Chusana Suankratay

Clinical and Epidemiological Analyses of Human Pythiosis in Thailand

BACKGROUND Pythiosis is an emerging and life-threatening infectious disease in humans and animals that is caused by the pathogenic oomycete Pythium insidiosum. Human pythiosis is found mostly in Thailand, although disease in animals has been increasingly reported worldwide. Clinical information on human pythiosis is limited, and health care professionals are unfamiliar with the disease, leading to underdiagnosis, delayed treatment, and poor prognosis. METHODS To retrospectively study the clinical and epidemiological features of human pythiosis, we analyzed clinical data from patients with pythiosis diagnosed during the period of January 1985 through June 2003 at 9 tertiary care hospitals throughout Thailand. RESULTS A total of 102 cases of human pythiosis were documented nationwide. A substantial proportion (40%) of cases occurred in the last 4 years of the 18-year study interval. Clinical presentations fell into 4 groups: cutaneous/subcutaneous cases (5% of cases), vascular cases (59%), ocular cases (33%), and disseminated cases (3%). Almost all patients with cutaneous/subcutaneous, vascular, and disseminated pythiosis (85%) had underlying thalassemia-hemoglobinopathy syndrome. Most ocular cases (84%) were associated with no underlying disease. A majority of the patients were male (71%), were aged 20-60 years (86%), and reported an agricultural occupation (75%). Regarding treatment outcomes, all patients with disseminated infection died; 78% of patients with vascular disease required limb amputation, and 40% of these patients died; and 79% of patients with ocular pythiosis required enucleation/evisceration. CONCLUSIONS Here, we report, to our knowledge, the largest case study of human pythiosis. The disease has high rates of morbidity and mortality. Early diagnosis and effective treatment are urgently needed to improve clinical outcomes. Because P. insidiosum is distributed worldwide and can infect healthy individuals, an awareness of human pythiosis should be promoted in Thailand and in other countries.

Failure of therapeutic coma and ketamine for therapy of human rabies

The recent success in treating a human rabies patient in Milwaukee prompted the use of a similar therapeutic approach in a 33-year-old male Thai patient who was admitted in the early stages of furious rabies. He received therapeutic coma with intravenous diazepam and sodium thiopental to maintain an electroencephalographic burst suppression pattern, which was maintained for a period of 46 h, as well as intravenous ketamine (48 mg/kg/day) as a continuous infusion and ribavirin (48 to 128 mg/kg/day) via a nasogastric tube. He never developed rabies virus antibodies and he died on his 8th hospital day. At least three other patients have been treated unsuccessfully with a similar therapeutic approach. Because of the lack of a clear scientific rationale, high associated costs, and potential complications of therapeutic coma, the authors recommend caution in taking this approach for the therapy of rabies outside the setting of a clinical trial. More experimental work is also needed in cell culture systems and in animal models of rabies in order to develop effective therapy for human rabies.

A randomized trial of 2% chlorhexidine tincture compared with 10% aqueous povidone–iodine for venipuncture site disinfection: Effects on blood culture contamination rates☆

