Romanee Chaiwarith

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.

Influenza vaccination reduces cardiovascular events in patients with acute coronary syndrome

AIMS Influenza infection has been shown to accentuate the progression of atherosclerosis and precipitate the occurrence of acute coronary syndrome (ACS). However, the protective effects of the influenza vaccine on cardiovascular events are still inconclusive. METHODS AND RESULTS The study was a prospective randomized open with blinded endpoint (PROBE) study. The 439 patients who had been admitted due to ACS within 8 weeks were enrolled and randomly allocated to receive inactivated influenza vaccine in the vaccine group and no treatment in the control group. All patients were treated with the standard therapy including revascularization according to primary cardiologists. The primary endpoint, which was the combined major cardiovascular events, including death, hospitalization from ACS, hospitalization from heart failure, and hospitalization from stroke, occurred less frequently in the vaccine group than the control group [9.5 vs. 19.3%, unadjusted HR 0.70 (0.57-0.86), P = 0.004]. There was no significant difference in the incidence of cardiovascular death between the vaccine and control groups [2.3 vs. 5.5%, unadjusted HR 0.39 (0.14-1.12), P = 0.088]. CONCLUSION The influenza vaccine reduced major cardiovascular events in patients with ACS. Therefore, it should be encouraged as a secondary prevention in this group of patients.

Diverse Contexts of Zoonotic Transmission of Simian Foamy Viruses in Asia

These infections are likely prevalent among persons who live or work near nonhuman primates.

Disseminated Nontuberculous Mycobacterial Infection in Patients Who Are Not Infected with HIV in Thailand

BACKGROUND Disseminated nontuberculous mycobacterial (NTM) infection is an emerging infectious disease worldwide that occurs mostly in immunocompromised hosts. Disseminated NTM infection is uncommon in persons who are not infected with human immunodeficiency virus (HIV). Recently, we described a group of non-HIV-infected Thai patients whose disease manifestation was a previously unrecognized clinical entity characterized by chronic bilateral lymphadenopathy due to rapidly growing mycobacteria. Most of the patients had coinfection with other opportunistic pathogens and reactive skin diseases. Therefore, in recognition of the increasing significance of this unique disease due to NTM in our country, we initiated a study to assess the prevalence, clinical characteristics, and geographic variations of this disease. METHODS There were 129 cases of disseminated NTM infection identified from 4 university hospitals located in major areas throughout Thailand. All patients but 1 were adults. Only 12% of patients had underlying diseases. The majority of the patients (81%) lived in the northeast of Thailand. RESULTS The most common organ involved was the lymph node (89%), followed by skin and soft tissue (26%), lung (19%), and others. Fifty-nine patients (46%) had 81 episodes of coinfection with other opportunistic infections (e.g., salmonellosis, 32 cases; cryptococcosis, 8 cases; penicilliosis, 8 cases; histoplasmosis, 5 cases). Seventy-seven patients had 86 episodes of reactive skin diseases (e.g., Sweet syndrome, 60 cases; pustular psoriasis, 6 cases; erythematous pustulosis, 5 cases). CONCLUSIONS These findings suggest a cell-mediated immune defect in these patients that needs to be further investigated. This study strongly suggests that the prevalence of NTM infection in Thailand is increasing. To our knowledge, this is the largest study of disseminated NTM infection among non-HIV-infected patients.

Immunodeficiency at the start of combination antiretroviral therapy in low-, middle- and high-income countries

Objective:To describe the CD4 cell count at the start of combination antiretroviral therapy (cART) in low-income (LIC), lower middle-income (LMIC), upper middle-income (UMIC), and high-income (HIC) countries. Methods:Patients aged 16 years or older starting cART in a clinic participating in a multicohort collaboration spanning 6 continents (International epidemiological Databases to Evaluate AIDS and ART Cohort Collaboration) were eligible. Multilevel linear regression models were adjusted for age, gender, and calendar year; missing CD4 counts were imputed. Results:In total, 379,865 patients from 9 LIC, 4 LMIC, 4 UMIC, and 6 HIC were included. In LIC, the median CD4 cell count at cART initiation increased by 83% from 80 to 145 cells/&mgr;L between 2002 and 2009. Corresponding increases in LMIC, UMIC, and HIC were from 87 to 155 cells/&mgr;L (76% increase), 88 to 135 cells/&mgr;L (53%), and 209 to 274 cells/&mgr;L (31%). In 2009, compared with LIC, median counts were 13 cells/&mgr;L [95% confidence interval (CI): −56 to +30] lower in LMIC, 22 cells/&mgr;L (−62 to +18) lower in UMIC, and 112 cells/&mgr;L (+75 to +149) higher in HIC. They were 23 cells/&mgr;L (95% CI: +18 to +28 cells/&mgr;L) higher in women than men. Median counts were 88 cells/&mgr;L (95% CI: +35 to +141 cells/&mgr;L) higher in countries with an estimated national cART coverage >80%, compared with countries with <40% coverage. Conclusions:Median CD4 cell counts at the start of cART increased 2000–2009 but remained below 200 cells/&mgr;L in LIC and MIC and below 300 cells/&mgr;L in HIC. Earlier start of cART will require substantial efforts and resources globally.

