Sayomporn Sirinavin

Clinical and Prognostic Categorization of Extraintestinal Nontyphoidal Salmonella Infections in Infants and Children

The study included 172 patients, aged 0-15 years, for whom at least 1 nonfecal, nonurinary specimen was culture-positive for nontyphoidal Salmonella. Ninety-five percent had positive blood cultures. Immunocompromising diseases were found in 19% of 74 infants and 77% of 98 children. Associations between the study factors and outcomes, as localized infection or death, were assessed by logistic regression analysis. Thirty-three patients had localized infections. An adjusted risk factor for development of localized infections was an age of <12 months (P=.003). There were 17 deaths. The case-fatality rates were 43% and 10% for immunocompromised and 5% and 0% for nonimmunocompromised infants and children, respectively. Adjusted risk factors for death were age of <12 months (P=.006), inappropriate antimicrobial therapy (P=.014), meningitis or culture-proven pneumonia due to nontyphoidal Salmonella (P=.004), and immunocompromised status (P<.001). The clinical courses and prognoses for infants and children with extraintestinal infection due to nontyphoidal Salmonella can be categorized into 4 groups according to the characteristics of age (infants vs. children) and host status (immunocompromised vs. nonimmunocompromised).

Norfloxacin and Azithromycin for Treatment of Nontyphoidal Salmonella Carriers

There has been inadequate evaluation of an antibiotic for eradication of nontyphoidal salmonellae (NTS) in asymptomatic carriers. In a randomized, placebo-controlled trial, such efficacy was evaluated using 2 five-day regimens (norfloxacin, 400 mg twice per day, and azithromycin, 500 mg once per day) compared with placebo. The study included 265 food workers in an area of Thailand where NTS are endemic who were asymptomatic NTS carriers. The presence of NTS in stool samples was assessed on days 7, 30, 60, and 90 after start of treatment. At each assessment visit, <4% of participants in each of the 3 groups carried an initial Salmonella serotype; 16%-35% had new Salmonella serotypes detected, except on day 7 in the azithromycin group, when the rate was 4%. Sanitation was good at work but not at home. Selection of multidrug-resistant Salmonella enterica serotype Schwarzengrund was demonstrated. The study regimens were not better than placebo for treatment of asymptomatic food workers who carried NTS in an area where these organisms are endemic, and use of the regimens resulted in antimicrobial resistance.

Neonatal Tuberculosis Associated With Shock, Disseminated Intravascular Coagulation, Hemophagocytic Syndrome, and Hypercalcemia: A Case Report

We report on a female infant with disseminated tuberculosis who presented with clinical sepsis and disseminated intravascular coagulation starting at 14 days of age. Parenteral ofloxacin combined with streptomycin were used because the enteral route was not possible and intravenous isoniazid and rifampicin were not available. Rare complications including infection-associated hemophagocytic syndrome, hypercalcemia, and adrenal insufficiency were detected and successfully managed.

A Bedside Prediction-Scoring Model for Late-Onset Neonatal Sepsis

OBJECTIVE:Insufficient tools for bedside prediction of late-onset neonatal sepsis (LNS) initiated this study. The objective was to develop and validate a simple prediction-scoring model for LNS defined as culture-proven sepsis occurring 72 hours after birth.METHODS:The study was performed at a university hospital in Bangkok. The derivation phase included medical records of 1870 neonates, randomly selected from 9347 records of neonates who had been hospitalized for >72 hours during 1998 to 2000, of which 1824 records were available. In all, 100 neonates were clinically suspected of sepsis and 17 had proven LNS. The validation phase included 73 neonates suspected of having sepsis during July 2002to June 2003 and 25 who had LNS. Weighted coefficients from Coxs proportional hazards model and receiver-operating-characteristic (ROC) curve analysis were used.RESULTS:The incidence density of LNS was 17/11355 (1.5/1000) person-days. A scoring model was developed and consisted of the following: hypotension (score 4), abnormal body temperature (score 3), respiratory insufficiency (score 2), neutrophil band form fraction >1% (score 2), platelet count <150 × 103/μl (score 2), and umbilical venous catheterization (1 to 7 or >7 days; score 2 or 4). The area under the ROC curves for prediction of LNS in a neonate suspected of sepsis in each of the two phases was 0.85 and 0.80, respectively (p=0.436). The mean probabilities of LNS were approximately 0.10 (low risk) for scores from 0 to 3; 0.50 (intermediate risk) for scores from 4 to 6; and 0.70 (high risk) for scores ≥7.CONCLUSION:A simple prediction-scoring model for LNS was developed. Validation of the scores suggested good diagnostic performance.

