Fast Track Publication Available
within 48 hours
Email! editor@casestudiesjournal.com
Skip to content

Volume 15, Issue 5

01-Jun-26

VOLUME 15, ISSUE 5
IMPACT FACTOR 4.428

1) Unusual Combination of Rare Dual Pathologies of the Pleura in a Young Male
Author Details:Madegedara RMD1, Nisha SH2, Jayarathna WAPH3 , Rathnayake RMDHM3
1Chair Professor of Medicine, Consultant Respiratory Physician 2Medical Officer ,3Research Assistant Respiratory Treatment Unit-II and Research Unit, National Hospital Kandy, Sri Lanka Corresponding Author: Madegedara RMD
Abstract:
We present a rare case of a seventeen-year-old male presenting with acute dyspnoea, fever, and right-sided pleural effusion. Pleural fluid analysis demonstrated a lymphocytic exudate, anti-tuberculosis (ATB) drugs were initially given. Subsequent computed tomography revealed a massive anterior mediastinal mass with internal fat attenuation and lymphadenopathy. Given the atypical clinicoradiological presentation, multisite tissue sampling was performed. Multiple thoracoscopic biopsies from pleural and nodular lesions revealed fungal infection highly suspicious for Aspergillus at one site and features suggestive of germ cell tumour at another. CT-guided biopsy of the mediastinal mass further supported germ cell tumour, while ultrasound-guided right supraclavicular lymph node biopsy confirmed metastatic germ cell tumour deposits. Extragonadal non-seminomatous germ cell tumor with pleural aspergillosis was supported by significantly elevated serum alpha-fetoprotein and beta-human chorionic gonadotropin, underscoring a rare dual pathology and the significance of multidisciplinary evaluation with histopathological confirmation in atypical presentations
Keywords: Pleural effusion; Mediastinal neoplasms; Teratoma; Aspergillosis; Case report
[Download Full Paper] [Page 01-06]
================================================================================

2) Determinants and Outcomes of Acute Asthma Exacerbations in a Tertiary Care Setting in Sri Lanka: A Prospective Study
Author Details:Wanninayake A1, Madegedara RMD2, Jayarathna WAPH3 , Rathnayake RMDHM3
1Medical Officer 2Chair Professor of Medicine, Consultant Respiratory Physician 3Research Assistant Respiratory Treatment Unit-II and Research Unit, National Hospital Kandy, Sri Lanka
Corresponding Author: Madegedara RMD 
Abstract:
Background and Aims: Asthma exacerbations remain a major cause of hospitalisation despite guideline-based management, with limited data in Sri Lanka. This study evaluated risk factors, treatment response, and outcomes of hospitalised exacerbations.
Methodology: A prospective descriptive study was conducted among 56 adults admitted with acute asthma exacerbations to National Hospital Kandy (August–December 2025). Data on clinical features, risk factors, comorbidities, treatment, and outcomes were collected using structured questionnaires, clinical records, and the Asthma Control Test (ACT), with follow-up after discharge. Data were analysed using descriptive and inferential statistics (Fisher’s exact test, chi-square, and non-parametric tests), with p<0.05 considered significant.
Results: Among 56 patients, the mean age was 60.2 ± 13.7 years, with female predominance (76.8%, n=43). Most had mild persistent asthma (64.3%, n=36), and 55.4% (n=31) had disease duration >10 years. Prior to admission, asthma control was suboptimal in 82.1% (n=46), with 69.6% (n=39) not well controlled and 12.5% (n=7) poorly controlled. Comorbidities were common, including hypertension (57.1%, n=32) and diabetes (35.7%, n=20). All patients presented with cough (100%, n=56), with frequent symptoms including shortness of breath (89.3%, n=50), wheeze (83.9%, n=47), and sputum production (71.4%, n=40).
Respiratory infection was identified in 42.9% (n=24). Environmental exposures were highly prevalent, including indoor air pollution (82.1%, n=46), biomass fuel exposure (69.6%, n=39), dust exposure (64.3%, n=36), and allergen exposure (87.5%, n=49). Most patients had multiple risk factors, with 89.2% (n=50) having ≥3 concurrent factors. Exacerbations were predominantly mild–moderate (76.8%, n=43), with severe exacerbations in 21.4% (n=12) and life-threatening episodes in 1.8% (n=1). During admission, all patients received nebulisation (100%, n=56) and most received systemic corticosteroids (96.4%, n=54). Oxygen therapy was required in 32.1% (n=18), and antibiotics in 48.2% (n=27). Most patients were managed in the ward (76.8%, n=43), with HDU (21.4%, n=12) and ICU (1.8%, n=1) admissions less frequent. All patients improved and were discharged.
At follow-up, symptoms improved in 91.1% (n=51), with well-controlled asthma (ACT ≥20) in 85.7% (n=48), good treatment compliance in 92.9% (n=52), and correct inhaler technique in 76.8% (n=43). Inhaler technique improved from 32.1% (n=18) pre-admission to 82.1% (n=46), while mean ACT score increased from 13.4 to 20.8. Asthma control (p<0.001), absence of comorbidities (p<0.001), treatment compliance (p=0.029), inhaler technique (p=0.019), atopy (p=0.040), functional limitation (p=0.024) and fever (p=0.042) were significantly associated with exacerbation severity.
Conclusion: Asthma exacerbations are multifactorial and driven by modifiable factors such as poor control, poor adherence, incorrect inhaler technique, and environmental exposure. Improved outpatient monitoring and patient education may reduce preventable hospitalisations and improve control.
Keywords: Asthma exacerbation; Risk factors; Asthma control
[Download Full Paper] [Page 07-38]
================================================================================

