Clinical trial: clotrimazole troche vs. itraconazole oral solution in the treatment of oral candidosis in AIDS patients.

This prospective study was designed to compare the efficacy and safety of itraconazole oral solution with those of clotrimazole troche in the treatment of oropharyngeal candidosis in acquired immunodeficiency syndrome (AIDS) patients. Patients were excluded if they had been treated with any antifungal agents 2 weeks prior to the study entry, were pregnant or nursing, or had significant liver disease. Twenty-nine patients (20 men and nine women), with a mean age of 32 years (15-62 years), were randomly, observer-blind treated with clotrimazole troche (10 mg, five times daily) or itraconazole oral solution (100 mg/10 mL, twice daily) for 1 week. Clinical and mycologic assessment were carried out on four consecutive days, in week 1, week 2, and week 4 after the start of treatment. Clinical evaluation was assessed by a scoring method (0-3, absent to severe) as follows: soreness, change in taste, erythema, removable white plaque, and extent of lesions. Mycologic assessment was performed by KOH preparation and fungal culture. Global evaluation, which is a summary of clinical and mycologic assessment at the end of treatment, was classified as cure (all signs and symptoms resolved with no evidence of infection), improvement (decrease in clinical score without complete resolution), or failure (lack of improvement or further deterioration). (Pons V, Greenspan D, Debruin M. Therapy for oropharyngeal candidiasis in HIV-infected patients: a randomized, prospective multicenter study of oral fluconazole versus clotrimazole troches. J Acquir Immune Defic Syndr 1993; 6: 1311-1316. ) Global evaluation at week 2 and week 4 was made in terms of no relapse or relapse. Any intercurrent medical events, whether human immunodeficiency virus (HIV)-related or not, were recorded. An intention-to-treat analysis was employed. Data were analyzed using the chi-squared test, Mann-Whitney U-test, and Student's t-test.

Erythroderma in Thai patients.

Erythroderma is a clinical manifestation of dermatoses from different causes. Our objective was to determine its incidence, causes and clinicopathological features. Clinical, laboratory, and biopsy materials of 49 patients diagnosed as having erythroderma were reviewed. They were treated in our department over a 10-year period (1985 through 1994). The male-female ratio was 2:1. The mean age at diagnosis was 51.7 years. The most common causative factors were drugs (38.77%) and preexisting dermatoses (26.5%). Hepatomegaly, jaundice and abnormal liver function tests were found more commonly in the drug allergy group, while in cases with preexisting dermatoses nail involvement was a common finding. Clinicopathologic correlation in our study did not inform the etiology because it showed chronic nonspecific dermatitis or psoriasiform dermatitis, without any clue as to its origin. Drug-induced-erythroderma had an acute onset and a good prognosis with rapid resolution when the causative drug was withdrawn, while histopathology and laboratory findings were largely unrewarding.

Clinical and microbiologic findings in cellulitis in Thai patients.

BACKGROUND: Cellulitis is an inflammation of subcutaneous tissue in which infective, generally bacterial cause is proven or assumed. However, attempts to culture bacteria from lesions are often unsuccessful. METHOD: One hundred and fifty cases diagnosed as cutaneous cellulitis at Siriraj Hospital between 1992 and 1995 were retrospectively studied. RESULTS: Our study in 150 adult Thai patients with cellulitis showed that the most common site of infection was the lower extremity. Forty two per cent of the patients had history of preceding local trauma. Fever and regional lymphadenopathy were detected in 77.3 per cent and 22.6 per cent respectively. Sixty nine per cent of patients had leukocytosis with a mean neutrophil ratio of 79.7 per cent of patients with underlying diseases predisposed to the infection, 61.6 per cent had positive lesional culture results in contrast to 31.6 per cent in patients without. Needle aspiration and blood gave low positive culture yields. The common organisms detected were S.aureus and Streptococcus group A (83%) in immunocompetent patients. Of immunocompromised patients, in one half of the cases gram negative bacteria were found. CONCLUSIONS: This study showed that in immunocompetent patients, the major bacterial isolated in cellulitis were S.aureus and Streptococcus group A. In immunocompromised patients, gram negative bacteria were found in one half. These findings may help in the selection of antimicrobials before the results of bacterial cultures are available or in culture negative cases.

Deep fungal and higher bacterial skin infections in Thailand: clinical manifestations and treatment regimens.

BACKGROUND: Deep fungal and higher bacterial skin infections occur fairly frequently in Thailand. METHODS: Cases with a provisional diagnosis of deep fungal and higher bacterial infections were prospectively collected from 1994 to 1997 in the Granuloma Clinic, Department of Dermatology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand. Demographic data, clinical manifestations, causative organisms, histologic features, treatment, and outcome were investigated. RESULTS: The total cases in a 4-year period numbered 27. The male to female ratio was approximately 1:1. Mycetoma was most common, followed by chromoblastomycosis. Actinomycetoma was similar in incidence to eumycetoma. The only causative organism that could be identified among the mycetoma cases was Cladosporium carrionii, which caused mycetoma of the buttock of an aplastic anemia patient at the site of bone marrow aspiration. Surgical treatment was recommended for eumycetoma. Chromoblastomycosis was caused by C. carrionii and F. compactum and responded well with itraconazole orally. Mycotic abscesses were found in four cases, basidiobolomycosis in two cases, and cutaneous nocardiosis in one case. Cotrimoxazole was recommended in the treatment of actinomycetoma, cutaneous nocardiosis, and basidiobolomycosis. CONCLUSIONS: Localized, chronic, slow, progressive, and usually asymptomatic were the main cutaneous manifestations of deep fungal and higher bacterial skin infections. A skin biopsy for histologic study and culture identification should be performed in every suspected case. The causative organisms were found in the histologic sections of every case, but only about one-third were found by culture.

