Kushalee Jayawickreme - Academia.edu (original) (raw)

Papers by Kushalee Jayawickreme

Sri Lanka Journal of Diabetes Endocrinology and Metabolism, Aug 8, 2023

Vanishing testicle syndrome (VTS) is due to regression of already formed testes. This could occur... more Vanishing testicle syndrome (VTS) is due to regression of already formed testes. This could occur at any stage during or after testicular descent due any insult resulting in testicular atrophy. VTS is estimated to affect 1:1250 males. We present a rare case of a 12-year-old boy presenting with absent secondary sexual characteristics and short stature found to have bilateral vanishing testicle syndrome. His testes were impalpable at neonatal examination. At the age of 1.5 years an ultrasound scan detected the right testis in the inguinal ring, measuring 1.5 x 1 cm with features suggestive of ischaemia with likely acute or subacute torsion. The left testes was seen in the inguinal canal already atrophied by that time. Subsequently, on surgical exploration the right testis was found atrophied in the inguinal canal, and was replaced in the right sub-dartose pouch, but left testis could not be identified. Surprisingly, 4 months later laparoscopic exploration failed to identify either of the testes except for bilateral atrophied gubernaculum, indicating testicular regression. At the age of 7 years, magnetic resonance imaging confirmed the absence of either of the testes, with no remnants. On examination his height was 146.5cm, which was between the 25 th and 50 th percentile for that age, and below his mid-parental height range. He had no androgenic hair growth, testes were impalpable and had a prepubertal penis accounting to tanner stage of 1. He had hypergonadotrophic hypogonadism. Pubertal induction was done with testosterone injections which resulted in height gain and development of secondary sexual characteristics.

Journal of Medical Case Reports

Background Systemic lupus erythematosus is a rare autoimmune disorder, with the prevalence in Asi... more Background Systemic lupus erythematosus is a rare autoimmune disorder, with the prevalence in Asia ranging from 30 to 50/100,000. The diagnosis of systemic lupus erythematosus is made according to the 2019 European League Against Rheumatism/American College of Rheumatology classification criteria, and it does not contain lymphadenopathy as diagnostic criteria. However, lupus lymphadenopathy has an estimated prevalence of 5–7% at the onset of disease, and 12–15% at any stage of the disease. Case presentation A 19-year-old Sinhalese girl had neck nodules since the age of 5 years, which increased in size and became tender since 1 year. She had alopecia and joint stiffness for 6 months. She presented with a 5-day history of worsening joint pain, fever, and painful, enlarging cervical nodules. She had tender cervical lymphadenopathy, and a vasculitic rash on both lower limbs. She had pancytopenia, an erythrocyte sedimentation rate of 92, positive antinuclear antibody titer, and high anti...

Journal of the Postgraduate Institute of Medicine, 2017

Background and Objectives Ambulatory blood pressure monitoring (ABPM) is more reflective of an in... more Background and Objectives Ambulatory blood pressure monitoring (ABPM) is more reflective of an individual's blood pressure (BP) profile and its control, eliminating several confounding and contributory factors. This study looked at the circadian pattern of BP variation with respect to nocturnal BP fluctuations and compared clinic BP measurements with ambulatory readings in patients on treatment for essential hypertension Methods A prospective study was conducted at Teaching Hospital, Kandy from August to October 2015. The study participants were 100 patients, above 18 years of age, with stage I to III essential hypertension with normal renal functions and having no history of coronary or cerebro-vascular events. All patients underwent electrocardiography, 2D echocardiography, manual BP measurement and 24-hour ambulatory blood pressure monitoring. Results There was a female preponderance 72(72%) and the mean age was 61 ± 9 years. One third had uncontrolled BP, according to clinic BP readings, whereas 60% had uncontrolled BP according to ambulatory blood pressure monitoring. The agreement between the office BP and ABPM in diagnosing controlled or uncontrolled BP was low (58%, Kappa = 0.23). A significant statistical difference (p<0.001) was observed between day and night time measurements, irrespective of BP control. In the sample, 70% had abnormal dipping patterns including non-dipping (45%), reverse dipping (25%) and extreme dipping (5%). Conclusions and Recommendations ABPM is more reflective of an individual's naïve BP pattern. It captures the different types of diurnal variation of BP thus guiding the physician to treat the patient optimally. Moreover, its noninvasive and portable nature allows it to be used with ease. It is likely that ABPM will gather widespread recognition and acceptance as a more reliable diagnostic and prognostic tool in the future

