BackgroundPropanil is an important cause of herbicide poisoning in Sri Lanka, accounting for about 2% of all cases of self-poisoning. The outcome is extremely poor when the poisoning is severe and current medical care is of limited efficacy. Death usually occurs due to the severe and prolonged methaemoglobinaemia. We describe a case of severe Propanil poisoning, successfully treated by exchange transfusion at a tertiary care hospital in Sri Lanka.Case presentationA 17-year old Sri Lankan male (body weight – 42 kg), presented to a local hospital 1 hour after self-ingestion of nearly 500 ml (4.3 g/kg) of liquid Propanil (concentration – 360 g/l). On admission he had dizziness and peripheral cyanosis. He was given intravenous methylene blue (1 mg/kg) within one hour of admission, which was repeated subsequently due to minimal response. The next day morning, (18 hours after poisoning) the patient was transferred to the National Hospital of Sri Lanka (NHSL) for further management. On admission to NHSL, he was drowsy and confused, had a shallow respiratory effort and marked central and peripheral cyanosis. Respiratory rate was 20/min, with a pulse-oximetry of 77% on room air. The arterial blood gas analysis was as follows; pH–7.24, HCO3−–12 mmol/l, pCO2–28 mmHg, pO2–239 mmHg and O2 saturation–100%. Exchange transfusion was commenced within two hours of admission to NHSL. A dramatic improvement in oxygen saturation was observed immediately afterwards, with the saturation in pulse-oximetry rising to >95%. The level of consciousness and respiratory effort also improved. He was discharged subsequently 8 days after the initial poisoning.ConclusionPropanil has potential to produce severe life threatening clinical manifestations, despite categorization as a herbicide with low toxicity. In cases of severe poisoning, exchange transfusion may be life saving. Since methylene blue, intensive care and exchange transfusion facilities are also not readily available in local hospitals, which frequently encounter cases of severe Propanil poisoning, early transfer of patients to tertiary care hospitals should be considered. Exchange transfusion may be helpful even in late stages in patients with severe poisoning.

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BackgroundDengue fever is the most rapidly spreading mosquito-borne viral disease in the world. Haemophilia A is the commonest inherited bleeding disorder. There is little data on the incidence and outcome of dengue in patients with haemophila. We report a case of a patient with severe haemophila A, presenting with dengue fever, managed at a tertiary care hospital in Sri Lanka.Case presentationA 16-year-old Sinhalese male with severe haemophilia A (factor level < 1percent) was admitted to a teaching hospital in Sri Lanka on day 1 of an acute febrile illness, associated with arthralgia, myalgia, vomiting and headache. On admission, he had a tachycardia of 120 beats per minute, and blood pressure of 110/70 millimetres of mercury, with no bleeding manifestations. Baseline investigations revealed leukocyte and platelet counts of 4400 and 241,000 per cubic millimtre, respectively, and a haematocrit of 34.5 percent. Dengue was confirmed later by sero-conversion of the dengue IgM antibody test. Fluid balance, pulse rate and blood pressure were monitored hourly. The haematocrit and platelet counts were checked thrice daily, while he was clinically assessed for bleeding. On day 3 he developed bleeding from a tooth extraction site, with vomiting of dark red blood. His platelet level at that point was 124,000 per cubic millimetre with a haematocrit of 32 percent. Intravenous factor VIII was given to achieve a 100 percent factor correction over twenty-four hours. His platelet count dropped progressively from admission to a nadir of 50,000 per cubic millimetre on day 6. He did not develop clinical evidence of fluid leakage. On day 7 he was discharged after complete recovery.ConclusionsPeople with haemophilia may exhibit bleeding from the early febrile stage and at higher platelet levels than most other patients with dengue. Further discussion and research is necessary to decide on the optimal management of these patients, with regard to monitoring and timely treatment with blood products and/or factor correction, in order to prevent dengue-related morbidity and mortality whilst avoiding overtreatment. In endemic areas it is advisable that such patients seek early medical help in the event of an acute fever.