Deep vein thrombosis after hip surgery among Thai.

A pilot study was done during April 1984 through June 1986 to determine the incidence of postoperative deep vein thrombosis (DVT) among 50 Thai patients who underwent hip surgery, which mainly consisted of total hip replacement (19 patients) and repair of hip fracture (29 patients). Most patients were in the sixth to seventh decade of life, and the male-to-female ratio was 32:18. Most patients were of normal or low weight, few had known risk factors for DVT, and all but three had general anesthesia. Venography performed on the operated on legs on the seventh to tenth postoperative days showed that only two patients had DVT, one in the calf and another in the calf and thigh veins. The low incidence of DVT in the Thai population even after such extensive surgery, which is associated with a high (40% to 70%) frequency of DVT in the Western world, suggests that routine prophylactic anticoagulant measures are not presently needed in this country.

Nasopharyngeal carcinoma: result of treatment with cis-diamminedichloroplatinum II, 5 fluorouracil, and radiation therapy.

Combined CT (CDDP + 5FU) and RT were given to 28 patients with NPC during July 1982-May 1985. Two, 1, 4, and 21 were in Stages I-IV (AJC), respectively. None had distant metastasis. Four did not complete the planned treatment, and one each had more or fewer CT courses than planned. The median duration of follow-up of surviving patients was 29 months (19-52,x 31.1). Objective response (CR + PR) at the primary lesion was 27/28 (96.4%), whereas CR was 23/28 (82%). CR + PR and CR of the regional nodes were 21/22 (95.5%) and 18/22 (82%) respectively. Remaining node in the 2 patients, who did not prematurely die were pathologically negative. Response at N site should therefore be 100% CR. Only patients with T3 (1/5) and T4 (3/13) lesions had residual disease at the T site after initial treatment. Salvage therapy was able to induce CR in all asymptomatic PR patients. There were 4 relapses, 2 at T, and 1 each at T + N and T + M sites. All M disease occurred in patients with huge and/or low cervical lymphadenopathy. Five patients died, one of an unrelated disease, and one each of T, M, T + N, and T + M diseases. The remaining 23 patients were still alive, and all except 3 were free of disease. Side effects, mainly from RT, were clinically acceptable. One had transient cervical myelitis. Myelosuppression was mild and of short duration. Activity of CT was seen at both T, and N sites after the upfront CT. Compared to our previous experience using RT alone, the result of this study suggested a positive role of CT in this disease. However, future prospective randomized trials are required to better define its role.

Penicilliosis marneffei in Thailand: report of five human cases.

The first two cases of Penicillium marneffei infection in humans were reported in 1959 and 1973. There had been no additional clinical reports of penicilliosis marneffei, until the five new cases of human infection described in this paper, the first from Thailand. The patients, three of whom died, came from various parts of the country. Their common clinical manifestations were fever and generalized lymphadenopathy, with multiple soft tissue, bone, joint and pulmonary involvement. Pericarditis with effusion was also seen. The diagnosis was established by isolating and identifying a dimorphic Penicillium species that produced a soluble red pigment in its mycelial form. The histopathologic features of the lymph nodes and bone marrow were similar to those of histoplasmosis capsulati. However, the yeast-like tissue form of P. marneffei divides by fission; that of Histoplasma capsulatum by budding. Treatment with amphotericin B was effective when this antifungal antibiotic was administered early in the course of the disease.

Acute nonlymphocytic leukemia with a translocation (1;3)(p36;q21) in an XYY man.

Neoplastic disease is quite rare in an XYY syndrome. We report the fifth known case, who suffered from acute nonlymphocytic leukemia (ANLL). Cytogenetic study of his bone marrow revealed a new chromosomal translocation (1;3)(q36;q21), which has only recently been described in patients with myelodysplastic syndrome.

Renal tubular acidosis with simultaneous lactic and keto acidoses: unusual manifestations of acute myelomonoblastic leukemia.

A 16-year-old male with severe metabolic acidosis required huge doses of sodium bicarbonate to alleviate his symptoms. Subsequent investigation showed that his bone marrow and kidneys were infiltrated with myelomonoblasts. His clinical course showed a temporal relationship between acute myelomonoblastic leukemia and metabolic acidosis. The literature on various etiologies of metabolic acidosis is reviewed. This is probably the first documented case of acute leukemia with the simultaneous occurrence of renal tubular, lactic and ketoacidoses.