Prevalence of skin disease in patients infected with human immunodeficiency virus in Bangkok, Thailand.

A detailed study of the skin lesions of 248 patients infected with the human immunodeficiency virus (HIV) in Bangkok, Thailand, is reported. The study population consisted of 140 patients with asymptomatic disease (stage I), 27 patients with symptomatic disease (stage II), and 81 patients with advanced stage of the disease (stage III). Ninety-five percent of all patients were observed to have one or more skin disorders. Conditions with prevalence higher than 5% included oral candidiasis (34.3%), pruritic papular eruption (32.7%), seborrhoeic dermatitis (21.0%), herpes zoster (16.1%), oral hairy leucoplakia (14.9%), herpes simplex (10.9%), onychomycosis (9.3%), cutaneous ringworm (7.7%), psoriasis (6.5%), and folliculitis (5.6%). Patients in the stage II and III subgroups were found to have a significantly more number of skin disorders than patients in stage I. The prevalence pattern of skin disorders in this study are generally similar to previous studies in the literature. Three notable differences, however, emerge from this study: (1) the high prevalence of pruritic papular eruption in all subgroups, (2) the high prevalence of Penicillium maneffei infection in patients with advanced disease, and (3) the absence of Kaposi's sarcoma in the study population. Knowledge about the cutaneous disease pattern in the locals will be more clinically relevant for proper care of the patients.

PIP: During July 1993-June 1994 in Bangkok, Thailand, dermatologists examined the skin of 248 HIV-infected patients attending the outpatient clinic or admitted to the medical wards of Siriraj Hospital and performed a CD4+ T-lymphocyte count to determine the prevalence of skin disorders in HIV-infected people and to categorize them into clinical stages. 86% of the patients were male. 140 people were in the asymptomatic group, 27 in the symptomatic group, and 81 in the advanced group (CD4+ 50 cells/sq m). 95% of all HIV-infected patients had at least 1 skin disorder, especially oral candidiasis (34.3%) and pruritic papular eruption (PPE) (32.7%). Other skin disorders included seborrhoeic dermatitis (21%), herpes zoster (16.1%), oral hairy leukoplakia (14.9%), herpes simplex (10.9%), onychomycosis (9.3%), cutaneous ringworm (7.7%), psoriasis (6.5%), and folliculitis (5.6%). No one had Kaposi's sarcoma. 3.2% of all HIV-infected patients had Penicillium maneffei infection, which was limited to only AIDS patients. 9.9% of AIDS patients had Penicilliosis maneffei. Prior to the AIDS epidemic, this infection was unknown to most physicians. AIDS patients were more likely to have at least 3 skin disorders. AIDS patients were more likely to have severe skin lesions than asymptomatic and symptomatic patients (14.8% vs. 9.4% and 7.5%, respectively). Asymptomatic patients had higher prevalence of the frequently seen skin disorders, except cutaneous ringworm, than general patients attending the outpatient clinics (e.g., 3-fold increase for psoriasis, about 25-increase for candidiasis). PPE and oral hairy leukoplakia were unique to HIV infection. This population tended to share a similar pattern of skin manifestations of HIV disease. It is unusual that this population has a high prevalence of PPE and P. maneffei infection and no Kaposi's sarcoma.

The use of fluoroquinolones in sexually transmitted diseases in Southeast Asia.

This paper reviews the use of the fluoroquinolone antibiotics in the management of sexually transmitted diseases (STD) in Southeast Asia. Numerous clinical trials performed in the region have shown that the quinolones are highly effective for treating uncomplicated gonorrhoea. Norfloxacin 800 mg, ofloxacin 400 mg, ciprofloxacin 250 mg, and pefloxacin 400 mg in single oral doses have yielded excellent clinical results. Overall cure rates were greater than 95%, with full eradication of penicillinase-producing Neisseria gonorrhoeae in all studies. Strains of gonococci resistant to the quinolones have already emerged and should be closely monitored. However, this has not become a serious problem to date, as large scale evaluation has shown that the quinolones remain highly efficacious for the treatment of gonorrhoea. These antibiotics in single doses are not effective for postgonococcal urethritis (PGU); therefore, concomitant use of an antichlamydial regimen for all patients with gonorrhoea is recommended. The quinolones are also highly effective for chancroid. Excellent results, with cure rates approaching 100%, were achieved with single oral doses of ciprofloxacin 500 mg, norfloxacin 800 mg, and ofloxacin 400 mg. Widespread use of these drugs in STD treatment regimens may be one of the main factors causing a dramatic decline in the number of cases of chancroid seen in recent years. Ofloxacin in variable dosages for a period of 10 to 21 days was found to be effective in nongonococcal urethritis (NGU). However, when compared with the tetracyclines, it is less cost effective and can thus be regarded as an alternative treatment for NGU.

