Ko Chang

Impact of renal failure on the outcome of dengue viral infection.

BACKGROUND AND OBJECTIVES In the 2002 dengue outbreak in Taiwan, some fatal cases had the underlying disease of renal failure (RF). Physicians faced difficulty in diagnosis and treatment of these patients; however, the impacts of RF on the clinical presentations and outcomes of dengue infection have not been reported previously. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A retrospective review was conducted of medical records, clinical presentations, laboratory findings, and underlying diseases for all cases of dengue infection in a medical center. Characteristics and outcomes of dengue-infected patients with and without RF were compared. RESULTS From January 2002 through January 2003, 519 dengue-infected patients were enrolled, including 412 patients with classical dengue fever (DF) and 107 patients with dengue hemorrhagic fever (DHF)/dengue shock syndrome (DSS). Twelve patients died in this outbreak, and all had DHF/DSS. Twenty-one (4.0%) patients were defined as being in the RF group. The RF group had a higher mortality rate than non-RF group (28.6 versus 1.2%; P < 0.001). The severity of GFR impairment was associated with higher percentages of DHF/DSS (P = 0.029) and mortality (P < 0.001). Differences in symptoms/signs and laboratory abnormalities between DF and DHF/DSS were significant in the non-RF group but not apparent in the RF group. CONCLUSIONS The diagnosis and management of dengue infection among patients with RF must be cautious, because complicated clinical courses with a higher mortality rate were well observed.

Laboratory diagnostics of dengue fever: An emphasis on the role of commercial dengue virus nonstructural protein 1 antigen rapid test

BACKGROUND/PURPOSE(S) In 2008, the Dengue NS1 Ag STRIP (Bio-Rad Laboratories, Marnes-la-Coquette, France) was introduced to routine dengue diagnostics in Taiwan, in addition to real-time reverse-transcription polymerase chain reaction (PCR), virus isolation, and capture immunoglobulin (Ig)M/IgG enzyme-linked immunosorbent assay (ELISA). This study aimed to evaluate the benefit of this assay and factors influencing the results of these diagnostic tests. METHODS Retrospectively, the authors enrolled laboratory-confirmed adult dengue patients from July 2008 to January 2012 in a tertiary hospital. The sensitivities of each test alone and in combination were analyzed by the duration of illness (early stage: day 0-day 3 and late stage: day 4-day 8). The factors influencing sensitivity of the Dengue NS1 Ag STRIP were examined. RESULTS There were 392 patients enrolled. The overall sensitivity of the Dengue NS1 Ag STRIP was 68.37% and PCR was 71.94%. With the assistance of the Dengue NS1 Ag STRIP, a diagnosis was made in 10.97% of patients without the need for second convalescent samples, and 4.34% more cases were detected. Independent factors for reduced Dengue NS1 Ag STRIP sensitivity were dengue virus (DENV) IgG seropositivity and a sample taken after the fifth day of illness. At the early stage, the PCR and the Dengue NS1 Ag STRIP combination had the highest sensitivity rate than other combinations. At the late stage, a combination of the Dengue NS1 Ag STRIP and capture IgM/IgG ELISA had better sensitivity rates. PCR and capture IgM/IgG ELISA in combination had sensitivity above 90% through the course of illness. CONCLUSION Dengue NS1 Ag STRIP is a useful tool for early dengue diagnosis. Its use can increase the diagnostic sensitivity and decrease the need of convalescent samples. Seeking treatment late (days postonset > 4) and DENV IgG seropositivity independently decrease the sensitivity of the Dengue NS1 Ag STRIP.

Fatal Pasteurella multocida septicemia and necrotizing fasciitis related with wound licked by a domestic dog

A 68-y-old male had necrotizing fasciitis and bacteremia due to Pasteurella multocida. Saliva culture from his dog grew P. multocida and Pseudomonas aeruginosa. The human and dog P. multocida strains were of the same antibiogram but not identical tested with ribotyping. The wound licked by his dog was the only risk factor.