Chemo-radiotherapy in nasopharyngeal carcinoma at Ramathibodi Hospital, Bangkok.

Combined chemotherapy (Cis-platinum and 5 FU) and radiation therapy were given to 11 patients with stage IV (except 1) nasopharyngeal carcinoma. None had distant metastasis. Mean duration of follow-up was 16.2 months. Objective response (CR+PR) at the primary lesion were 10 out of 11 (90.9%), while CR was 7 out of 11 (63.6%). CR+PR at the regional node were 10 out of 10 (100%), while CR was 9 out of 10 (90%). There has been no recurrence so far. One patient died of hepatocellular carcinoma. Side effects, mainly from radiation therapy, were clinically acceptable. One had transient cervical myelitis, which improved after medical treatment. There was no significant myelosuppression.

Pure red cell aplasia in Thailand: report of twenty four cases.

Twenty four cases of pure red cell aplasia were reported. No underlying diseases were found in two cases. Of the 22 cases with secondary form, 10 were from infections, mostly gram negative organisms. Three cases had systemic lupus erythematosus, two had autoimmune hemolytic anemia. The following conditions were found in one each: thymoma, thyroid carcinoma, protein calorie malnutrition, rheumatoid arthritis, non-Hodgkin lymphoma and Sheehan's syndrome. Three patients died, two from uncontrolled infection, the other from uncontrolled SLE and subsequently systemic fungal infection. Only one of the 2 primary cases responded to immunosuppressive drugs. The majority of patients with underlying infections, PRCA resolved after the infections were treated. This is the first reported series of PRCA in Thailand.

Therapy related acute non-lymphocytic leukemia: report of 4 cases.

Four cases of acute myelodysplastic-non-lymphocytic leukemia secondary to cytotoxic agents were reported. Primary diseases were breast cancer (1 patient), ovarian cancer (2 patients) and multiple myeloma (1 patient). All except one (with multiple myeloma) were in clinical remission of their primary diseases. Common cytotoxic agent used was melphalan. Median total drug dose and median latent period from diagnosis of primary diseases were 1299 mg and 63 months respectively. None with the exception of one received specific treatment. All died except one who is in a very poor condition. Survival from the diagnosis of hematologic diseases ranged from 3-9 months. Clinical features, cytogenetic findings, pathogenetic mechanism and risk of the disease were briefly discussed.

Immunoproliferative small intestinal disease (IPSID) in Thailand.

Immunoproliferative small intestinal disease (IPSID) is prevalent in the Mediterranean region and in many Third World countries but is rare in Southeast Asia. Between 1980-1990, 4 cases of IPSID were admitted to Ramathibodi Hospital, Bangkok. Three were males and the mean age was 32 +/- 20.2 years. All patients presented with chronic diarrhea of 7 months to 6 years duration, and weight loss of 15 to 31 kg. All were malnourished, three cachectic, and one patient showed growth retardation. Intestinal parasites were found in all cases: two had multiple infections and three had uncommon protozoal infections (coccidium, cryptosporidium). Barium radiographs revealed intestinal mucosal fold thickening with malabsorption pattern in all cases. Alpha chain IgA was detected in one patient. The remainder underwent exploratory laparotomy and the histological finding was of plasma lymphocytic infiltration of the small intestinal mucosa. All patients responded to oral tetracycline with complete remission occurring in one case. During the follow-up period, 3 cases had progressive retractable clinical courses but all died 2 to 5 years after the diagnosis. The causes of death in these patients were secondary bacterial infection (1 case), intestinal tuberculosis (1 case), fungal infection (1 case) and immunoblastic sarcoma in another case. The results of this study confirm the occurrence of IPSID in Thailand. IPSID responds to oral antibiotic therapy and complete remission may be achieved during the early reversible benign phase, thus an awareness of its occurrence is of clinical importance.

Acute massive intravascular hemolysis and disseminated intravascular coagulation.

Two cases of acute intravascular hemolysis complicating acute disseminated intravascular coagulation were presented, one after normal delivery and the other after group A beta hemolytic streptococcal septicemia complicating acute myelomonoblastic leukemia. Neither case received heparin therapy. The first one survived while the latter succumbed. Intravascular hemolysis may not be a bad prognostic sign in such a condition.

Experience with factor VIII: C inhibitors and acquired von Willebrand's disease in an adult at Ramathibodi Hospital.