3) Determinants and Short-Term Outcomes of Acute Exacerbations of COPD in A Sri Lankan Tertiary Care Centre – Prospective Study
Author Details:Kularatne SAMSU1, Madegedara RMD2, Rathnayake RMDHM3, Jayarathna WAPH3, De Silva PBPMN3 1Medical Officer 2Chair Professor of Medicine, Consultant Respiratory Physician 3Research Assistant Respiratory Treatment Unit-II and Research Unit, National Hospital Kandy, Sri Lanka – Corresponding Author: Madegedara RMD
Abstract:
Background
Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are a major cause of morbidity, mortality, and recurrent hospitalisation worldwide. In low- and middle-income countries such as Sri Lanka, limited regional data are available regarding exacerbating factors, inpatient outcomes, and short-term post-discharge deterioration following AECOPD. This study aimed to identify factors associated with acute exacerbations of COPD, evaluate the response to standard inpatient treatment, determine predictors of prolonged hospital stay, and assess short-term clinical outcomes over a three-month follow-up period.
Methodology
A prospective descriptive study was conducted among 50 patients admitted with AECOPD to Respiratory Unit 2, National Hospital Kandy, Sri Lanka, from August to December 2025 via consecutive non-probability sampling. Demographic characteristics, exacerbating factors, treatment interventions, and inpatient outcomes were recorded using interviewer-administered questionnaires and medical records. Patients were followed monthly for three months after discharge to evaluate symptom burden using the COPD Assessment Test (CAT) and modified Medical Research Council (mMRC) dyspnoea scale, lung function (FEV1), six-minute walk test (6MWT), and re-exacerbation rates. Statistical analysis was performed using SPSS.
Results
The cohort had a mean age of 69.6 ± 8.3 years and was predominantly male (88%, n=44). Most patients belonged to low socioeconomic groups (54%, n=27) and had significant smoking exposure (60%). The majority were classified as GOLD Group E (86%) with severe or very severe airflow limitation (58%). Respiratory tract infections were the most common exacerbating factor (62%), followed by exposure to air pollutants (52%) and climatic variations (32%). Poor medication compliance and incorrect inhaler technique were observed in 30% of patients. During admission, 38% required oxygen supplementation and 16% required non-invasive ventilation (NIV). All patients survived to discharge, although 24% required hospitalisation for ≥7 days. The Higher CAT scores were associated with prolonged hospital stay (ρ = 0.279, p = 0.050), while NIV requirement showed a strong association with increased length of stay (H = 16.334, p < 0.001), indicating that patients with greater baseline symptom burden and more severe exacerbations required longer hospitalisation. At three-month follow-up, 60% experienced recurrent exacerbations. Clinically and statistically significant deterioration was observed in mean FEV1 (43.5% vs 37.6%, p<0.001), CAT score (21.5 vs 24.7, p<0.001), and mMRC score (2.53 vs 3.00, p<0.001) at three-month follow-up.
Conclusions
AECOPD in this Sri Lankan cohort predominantly affected elderly males with advanced disease, significant smoking exposure, and socioeconomic vulnerability. Respiratory infections and environmental exposures were major exacerbating factors. Although standard inpatient management achieved excellent short-term survival, substantial post-discharge deterioration and recurrent exacerbations were observed within three months. Strengthening preventive strategies, vaccination coverage, pulmonary rehabilitation, inhaler education, and structured post-discharge follow-up may help reduce recurrent exacerbations and progressive respiratory decline.
Keywords: Short-Term Outcomes, Acute Exacerbations, COPD, Care Centre
[Download Full Paper] [Page 39-66]
================================================================================

