Molecular epidemiology and genotype distribution of noroviruses in children in Thailand from 2004 to 2010: a multi-site study.

This study identified norovirus in children presenting with acute gastroenteritis and determined the capsid genotypes of the circulating norovirus strains in multiple regions in Thailand during October 2004 to December 2006 and March 2008 to August 2010. A total of 7,420 stool samples were collected from both cases (3621) and controls (3799). The stool samples were screened by two real-time RT-PCR assays to detect genogroup I and genogroup II noroviruses. Norovirus-positive samples were identified in 516 cases (14.3%) and 181 controls (4.8%) with more than half of norovirus positive samples from 7-24 months old children. Positive samples were sequenced and genotyped for the capsid gene. GII.4 was the genotype observed most frequently (56.4%) followed by GII.3 (28.2%). Five peaks of infection were observed, with predominant capsid genotypes that alternated during the surveillance periods between GII.4 and GII.3. Analyses of positive samples showed variation in genotype from each region as well as from different study periods. This emphasizes the importance of multi-site studies to investigate norovirus epidemiology. Additionally, the observed regional and temporal variations suggest that a systematic nation-wide surveillance effort in Thailand is needed to track the continually changing norovirus epidemiology.

Persistent diarrhea: 15 years experience at a tertiary care hospital.

OBJECTIVE: To determine the risk factors, causative enteric pathogens, final diagnosis and treatment outcomes of persistent diarrhea in children. MATERIAL AND METHOD: A retrospective study of the patients who had diarrheal symptoms for at least 14 days diagnosed as persistent diarrhea (PD) and admitted at QSNICH during January 1997 and December 2011. Demographic data, risk factors, causative enteric pathogens, management and outcome were reviewed. RESULTS: The review included 79 PD patients. Excluded were patients who were HIV seropositive, had GI anomalies and/or other underlying immune deficiencies. The demographic data showed mean age 11.42 months and male:female 56:23 (2.43:1). Feeding with infant formula before admission was 43% compared to exclusive breastfeeding that was only 10%. Normal nutritional status was found in half of the cases (52.1%) and protein energy malnutrition (PEM) was present in 42.3%. Stool for enteropathogens was positive only in 49.4% and the most common being mixed enteropathogens. Secondary lactase deficiency was the cause of PD in half (50%) of the patients. Management consisted of rehydration, intravenous antibiotics 53%, and other adjuvant therapies such as cholestyramine, zinc and probiotics. Along with rehydration, all patients received aggressive nutritional management upon admission. The diarrhea subsided in less than 7 days in about 70% of the patients. CONCLUSION: The present study supports that important risk factors for PD are very young age group (especially under 1 year old), lack of breastfeeding and malnutrition. Enteropathogens were found in only about half of the patients and the most common cause of PD was secondary lactase deficiency. Most of the diarrhea subsided in less than 7 days of admission with proper management and aggressive nutrition upon admission.

Eosinophilic gastrointestinal disease: analysis of sixteen cases from ten years experience in Thailand.

OBJECTIVE: To study eosinophilic gastrointestinal disease (EGIDs) in children concerning the clinical presentations, diagnostic methods and results of treatment. MATERIAL AND METHOD: A retrospective study of EGIDs was done from January 2000 to December 2009. All patients diagnosed as EGIDs according to gastrointestinal symptoms combined with eosinophilic infiltration in mucosal, muscular or serosal layer of involvement. Exclusion of extraintestinal eosinophilic involvement and parasitic infestations were done. Analysis of clinical presentations, diagnostic methods and results of treatment were reviewed. RESULTS: Sixteen children fulfilled criteria of EGIDs. Mucosal type was the most common finding type (12 out of 16 cases) (75%). Muscular and serosal type was found in equal numbers (2 of each in 16 cases) (12.5% each). Ages ranged from 6 months to 13 years. The male: female ratio was 1: 1.2. Abdominal pain was the most common presenting symptom followed by diarrhea. Allergic history was detected in 68.75% of all patients. Peripheral eosinophilia was found in only 37.5% of all cases. Radiographic findings showed non-specific findings. Endoscopy was performed in 14 out of 16 cases (87.5%). Lymphoid hyperplasia was the most common endoscopic finding especially in mucosal type. Eosinophil (more than 20 per high power field) was found from biopsied tissues obtained from the esophagus, stomach, colon or from ascitic fluid. Prednisolone was used in 13 out of 16 cases with satisfactory results in 11 cases. The two resisted cases responded to ketotifen in one and the other in combination with montelukast. One out of 16 cases subsided with only proton pump inhibitor The last two cases improved by allergic food elimination. CONCLUSION: Eosinophilic gastrointestinal disease in children presents with varieties of gastrointestinal symptoms. Biopsied tissues or ascitic fluid are required to demonstrate significant eosinophilic infiltration or presence of eosinophil. Allergic history seems to play an important role in more than half of the patients. Specific dietary elimination is the most important treatment in allergic cases. Corticosteroid is the treatment of choice in the non-allergic group or for those who did not improve with food elimination.

