Febrile illnesses of infective aetiology are common causes of hospital admission in tropical countries. In Sri Lanka, the incidence of dengue infection has markedly increased during the last 15 years whilst infections such as leptospirosis and viral hepatitis A remain endemic. Most of the common infections share a common and non-specific symptomatology, making diagnosis at initial presentation difficult. Similarly co-infections can complicate the clinical course but may remain undetected unless a high index of suspicion is maintained especially during epidemics of one infection. We report two cases of co-infections, highlighting the importance of this possibility. Coexistence of dengue infection with hepatitis A in one patient and with leptospirosis in another patient resulted in an atypical and protracted course of illness with confusing clinical features in either case.

ObjectiveA descriptive study to evaluate the pattern of presentation of lymphoedema of limbs to a tertiary care clinic in the central province of Sri Lanka. Patients and MethodPatients with lymphoedema seen over 28 years, (1980-2007) in the vascular clinic at the General Hospital Peradeniya were reviewed retrospectively. Results649 cases of lymphoedema of limbs were seen. 47 were in the upper limb, 36 of whom were secondary, mostly following axillary clearance associated with a mastectomy, and 11 cases were idiopathic. 602 patients had their lower limbs involved, with 96 cases amongst them being secondary, mostly to trauma, filariasis and a few with pelvic carcinoma and lymphoma. The rest (n =506) were considered to have lymphoedema of primary aetiology. The involvement of the legs was predominantly below the knees. A late onset group of lymphoedema patients, predominantly males above 60 years posed a problem in diagnosis and is worth future study.Complications among patients with lymphoedema of lower limbs with no overt secondary cause included inter digital cleft sepsis in 54.5 %, cellulitis or a history of the same in 66 %, lymphangitis 16 % lymphadenitis 3.5% and 11 % had septicaemia which aggravated the clinical state. ConclusionPrimary lymphoedema needs recognition as the dominant cause of limb lymphoedema especially in the Central Province. This diagnosis is required to prevent complications which need long term treatment. A filarial aetiology for most cases, as is popularly believed, is not evidence based. Secondary causes for lower limb lymphoedema must be looked for, such as pelvic malignancy and lymphoma. Trauma or surgery over lymphatic pathways should be avoided to prevent limb lympheodema. IntroductionNo significant documentation exists on the pattern of presentation of lymphoedema in Sri Lanka, though there exists records of its presence as a disease entity since the eighteenth century [1]. Lymphoedema is a disorder that has geographical implications such as possible association to Filaria [2], bare foot walking and the soil texture as in podoconioses [3]. It also involves genetic factors [4], with a pathogenesis seen to be of protean origin.The complications associated with lymphoedema, namely interdigital cleft sepsis, lymphangitis, lymphadenitis and cellulitis are quite disabling and aggravate the morbidity of the disease [5]. Surgical procedures that have been attempted to rectify lymphedema have yielded poor long-term results [5].The data regarding prophylactic care given to such limbs is inadequate, and makes it difficult to adopt focused and effective remedial measures. We present a database collected and collated over twenty eight years of attending to such patients in the hope that it will provide a scaffolding for care of this as yet mostly ignored area of clinical care. Patients and MethodOver a period of 28 years , 649 patients with limb lymphoedema were seen in the vascular clinic of the General Hospital Peradeniya. Majority of patients were from Central Province of Sri Lan...

Bilateral lower limb swelling is a common clinical scenario with a wide differential diagnosis. We present a young man with gradually worsening bilateral leg swelling, who was diagnosed with eosinophilic fasciitis. A 20 year old Hispanic male presented with a six week history of bilateral lower limb pain and swelling, later involving the upper limbs, but sparing the hands, feet and face. He had initial pitting, followed by non-pitting oedema and had a positive ‘groove sign’. With peripheral eosinophilia, a clinical diagnosis of eosinophilic fasciitis was suspected and was later confirmed on histology. He improved with prednisolone initially and is currently maintained on tapering prednisolone alongside methotrexate.