BACKGROUND Contaminated blood cultures have been recognized as a bothersome issue, and continue to cause frustration for clinicians. Skin antiseptics can prevent blood culture contamination. To our knowledge, there have been no randomized studies to compare 2% alcoholic chlorhexidine and 10% aqueous povidone-iodine for venipuncture site disinfection. OBJECTIVE This study aimed to evaluate the efficacy of venipuncture site disinfection with 2% chlorhexidine in 70% alcohol and 10% aqueous povidone-iodine in preventing blood culture contamination. PATIENTS AND METHODS A prospectively randomized investigator-blinded trial was conducted in all patients in the medical wards and emergency room (ER) at King Chulalongkorn Memorial Hospital, Bangkok, Thailand, from August to October, 2006. Venipuncture sites were disinfected with 2% chlorhexidine in 70% alcohol or 10% aqueous povidone-iodine, and blood cultures were taken by students, residents, or nurses. RESULTS Of 2146 blood cultures, 108 (5.03%) were contaminated with skin flora. The blood culture contamination rate with 2% alcoholic chlorhexidine was 3.2% (34 of 1068), compared with a rate of 6.9% (74 of 1078) (P<0.001) with 10% aqueous povidone-iodine. In medical wards, the contamination rates were 2.6% and 3.9% with 2% alcoholic chlorhexidine and 10% aqueous povidone-iodine (P=0.2). In ER, the contamination rates were 4.3% and 12.5% with 2% alcoholic chlorhexidine and 10% aqueous povidone-iodine (P<0.001). The most common contaminant was coagulase-negative Staphylococcus (80.6%), followed by Corynebacterium (7.4%), Micrococcus (6.5%), and Bacillus (5.5%). CONCLUSION Two percent alcoholic chlorhexidine is superior to 10% aqueous povidone-iodine for venipuncture site disinfection before obtaining blood cultures.

Autochthonous visceral leishmaniasis in a human immunodeficiency virus (HIV)-infected patient: the first in thailand and review of the literature.

We report a case of visceral leishmaniasis in a human immunodeficiency virus (HIV)-infected 37-year-old Thai fisherman who presented with nephritonephrotic syndrome, fever, anemia, and thrombocytopenia. Bone marrow biopsy revealed many amastigotes within macrophages. Kidney biopsy showed membranoproliferative glomerulonephritis. Polymerase chain reaction (PCR) and nucleotide sequence analysis of the internal transcribed spacer 1 of the small subunit ribosomal RNA gene in blood and kidney biopsy specimens showed Leishmania species previously described in a Thai patient with visceral leishmaniasis. Only four autochthonous cases of leishmaniasis have been reported in Thailand since 1996. To the best of our knowledge, this is the first report of autochthonous visceral leishmaniasis in an HIV-infected Thai. With an increasing number of patients with autochthonous leishmaniasis in association with the presence of potential vector, it remains to be determined whether this vector-borne disease will become an emerging infectious disease in Thailand.

Immunological response to hepatitis B vaccination in patients with AIDS and virological response to highly active antiretroviral therapy

Previous studies showed that an immunological response to hepatitis B virus (HBV) vaccination in patients with AIDS was lower than in the normal population. However, those with virological response to highly active antiretroviral therapy (HAART) may have a normal immunological response to HBV vaccination. In our study, patients with AIDS who had a virological response to HAART and no immunity to HBV received 3 doses of HBV vaccine (20 µg of Engerix-B®) on d 0, 30, and 180. Anti-HBs level was measured 1 month after complete vaccination. Of 28 patients, overall response rate to vaccination was 71.4%. The responder group had a significantly higher CD4 count at 1 month after complete vaccination than the non-responder group (466.95±146.94 and 335±112.62 cells/µl, p =0.035). The patients receiving efavirenz-containing HAART had better response than those without efavirenz-containing HAART (p =0.030). The responder group had received a longer duration of HAART. In conclusion, to our knowledge, ours is the first prospective study to determine the immunological response to HBV vaccination in all patients with AIDS who had maintained the virological response after receiving HAART throughout the study period. Patients with AIDS and virological response to HAART have a good immunological response to HBV vaccination.

Human Gongylonema infection in Southeast Asia.

