Strongyloidiasis infection in a borderline lepromatous leprosy patient with adrenocorticoid insufficiency undergoing corticosteroid treatment: a case report

BACKGROUND

Strongyloidiasis is a soil-transmitted helminthiasis mainly caused by Strongyloides stercoralis. It is endemic to the tropics and subtropics. Sri Lanka has a 0-1.6% prevalence rate. S. stercoralis infection was identified in a 33-year-old Sri Lankan male patient treated with corticosteroids for borderline lepromatous leprosy with adrenocortical dysfunction.

CASE PRESENTATION

In March 2020, a 33-year-old Sri Lankan (Sinhalese) male patient presented with watery diarrhea, lower abdominal pain, and post-prandial abdominal fullness. Previously, he was diagnosed with borderline lepromatous leprosy and was treated with rifampicin, clofazimine, and prednisolone 60 mg daily since July 2019. After developing gastrointestinal symptoms, he had defaulted leprosy treatment including the prednisolone for 3 months. Duodenal biopsy revealed numerous intraepithelial nematodes within the lumina of glands in the duodenum whose appearance favored Strongyloides. Fecal wet smear revealed numerous Strongyloidis stercoralis L1 rhabditiform larvae. Larval tracks were seen in the agar plate culture. L3 filariform larvae of Strongyloidis stercoralis were seen in the Harada-Mori culture. In addition, the short synacthen test revealed adrenocortical insufficiency, and oral hydrocortisone and fludrocortisone were started with albendazole treatment against strongyloidiasis. Fecal wet smear and culture repeated after treatment with albendazole were negative for Strongyloidis stercoralis. The patient was discharged in July 2020 on oral hydrocortisone. One month later his condition was reviewed and the repeated fecal wet smear and agar plate culture was normal. He is being followed up every 3 months.

CONCLUSION

This is the first case of strongyloidiasis diagnosed in a patient with borderline lepromatous leprosy from Sri Lanka. The patient manifested symptoms of strongyloidiasis while on high-dose steroid therapy for his lepromatous reaction. Subsequently, the patient not only discontinued his steroid therapy, but also developed adrenocortical insufficiency as a complication of leprosy. Therefore, although diagnosis of strongyloidiasis was delayed, his subsequent low steroid levels probably protected him from disseminated disease. This is an interesting case where symptomatic strongyloidiasis was diagnosed in a patient who was initially treated with high-dose steroids but subsequently developed adrenocortical insufficiency. We emphasize the need to screen all patients prior to the commencement of immunosuppressive therapy.

Experimental rat model for acute tubular injury induced by high water hardness and high water fluoride: efficacy of primary preventive intervention by distilled water administration

Background

High water hardness associated with high water fluoride and the geographical distribution of Chronic Kidney Disease of unknown etiology (CKDu) in Sri Lanka are well correlated. We undertook this study to observe the effects of high water hardness with high fluoride on kidney and liver in rats and efficacy of distilled water in reducing the effects.

Methods

Test water sample with high water hardness and high fluoride was collected from Mihinthale region and normal water samples were collected from Kandy region. Twenty-four rats were randomly divided into 8 groups and water samples were introduced as follows as daily water supply. Four groups received normal water for 60 (N1) and 90 (N2) days and test water for 60 (T1) and 90 (T2) days. Other four groups received normal (N3) and test (T3) water for 60 days and followed by distilled water for additional 60 days and normal (N4) and test (T4) water for 90 days followed by distilled water for another 90 days. The rats were sacrificed following treatment. Serum samples were subjected to biochemical tests; serum creatinine, urea, aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP) and elemental analysis. Histopathological examinations were carried out using kidney and liver samples.

Results

Test water treated groups were associated with acute tubular injury with loss of brush border and test water followed with distilled water treated groups maintained a better morphology with minimal loss of brush border. Serum creatinine levels in T1 and T2 groups and urea level in T2 group were significantly (p < 0.05) increased compared to control groups. After administration of distilled water, both parameters were significantly reduced in T4 group (p < 0.05) compared to T2. Serum AST activity was increased in T4 group (p < 0.05) compared to control group with no histopathological changes in liver tissues. The serum sodium levels were found to be much higher compared to the other electrolytes in test groups.

