Piyaporn Apisarnthanarak

ATYPICAL AVIAN INFLUENZA (H5N1)

We report the first case of avian influenza in a patient with fever and diarrhea but no respiratory symptoms. Avian influenza should be included in the differential diagnosis for patients with predominantly gastrointestinal symptoms, particularly if they have a history of exposure to poultry.

Seroprevalence of Anti-H5 Antibody among Thai Health Care Workers after Exposure to Avian Influenza (H5N1) in a Tertiary Care Center

After the initial atypical presentation of a patient with avian influenza (H5N1) infection, paired acute-phase and convalescent-phase serum samples obtained from 25 health care workers (HCWs) who were exposed to the patient were compared with paired serum samples obtained from 24 HCWs who worked at different units in the same hospital and were not exposed to the patient. There was no serologic evidence of anti-H5 antibody reactivity or subclinical infection in either of the groups.

Outbreak of varicella-zoster virus infection among Thai healthcare workers.

OBJECTIVE To evaluate the correlation between self-report of a prior history of chickenpox and results of varicella-zoster virus (VZV) immunoglobulin (Ig) G serologic test results in an outbreak of VZV infection among Thai healthcare workers (HCWs) and to conduct a cost-benefit analysis of establishing routine VZV immunization as part of an occupational health program on the basis of the outbreak data. METHODS All exposed patients received prophylaxis and the HCWs in our 3 intensive care units (ICUs) were prospectively evaluated. HCWs were assessed for disease history and serologic evidence of VZV IgG. A cost-benefit analysis was performed. RESULTS After 140 HCWs and 18 ICU patients were exposed to VZV, 10 HCWs (7%) with active VZV infection were relieved from work until skin lesions were crusted. Acyclovir (ACV) was prescribed to all 10 HCWs with active disease, and all 18 exposed patients received prophylaxis with ACV. Of 140 HCWs, 100 consented to longitudinal follow-up. Twenty-three (100%) of the HCWs who reported a history of chickenpox also had serologic test results that were positive for VZV IgG, compared with 30 (39%) of 77 HCWs who reported no prior history of chickenpox, yet had test results that were positive for VZV IgG. Reported history of chickenpox had a sensitivity of 43%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 61% with respect to VZV infection immunity. The total cost estimate for this outbreak investigation was

Alvarado score: can it reduce unnecessary CT scans for evaluation of acute appendicitis?

23,087. CONCLUSIONS An HCWs reported history of chickenpox was a reliable predictor of immunity; a report of no prior history of chickenpox was unreliable. Our cost-benefit analysis suggests that the costs of an occupational health program that included VZV surveillance and immunization for the next 323 HCWs would be approximately equal to the excess costs of

Intervention with an Infection Control Bundle to Reduce Transmission of Influenza-Like Illnesses in a Thai Preschool

17,227 for the ACV therapy, HCW furloughs, and staff overtime associated with this outbreak.

Fulminant Epiglottitis with Evolution to Necrotizing Soft Tissue Infections and Fasciitis due to Aeromonas hydrophila

OBJECTIVE The objective of the study is to assess the utility of Alvarado score in the diagnosis of acute appendicitis and the utility of computed tomographic (CT) scan for evaluation of acute appendicitis when stratified by Alvarado scores. MATERIALS AND METHODS Retrospective cohort study comprised adult patients who underwent abdominal CT for suspected acute appendicitis between January 2006 and December 2009. Two abdominal radiologists independently reviewed the CT scans; any discrepancies were resolved by a consensus review. Alvarado scores were calculated and categorized as low (0-3), equivocal (4-6), or high (7-10) probability for appendicitis. The diagnostic utility of CT scans and Alvarado score for acute appendicitis were compared with the criterion standard of combined medical chart review and pathology findings. RESULTS In a cohort of 158 subjects, 73 (46.2%) had clinical diagnoses of acute appendicitis. The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of CT scan in the diagnosis of acute appendicitis were 97.5%, 98.6%, 96.5%, 96.0%, and 98.8%, respectively. The mean Alvarado score for subjects with complicated appendicitis was significantly higher (7.95) than subjects with uncomplicated appendicitis (6.67) and those with other diagnoses (5.95). Acute appendicitis was confirmed in 2 (13.3%) of 15 subjects with low probability Alvarado scores, 16 (30.8%) of 52 subjects with equivocal scores, and 55 (60.4%) of 91 subjects with high probability scores. CONCLUSION The CT scan had high diagnostic utility for acute appendicitis. The Alvarado score was not a reliable independent predictive tool for acute appendicitis and could not replace CT scan.

