First case report of brucellosis in a child in Thailand.

Brucellosis is uncommon in children. In Thailand, there have been only seven adult cases reported, all with Brucella melitensis. We describe here the first reported pediatric case of brucellosis in Thailand. A 12-year old boy presented with prolonged fever for one month, pancytopenia, pneumonia and peritonitis. The blood culture grew out Brucella melitensis. He responded well to combination therapy consisting of doxycycline and gentamicin. He recovered fully without relapse during the 6 month follow-up.

Emergence of human rotavirus genotype G9 in metropolitan Detroit between 2007 and 2009.

Between January 2007 and April 2009, rotavirus (RV)-positive stool samples from 238 children with acute gastroenteritis, seen at Children's Hospital of Michigan in Detroit, USA, were collected and RV genotyping was performed. G and P genotypes were determined by RT-PCR and nucleotide sequencing was conducted on selected G9 and P[6] strains. Correlation between the severity of gastroenteritis episode and the infecting G genotype was done using a 14-point scoring system. The predominant G genotype was G9 (39.5 %), followed by G1 (35.3 %) and G4 (15.5 %), while P[8] was the most prevalent P genotype (66.5 %), followed by P[4] (21.9 %) and P[6] (11.2 %). The gene combinations G1P[8] and G9P[8] were the most prevalent (21.4 % and 20.6 %, respectively), followed by G4P[8] (13 %) and G9P[6] (8.8 %). Immunization data showed that only 17/238 (7.1 %) children received ≥one dose of RV vaccine (the pentavalent vaccine RotaTeq or the monovalent vaccine Rotarix) and that 10/17 were infected with G4P[8] strains. Severity of RV gastroenteritis episodes was not related to the infecting G genotype. Our results suggest a high proportion of genotype G9 strains in combination with P[8], P[6] and P[4] specificity circulating in the metropolitan Detroit area. While the protective efficacy of the RV vaccines has been demonstrated against G9P[8] strains, the level of cross-protection offered by the vaccines against G9 strains with P[6] and P[4] genotypes in the Detroit paediatric population remains to be determined.

Boosted p24 antigen assay for early diagnosis of perinatal HIV infection.

OBJECTIVE: The authors evaluated the accuracy of in-house boosted-p24 antigen assay for diagnosis of perinatal HIV infection. MATERIAL AND METHOD: The author has retrospectively reviewed the medical records of infants born to HIV-positive mothers. The infants were tested for boosted-p24 antigen assay at the age of 1-2 months and 4-6 months. HIV infection was defined as positive anti-HIV at the age 18 months or older, or had positive HIV-PCR with clinical signs and symptoms compatible with HIV/AIDS. RESULTS: There were 168 infants included in this review and six were HIV-infected. The boosted-p24 antigen assay had the sensitivity, specificity, positive predictive value, and negative predictive value of 33.33%, 98.27%, 50%, and 95.8%, respectively at 1-2 month-old, and 100%, 98.27%, 71.43%, and 100%, respectively at 4-6 month-old. CONCLUSION: Boosted-p24 antigen assay could be a cheaper alternative test to help diagnosis of perinatal HIV infection in infants. The test was very accurate when performed at 4-6 months.

A comparative study of the serological response to Japanese encephalitis vaccine in HIV-infected and uninfected Thai children.

We report a prospective study of mouse brain derived inactivated Japanese encephalitis (JE) vaccine, given in 3-dose EPI program to human immune deficiency virus (HIV)-exposed Thai infants. 18 HIV-infected receiving antiretroviral therapy with median baseline CD4 of 33.1%, and 92 HIV-uninfected children were studied. All but one HIV-infected child seroconverted after the second dose. The geometric mean titers (GMTs) 3 months after the second and third doses in HIV-infected vs HIV-uninfected children were 247 vs 938 (p=0.022), and 2273 vs 24069 (p=0.009), respectively. Urticaria or angioedema found in 4% and 6% in HIV-infected and -uninfected children, respectively (p=1.0). The vaccine was safe and immunogenic but antibody response in HIV-infected children was not as high as in uninfected children.

Efficacy and tolerability of nevirapine- versus efavirenz-containing regimens in HIV-infected Thai children.

