detected and treated promptly. Aneurysms caused by Aspergillus species usually occur due to invasive pulmonary aspergillosis, septic embolisation or direct extension from the lung, mainly in immuno-compromised individuals. We report a case of descending aortic aneurysm caused by Aspergillus species in a previously immuno-competent individual