Implementation of an Infection Control Bundle in a School to Reduce Transmission of Influenza‐Like Illness during the Novel Influenza A 2009 H1N1 Pandemic

BACKGROUND Infection-control interventions are needed to minimize transmission of influenza-like illness (ILI) and other infections in settings where children are in close proximity. SETTING A 240-children Thai kindergarten. METHODS Three-year, quasi-experimental study was conducted to assess the association between the use of a bundle of 4 infection control interventions and the incidence of ILI, diarrheal illnesses, and hand-foot-mouth infections among preschool children. The numbers of incident infections were calculated for the preintervention year (period 1), the immediate postintervention year (period 2), and the sustained postintervention year (period 3). RESULTS The monthly incidence of ILI in period 1 (mean, 124 episodes per month) was 25.8 cases per 1,000 child-days; in period 2, it was 10.1 cases per 1,000 child-days (a reduction of 60.8%; P = .008); and in period 3, it was 8.2 cases per 1,000 child-days (a further reduction of 19%; P = .002). The monthly incidence of diarrheal illnesses in period 1 was 14 cases per 1,000 child-days; in period 2, it was 4 cases per 1,000 child-days (P = .01); and in period 3, it was 3 cases per 1,000 child-days (P = .007). The yearly incidence of hand-foot-mouth infection in period 1 was 10 cases per 1,000 child-days; in period 2, it was 1 case per 1,000 child-days (P = .01); and in period 3, it was 0.5 cases per 1,000 child-days per year (P = .007). CONCLUSION Use of the infection control intervention bundle was associated with reduced incidence of ILI at the Thai preschool.

Mycobacterium tuberculosis associated chylous ascites in HIV-infected patients: case report and review of the literature.