Ceylon Medical Journal, 2018

Introduction Understanding the diurnal variation of blood pressure (BP) is important in the manag... more Introduction Understanding the diurnal variation of blood pressure (BP) is important in the management of hypertension. Objectives Primary objectives of the study were to analyse the pattern of nocturnal BP in patients with essential hypertension who are already on treatment. Methodology Cross-sectional descriptive study was conducted at cardiology unit Teaching Hospital Kandy, in 2015, in patients referred from the hypertensive clinic at Teaching Hospital Peradeniya. A consecutive sample of 100 essential hypertensives aged >18 years with stage I to III hypertension were included. Patients with a history of previous ischemic heart disease or cerebro-vascular events were excluded. Twenty-four-hour ambulatory blood pressure monitoring was performed in all patients after complete clinical evaluation. Results Sample size was 100. Mean age was 60.86 ± 8.73 years. Twenty eight were male. In the sample 32 had normal dipping patterns. Out of the 68 with abnormal dipping, 45 had sub-optimal dipping, 19 had reverse dipping and 4 had extreme dipping. There were 72 patients with nocturnal hypertension, of them 29 (39.7%) had isolated nocturnal hypertension. Conclusion A high prevalence of abnormal dipping, nocturnal hypertension and isolated nocturnal hypertension among our sample of patients with essential hypertension. Therefore, it is important to increase awareness and to consider ambulatory blood pressure monitoring to detect these abnormal nocturnal blood pressure variations.

Journal of Medical Case Reports, 2019

Background Brugmansia suaveolens is the commonest species under the Solanacea (“Angels Trumpet” i... more Background Brugmansia suaveolens is the commonest species under the Solanacea (“Angels Trumpet” in English; “Attana” in Sinhalese) plant family in Sri Lanka. It contains alkaloids like scopolamine, atropine and hyoscyamine which can cause an anticholinergic toxindrome. There have been a few reported cases of accidental ingestion of Brugmansia seeds among children, seeds being the most toxic part, but no such reported cases of Brugmansia leaves poisoning among adults. Case presentation A 60-year-old-female Sinhalese presented with acute confusion, delirium, and agitation. She had ingested a herbal drink made from leaves of an unknown plant from her garden prior to onset of symptoms. She had urinary retention, mydriasis and sinus tachycardia. She was managed supportively with activated charcoal and hydration and the delirium completely resolved within 15 hours. The presented unkown plant leaves were identified as Brugmansia suaveolens. Conclusion Although seeds are the most toxic plan...

Clinical and Experimental Hypertension, 2017

Microalbuminuria, a subtle increase in the urinary excretion of albumin that cannot be detected b... more Microalbuminuria, a subtle increase in the urinary excretion of albumin that cannot be detected by the conventional urinalysis method, is an early marker of cardiovascular complications and increased cardiovascular risk in hypertension. The prevalence of microalbuminuria (MAU) is prone to modification by factors such as age, race, and severity of the disease process and presence of co-morbid factors. In view of this, a range of rates abound from various studies. In addition the methodologies of evaluation of MAU also contribute to the observed differences in prevalence reported in literature. Due to the challenges of 24-hour urine estimation, albumin excretion rate (AER) methods using spot urine has gained wide clinical acceptance. In our environment however, AER methods are not in widespread routine use and patients are still assessed by conventional dipsticks for urinalysis with the consequence outcome of not identifying patients with MAU. In this study, we evaluated sixty-four newly diagnosed hypertensives for MAU using a semi-quantitative urine test strip based on the immunoassay principle (ChemstripMicral TM-Roche). The prevalence of MAU was 47% in our study and these subjects had all been evaluated with the conventional urine dipsticks. Of our study subjects, only a third was on reno-protective medications such as angiotensin-converting enzyme inhibitors. These findings indicate the need for the introduction of screening for MAU using these types of strips in lieu of the current conventional urinalysis in the assessment of hypertensives. This can be used for stratification of the patients to allow for subsequent AER evaluation in those detected as having MAU by this screening tool. This is important as it will guide treatment choices for the patients, especially given the challenges of cost in our resource-poor environment.