Severe Dengue Fever Outbreak in Taiwan

Dengue fever (DF) is a vector-borne disease caused by dengue viruses (DENVs). Epidemic dengue occurs intermittently in Taiwan. In 2014, Taiwan experienced its largest DF outbreak. There were 15,732 DF cases reported. There were a total of 136 dengue hemorrhagic fever (DHF) cases, of which 20 resulted in death. Most DF cases were reported in southern Taiwan. A total of 15,043 (96%) cases were from Kaohsiung, a modern city in southern Taiwan. This report reviews DF epidemics in Taiwan during 2005-2014. The correlation between DF and DHF along with temperature and precipitation were conjointly examined. We conclude that most dengue epidemics in Taiwan resulted from imported DF cases. Results indicate three main factors that may have been associated with this DF outbreak in Kaohsiung: an underground pipeline explosion combined with subsequent rainfall and higher temperature. These factors may have enhanced mosquito breeding activity, facilitating DENV transmission.

How carbapenem-resistant Acinetobacter spp. established in a newly constructed hospital

Annually increasing rates of carbapenem-resistant Acinetobacter spp. were observed in a Taiwan hospital since its establishment in November 1998 to March 2005. Increasing consumption of carbapenems was also noticed. Carbapenem-resistant Acinetobacter spp. from 33 patients carried a class 1 integron. Twenty-eight isolates were Acinetobacter baumannii harbouring both ISAba1 and an OXA-51-like gene. Twenty-four of the 28 A. baumannii isolates had ISAba1 upstream of the OXA-51-like gene. Four A. baumannii isolates harboured the OXA-24-like gene and one isolate had the VIM-11 gene. Regarding the five non-baumannii Acinetobacter spp., three Acinetobacter genomic species 3 isolates and one Acinetobacter radioresistens isolate had both IMP-1 and OXA-58-like genes. One A. radioresistens isolate had an OXA-23-like gene. One major clone of A. baumannii (25/28; 89.3%) was identified by ribotyping. Three ribotypes were identified as being brought into the hospital by patient transfer from other hospitals. In conclusion, an insidious clonal dissemination with various resistance mechanisms contributed to the spread of carbapenem-resistant Acinetobacter spp. in a hospital setting, with increasing usage of carbapenems as the possible selection pressure. Notification of carbapenem-resistant Acinetobacter spp. infection when patients are transferred between hospitals is important to control the spread of carbapenem resistance.

Sporadic and Outbreak Cases of Melioidosis in Southern Taiwan: Clinical Features and Antimicrobial Susceptibility

Background:Melioidosis has been well known to be endemic in Thailand and Northern Australia, and was reported sporadically in Taiwan before 2005.Methods:We retrospectively analyzed 58 patients with melioidosis in southern Taiwan from 2000 to 2005, including 40 clustered and 18 sporadic cases, for clinical characteristics and antimicrobial susceptibility.Results:Fifty-one (88%) cases were found during the rainy season, and there was a significant correlation between the average monthly rainfalls and the case number (r = 0.37; p = 0.001). Diabetes mellitus was the most common underlying disease (35 cases, 60%). The majority (52 cases, 90%) had never traveled abroad before illness, indicating indigenous acquisition of Burkholderia pseudomallei. In comparison, clustered cases were older, less often had underlying diabetes mellitus and had a shorter duration of clinical symptoms before admission than sporadic cases. Acute form of melioidosis predominated, and shock at admission was independently associated with a grave prognosis. Overall, 22% of 58 patients died in hospitals. Ceftazidime, imipenem, meropenem, amoxicillin/clavulanic acid, co-trimoxazole, and doxycycline, as previously recommended, were the potentially therapeutic choices. The role of piperacillin/ tazobactam for melioidosis remains undefined.Conclusions:Melioidosis can occur sporadically or in a cluster in diabetic patients during rainy seasons in Taiwan.

Hepatitis C Virus Infection among Injection Drug Users with and without Human Immunodeficiency Virus Co-Infection