Conclusion

Hard water with high fluoride content resulted in acute tubular injury with a significant increase in serum levels of creatinine, urea and AST activity. These alterations were minimized by administering distilled water.

Heart and liver are infected in fatal cases of dengue: three PCR based case studies

Background

Dengue is a global problem mainly in the tropics. Meticulous clinical management of cases has reduced the death rate significantly, but large numbers of people still succumb to severe complications of the infection. Presence of myocarditis is often overlooked leading to a poor outcome. Clinical management guidelines of dengue do not stress the importance of myocarditis as a manifestation in dengue infection. Severe hepatic dysfunction also needs emphasis.

Case presentation

We present three patients who had come to hospital on the 3rd day of fever. Two of them (case 1 and 3) were in shock on admission and case 2, who was stable on the3^rd day, went into the critical phase and developed shock while in the hospital on the 4^thday. All three had tachycardia on admission that got worse with time. The clinical course was unstable with fluctuations in urine output and deterioration of organ function. Despite frequent monitoring and life support they survived only 2–3 days in hospital. All three patients had myocarditis during the critical phase. In the first case, myocarditis was confirmed by troponin estimation and echocardiogram. In the second and third cases, histopathology confirmed myocarditis. Haemorrhagic necrosis of the liver was found in case 2 and 3 with exponential rise of transaminases. In all three cases, viral RNA was detected in both heart and liver tissues by PCR amplification.

Conclusions

We stress that detection of myocarditis and liver involvement in any dengue patient is important from the onset of the illness where treatment should be tailored to prevent development of hypotension. Our findings are novel as PCR and histology are rarely done on tissues of deceased dengue patients in the world. Studies are needed to find therapeutic interventions to reverse cardiac and hepatic dysfunction in dengue infection.

Effect of fluoride on major organs with the different time of exposure in rats

Background

High fluoride levels in drinking water in relation to the prevalence of chronic kidney disease of unknown etiology (CKDu) in Sri Lanka were investigated using rats as an experimental model.

Method

The effects of fluoride after oral administration of Sodium fluoride (NaF) at levels of 0, 0.5, 5 and 20 ppm F⁻ were evaluated in adult male Wistar rats. Thirty-six rats were randomly divided into 4 groups (n = 9), namely, control, test I, II, and III. Control group was given daily 1 ml/rat of distilled water and test groups I, II, and III were treated 1 ml/rat of NaF doses of 0.5, 5, and 20 ppm, respectively, by using a stomach tube. Three rats from the control group and each experimental group were sacrificed after 15, 30, and 60 days following treatment. Serological and histopathological investigations were carried out using blood, kidney, and liver.

Results

No significant differences were observed in body weight gain and relative organ weights of the liver and kidney in fluoride-treated groups compared to control group. After 60 days of fluoride administration, group I showed a mild portal inflammation with lytic necrosis while multiple areas of focal necrosis and various degrees of portal inflammation were observed in groups II and III. This was further confirmed by increased serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase (ALP) activities. As compared with control and other treated groups, group III showed a significantly higher serum AST activity (p < 0.05) and ALT activity (p < 0.05) after 60 days and ALP activity with a significant difference (p < 0.05) after 15, 30, and 60 days. The renal histological analysis showed normal histological features in all groups with the elevated serum creatinine levels in group III compared to those in the groups I and II (p < 0.05) after 60 days. Significantly elevated serum fluoride levels were observed in group II of 30 and 60 days and group III after 15, 30, and 60 days with respective to control groups (p < 0.05).

Conclusion

Taken together, these findings indicate that there can be some alterations in liver enzyme activities at early stages of fluoride intoxication followed by renal damage.

