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Gallbladder duplication is a rare anomaly of the biliary tree. Implications of misdiagnosis include unwarranted surgery and morbidity such as when liver resections are done suspecting cystic intraductal papillary neoplasm of the bile duct. The use of appropriate imaging, when suspected, facilitates diagnosis and avoids adverse surgical outcomes. We describe a case of an intrahepatic duplicate gallbladder containing calculi detected incidentally during a Focused Assessment Sonography for Trauma after a blunt trauma.

Fibrolipomatous hamartoma is a rare nonhereditary, congenital condition characterized by benign hyperplasia of fibroadipose tissue around nerve bundles. The median nerve is commonly affected. Underlying pathological process is mature adipose and fibrous tissue infiltrating the epineural and perineural compartments giving typical “pseudo-onion bulb” appearance on histology and “coaxial cable” appearance on magnetic resonance imaging (MRI). This case of fibrolipomatous hamartoma well illustrates its characteristic clinical, radiological, and histopathological features. Patient is a teenage female presented with painless gradually enlarging mobile lump in the central left palm. Ultrasound scan revealed a hyperechoic subcutaneous lesion, with intervening fine hypoechoic cable like structures following the course of median nerve which was thickened. Computed tomography (CT) confirmed thickened left median nerve with radiating isodense fascicles surrounded by fatty areas. There were no calcifications. MRI showed classic “coaxial cable” like T1, T2 isointense fascicles continuous with the median nerve surrounded by a fusiform lesion demonstrating fat signals on spin-echo sequences which dropped on fat-suppressed gradient echo sequences. Diagnosis of fibrolipomatous hamartoma arising from left median nerve was made, based on typical imaging findings. Biopsy confirmed fibrolipomatous hamartoma. Diagnosis can be made confidently on imaging alone especially with MRI, without the need of biopsy. Both CT and MRI demonstrate fatty mass encasing the thickened nerve fibers. On MRI, characteristic appearance is seen as T1 and T2 low intense tubular thickened neural bundles surrounded by high signal fatty tissue.

No abstract available

Congenital adrenal hyperplasia (CAH) is a group of inherited autosomal recessive disorders characterized by a defect in enzymes involved in biosynthesis of cortisol, aldosterone or both. We report two patients presented with recurrent haematuria with two different forms of CAH who presented late and reared as males. We describe the challenges posed on managing them and how the quality of life will be improved by offering hormonal and surgical remedies without changing or reassigning the gender to females.

End TB strategy by the WHO suggest active screening of high-risk populations for tuberculosis (TB) to improve case detection. Present study generates evidence for the effectiveness of screening patients with diabetes mellitus (DM) for Pulmonary TB (PTB). A study was conducted among 4548 systematically recruited patients over 45 years attending DM clinic at the National Hospital of Sri Lanka. The study units followed an algorithm specifying TB symptom and risk factor screening for all, followed by investigations and clinical assessments for those indicated. Bacteriologically confirmed or clinically diagnosed PTB were presented as proportions with 95% CI. Mean (SD) age was 62·5 (29·1) years. Among patients who completed all indicated steps of algorithm, 3500 (76·9%) were investigated and 127 (2·8%) underwent clinical assessment. Proportion of bacteriologically confirmed PTB patients was 0·1% (n = 6,95%CI = 0·0-0·3%). None were detected clinically. Analysis revealed PTB detection rates among males aged ≥60 years with HbA1c ≥ 8 to be 0·4% (n = 2, 95%CI = 0·0-1·4%). The study concludes that active screening for PTB among all DM patients at clinic settings in Sri Lanka, to be non-effective measure to enhance TB case finding. However, the sub-category of diabetic males with uncontrolled diabetics who are over 60 years of age is recommended as an option to consider for active screening for PTB.

No abstract available

Abstract Background Melioidosis is an infection caused by a facultative intracellular Gram-negative bacterium, Burkholderia pseudomallei. It can present as septicemia, localized infection with/without septicemia, asymptomatic infections, ulcers, pneumonia, visceral abscesses, neurological infection, musculoskeletal infections and can involve any organ. Case presentation A 56 year old Sri Lankan diabetic female presented with fever, chills and rigors for 2 weeks. She also had malaise and loss of appetite, but no other features. On examination, she was febrile (temperature was 101.4 0 F) and rest of the examination was unremarkable. Her blood culture was positive for Burkholderia pseudomallei and she was started on IV antibiotics, on day 3. During her 2nd week of hospital stay, she developed right sided low back pain with buttock pain, right hip joint pain and restricted hip joint movements suggestive of right sacroiliitis. CE CT and MRI scans confirmed the diagnosis of right iliopsoas abscesses and right sacroiliitis. Incision and drainage was performed and a pigtail catheter was left in place for continuous drainage of abscesses. Her intensive phase was initiated with IV ceftazidime 2 g every 6 h for 12 days, then changed over to IV meropenem 2 g every 8 h together with oral co-trimoxazole. 2 weeks later, oral co-trimoxazole was replaced by oral doxycycline for another 6 weeks (due to transient pancytopaenia). She made a complete and uneventful recovery with oral co-trimoxazole for another 6 months, in her eradication phase. We report this case to show the importance in early diagnosis of melioidosis, and to consider it in the differential diagnosis of multiple abscesses and to emphasize the importance in suspecting melioidosis as a causative agent in infective sacroiliitis. Discussion Melioidosis can have 2 major presentations; acute infection (symptoms lasting less than 2 months) and chronic infection (symptoms lasting more than 2 months). Musculoskeletal melioidosis is a well-recognized manifestation of the disease, which can manifest as soft tissue abscesses, septic arthritis, spondylitis, sacroiliitis and osteomyelitis. Management of melioidosis consists of 2 phases. The intensive phase and the eradication phase. These are aimed at the importance of rapidly treating the septicemia, the need of eradication of the persistent disease and the prevention of recurrent infections or relapses. The intensive phase consists of minimum 10–14 days of IV antibiotics: IV ceftazidime or IV carbapenem (meropenem/ imipenem). Eradication phase should be followed by 3–6 months of oral co-trimoxazole alone or in combination with oral doxycycline/ oral amoxiciliin-clavulanic acid.