The aim of this study is to explore the prevalence of hepatitis C virus (HCV) infection among injection drug users (IDUs) with and without human immunodeficiency virus (HIV) infection in southern Taiwan. For 562 IDUs (265 anti-HIV negative, 297 anti-HIV positive), we analyzed liver function, anti-HIV antibody, anti-HCV antibody, HCV viral loads, and hepatitis B surface antigen (HBsAg). HIV RNA viral loads and CD4 cell count for anti-HIV-seropositive IDUs and the HCV genotype for HCV RNA-seropositive IDUs were measured. The seroprevalence rates of anti-HIV, anti-HCV, and HBsAg were 52.8%, 91.3%, and 15.3%, respectively. All the anti-HIV-seropositive IDUs were positive for HIV RNA. Anti-HCV seropositivity was the most important factor associated with HIV infection (odds ratio [OR], 25.06; 95% confidence intervals [CI], 8.97–74.9), followed by male gender (OR, 6.12; 95% CI, 4.05–9.39) and HBsAg seropositivity (OR, 1.90; 95% CI, 1.11–3.34). Among IDUs positive for anti-HCV, 80.7% had detectable HCV RNA. HCV viremia after HCV exposure was strongly related to HIV infection (OR, 6.262; 95% CI, 1.515–18.28), but negatively correlated to HBsAg seropositivity (OR, 0.161; 95% CI, 0.082–0.317). HCV genotype 6 was the most prevalent genotype among all IDUs (41.0%), followed by genotypes 1 (32.3%), 3 (12.8%), and 2 (5.6%). In conclusion, about half IDUs were infected with HIV and >90% with HCV infection. Male and seropositivity for HBsAg and anti-HCV were factors related to HIV infection among our IDUs. HIV was positively correlated, whereas hepatitis B co-infection was negatively correlated with HCV viremia among IDUs with HCV exposure. Different HCV molecular epidemiology was noted among IDUs.

Murine Typhus in Southern Taiwan during 1992–2009

Clinical information regarding murine typhus in Taiwan is limited. In this study, 81 cases of serologically documented murine typhus during 1992-2009 at four referral hospitals in southern Taiwan were analyzed. There was a significant correlation between average environmental temperature and case numbers of murine typhus (r = 0.747, P = 0.005). Acute hepatitis was found in 67% of cases, and hyperbilirubinemia (serum total bilirubin ≥ 23.9 μmol/L) was found in 38%. The intervals between the initiation of appropriate therapy to defervescence were longer in patients with hyperbilirubinemia than those without hyperbilirubinemia (6.1 versus 4.1 days; P = 0.015). Nine (11.1%) showed development of severe illnesses such as acute respiratory distress syndrome (2 patients), aseptic meningitis (3), and acute renal failure (4). Only one died of acute respiratory distress syndrome. Cases of murine typhus were often found during the summer and had acute febrile hepatitis. Those patients with hyperbilirubinemia tended to have a delayed recovery even with appropriate therapy.

Dengue fever scoring system: new strategy for the early detection of acute dengue virus infection in Taiwan.

BACKGROUND/PURPOSE Dengue fever is an important public health problem in Southern Taiwan. The purpose of this study was to develop a dengue scoring system using a three-stage process, which may be used as a guidance tool for the early diagnosis of dengue fever. METHODS A retrospective study was conducted to identify factors useful for the early diagnosis of dengue fever. We assessed the clinical and laboratory features of 89 adult patients with dengue from 2002 to 2004 at a community-based hospital. They were compared with 14 patients with scrub typhus, 104 with Q fever, and 35 with murine typhus, which might present similar symptoms and signs as dengue infection. A scoring system was designed after analysis of the retrospective study and with the assistance of 10 expert clinicians. For the second stage, we evaluated efficiency in differentiating dengue fever from Q fever, scrub typhus and murine typhus in three hospitals from 2002 to 2005. For the third stage, we prospectively used the dengue scoring system for 498 cases that clinically were suspected as having dengue infection in the city of Kaohsiung from January 2006 to September 2006. RESULTS The performance of the scoring system was 88.1% sensitivity, 94.9% specificity, 95.7% positive predictive value (PPV), and 86.1% negative predictive value (NPV). Evaluation of the scoring system at the third stage revealed 90.7% sensitivity, 86.9% specificity, 81.4% PPV, and 93.6% NPV. CONCLUSION The dengue scoring system had a high NPV that might be helpful in the early diagnosis of dengue fever in adults before laboratory data are available.

Acute Q fever with Hemophagocytic Syndrome: Case Report and Literature Review

Hemophagocytic syndrome is a rare complication of acute Q fever. We reported the case of 26-year-old man with fever, chills, severe headache, non-productive cough and progressive thrombocytopenia. Bone marrow aspirate revealed hemophagocytosis. We discussed the differences among the three previous reported cases and the possible mechanisms of hemophagocytic syndrome.