Stevens-Johnson syndrome and toxic epidermal necrolysis in Thailand.

BACKGROUND: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are potentially life-threatening illnesses that have often been linked to drug exposure. METHODS: We looked retrospectively for all cases of SJS and TEN that were admitted to Siriraj Hospital between 1981 and 1990 to determine the drug etiology. RESULTS: Fifty-eight cases of SJS and 20 cases of TEN were identified. Eight patients initially had an SJS-like aspect, which subsequently evolved into TEN. A culpable drug was determined in 60 patients (77%). The mean time from first drug administration to onset of SJS or TEN was 6.8 +/- 6.5 days (range, 1 to 28 days). A longer incubation period was observed with thiacetazone (10.5 +/- 5.6 days), phenytoin (12 +/- 8.5 days), and carbamazepine (11.3 +/- 3.4 days). CONCLUSIONS: The culprit drugs included the following: antibiotics, 32 cases (penicillin, sulfonamides, tetracycline, erythromycin); anticonvulsants, nine (phenytoin, carbamazepine, barbiturates); antitubercular drugs, eight (thiacetazone); analgesics, four (acetylsalicylic acid, fenbufen); sulfonylurea, two; allopurinol, one; and others, four. The most frequent underlying diseases justifying the ingestion of one or more drugs in our patients were infections (52.7%), followed by pulmonary tuberculosis (10.8%), and by seizures (8.1%). The total mortality rate was 14%; 5% for SJS, and 40% for TEN. Mortality was not affected by the type of drug responsible.

HIV infection in male patients attending a sexually transmitted disease clinic.

Three hundred and fifty-two heterosexual males, attending a sexually transmitted disease clinic at Siriraj Hospital from December 1989 to February 1991 were studied for the prevalence of HIV infection. Of these, 334 men reported prostitutes as the main source of their sexually transmitted disease. No one had received blood transfusion in the last 5 years, and there was no history of intravenous drug use, homosexuality or bisexuality. HIV antibody was found in the sera of 24 men (6.8%). HIV seropositivity was associated with serologic makers of syphilis (P < 0.05) but was not associated with present genital ulcers on physical examination or other STDs. These data indicate the high rate of female prostitutes to male transmission of HIV infection in the presence of sexually transmitted disease and confirms the relationship between syphilis and HIV infection. HIV/AIDS educational programmes and campaigns to promote condom use among prostitutes and clients are an urgent need in Thailand.

PIP: The study subjects were recruited among heterosexual men attending the male sexually transmitted disease (STDs) clinic operated by the Dermatology Unit, Siriraj Hospital, Mahidol University, Bangkok, Thailand. The subjects had no history of intravenous drug use, homosexuality, or bisexuality, had not received blood transfusion in the preceding 5 years, and claimed that they had contracted the disease from prostitutes. Between December 1989 and February 1991, 352 men enrolled in the study who had a median age of 28 years (range 15-63 years). The participants completed a questionnaire about occupation and clinical symptoms of STDs. Sera were assayed for VDRL and TPHA. HIV antibody screening was performed by gel particle agglutination or ELISA technique, and the specimens were confirmed as positive by HIV antibody Immunoblot technique. Of the 328 HIV seronegative men, 44% had nonspecific urethritis, 13.3% had gonorrhea, 13.1% had genital ulcers (including syphilis and chancroid), and 7.6% had syphilis (including positive VDRL or TPHA 1:160). 334 of 352 men (94.9%) reported prostitutes as the source of their STDs. HIV antibody was detected in 19 (5.4%) of 352 men. Only 100 of the 333 men whose first HIV antibody was negative returned to the clinic for a second HIV antibody test within 12 weeks, and HIV antibody was detected in 5 (5.0%) of these 100 men. Thus, the HIV antibody was found in a total of 24 (6.8%) of 352 men. This rate was 15 times the rate found in blood samples from healthy donors at Siriraj Hospital during the period between 1989 and 1990. The HIV seropositivity was significantly associated with syphilis (including positive VDRL or TPHA 1:160), but was not associated with genital ulcers (including syphilitic ulcer and chancroid). None of the 24 seropositive men had clinical evidence of AIDS-related complex or full-blown AIDS. The lack of association between HIV seropositivity and genital ulcer remains to be further investigated.

An unusual combination of phototoxicity and Stevens-Johnson syndrome due to antimalarial therapy.

A 12-year-old boy developed a phototoxic rash with subsequent progression to Stevens-Johnson syndrome due to prophylactic ingestion of antimalarials (chloroquine and sulfadoxine-pyrimethamine; Fansidar). The patient recovered from his skin symptoms after 4 weeks during which he received systemic corticosteroids and antibiotics. This unusual combination of two different patterns of adverse cutaneous drug reactions was most probably caused by the sulfonamide component of Fansidar.