BMC Infectious Diseases, 2021

Background The World Health Organization (WHO) has ranked dengue as one of the top ten threats to... more Background The World Health Organization (WHO) has ranked dengue as one of the top ten threats to Global health in 2019. Sri Lanka faced a massive dengue epidemic in 2017, the largest outbreak in the country during the last three decades, consisting of 186,101 reported cases, and over 320 deaths. The epidemic was controlled by intense measures taken by the health sector. However, the reported dengue cases and dengue deaths in 2019 were significantly higher than that of 2018. Deaths were mostly due to delay in hospitalization of severe dengue patients. The mortality of dengue hemorrhagic fever is 2–5% if detected early and treated promptly, but is high as 20% if left untreated. Methods A descriptive cross-sectional study was done among patients with dengue fever presenting to the Sri Jayawardenepura General Hospital during October 2019. Data was collected using a questionnaire comprising 20 questions based on knowledge, attitudes and practices on dengue, which were categorized into q...

Case Reports in Infectious Diseases, 2021

Dengue is an arboviral infection that affects humanscausing significant morbidity and mortality i... more Dengue is an arboviral infection that affects humanscausing significant morbidity and mortality in tropical countries. Our first patient who had diabetes presented with shock and was managed as dengue hemorrhagic fever with superadded sepsis which required noradrenalin plus broad-spectrum intravenous antibiotics. The second patient developed severe bradycardia during the ascending limb of the critical phase with hemodynamic stability, which recovered on discharge. Third patient presented with severe and rapid leaking; we used intravenous albumin as an alternative colloid with good outcome. The fourth patient was a pregnant mother at term, and she went into spontaneous labor during the latter half of the critical phase. The fifth patient developed dengue hemorrhagic fever complicated with probable haemophagocytic lymphohistiocytosis. She was treated with intravenous steroids andimmunoglobulin, yet succumbed on day 7. Conclusion. Dengue is an extremely challenging and dynamic disease,...

Background: Ewing sarcoma is a primary bone neoplasm, which is a high grade aggressive small roun... more Background: Ewing sarcoma is a primary bone neoplasm, which is a high grade aggressive small round blue cell tumour, and is currently recognized as a part of the Ewing family of tumours. It is the most lethal bone tumor, and is a rare malignant bone tumor accounting for 10 % of all primary bone tumors, and 6 % of malignant bone tumors. It has an average annual incidence of 3 per 1 million, found almost exclusively in Caucasians. It commonly occurs in long bones and pelvis but rarely involves the scapula. 85 % of cases have metastasis within 2 years of diagnosis, rarely involving the meninges. Case presentation: We report a case of a 25 year old Sinhalese Sri Lankan female, presenting with a 1 day history of bilateral lower limb weakness and urinary incontinence. She had a sensory level with flaccid paralysis of lower limbs and a painless bony lump in the left dorsal scapula. Investigations showed scapular primary Ewing sarcoma giving rise to spinal intradural metastasis. For the bes...

Background: Vitamin B12 deficiency is often diagnosed with hematological manifestations of megalo... more Background: Vitamin B12 deficiency is often diagnosed with hematological manifestations of megaloblastic macro-cytic anemia, which is usually the initial presentation. Neurological symptoms are often considered to be late manifes-tations and usually occur after the onset of anemia. Sub acute combined cord degeneration, which is a rare cause of myelopathy is however the commonest neurological manifestation of vitamin B12 deficiency. Case presentation: We present a case of a 66 year old Sinhalese Sri Lankan female, who is a strict vegetarian, pre-senting with one month’s history suggestive of Sub-acute combined cord degeneration in the absence of haema-tological manifestations of anaemia. Her Serum B12 levels were significantly low, after which she was treated with hydroxycobalamine supplementation, showing marked clinical improvement of symptoms, with normalization of serum B12 levels. Hence, the diagnosis of vitamin B12 deficiency was confirmed retrospectively. Conclusion: Vitamin B...

Endocrinology, Diabetes & Metabolism Case Reports

Summary Treatment of insulinoma can be challenging, while surgical resection is considered the fi... more Summary Treatment of insulinoma can be challenging, while surgical resection is considered the first line. When surgery is contraindicated or is refused, minimally invasive procedures such as selective arterial embolization, local ablative techniques including alcohol ablation, radiofrequency ablation and microwave ablation are being used of late. The world’s first microwave ablation of insulinoma was performed in 2015, after which there have been only a handful of reported cases. A 78-year-old female presented with painful swelling of the left lower limb. She was drowsy and was previously misdiagnosed as epilepsy when she had similar episodes since 2 years ago. She had hypoglycaemia with high serum insulin and C-peptide, and mildly high adjusted calcium, serum prolactin. MRI did not show pituitary adenoma. Lower limb venous duplex scan showed left lower limb deep vein thrombosis for which she was treated with anticoagulation. CT of the abdomen showed a tumour measuring 1.8 cm, loca...