Aeromonas hydrophila epiglottitis has been rarely described. We reported an unusual case of fulminant epiglottitis with evolution to necrotizing soft tissue infections and fasciitis due to A. hydrophila. A 61-year-old retired Thai man with known cirrhosis presented to the emergency room (ER) with fever, sore throat, dysphagia and muffled voice. He had no history of trauma, dental work, tooth pain, ear aches, tobacco use or animal contact. Lateral neck film revealed marked swelling of the epiglottis and a thickened aryepiglottic fold (‘‘thumb sign’’). After epinephrine nebulizer therapy, the patient was sent home with oral amoxicillin. Six hours later, symptoms progressed to include dyspnea, platypnea and neck swelling, requiring him to sleep in upright position. He returned to the ER with temperature 38.8 C, pulse 128/min, respiratory rate 24 min, blood pressure 120/70 mmHg, and room air pulse oximetry of 94%. He was alert with inspiratory stridor and a muffled voice. The tongue was large, protruding anteriorly, without drooling or sublingual swelling. There was massive external swelling, tenderness, and erythema of the anterior neck from the chin caudad to the mid-sternum, obliterating all cervical landmarks and the soft palate and posterior pharynx were diffusely swollen and covered with exudates. There were no signs of meningeal irritation or jugular venous distention; heart and lung exams were normal. The initial data were remarkable for a leukocyte count of 27,100 cells/mm (95% neutrophils, 5% lymphocytes), blood urea nitrogen 55 mg/dl, and creatinine 2.6 mg/dl; two blood samples, debris from neck soft tissue and fascia, and a rectal swab were sent for bacterial cultures. An emergency neck CT were obtained and revealed marked soft tissue swelling of the floor of mouth and left neck with multiple pockets of air located within the subcutaneous soft tissue of the left neck, extending along the fascial planes (Figure 1). Intravenous fluid hydration and ampicillin-clavulanate was started, and the patient underwent direct laryngoscopy, which revealed marked erythema and swelling of the epiglottis with yellow discharge. There was no discrete abscess. The patient had tracheostomy with debridement of the soft tissue and fascia of the neck. Gram’s stain of tissue debris showed abundant gramnegative bacilli and neutrophils. Ampicillin-clavulanate was discontinued; ceftriaxone, clindamycin and ciprofloxacin were initiated. On hospital day 3, blood cultures, intraoperative cultures of the epiglottis, neck soft tissue and fascia, and a rectal swab culture all grew oxidasepositive gram-negative bacilli. The bacterium was identified to be A. hydrophila by conventional biochemical tests and GN card of Vitek 2 using the Advanced EXPERT system version VT2-R4.01 for interpretation (bioMerieux Viek, Inc., USA). After surgery, this patient received a 3week course of ceftriaxone after which post-treatment blood cultures were negative. Epiglottitis, primarily a disease of children, has a wide geographic variation in incidence and risk factors [1]. Lateral neck films showing an enlarged epiglottis or ‘‘thumb sign’’ are helpful, yet sometimes absent in severe disease. Typical microorganisms associated with epiglottitis in adults include Haemophilus parainfluenzae, Streptococcus pneumoniae, Streptococcus pyogenes, and Staphylococcus aureus [2]. Fulminant disease has been reported with Neisseria meningitidis [3]. Although A. hydrophila epiglottitis has been previously reported [4], our case is the first to suggest a fulminant clinical course that evolved to a necrotizing fasciitis of the neck. Infections due to A. hydrophila usually occur either after accidental puncture of the skin with exposure to contaminated water/ soil or by hematogenous dissemination from the gastrointestinal tract, primarily in individuals with compromised

Computed tomography characteristics of hepatic and splenic abscesses associated with melioidosis: A 7‐year study

To the Editor—We report the implementation of an infection control bundle to reduce transmission of novel influenza A 2009 HlNl virus in a Thai preschool. Prior interdisciplinary efforts to reduce the incidence of influenza-like illness (ILI) were associated with lower incidence of ILI at this same Thai preschool. From May 1, 2009 through July 31, 2009, we prospectively studied the incidence of novel influenza A 2009 HlNl and seasonal influenza among children at the Satit School of Rangsit University, a private school in central Thailand (Pratumthani). The intervention bundle was introduced in the kindergarten, and the primary school served as the control group. Components of the infection control bundle included (1) education about hand hygiene for preschool children, parents, and teachers, with an emphasis on beforeand-after activities (eg, use of toilets, diaper changes, and food preparation), by using cartoons and workshops to demonstrate the impact of hand hygiene on the transmission of respiratory tract and gastrointestinal tract infections; (2) education about cough etiquette for kindergarten children, parents, and teachers that emphasized use of this practice at both school and home, in accordance with the American Academy of Pediatrics Committee on Infectious Diseases; (3) compliance with an annual influenza vaccination day; and (4) enforcement of the schools rule to promote absenteeism of sick children. In addition, during the epidemic of novel influenza A 2009 HlNl, kindergarten children were screened before daily school entry by measurement of temperature and inquiry about ILIs. Parents of children with fever or symptoms of ILI were contacted, and children were sent home until fever or ILI resolved.

Knowledge and attitudes of influenza vaccination among parents of preschool children in a region with avian influenza (H5N1)

AbstractChylous ascites (CA) is a rare manifestation of tuberculosis. We report a case of CA due to tuberculosis in an HIV-infected patient and review the literature on CA in HIV disease. This patient was successfully treated with large volume abdominal paracentesis, antituberculous drugs, and parenteral medium chain triglycerides.