Eleven cases of acquired inhibitors against factor VIII: C and von Willebrand's factor (vWF) seen at the Department of Medicine, Ramathibodi Hospital from 1979 to 1991 were reviewed. Factor VIII: C inhibitor was found in 6 of 36 patients (17%) with hemophilia A (median age 18 years). Three patients each were weak (titer < 10 Bethesda units/ml), and strong antibody producers. Two cases of weak antibody producers had spontaneous disappearance of inhibitor, while all 3 strong antibody producers required specific treatment (corticosteroids, immunosuppressive drugs, and plasmapheresis). The inhibitor level temporarily declined in 2 patients, and disappeared in one. Spontaneous acquired inhibitor to factor VIII: C was seen in 3 patients. One each respectively had pemphigus vulgaris and bullous pemphigoid, autoimmune disease, and NIDDM. They were characterized by older age (median age 54 years), frequent skin and soft-tissue hematoma, but less hemarthroses. Inhibitor titer ranged from 15-280 Bethesda units/ml. Disappearance of the inhibitor after treatment with corticosteroids and immunosuppressive drugs were observed in all patients. Acquired von Willebrand's disease developed in 2 previously healthy patients. One patient was in the postpartum period, while the other had simultaneous acute viral hepatitis A infection. Both presented with the recent onset of spontaneous severe gingival bleeding, and demonstrated a prolonged bleeding time, reduced vWF:Ag (F VIIIR:Ag), and ristocetin cofactor (F VIIIR:vWF). Treatment with cryoprecipitate and corticosteroid resulted in remission of bleeding symptoms. Despite the rarity of these disorders, the recognition and proper management are of importance.

Alpha chain disease in the Thai man.

A 61-year-old Thai man presented with a history of chronic diarrhoea of 1-2 years duration. Stool examination revealed a heavy parasitic infection. Several anthelminthics were given without benefit, despite disappearance of the intestinal parasites. Serum protein studies revealed abnormal alpha heavy chain. Two courses of cyclophosphamide, vincristine and prednisolone were followed by a brief remission in his symptoms. A 21 day course of tetracycline was then given, resulting in an improvement in his condition. He is still symptom free nine months after confirmation of the diagnosis, without any further treatment. Serum protein studies should be included in laboratory investigations of a patient with chronic diarrhoea.

Multivariate analysis of prognostic factors in Philadelphia chromosome positive chronic myeloid leukemia: an update of the first series in Thailand.

The prognostic importance of pretreatment clinical and laboratory features was investigated in a group of 243 patients with Philadelphia chromosome positive chronic phase chronic myeloid leukemia from 1977-1995. Chemotherapy consisted of busulfan before 1993 or hydroxyurea after 1993. The overall median survival from diagnosis was 28 months. The mean age of the patients was 38 years, about 10 years below that of Western populations. Univariate analysis identified 4 poor prognostic features: thrombocytopenia, more than 5% peripheral blasts, more than 5% erythroid precursors and less than 7 g/dl of hemoglobin. The median survival times of patients with these 4 risk factors were 5, 11, 11 and 12 months respectively. Multivariate analysis only identified 2 significant prognostic features: thrombocytopenia and more than 5% peripheral blasts. Splenomegaly of more than 10 cm, basophilia and leukocytosis were associated with a shorter median survival but was not statistically significant. A risk scoring system was developed and used to classify patients into low, intermediate and high risk groups at 30.9%, 30.2% and 38.8% respectively. The median survival time according to the low, intermediate and high risk group was observed at 60, 27 and 14 months respectively. Prognostic factors for Thai patients with chronic myeloid leukemia have both similarities and differences with previously observed factors but the median patient survival time is shorter.

Treatment of nasopharyngeal carcinoma.

Nasopharyngeal carcinoma is a common cancer among Thai males. When first seen, the disease is almost always locoregional. Evaluation of the tumor volume at the nasopharynx by computerized axial tomogram must be done prior to therapy. Treatment is done by radiation therapy to the nasopharynx and cervical lymph nodes, and is effective. Chemotherapy has high activity in this disease. However, more studies are needed to define its role. Side effects of treatment are radiation related, and confined to the area of previous radiation. They can be minimized if the patients strictly adhere to the physician's advice. Causes of treatment failure and death can be due to both locoregional failure and distant metastasis, notably to bone, liver and lungs.

Anti-HIV seroconversion in hemophilia A patient after transfusion of anti-HIV negative blood components.

