Dinesh Malcolm Gerard Fernando

Necrotizing fasciitis and death following an insect bite.

AbstractA healthy man who presented to hospital with painful swelling of the left arm following a history of insect (tick) bite developed shock and died within 48 hours. The postmortem examination revealed swelling and desquamation of skin and erythema on the left arm extending below the elbow. The subcutaneous tissue was necrotic with healthy underlying muscles. Group A &bgr;-hemolytic streptococcus was isolated from postmortem swabs of the infected tissue. Histopathologic changes were consistent with necrotizing fasciitis.Secondary bacterial infection is an important possible complication following insect bite, and a high degree of suspicion with aggressive early treatment is required in cases of necrotizing fasciitis to prevent fatalities. Both clinicians and pathologists need to be aware of this rare, rapidly fatal condition that may follow an insect bite.

4. Occlusion of a Coronary Ostium by an Ingrowing Endocardial Vegetation

A 21-year-old primi, with a period of gestation of 35 weeks, was found collapsed in the toilet of a maternity hospital in Colombo, Sri Lanka. She had been admitted five days previously and echocardiography had detected a tight aortic stenosis with grade I aortic regurgitation. At autopsy, the heart showed multiple, large (>10mm), friable vegetations on a stenosed, bicuspid aortic valve. A 5mm long part of a vegetation had extended into the ostium of the left main coronary artery and caused an obstruction. Histopathology showed scattered fibrosis and focal inflammatory cell infiltrate in the myocardium. The vegetations on the valve cusp were composed of colonies of bacteria, fibrin exudate and polymorphs. The cause of death was acute myocardial infarction in a pregnant woman due to occlusion of the left coronary artery by an infective endocarditis vegetation. A medline search of the past 25 years failed to find a similar case.

Is it appropriate to use WHO Multicentre Growth Reference Study standards to assess the growth parameters of Sri Lankan babies? A single-centre cross-sectional study

Objective To compare the anthropometric measurements of newborns in a tertiary care hospital in Sri Lanka, with WHO standards. Methods Birth weight, length and occipitofrontal circumference (OFC) of 400 consecutive, term newborns of healthy mothers were measured in a tertiary care hospital. Results 400 subjects were approached and seven were excluded, concluding the study population to 184 boys and 209 females. Medians of birth weight, length and OFC were 3000 g, 49.95 cm and 34.15 cm of males and IQRs were 555.00, 2.70 and 1.70, respectively. For females, the medians of birth weight, length and OFC were 2900 g, 48.9 cm and 34.00 cm with IQRs of 450.00, 2.70 and 1.50, respectively. The two-tailed t-test revealed that median weights of males (t=9.632) and females (t=12.04) and OFC of males (t=3.98) were significantly lower than the WHO medians. There was a significant association of birth weight, with mother’s prepregnancy weight, in males (β coefficient=12.629 with 95% CI 6.275 to 18.982) and females (β coefficient=5.880, 95% CI 1.434 to 10.325). Significant associations of length (β coefficient=0.046, 95% CI 0.012 to 0.080) and OFC (β coefficient=0.033, 95% CI 0.014 to 0.053) with mother’s prepregnancy weight in males and length (β coefficient=0.084, 95% CI 0.022 to 0.145) and weight (β coefficient=10.780, 95% CI 0.93 to 20.629) with maternal age in females were found. Furthermore, birth weight in males was significantly associated with maternal height (β coefficient=10.899, 95% CI 0.552 to 21.247). Education level, ethnicity and parity showed no significant associations with above parameters. Conclusion The median weights of both sexes and OFC in males were significantly lower than the WHO standards. Island-wide studies are indicated to evaluate the appropriateness of applying WHO standards to Sri Lankan newborns.

Adrenaline toxicity following accidental administration of the 1:1000 solution during dental procedures: Four case reports

Four patients aged between 35 and 50 years attended the out patients department of a dental hospital for tooth extraction. Following administration of, what was thought to be the local anesthetic, Lignocaine, to the gum and sub mucosa, they all collapsed. What had, in fact, been injected was 1:1000 adrenaline. We would like to report the symptoms, signs and investigation findings that followed. Significantly elevated Troponin T, CPK (total), CPK (MB) and ECG changes were seen. Electromyography and Nerve Conduction Studies showed a myopathic pattern and reduction in motor and sensory conduction respectively. These patients were followed up for a period of five years. Long term effects such as tremor, muscle weakness, easy fatigability and shortness of breath on exertion, which is not reported in the literature, were reported by all patients.

Relationship between the tensile strengths and diameters of human umbilical cords

Mothers of alleged infanticides might claim that umbilical cord broke during precipitate delivery causing injuries detected on baby at autopsy. There is paucity of evidence regarding this possibility. The objective of the study was to determine relationship between tensile strength and diameter or weight per unit length of cord. Diameters and weights per unit length of fresh umbilical cords were determined. Tensile strengths were measured by Hounsfield Testing Machine. Relationship between tensile strength versus cord diameter and weight per unit length were analyzed. Of 122 cords, average tensile strength, diameter and weight per centimeter were 50.4 N, 7.73 mm and 6.87 g respectively. The tensile strengths were directly proportional to diameter. There was no association between tensile strength and weight per centimeter. Measurement of the diameter of cord is important during autopsy to predict tensile strength and thereby to presume whether cord could have broken by the weight of the baby.

Penetrative injury to the face resulting in delayed death after rupture of a cavernous sinus aneurysm on the contralateral side

Delayed deaths after assault give rise to medicolegal issues such as whether the assault was directly responsible, did it contribute or was it totally unrelated to the death. We present the case of a patient who sustained penetrative trauma to the face resulting in the formation of a contralateral, carotid-cavernous fistula, which resulted in aneurysm formation, delayed rupture, and death. A literature search failed to find a similar case.