BACKGROUND: Non-nucleoside reverse transcriptase inhibitor (NNRTI)-based highly active antiretroviral therapy (HAART) has been the most affordable regimen for the HIV-infected in developing countries. There are limited data comparing nevirapine (NVP) to efavirenz (EFV) in HIV-infected children. This study aimed to assess the efficacy and tolerability of NVP-based regimens compared to EFV-based regimens in HIV-infected children in Thailand. METHODS: The medical records of HIV-infected children who had received NNRTI-based regimens for more than 6 months at the Department of Pediatrics, Siriraj Hospital, Mahidol University, Thailand, were reviewed. RESULTS: Of the 139 HIV-infected children studied, 70 were male, and the median age at treatment initiation was 6.08 years (range 0.32-14.56 years); the median duration of follow-up was 36 months (range 6-66 months). The median baseline CD4 cell count was 185cells/mm(3) (range 2-3482cells/mm(3)) and the median baseline CD4 percentage was 7.20% (range 0.11-36.57%). An NVP-based regimen was initiated in 61 (44%): 38 antiretroviral (ARV)-naïve and 23 ARV-experienced. An EFV-based regimen was initiated in 78 (56%): 34 ARV-naïve and 44 ARV-experienced. The CD4 cell count and percentage gains were not different between the NVP and EFV groups in both the ARV-naïve and the ARV-experienced. However, ARV-naïve children who received an EFV regimen had significantly lower baseline CD4 levels than those who received an NVP regimen. ARV-naïve children had a better CD4 response than the ARV-experienced. The survival rates of children in the NVP groups were not different from those in the EFV groups for both the ARV-naïve and the ARV-experienced. Treatment failure occurred in one ARV-naïve NVP case (2.6%), two ARV-naïve EFV cases (5.8%), and nine ARV-experienced NVP cases (39%) at 24 months of treatment, and 11 ARV-experienced EFV cases (25%) at 18 months of treatment. Seven (10%) children had adverse effects from treatment with NVP. The main side effects were rash and hepatitis; six had to switch to EFV. Four (5%) children had adverse effects from treatment with EFV; two had to switch to NVP. CONCLUSIONS: Both NVP- and EFV-based HAART regimens were effective in children in Thailand for at least 3 years. HIV-infected Thai children generally tolerated NNRTI well.

Evaluation of a practical method to assess antiretroviral adherence in HIV-infected Thai children.

The objective of this study was to evaluate a practical method to assess adherence to antiretroviral therapy by observing virological and immunological responses. We conducted a 12-month longitudinal cohort study of 162 HIV-infected Thai children. Adherence was assessed using 5 methods (self reporting calendar, records of missed doses, pill counts, physician assessment, and an interview questionnaire). CD4 count, percentage and viral load were performed at baseline and at 12 months. Mean adherence rates at 2, 6, and 12 months were 98, 100, and 99% by the calendar method; 98, 100, and 100% by recording missed doses; 96, 96, and 92% by pill count; and 90, 94, and 97% by physician assessment. Poor agreement (kappa < or = 0.1) was found among the methods. There was a statistically significant difference (p = 0.05) in virological response between participants with > or = 95% adherence (0.8 log10) and those with < 95% adherence (0.2 log10) when pill counts were used to assess adherence. In conclusion, despite poor agreement among these tools, a pill count appeared to be the only practical, validated method to differentiate the virological outcome between those who were fully and partially adhere to the treatment regimen.

Clostridial liver abscess following blunt abdominal trauma: case report and review of the literature.

An 11-y-old boy developed a liver abscess 3 weeks following blunt abdominal trauma. Abscess culture yielded pure growth of Clostridium novyi type B, not previously reported as a cause of human infection. The patient was managed successfully with antibiotic therapy and continuous percutaneous drainage. Clostridial liver abscess following blunt abdominal trauma may occur as a delayed complication and may be managed without resectional debridement.

New antiviral agents.

During the last three decades, a better understanding of viral replication and disease states caused by viral infections have led to the development of newer antiviral agents with enhanced activity and better tolerability. This review focuses on newer systemic and topical antiviral agents that are used in treatment of herpes viruses including herpes simplex type-1 (HSV-1) and type-2 (HSV-2), varicella-zoster virus (VZV) and cytomegalovirus CMV) as well as the human papilloma virus (HPV). Included in this article are the agents famciclovir, penciclovir, valganciclovir, imiquimod, docosanole and brivudin.

Antibiotics for treatment of resistant gram-positive coccal infections.

Vancomycin is considered the workhorse for the treatment of most drug-resistant gram-positive bacterial infections. However, concerns have been raised regarding the increasing rates of vancomycin-resistant enterococci and the clinical shortcomings of vancomycin in the treatment of invasive Staphylococcus aureus infections. Resources have been committed to the development of antimicrobial agents with activity against these organisms. This review will focus on the newer antibacterial agents that have been developed for the treatment of resistant gram-positive pathogens. Included in this review are the agents: quinupristin-dalfopristin, linezolid, daptomycin, telithromycin, and tigecycline.

New antiretroviral drugs in clinical use.