A Thai male hemophiliac A patient has been anti-HIV seroconverted in the hospital after a 2-year admission for a large infected retroperitoneal hematoma. The source of HIV is thought to be one or more of more than 20,000 units of blood components used during the admission. All were screened as anti-HIV negative. Although he received heat treated factor VIII concentrate before this admission, it was not thought to be the cause. Autologous blood transfusion and HIV antigen screening are suggested as a safer way of blood transfusion.

Multivariate analysis of prognostic factors in chronic myelogenous leukemia.

The prognostic importance of patient pretreatment clinical and laboratory features were investigated in a group of 50 patients with Philadelphia chromosome-positive benign phase chronic myelogenous leukemia. The overall median survival time was 30 months. The patient characteristic associated with shortened survival was the male sex. Anemia, thrombocytosis or thrombocytopenia tened to have adverse effect on survival. A multivariate regression analysis demonstrated only sex difference to be of prognostic importance. Evaluation of the effect of therapy showed that intensive chemotherapy was not superior to single agent chemotherapy.

Lethal midline granuloma and lymphoproliferative disorders.

Seventeen patients, who presented with unhealing ulcers or destructive lesions of the upper aero-digestive tract at Ramathibodi hospital from 1977 to 1985 were reported. Lesions caused by infection, Wegener's granulomatosis or non-hematopoietic malignancy were excluded. A spectrum of histopathologic findings were evident in our patients, ranging from acute and chronic inflammatory changes with or without necrosis, polymorphic reticulosis or lymphamatoid granulomatosis, and malignant lymphoma of the non-Hodgkin's type (NHL). Although some initial histopathologic findings were non-specific, evidence of lymphoproliferative disorders finally emerged. These malignant lymphoid cells had a predilection for the GI tract and skin. Lymphoma staging should thus be done. Bleeding from the lesion, treatment-induced leucopenia, and sepsis were common in these patients. Early aggressive treatment including adequate antibiotic coverage for superimposed infection, improved nutritional status, and early radiation to the primary lesion are suggested for those diseases.

Levels of serum interleukin-6 and tumor necrosis factor in postsplenectomized thalassemic patients.

Levels of serum interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-alpha) were studied in 34 nonsplenectomized thalassemic patients (Thal/nonsplenec), 43 postsplenectomized thalassemic patients (Thal/postsplenec), 13 splenectomized non-thalassemic patients (nonThal/ postsplenec) and 18 normal control by enzyme linked immunosorbent assay method. Serum IL-6 concentration in Thal/postsplenec was significantly increased when compared with Thal/ nonsplenec and normal volunteers (3.55 +/- 2.47 pg/ml vs 2.38 +/- 2.31 pg/ml, p = 0.036 and 3.55 +/- 2.47 pg/ml vs 2.66 +/- 0.45 pg/ml, p = 0.028, respectively). This study also demonstrated that TNF-alpha value in Thal/postsplenec was drastically increased above normal control level (15.8 +/- 4.86 pg/ml vs 9.16 +/- 2.18 pg/ml, p = 0.001) and the level was statistically significantly higher than that in Thal/ nonsplenec (15.5 +/- 4.86 pg/ml vs 9.96 +/- 5.19 pg/ml, p = 0.001). There was a trend toward increasing of cytokine levels in Thal/postsplenec with higher platelet count although no correlation was observed. This study addresses the possible role of IL-6 and TNF-alpha in the pathogenesis of reactive thrombocytosis in Thal/postsplenec.

Changes in T-staging of nasopharyngeal carcinoma by CT-scan.

To evaluate the value of computerized axial tomogram (CT-scan) of the nasopharynx in the management of patients with nasopharyngeal carcinoma (NPC), comparisons between clinical T-staging by means of indirect or direct nasopharyngeal examination, and CT-scan were performed in 101 cases. CT-scan has upstaged clinical T-staging in 83.9 per cent of Tx-T3 cases, or 80 per cent in Tx, 98 per cent in T1, 65.4 per cent in T2, and 50 per cent in T3 cases. CT-scan was also able to show the destruction of the base of the skull in 85.7 per cent of T4 cases. With regard to tumor extensions into the surrounding regions, the CT-scan proved to out-perform clinical T-staging by 82.2, 57.4, and 25.7 per cent respectively in superior, anterior, and lateral and inferior extensions. We, therefore, recommend that a CT-scan be done in every new case of NPC, because it provides more accurate T-staging, and more details of tumor extension, which is essential in the management of NPC, especially in the proper planning of radical radiotherapy.