Case Reports in Endocrinology, 2021

Introduction Recurrent vomiting is a commonly overlooked debilitating symptom which causes signif... more Introduction Recurrent vomiting is a commonly overlooked debilitating symptom which causes significant impact on the quality of life. There are several causes for vomiting, ranging from commonly known causes to rare causes. Nonfunctioning pituitary macroadenomas generally present with visual disturbances, headache, and symptoms due to anterior pituitary hormone deficiencies. This case report is about an atypical presentation of a nonfunctioning pituitary macroadenoma in which the patient presented with cyclical vomiting with severe hyponatremia. Case Report. A 23-year-old girl presented with four to five episodes of vomiting per day for two days duration. She had a history of similar episodes of vomiting since 2016, with each episode generally lasting for 4-5 days and occurring in every four to six months. All episodes exhibited similar symptomatology and she was free of symptoms in-between. Generalized body weakness, postural dizziness, reduced appetite, and secondary amenorrhea we...

Background: Pulmonary hemorrhage is a very rare complication of dengue infection. This condition ... more Background: Pulmonary hemorrhage is a very rare complication of dengue infection. This condition presenting with hemoptysis has been reported in 1.4% of dengue infections. However, major hemorrhage is unusual except when associated with profound or prolonged shock. In contrast although this case showed no features of plasma leakage, it resulted in massive pulmonary hemorrhage leading to death. Case Presentation A 17 year old previously healthy Sri Lankan, Sinhalese male presented with a 5 day history of fever. On admission he was ill looking and the hematocrit was 44.8%. He was treated in the High Dependency Unit with close monitoring and was started on normal saline 100 ml per hour and showed improved blood pressure and hematocrit value of 41.5% with the initial chest X-ray and ultrasound on abdomen showing no fluid leakage. But within a few hours he developed sudden onset of hemoptysis and respiratory distress, and an urgent chest X-ray taken showed a patchy right sided middle lob...

Clinical and Experimental Hypertension

Sri Lanka Journal of Medicine

Background A significant number of patients presenting with ureteric colic and other urinary symp... more Background A significant number of patients presenting with ureteric colic and other urinary symptoms have been observed at Rikillagaskada District Base Hospital, situated in the Nuwara-Eliya District, Sri Lanka. Materials and Methods Clinical and demographical features of a total of 116 patients presenting with features of urinary stone disease were analysed from May 2010 to December 2011. Results The mean age of the study sample was 46.61 years (SD=13.22) (range: 18-81 years). This included 72 (62.1%) males with a mean age of 47.69 ± 14.28 years, while the mean age of females was 44.84 ± 11.21 years. The major presenting symptom was flank pain (in 89.7 % of participants) , and dysuria (in 56% of participants). Forty two (36.2%) patients had a past history of ureteric colic. Conclusions Further studies with larger populations will be useful in further characterization of clinical and epidemiological data of the population.