The advent of combination antiretroviral therapy for the treatment of human immunodeficiency virus (HIV) infection has dramatically changed the prognosis and quality of life of HIV-infected adults and children. To date, there are 21 antiretroviral agents available with only 11 agents being approved for the use in young children less than 6 years of age. The currently available antiretroviral agents belong to four different classes; nucleoside/nucleotide reverse transcriptase inhibitors (NRTI, NtRTI), non-nucleoside reverse transcriptase inhibitors (NNRTI), protease inhibitors (PI), and a new class of fusion inhibitors (FI). It is recommended that the treatment regimen should be a combination of at least 3 drugs from different drug classes as this has been shown to slow disease progression, improve survival, and result in better virologic and immunologic responses. Treatment with antiretroviral agents is frequently complicated by the issues of adherence, tolerability, long term toxicity and drug resistance. Many efforts have been made to develop new antiretroviral agents with greater potency, higher tolerability profiles and better convenience. Some new agents are also effective against drug-resistant strains of HIV. Since 2001, there were 7 new antiretroviral agents and 2 fixed-dose multidrug formulations being approved for the treatment of HIV infection, most are approved only for use in adults. In this article, we will review new antiretroviral agents including emtricitabine, tenofovir disoproxil fumarate, atazanavir, fosamprenavir, tipranavir and enfuvirtide. Pediatric information on these drugs will be provided when available.

Dyslipidemia and lipodystrophy in HIV-infected Thai children on highly active antiretroviral therapy (HAART).

BACKGROUND: Previous cross sectional studies revealed that dyslipidemia occurs in 50-70% of children receiving highly active antiretroviral therapy (HAART). However, there is no information in children in developing countries where children may have a different nutritional status. OBJECTIVE: To evaluate the incidence and associated risk factors of dyslipidemia following HAART in HIV-infected Thai children. The occurrence of clinical lipodystrophy among these children was also evaluated. MATERIAL AND METHOD: Twenty-three HIV-infected children who initiated HAART from "Access to Care Program" sponsored by MOPH around October 2001. Non-fasting blood tests for lipid profile were performed at enrollment and every 6 months. Triglyceride level was not analysed due to a non-fasting condition. The assessment of clinical lipodystrophy was done every 1-2 months. RESULTS. As of October 2003, 19 (83%) children experienced dyslipidemia. There were 10, 13, 5, and 8 children who had dyslipidemia at 6, 12, 18, and 24 months of HAART The mean total cholesterol, low density lipoprotein (LDL), and high density lipoprotein (HDL) tended to increase over time while the children were on HAART: There was a correlation of elevated total cholesterol and CD4 percentage gain particularly at 18-24 months of treatment (r = 0.596, p = 0.007). Two children developed peripheral lipoatrophy. There were no dyslipidemia-associated risk factors identified. Most of the children had transient abnormal lipid profile. There were only 3 children that had persistent abnormality throughout the 24 months of HAART CONCLUSION: Dyslipidemia was found from 6-12 months of HAART and were mostly transient over time. Peripheral lipoatrophy were found in 2 children. Further follow-up will elucidate the long-term incidence, the association factors, and clinical consequences.

A child with avian influenza A (H5N1) infection.

Human infections with avian influenza viruses can be severe and may be harbingers of the evolution of a pandemic strain. We present a patient in Thailand who was infected with influenza A (H5N1) virus. Prominent features included the progression from fever and dyspnea to the acute respiratory distress syndrome in a short period, lymphopenia and thrombocytopenia. Establishing the diagnosis for this patient increased public awareness of the virus and was soon followed by a halting of poultry-to-human transmission. On the basis of available data, any child with suspected avian influenza infection should be treated with oseltamivir.

Effect of antiretroviral therapy in human immunodeficiency virus-infected children.

BACKGROUND: The appropriate timing of antiretroviral (ARV) therapy initiation in children with human immunodeficiency virus (HIV) infection has been uncertain. There was evidence of poorer outcome in adults who initiated treatment at lower baseline CD4 cell count. However, early initiation may not be possible in resource-limited setting and would increased risk of long term side effects and non-adherence. OBJECTIVE: To elucidate the outcome of HIV-infected children who ARV treatment was initiated at different disease stages. MATERIAL AND METHOD: Data from medical records of HIV-infected children who had been followed at Infectious Disease Division, Department of Pediatric Siriraj Hospital were retrospectively reviewed. Clinical response and outcome data were analyzed. RESULTS: From September 1996 to March 2004, there were 200 patients with a median age at treatment initiation of 38 (2-175) months. The median duration of follow up period was 26 (1-91) months. The median baseline CD4 cell count was 545 (2-5016) cells/mm3. The median baseline CD4 percentage was 14.25 (0.11-60). Monotherapy or dual nucleoside reverse transcriptase inhibitor (NRTI) regimens were initiated in 134 (67%), and HAARTwas initiated in 66 (33%) patients. The survival rate in patients who initiated with HAART tended to be better than those initiated with dual NRTI regimens but salvaged appropriately (p=0.2377). The survival rate in those initiated treatment at baseline CD4 > or = 15% was better than those initiated at baseline CD4 < 15% (p=0.0471). CONCLUSION: Initiation of ARV treatment at CD4 more than 15% resulted in a better survival rate than at CD4 below 15%. Initiation with HAART regimen tended to improve survival and resulted in higher CD4 gain especially in cases with baseline CD4< 15%.