There are 25 species of Gongylonema, a spirurid nematode found in mammals, and a further 10 in birds.1,2 Human infection has usually been attributed to Gongylonema pulchrum,Molin 1857. In its natural hosts, the adult worms are found in burrows in the mucosal lining of the esophagus and rumen.Human infection,although occurring very rarely, is widely distributed. To date, nearly 50 cases of human gongylonemiasis have been described worldwide since 1864 in Italy,3 United States,4–11 Europe,12–16 Sri Lanka,17 China,18–20 the Middle East,21 Australia,22 New Zealand,23 and Japan.24 This infestation has not previously been reported in animals or humans in Southeast Asia. About 50 species of arthropods are possible intermediate hosts of G.pulchrum. They are coprophagous insects such as dung beetles, cockroaches, etc.Embryonated eggs are passed in the feces of the host, and are ingested by intermediate hosts. The larvae perform two moults toward the infective third stage in about 4 weeks. Human infestation is presumably due to accidentally ingesting infected insects,or drinking contaminated water. In humans, the worms tend to localize in the buccal cavity including the lips, gums, tongue,and palate.Many patients reported the sensation of a moving worm(s). In some cases, the patients pull out the worms. In others, the worms have been removed by insertion of two needles under the worm in its tunnel. The present report describes, what we believe, represents the first human case in Southeast Asia. Case Report

Non-Serogroup O:1 Vibrio cholerae Bacteremia and Cerebritis

We describe a case of non-serogroup O:1 Vibrio cholerae bacteremia and cerebritis in a 41-year-old Thai man with alcoholism who presented with fever and cellulitis of the right ankle. He was successfully treated with parenteral cefotaxime and then was switched to treatment with oral ciprofloxacin.

Spindle cell pseudotumor of the brain associated with Mycobacterium haemophilum and Mycobacterium simiae mixed infection in a patient with AIDS: the first case report

BACKGROUND Spindle cell pseudotumors may occur due to mycobacterial infection, especially in immunocompromised hosts including those with AIDS. They have been reported from many body sites; the lymph nodes are predominantly involved, most frequently associated with Mycobacterium avium complex infection. To the best of our knowledge, Mycobacterium-associated spindle cell pseudotumors have not been previously described in the brain stem and in association with mixed mycobacterial infection. CASE REPORT We describe a man with AIDS who presented with right hemiparesis and truncal ataxia. Magnetic resonance imaging revealed enhancing nodular lesions at the cerebral peduncle and medulla. A mycobacterial spindle cell pseudotumor was diagnosed on surgical specimens. Blood and brain tissue cultures grew Mycobacterium haemophilum and Mycobacterium simiae. CONCLUSIONS To our knowledge, this is the first case of spindle cell pseudotumor of the brain associated with M. haemophilum and M. simiae mixed infection.

Mycotic aneurysm caused by Burkholderia pseudomallei with negative blood cultures.

We describe a case of bacterial aortitis caused by Burkholderia pseudomallei. This patient presented with prolonged fever and hoarseness of voice. Aneurysm removal with Dacron graft replacement was performed, followed by a prolonged course of antibiotics. The patient has progressed satisfactorily without recurrence of symptoms. Previous case reports are summarized.

Alternate-day versus once-daily administration of amphotericin B in the treatment of cryptococcal meningitis : A randomized controlled trial

Animal studies and case series have demonstrated the dose-dependent efficacy and long half-life of amphotericin B deoxycholate (ABd), providing the rationale for our randomized controlled study to compare once-daily (OD) (1 mg/kg) and alternate-d (AD) (2 mg/kg) administration of ABd in the treatment of cryptococcal meningitis in patients with AIDS hospitalized at King Chulalongkorn Memorial Hospital, Thailand, from 2003 to 2004. Of 28 patients, 15 and 13 received OD and AD administration, respectively. There was no significant difference between the 2 groups regarding the demography, clinical features, and laboratory data. After 2 weeks of the intensive-phase treatment, there was no significant difference in the clinical response between the OD (80%) and AD (76.9%) groups. Mycological response was observed in 33.3% and 10% of patients in the OD and AD groups, respectively (p=0.3). There was no difference in nephrotoxicity and infusion-related events. In conclusion, this is the first randomized controlled study comparing OD and AD administration of ABd in the treatment of cryptococcal meningitis. Although our study was not sufficiently powered to draw conclusions on clinical efficacy and toxicities, the results are encouraging and should warrant further clinical trials evaluating the efficacy and adverse effects with a larger sample size.