European Oncology & Haematology

BMC Cardiovascular Disorders

Background: Acute Coronary Syndrome (ACS) is one of the leading causes of death worldwide and stu... more Background: Acute Coronary Syndrome (ACS) is one of the leading causes of death worldwide and studies have shown higher mortality rates and premature death in South Asian countries. The occurrence and effect of risk factors differ by type ofACS.Epidemiological studies in the Sri Lankan population are limited. Methods: This is a cross sectional descriptive study conducted at the Teaching Hospital Peradeniya, Sri Lanka among patients presenting with ACS. Data was collected by an interviewer administered structured questionnaire and epidemiological patterns and risk factors were analyzed. Results: The sample of 300 patients had a mean age of 61.3+/− 12.6 and male sex showed higher association with all three type of ACS compared to female with a P value of 0.001. This study showed higher mean age of 62.2 ± 11.4 years amongst unstable angina (UA) patients and 61.9 ± 14.5 years amongst non ST elevation myocardial infarction (NSTEMI) patients compared to 59.2 ± 11.2 years for ST elevation myocardial infarction (STEMI) patients with no significant statistical difference (P = 0.246). Approximately 55.8% STEMI patients, 39.8% UA and 35.5% NSTEMI patients were smokers indicating a significant association between smoking and STEMI (P = 0.017). Nearly 54.5% STEMI, 35.4% UA and 32.7% NSTEMI patients consumed alcohol and there was a very strong association between alcohol consumption and STEMI (P = 0.006). Almost 51.8% NSTEMI patients, 47.8% UA patients and 29.9% STEMI patients had hypertension(HT) (P = 0.008) indicating significant association of HT with UA and NSTEMI. About 33.6% UA patients and 30.0% NSTEMI patients had DM whilst only 22.1% of STEMI patients had DM of no significance (p = 0.225). Around 15.0% patients with UA, 25.5% with NSTEMI and 11.7% with STEMI had dyslipidemia (P = 0.032). There was a very strong association between a past history of ACS or stable angina with NSTEMI and UA (P = 0.001). Conclusion: Smoking and alcohol abuse are significantly associated with STEMI.Patients with NSTEMI or Unstable Angina had higher rates of hypertension and were more likely to have a history of ACS or stable angina than STEMI patients. Patients with NSTEMI were more likely than patients with STEMI or UA to have dyslipidemia.

BMC Research Notes, 2016

Background: Advanced life support (ALS) and cardio pulmonary resuscitation, provided at the right... more Background: Advanced life support (ALS) and cardio pulmonary resuscitation, provided at the right time is essential for improving mortality in medical emergencies. Accurate knowledge and skills on this regard, in all medical personals is an essential part of medical education and it should be up to date with varying protocols. The aim of this study is to assess the knowledge and attitudes among the undergraduate medical students and medical officers in the Teaching Hospital Peradeniya and provide suggestions to improve the training programme on ALS. Methods: A standardized self-administered questionnaire regarding knowledge and attitudes on ALS was filled by 4th and final year medical students, and medical officers, and the data was analyzed. Results: There were 411 eligible candidates and of them 130 (31.6 %) were 4th year medical students, 221 (53.8 %) were final year medical students and 60 (14.6 %) were medical officers. Of the medical officers, only 15.8 % indicated that the internship training was adequate to handle an emergency confidently. Approximately 45 % of the medical officers and 34.6 % of the final year medical students were confident of saving lives with their current ALS knowledge. However, only 22 % of 4th year medical students were confident in saving the life of a patient. Conclusions: Overall, just over 10 % of participants demonstrated inadequate ALS knowledge scores. A significantly higher proportion of final year medical students had good knowledge, compared to medical officers and 4th year students. Only one-third of participants were confident in saving a life with their current ALS knowledge. Nearly all participants thought that the ALS course should be reevaluated frequently.

BMC Pharmacology and Toxicology, 2016

Background: Sri Lanka has a high suicide rate, with more than 40 % of poisoning admissions due to... more Background: Sri Lanka has a high suicide rate, with more than 40 % of poisoning admissions due to overdose of drugs with Paracetamol being the commonest. Data regarding cardiotoxicity to paracetamol is very minimal though hepatotoxicity following poisoning is well studied. Paracetamol cardiotoxicity has rarely been clinically significant and may have well been overlooked. The possibility that paracetamol overdose might be directly cardiotoxic has been the subject of a few reports. Unexplained deaths and electrocardiographic changes associated with paracetamol poisoning have also been reported in which cardiac origin cannot be clearly ruled out. Although some studies state that paracetamol poisoning has no direct cardiotoxic effect, electrocardiographic changes due to metabolic derangement of hepatotoxicity have been shown in certain studies. Thus, we conducted this study to assess in detail the cardiotoxic effect of paracetamol poisoning. Methods: This is a cross sectional descriptive study done on those with confirmed paracetamol poisoning. Serum paracetamol levels, Electrocardiogram, Echocardiogram, troponin I, and other basic investigations were done. Results: Paracetamol ingestion is more common among teenagers and the young population in Sri Lanka. Although several cases of paracetamol poisoning induced cardiotoxicity has been described in the past, this study demonstrated no electrocardiographic, echocardiographic or cardiac biomarkers changes of myocardial toxicity. Conclusion: Though literature review support cardiotoxicity following paracetamol poisoning, our study does not provide enough evidence for this. Continuous cardiac monitoring, serial troponin and echocaediogram assessment would be voluble adjunct in its management. Further experiments and research in this subject would be useful with a larger number of samples to further evaluate this important problem.