Impact of molecular structure on the physicochemical properties of starches isolated from different field pea (Pisum sativum L.) cultivars grown in Saskatchewan, Canada

The objective of this study was to determine the molecular structure and properties of recently released cultivars of field peas [CDC Golden (CDCG), Abarth (ABAR), CDC Patrick (CDCP) and CDC Amarillo (CDCA)] grown at different locations in Saskatchewan, Canada. Starch yield (on whole seed basis), apparent amylose, total lipid and specific surface area were in the range 34-37%, 38.2-42.6%, 1.07-1.38% and 0.31-0.38m2/g, respectively. The proportion of short (DP 6-12) amylopectin chains, amylopectin branching density, molecular order, crystallinity, crystalline heterogeneity, gelatinization transition temperatures, pasting temperatures, peak viscosity, extent of acid hydrolysis, and resistant starch content were higher in CDCG and ABAR. However, amylopectin long chains (DP 13-26), average chain length and thermal stability were higher in CDCP and CDCA. The results of this study showed that differences in physicochemical properties among cultivars were mainly influenced by amylopectin chain length distribution, amylopectin branching density and co-crystallization of amylose with amylopectin.

Fatal acute pulmonary oedema and acute renal failure following multiple wasp/hornet (Vespa affinis) stings in Sri Lanka: two case reports

Introduction

Vespa affinis is a hornet widely distributed in Sri Lanka and it is responsible for the highest number of deaths related to Hymenoptera stings. Apart from the early reactions, victims often die in hospital many hours later due to complications such as myocardial infarction and multiple organ failure. Increased microvascular permeability and acute pulmonary oedema as the primary pathology is less known in hornet envenoming.

Case presentation

Here, we report clinical and postmortem findings of two Sinhalese patients, a 48-year-old husband and his 46-year-old wife, who both died following a massive attack by hornets 32 hours and 9 hours after the incidence respectively. At postmortem examination, both patients had pleural effusions, acute pulmonary oedema and red cell casts in their urine. Their coronary arteries and histology of myocardium were normal.

Conclusion

Early recognition of acute pulmonary oedema in hornet stings is needed with implementation of crucial treatments to avert deaths.

Metabolic and polycystic ovary syndromes in indigenous South Asian women with previous gestational diabetes mellitus

OBJECTIVE

To determine the risk of metabolic syndrome (MS) and polycystic ovary syndrome (PCOS) in a cohort of indigenous South Asian women with a recent history of gestational diabetes mellitus (GDM).

DESIGN

Case-control study.

SETTING

Department of Obstetrics & Gynaecology, University of Colombo, Sri Lanka.

SAMPLE

Two hundred and seventy-four indigenous Sri Lankan women with previous GDM and 168 ethnically matched controls. Of these, 147 with previous GDM and 67 controls not taking hormonal contraception participated in an in-depth endocrine study.

METHODS

Assessing the prevalence of MS and PCOS based on clinical features, biochemistry and ovarian ultrasound examination at 3 years postpartum.

MAIN OUTCOME MEASURES

Prevalence of MS and PCOS.

RESULTS

Women with previous GDM and controls were studied at a mean (range) of 34.6 (13.4-84.1) and 46.5 (17.5-78) months postpartum, respectively. Those with previous GDM had a larger mean +/- 95% confidence interval waist circumference (90.9 +/- 1.3 versus 81.2 +/- 2.8 cm, P = 0.0004) and were more likely to have hypertension (17.6 versus 7.4%, P = 0.001), glucose intolerance (51.7 versus 10.4%, P = 0.00001), hypertriglyceridaemia (16.3 versus 5.9%, P = 0.02) and a lower level of high-density lipoprotein (70 versus 56.7%, P = 0.04) than the controls. Of the women who had GDM, 72 (49%) had MS, 86 (58.5%) had polycystic ovaries and 59 (40%) had PCOS, significantly more than the control women-4 (6%), 9 (13%) and 2 (3%), respectively (P = 0.00001).

CONCLUSIONS

The prevalence of MS and PCOS in indigenous Sri Lankan women 3 years postpartum is significantly higher in those with previous GDM compared with ethnically matched controls. This confirms an association between GDM and subsequent PCOS and MS.