Hepatocellular carcinoma in children presents with massive upper gastrointestinal bleeding: a case report.

Hepatocellular carcinoma (HCC) is a very rare pediatric tumor. The incidence is 0.5-1.0 cases per million children. The most common clinical sign is abdominal mass. HCC often develops in the presence of underlying liver disease and cirrhosis, especially viral hepatitis. The authors hereby report a 9-year-old girl with hepatocellular carcinoma associated with positive hepatitis B surface antigen at Queen Sirikit National Institute of Child Health. She was admitted because of massive upper gastrointestinal bleeding (UGIB) due to esophageal varices. Multiple sessions of esophagogastroscopy with sclerotherapy banding ligation and glue injection of esophageal varices were performed but she still had massive UGIB. Sengstaken-Blakemore tube was used, after which she developed a ruptured esophagus. Finally she passed away. Liver necropsy was performed and diagnosed as HCC.

Clinical features of gastrointestinal salmonellosis in children in Bangkok, Thailand.

This retrospective descriptive study was conducted at Queen Sirikit National Institute of Child Health (QSNICH), Bangkok, Thailand to describe the clinical features of gastrointestinal salmonellosis in children. The medical records of 134 patients admitted to QSNICH in 2009 who had a positive stool culture for Salmonella spp were reviewed. Demographic, clinical, laboratory, treatment, culture and antimicrobial sensitivity data were collected and analyzed. The mean age of the patients was 22.9 months (range 0.5 to 158 months); 76.9% were < 2 years old. The male to female ratio was 1.5:1. Salmonella B was most commonly found serogroup (47%). The common clinical manifestations included diarrhea (99.3%), fever (93.3%), dehydration (64.9%) and nausea/vomiting (48.5%). Most of the Salmonella isolates were sensitive to a fluoroquinolone and many were sensitive to Cotrimoxazole, but few were sensitive to ampicillin. There were no significant differences in the clinical manifestations and drug sensitivities of the different Salmonella serogroups, except convulsions were more common in Salmonella E infected patients (p = 0.04) and more Salmonella C isolates were sensitive to ampicillin (p = 0.04). There was no significant correlation between clinical course and antimicrobial treatment, except the duration of diarrhea was significantly longer in patients who received antimicrobial treatment (mean 6.1, SD 4.7 days vs mean 4.2, SD 2.1 days) (p = 0.03). Three patients had Salmonella bacteremia. Three patients died but not directly due to Salmonella infection.

Gastrointestinal manifestations in severe strongyloidiasis: report of 3 cases and literature review.

We report here three cases of severe strongyloidiasis in normal and immunocompromised hosts. The first was a patient with a normal immune system who presented with acute severe abdominal pain. The second and third patients were immunocompromised due to steroid and chemotherapy treatment of underlying diseases. Both presented with obstructive symptoms. In all three cases, Strongyloides stercoralis larvae were detected in stool concentration samples, and in biopsied specimens from the duodenum in the first and second cases.

Chronic diarrhea and abnormal serum immunoglobulin levels: a case report.

A 15-year-old Thai boy with multiple episodes of chronic diarrhea caused by giardiasis with hypogammaglobulin M and IgG4 subclass deficiency (but normal antibody response to rabies vaccine) is reported. Immune status follow-up is necessary for a definite diagnosis and proper management.

A rapid serologic test and immunoblotting for the detection of Helicobacter pylori infection in children.

The gold standard for the diagnosis of Helicobacter pylori infection requires an endoscopic biopsy of gastric mucosa for histological examination, urease test and culture. Noninvasive serological tests are useful as a screening test for H. pylori infection. The aim of this study was to evaluate the performance of a rapid office-based serologic test, using immunochromatography ICM, and the immunoblotting for the diagnosis of H. pylori infection in Thai children. Eighty-two symptomatic children, 30 boys and 52 girls (mean age 9.2+/-3.8 years; range, 1.2-16.0 years) who had no previous treatment for H. pylori underwent upper endoscopy. Biopsies were obtained from the gastric body and antrum for histopathology and rapid urease test. Serum samples collected from all patients were tested for H. pylori IgG antibodies using ICM (Assure H. pylori Rapid Test, Genelabs Diagnostics, Singapore). Immunoblotting (HelicoBlot 2.1, Genelabs Diagnostics, Singapore) was tested in sera of 75 patients to detect antibodies to specific antigens of H. pylori. Positive H. pylori status was defined as positive for both histology and rapid urease test. Of 82 patients, 25 (30.5%) were H. pylori positive, 56 (68.3%) were H. pylori negative and one was equivocal. ICM assay yielded a positive result in 24 of the 25 H. pylori-positive patients (96.0%) and 3 of the 56 H. pylori-negative patients (5.4%). The immunoblotting yielded a positive result in all of 22 H. pylori-positive patients (100%) and in 2 of the 52 H. pylori-negative patients (3.8%). Obtained ICM's sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 96.0, 94.6, 88.9, 98.1 and 95.1%, with immunoblotting 100.0, 96.2, 91.6, 100.0, and 97.3%, respectively. The immunochromatographic and immunoblot tests are non-invasive, reliable and useful for the diagnosis of H. pylori infection in Thai children.