Discontinuation of secondary prophylaxis against penicilliosis marneffei in AIDS patients after HAART.

A retrospective cohort study was conducted to determine the relapse rate of penicilliosis marneffei after the discontinuation of itraconazole secondary prophylaxis in 33 HIV-infected patients who received HAART and had CD4 cell counts of 100 cells/μl or greater for at least 6 months. The observed incidence of relapse of penicilliosis marneffei was zero cases per 641 person-months (95% confidence interval 0–0.6 cases per person-month) after a median follow-up of 18 months (range 6–45).

Clinical and laboratory characteristics of penicilliosis marneffei among patients with and without HIV infection in Northern Thailand: a retrospective study

BackgroundPenicilliosis marneffei is increasingly observed in individuals without HIV infection. This study aimed to compare the clinical and laboratory features among HIV infected and uninfected individuals with penicilliosis marneffei.MethodsA retrospective cohort study was conducted between January 1, 2007 and December 31, 2011 at Chiang Mai University Hospital. We included individuals who were ≥15 years of age and presented with culture-proven P. marneffei infection.Results116 HIV-infected and 34 HIV-uninfected patients were enrolled. Comparing to HIV-infected patients, HIV-uninfected patients were older; less likely to have fever, splenomegaly, and umbilicated skin lesions; more likely to have Sweet’s syndrome and bone and joint infections; had higher white blood cell count, platelet count, and CD4 cell count; had lower alanine transaminase (ALT); and less likely to have positive fungal blood cultures. The mortality rates were 20.7% and 29.4% among HIV infected and uninfected patients, respectively.ConclusionsClinical manifestations of penicilliosis marneffei are different between patients with and without HIV infection. Physician’s awareness of this disease in HIV-uninfected patients may prompt the diagnosis and timely treatment, and can lead to a better outcome.

First Isolation of Leishmania from Northern Thailand: Case Report, Identification as Leishmania martiniquensis and Phylogenetic Position within the Leishmania enriettii Complex

Since 1996, there have been several case reports of autochthonous visceral leishmaniasis in Thailand. Here we report a case in a 52-year-old Thai male from northern Thailand, who presented with subacute fever, huge splenomegaly and pancytopenia. Bone marrow aspiration revealed numerous amastigotes within macrophages. Isolation of Leishmania LSCM1 into culture and DNA sequence analysis (ribosomal RNA ITS-1 and large subunit of RNA polymerase II) revealed the parasites to be members of the Leishmania enriettii complex, and apparently identical to L. martiniquensis previously reported from the Caribbean island of Martinique. This is the first report of visceral leishmaniasis caused by L. martiniquensis from the region. Moreover, the majority of parasites previously identified as “L. siamensis” also appear to be L. martiniquensis.

Streptococcus agalactiae in adults at chiang mai university hospital: a retrospective study

BackgroundInfection caused by Streptococcus agalactiae, a Group B streptococcus, is an emerging disease in non-pregnant adults. This study describes the epidemiological, clinical, and microbiological characteristics of S. agalactiae infection in adult patients in northern Thailand.MethodsA retrospective study was conducted between January 1, 2006 and December 31, 2009 at Chiang Mai University Hospital among patients aged ≥15 years, whose clinical specimens obtained from normally sterile sites grew S. agalactiae.ResultsOne-hundred and eighty-six patients and 197 specimens were identified during the 4-year period. Among 186 patients, 82 were documented as having invasive infection; 42 patients were male (51.2%) with the mean age of 48.5 ± 19.4 years (range 17, 83). Fifty-three patients (64.6%) had underlying medical conditions; 17 patients (20.7%), 10 (12.2%), 8 (9.7%) had diabetes, chronic renal diseases, and malignancy, respectively. Among 40 patients (48.8%) with bloodstream infection, no other site of infection was determined in 29 (35.4%) patients. In the remaining 11 patients, 5 patients (6.1%), 5 (6.1%), and 1 (1.2%) had meningitis, arthritis, and meningitis with arthritis, respectively. Forty-two patients (51.2%) presented with localized infection, i.e., subcutaneous abscess (19 patients, 23.2%), chorioamnionitis (10 patients, 12.2%), urinary tract infection (5 patients, 6.1%), arthritis (3 patients, 3.7%), meningitis (2 patients, 2.4%), and spontaneous bacterial peritonitis, uveitis, and tracheobronchitis (1 patient each, 1.2%). The overall mortality was 14.6% (12 patients).ConclusionsS. agalactiae infection is a growing problem in non-pregnant patients, particularly in those with underlying medical conditions. Physicians should add S. agalactiae infection in the list of differential diagnoses in patients with meningitis and/or septicemia.

Trends of CD4 cell count levels at the initiation of antiretroviral therapy over time and factors associated with late initiation of antiretroviral therapy among Asian HIV-positive patients

Although antiretroviral therapy (ART) has been rapidly scaled up in Asia, most HIV‐positive patients in the region still present with late‐stage HIV disease. We aimed to determine trends of pre‐ART CD4 levels over time in Asian HIV‐positive patients and to determine factors associated with late ART initiation.