Pediatric invasive pneumococcal disease in a teaching hospital in Bangkok

BACKGROUND Increased problems with drug-resistant Streptococcus pneumoniae (SP) and the dearth of epidemiologic and clinical information on invasive pneumococcal disease in children in Asia formed the basis for this study. METHODS A periodic retrospective review of the records of 0-15-year-old patients was conducted at a teaching hospital in Bangkok, during 1971-2000. RESULTS Infections with penicillin-non-susceptible SP (PNSSP) strains rapidly increased after they first appeared in 1988, and they accounted for 71% (29/41) of the total cases during 1996-2000. Of 137 patients, 74% were <60 months old, and 66% had an underlying condition. Infections included: bacteremia without focus 51; pneumonia 38; meningitis 35; peritonitis 13; and bone/joint infection 2. Two patients had two foci of infection. Eight of 10 episodes in patients with AIDS were bacteremic pneumonia. Median ages (range) in months for patients with and without an underlying condition were 24 (1-174) and 10 (0-160); and for the patients without an underlying condition they were: pneumonia 23 (4-156); bacteremia without focus 12 (0-160); and meningitis 7 (2-156). Case-fatality rates were 18% and 2% for patients with and without an underlying condition. The study also examined factors associated with PNSSP infection and death. During 1991-2000, 74% (43/58) of the total cases occurred from November to April, which are dry months. CONCLUSIONS This study population contained a high proportion with both an underlying condition and infection with PNSSP, and a moderately low proportion with bacteremia without focus. The disease was two to three times more common in dry months than in rainy months.

Maternal and Umbilical Cord Serum Zidovudine Levels in Human Immunodeficiency Virus Infection

EDITORIAL COMMENT: Because of the low prevalence rate for HIV in Australian antenatal populations and lack of a national or state policy for offering routine HIV testing in pregnancy, we have relied on our colleagues from Thailand to provide readers with information concerning treatment of pregnant women known to be HIV positive. Readers are referred to the January 24, 1998 issue of the British Medical Journal which contains 7 papers concerning HIV infection in pregnancy and neonates. The editorial by Danielle Mercey ‘Antenatal HIV testing. Has been done badly in Britain and needs to improve’ (A) should interest readers since HIV testing has been sufficiently performed in the United Kingdom to provide the information that in 1996 only 15% of previously unrecognized HIV infections were diagnosed in pregnancy. The prevalence in tested women in London increased 6‐fold from 0.03% in 1988 to 0.191% in 1996; for the rest of the United Kingdom the comparable percentages in tested women were 0.005% and 0.016% (B). For comparison, as noted in this paper, the prevalence rate of HIV positive mothers in Thailand was 2% in 1993, or more than 10 times greater than in London in 1996 and 125 times greater than in the rest of the United Kingdom. Tourists with sex adventures in mind should be aware of these facts when planning their itinerary for overseas tours. Obstetricians in Australia should heed the statement that ‘The advantages of ascertaining a pregnant womans HIV positive status before delivery are clear’: transmission to the baby can be roughly halved by avoiding breastfeeding and reduced by a further two‐thirds by the administration of zidovudine (A).

Four novel and three recurrent mutations of the BTK gene and pathogenic effects of putative splice mutations

AbstractX-linked agammaglobulinemia is caused by mutations in the human BTK gene, leading to recurrent pyogenic infections. We describe four novel and three known BTK-mutations in seven patients from seven (six Thai and one Burmese) families. All but one were sporadic cases. Patients 1 and 2 had recurrent mutations in exon 10 (R288W) and exon 17 (R562W), respectively. Patient 3, a previously healthy individual who presented with pseudomonas sepsis with ecthyma gangrenosum had a known mutation in exon 17 (1749delT), leading to frameshift effect (F583fsX586). Patient 4 manifested with sepsis and concurrent acute appendicitis and pneumonia. He had a mutation, IVS8 + 1G > A, which led to an insertion of intron 8 into the transcripts. In Patient 5, a novel change in exon 7, c.588G > C, initially presumed Q196H, was found to cause a leaky splicing mutation, resulting in three distinct transcripts containing 17, 108, and 190 bp of the 5′-terminal of intron 7, which led to truncated peptides consisting of 203 and 211 amino acid residues (or Q196fsX204 and Q196fsX212, respectively). Patient 6 had a mutation in exon 14 (W421X), while patient 7 had a newly defined large deletion of exons 6-9. All of the mothers tested were mutation carriers. Transcript analysis in three mothers who were heterozygous for frameshift mutations revealed a minimal amount of aberrant transcripts, while their affected children had full expression of the mutant alleles, suggesting rapid degradation due to nonsense-mediated mRNA decay in the mothers. This is the first report of mutations of BTK from Thailand.

Detection of the impairment of CD80 expression on circulating monocytes in HIV-infected Thai children.

The mechanism of progressive anergic response in HIV‐infected children has yet to be adequately described. One possibility is inappropriate delivery of an essential second signal for T‐cell activation due to the inappropriate presentation of co‐stimulatory molecules. To determine whether the ligand for the secondary signal is impaired in pediatric AIDS, we compared the level of CD80 expression by circulating monocytes in HIV‐infected and ‐noninfected children (15 mild/asymptomatic, 13 symptomatic and 12 HIV seronegative children). By two‐color flow cytometry analysis, there was no statistically significant difference in the percentage of monocytes expressing CD80 among the groups (i.e., 63.2±15.8, 60.9±12.7, 61.04±10.9 for uninfected children, mild‐asymptomatic children and symptomatic children, respectively). However, both infected groups showed statistically significant lower levels of CD80 expression, with mean fluorescent intensities of 40.9±15.9 and 38.8±10.7 compared to 57.05±16.3 for the uninfected control group. Our data demonstrated a correlation between HIV infection and impairment of CD80 by circulating monocytes. Whether the impairment on CD80 expression contributes to destruction of the immunological network in HIV‐infected children requires further investigation.