Intussusception associated with a relapsing nephrotic patient: a case report.

BACKGROUND: Gastrointestinal disturbances are encountered frequently in the course of the nephrotic syndrome but intussusception is a rare association. It may be the result of incoordinate motility and bowel wall edema. OBJECTIVE: To report a case of intussusception associated with relapsing nephrotic syndrome. CASE REPORT: The authors reviewed the case of a 5-year-old boy who had been diagnosed as having nephrotic syndrome at Queen Sirikit National Institute of Child Health for 1 year, who later presented with nephrotic symptoms and an acute abdomen. Abdominal ultrasonography and barium enema were performed which diagnosed ileo-colic intussusception. Resection of the ileum and appendectomy were performed while the relapsing nephrotic syndrome was treated by prednisolone. The patient's recovery was excellent. Percutaneous renal biopsy was done because of the frequent relapsing condition and showed mesangial proliferative glomerulonephritis consistent with IgM nephropathy. Intussusception should be included in the differential diagnosis of relapsing nephrotic syndrome presenting with acute abdominal pain. Abdominal ultrasonography is helpful in confirming this condition.

Childhood Helicobacter pylori infection, clinical presentations, endoscopic, histologic features and results of treatment.

OBJECTIVE: To study childhood Helicobacter pylori infection concerning the clinical presentations, endoscopic, histologic features and results of treatment. MATERIAL AND METHOD: A retrospective study conducted at the Gastroenterology and Nutrition Unit, Queen Sirikit National Institute of Child Health (QSNICH) was done from January 1993 to December 2002. All patients presented with recurrent abdominal pain, upper GI bleeding (non-variceal bleeding) chronic vomiting and dyspeptic symptoms who underwent upper GI endoscopy were included in this study. Positive urease test verified by biopsied specimens from the gastric antrum and body and/or finding the organisms from the specimens were the criteria for diagnosis of H. pylori infection. Clinical presentations, endoscopic, histologic features and results of treatment in H. pylori infected cases were described. RESULT: A total of 144 patients who underwent upper GI endoscopy were included in the study. 22 out of 144 cases proved to be infected by H. pylori. Ages ranged from 2.6 to 14 years (mean age 9 years). The male/female ratio was 1:1.2. Vomiting and epigastric pain were the leading symptoms. Endoscopic findings were divided into inflammation in the stomach 12 cases, both stomach and duodenum 6 cases and duodenal ulcer 4 cases. Nodular hyperplasia of gastric antrum was found in 8 out of 22 cases. Histologic evidence of chronic gastritis was present in 12 cases, chronic gastroduodenitis 6 cases and chronic duodenitis in duodenal ulcer cases. Treatment regimen consisted of one H2 blocker (ranitidine) initially which was changed to omeprazole in 2001 combined with 2 antibiotics (amoxycillin and metronidazole) for 14 days. CONCLUSION: This study group represented middle and low income groups from around Bangkok and many parts of Thailand. The prevalence of H. pylori infection in the present study was 15.3 per cent which reflects that H. pylori infection is a common health problem in Thailand. However, because this was only a descriptive study, the authors cannot specify the association between symptoms, endoscopic findings, histologic features and disease.

Comparative antibiotic resistance of diarrheal pathogens from Vietnam and Thailand, 1996-1999.

Antimicrobial resistance rates for shigella, campylobacter, nontyphoidal salmonella, and enterotoxigenic Escherichia coli were compared for Vietnam and Thailand from 1996 to 1999. Resistance to trimethoprim-sulfamethoxazole, ampicillin, chloramphenicol, and tetracycline was common. Quinolone resistance remains low in both countries, except among campylobacter and salmonella organisms in Thailand. Nalidixic acid resistance among salmonellae has more than doubled since 1995 (to 21%) in Thailand but is not yet documented in Vietnam. Resistance to quinolones correlated with resistance to azithromycin in both campylobacter and salmonella in Thailand. This report describes the first identification of this correlation and its epidemiologic importance among clinical isolates. These data illustrate the growing magnitude of antibiotic resistance and important differences between countries in Southeast Asia.