4) Infection as the Dominant Driver of Acute Exacerbations in Interstitial Lung Disease: A Prospective Study from a Sri Lankan Tertiary Care Center
Author Details:Eramudugolla EWCH1, Madegedara RMD2, Jayarathna WAPH3 , Rathnayake RMDHM3 1Medical Officer 2Chair Professor of Medicine, Consultant Respiratory Physician 3Research Assistant Respiratory Treatment Unit-II and Research Unit, National Hospital Kandy, Sri Lanka – Corresponding Author: Madegedara RMD
Abstract:
Background: Acute exacerbations of interstitial lung disease (AE-ILD) are associated with significant morbidity and mortality; however, data from South Asian populations remain limited. Regional variations in ILD subtypes, environmental exposures, and healthcare access may influence disease characteristics and outcomes. This study aimed to evaluate the demographic profile, underlying ILD subtypes, precipitating factors, clinical features, and outcomes of patients presenting with AE-ILD in a tertiary care setting in Sri Lanka.
Methods: A prospective descriptive study was conducted at National Hospital Kandy, a tertiary care respiratory unit in Sri Lanka, from June 2025 to January 2026, with consecutive recruitment of adult patients (≥18 years) with established interstitial lung disease (ILD) admitted with acute exacerbations. Acute exacerbation was defined as an acute worsening of respiratory symptoms within one month with new radiological abnormalities not explained by cardiac failure or fluid overload.
Data on demographics, ILD subtype, comorbidities, environmental exposures, clinical features, laboratory and radiological findings, precipitating factors, treatment, and outcomes were collected using structured questionnaires and clinical records. Exacerbation severity was classified based on the need for intensive care, ventilatory support, or in-hospital mortality. Patients were followed up for three months to assess functional recovery.
Descriptive statistics were used to summarise data, and associations with exacerbation severity were analysed using Chi-square or Fisher’s exact test, with a p-value <0.05 considered statistically significant.
Results: A total of 50 patients with acute exacerbation of ILD were included, predominantly female (74.0%, n = 37) and aged 61–80 years (60.0%, n = 30). Non-IPF ILDs predominated, including unclassified ILD (44.0%, n = 22) and connective tissue disease–associated ILD (38.0%, n = 19), followed by hypersensitivity pneumonitis (16.0%, n = 8), while idiopathic pulmonary fibrosis was rare (2.0%, n = 1).
Comorbidities were present in 68.0% (n = 34), most commonly autoimmune diseases (38.0%, n = 19) and diabetes mellitus (28.0%, n = 14). Most patients were never smokers (88.0%, n = 44). Environmental exposure was highly prevalent, including indoor air pollution (98.0%, n = 49), biomass fuel exposure (94.0%, n = 47), and outdoor air pollution (84.0%, n = 42).
Infective triggers were most common (78.0%, n = 39), including community-acquired pneumonia (50.0%, n = 25) and viral or bacterial lower respiratory tract infections (28.0%, n = 14), followed by high environmental exposure (18.0%, n = 9), drug-induced causes (8.0%, n = 4), and aspiration (4.0%, n = 2).
Dyspnoea (94.0%, n = 47) and cough (92.0%, n = 46) were the most frequent symptoms, with fever in 38.0% (n = 19). Elevated inflammatory markers included raised C-reactive protein (64.0%, n = 32), leukocytosis (48.0%, n = 24), neutrophilia (44.0%, n = 22), and lymphopenia (46.0%, n = 23). Chest radiography demonstrated chronic fibrotic changes in 84.0% (n=42), with superimposed consolidation in 12.0% (n=6). On HRCT, NSIP was the predominant pattern (48.0%, n=24), followed by UIP, hypersensitivity pneumonitis, and mixed patterns (each 10.0%, n=5).
Severe exacerbations occurred in 8.0% (n = 4) and were significantly associated with hypersensitivity pneumonitis (p = 0.020), diabetes mellitus (p = 0.029), occupational exposure (p = 0.037), neutrophilia (p = 0.018), lymphopenia (p = 0.038), chest X-ray findings (p=0.011) and HRCT findings (p = 0.037), and respiratory failure on Arterial blood gas (p < 0.001).
All patients received treatment, including antibiotics (80.0%, n = 40), corticosteroids (36.0%, n = 18), and immunosuppressive therapy (18.0%, n = 9). ICU admission was required in 4.0% (n = 2) and non-invasive ventilation in 6.0% (n = 3), with an in-hospital mortality of 6.0% (n = 3).
At three-month follow-up, functional recovery was observed, with normal lung function in 36.0% (n = 18), improved exercise capacity in 72.0% (n = 36), and normalisation of inflammatory markers in 94.0% (n = 47).
Conclusion: AE-ILD in this Sri Lankan cohort predominantly affected older females and was mainly associated with non-IPF ILDs, with IPF being relatively uncommon. The female predominance may reflect greater exposure to indoor air pollution due to household cooking practices, particularly with biomass fuels. Environmental exposures including indoor and outdoor air pollution were highly prevalent and likely contribute to both ILD development and acute exacerbations.  Infections were the leading trigger for AE-ILD, emphasizing the importance of early recognition and prompt management. Despite limited resources, in-hospital mortality was relatively low, and substantial functional recovery was observed.  These findings highlight the need for targeted public health interventions to reduce indoor air pollution, promote cleaner cooking methods, and improve air quality. Strengthening preventive strategies and early management may improve outcomes, while further multicentre studies are needed to better define risk factors and long-term outcomes in this population.
Key words: Interstitial Lung Disease, Acute Exacerbation, Respiratory Tract Infections, Sri Lanka
[Download Full Paper] [Page 67-89]
================================================================================

Filed in Volume 15, Issue 5 | | Comments Off