Abstract Background Spinal cord infarction is an uncommon condition. Anterior cord syndrome present with paraparesis or quadriparesis with sparing of vibration and proprioceptive senses. The common causes of anterior cord syndrome are aortic dissection and aortic surgical interventions. Spontaneous unruptured nondissected aortic aneurysms with intramural thrombus can rarely cause anterior cord infarctions. Case presentation We report a case of anterior spinal cord syndrome due to aneurysm of the thoracic aorta with a mural thrombus. A 64 year old male presented with sudden onset paraparesis with a sensory level at T1 with preserved sense of proprioception and vibration. The MRI panspine revealed increased T2 intensity in the anterior portion of the spinal cord from C5 to T10 level with characteristic ‘owl eye’ appearance on axial imaging. The CT aortogram detected aneurysmal dilatation of the ascending aortic, arch and descending thoracic aorta with significant intimal irregularities, calcified atherosclerotic plaques and a small mural thrombus. Conclusion The possible mechanisms postulated are occlusion of ostia of radicular arteries by the atherosclerotic plaques and mural thrombus or thromboembolism to the anterior spinal artery. Nondissected atherosclerotic aortic aneurysms should be considered in patients presenting with spinal cord infarctions especially in the presence of vascular risk factors and smoking.

Abstract Background Primary hyperparathyroidism (PHPT) is uncommon among children with an incidence of 1:300,000. This diagnosis is often missed in children in contrast to adults where it is detected at a pre symptomatic stage due to routine blood investigations. Etiology of PHPT can be due to adenoma, hyperplasia or rarely carcinoma. Case presentation A 12 year old Sri Lankan girl presented with progressive difficulty in walking since 1 year. On examination she had bilateral genu valgum. Skeletal survey revealed valgus deformity of knee joints, bilateral subluxation of upper femoral epiphysis(SUFE), epiphyseal displacement of bilateral humeri, rugger jersey spine and subperiosteal bone resorptions in lateral aspects of 2nd and 3rd middle phalanges. There were no radiological manifestations of rickets. Metabolic profile revealed hypercalcemia with hypophosphatemia. Intact parathyroid hormone levels were elevated at 790 pg/ml. Vitamin D levels were deficient. She had low bone mineral density with Z score of −3.4. Vitamin D supplementation resulted in worsening of hypercalcemia without reduction in PTH levels. Tc 99 Sestamibi uptake scan showed abnormal tracer retention in left inferior pole of thyroid. A large parathyroid gland was removed with histology favoring parathyroid adenoma. Post operatively she developed hypocalcemia. Bilateral osteotomy was done for SUFE and further surgeries for correction of limb deformities planned. Conclusion PHPT in children is usually diagnosed late when irreversible organ damage has occurred. Children can present with non specific symptoms involving gastrointestinal, musculoskeletal, renal and neurological systems. PHPT can cause disarray in bone and epiphysis in children during pubertal growth spurt. Genu valgum and SUFE are rare skeletal manifestations in PHPT and only 10 cases of genu valgum and 9 cases of SUFE have been reported up to now. So far no cases have been reported on epiphyseal displacement of humeri. Awareness regarding the occurrence of these rare skeletal manifestations especially during puberty is important for early diagnosis to prevent irreversible outcomes.

Chronic kidney disease (CKD) of unknown etiology is recognized as a major public health challenge and a leading cause of morbidity and mortality in the dry zone in Sri Lanka. CKD is asymptomatic and are diagnosed only in late stages. Evidence points to strong correlation between progression of CKD and kidney fibrosis. Several biochemical markers of renal fibrosis have been associated with progression of CKD. However, no marker is able to predict CKD consistently and accurately before being detected with traditional clinical tests (serum creatinine, and cystatin C, urine albumin or protein, and ultrasound scanning). In this paper, we hypothesize that fibrosis in the kidney, and therefore the severity of the disease, is reflected in the frequency spectrum of the scattered ultrasound from the kidney. We present a design of a simple ultrasound system, and a set of clinical and laboratory studies to identify spectral characteristics of the scattered ultrasound wave from the kidney that correlates with CKD. We believe that spectral parameters identified in these studies can be used to detect and stratify CKD at an earlier stage than what is possible with current markers of CKD.

Chronic kidney disease (CKD) of unknown etiology is recognized as a major public health challenge and a leading cause of morbidity and mortality in the dry zone in Sri Lanka. CKD is asymptomatic and are diagnosed only in late stages. Evidence points to strong correlation between progression of CKD and kidney fibrosis. Several biochemical markers of renal fibrosis have been associated with progression of CKD. However, no marker is able to predict CKD consistently and accurately before being detected with traditional clinical tests (serum creatinine, and cystatin C, urine albumin or protein, and ultrasound scanning). In this paper, we hypothesize that fibrosis in the kidney, and therefore the severity of the disease, is reflected in the frequency spectrum of the scattered ultrasound from the kidney. We present a design of a simple ultrasound system, and a set of clinical and laboratory studies to identify spectral characteristics of the scattered ultrasound wave from the kidney that correlates with CKD. We believe that spectral parameters identified in these studies can be used to detect and stratify CKD at an earlier stage than what is possible with current markers of CKD.

No abstract available