The Predictive Factors Associated with In-Hospital Mortality of Melioidosis: A Cohort Study.

Background and Objectives: Melioidosis is an infectious disease caused by Burkholderia pseudomallei, and it has a wide range of clinical symptoms. It is endemic in tropical areas, including Southeast Asia. Despite the availability of effective treatment, the mortality rate is still high, especially in patients presenting with septic shock. The aim of this study was to determine and explore clinical characteristics, microbiology, treatment outcomes, and factors associated with in-hospital mortality which could predict prognosis and provide a guide for future treatment. Materials and Methods: The population in this retrospective cohort study included all 262 patients with a diagnosis of melioidosis who were hospitalized at Surin Hospital, Surin, Thailand, from April 2014 to March 2017. We included patients older than 15 years with a positive culture for B. pseudomallei. Data regarding the clinical characteristics, microbiology, and treatment outcomes of the patients were collected and analyzed. The patients were divided into two groups dependent on outcome, specifically non-survival and survival. Logistic regression was performed to determine the risk factors associated with in-hospital mortality. Results: Out of the 262 patients with melioidosis during the study period, 117 (44.7%) patients died. The mean age was 57.2 ± 14.4 years, and 193 (73.7%) patients were male. The most common comorbidity was diabetes (123, 46.9%), followed by chronic kidney disease (35, 13.4%) and chronic liver disease (31, 11.8%). Four risk factors were found to be associated with in-hospital mortality, including age (adjusted odds ratio (aOR) 1.04, 95%CI: 1.01-1.07), respiration rate (aOR 1.18, 95%CI: 1.06-1.32), abnormal chest X-ray finding (aOR 4.79, 95%CI: 1.98-11.59), and bicarbonate levels (CO2) (aOR 0.92, 95%CI: 0.85-0.99). Conclusions: Our study identified age, respiration rate, abnormal chest X-ray finding, and CO2 levels are predictive factors associated with in-hospital mortality in melioidosis patients. Physicians should be aware of these factors, have access to aggressive treatment options, and closely monitor patients with these risk factors.

Clinical characteristics and drug susceptibility profiles of Mycobacterium abscessus complex infection at a medical school in Thailand.

OBJECTIVES: This study investigated the differences in epidemiological and clinical data, and antimicrobial susceptibilities among different subspecies of Mycobacterium abscessus complex (MABSC) clinical isolates at a medical school in Thailand. METHODS: A total of 143 MABSC clinical isolates recovered from 74 patients were genotypically analyzed for erm(41), rrl, and rrs mutations, and antimicrobial susceptibilities were determined using a broth microdilution method. Patient characteristics and clinical outcomes were reviewed from the medical records. RESULTS: Seventy-four patients were infected with 28/74 (37.8%) M. abscessus subspecies abscessus (MAB), 43/74 (58.1%) M. abscessus subsp. massiliense (MMA), and 3/74 (4.1%) M. abscessus subsp. bolletii (MBO). The clinical findings and outcomes were generally indistinguishable between the three subspecies. All three subspecies of MABSC clinical isolates exhibited high resistance rates to ciprofloxacin, doxycycline, moxifloxacin, TMP/SMX, and tobramycin. MAB had the highest resistance rates to clarithromycin (27.8%, 20/72) and amikacin (6.9%, 5/72) compared to MBO and MMA, with p < 0.001 and p = 0.004, respectively. In addition, the rough morphotype was significantly associated with resistance to amikacin (8.9%, 5/56), clarithromycin (26.8%, 15/56), and imipenem (76.8%, 43/56) (p < 0.001), whereas the smooth morphotype was resistant to linezolid (57.1%, 48/84) (p = 0.002). In addition, T28 of erm(41), rrl (A2058C/G and A2059C/G), and rrs (A1408G) mutations were detected in 87.4% (125/143), 16.1% (23/143), and 9.1% (13/143) of MABSC isolates, respectively. CONCLUSIONS: Three MABSC subspecies caused a variety of infections in patients with different underlying comorbidities. The drug susceptibility patterns of the recent circulating MABSC strains in Thailand were different among the three MABSC subspecies and two morphotypes.

Invasive pulmonary infection caused by Chrysosporium articulatum: the first case report.

Chrysosporium species, saprobic soil fungi, comprise more than 60 species. There is some confusion regarding the taxonomy and nomenclature between Chrysosporium and Emmonsia since the causative agents of adiaspiromycosis, the development of big thick-walled spores (adiaspores) in humans or animals, were previously thought to be Chrysosporium. Chrysosporium articulatum has never been reported to cause invasive infection in humans. We report herein the first case of invasive pulmonary infection caused by Chrysosporium articulatum in a 16-year-old man with acute T-cell lymphoblastic leukaemia. He was successfully treated with voriconazole.

PROSPECTIVE EVALUATION OF A NOVEL TWO-STEP PROTOCOL FOR SCREENING OF CLOSTRIDIUM DIFFICILE INFECTION IN HOSPITALIZED ADULT PATIENTS.

Abstract. Clostridium difficile infection (CDI) is one of the most common nosocomial infections in Thailand and worldwide. The clinical spectrum ranges from annoy- ing diarrhea to severe life-threatening disease. Enzyme-linked immunofluorescent assay for cytotoxins A/B (cytotoxins A/B ELFA), which has been widely used in our institute, generally is considered as having low sensitivity for diagnosis of CDI. The study was a prospective evaluation of a novel two-step diagnostic algorithm, in which the first step involved concurrent cytotoxins A/B ELFA and enzyme immunoassay for glutamate dehydrogenase (GDH EIA) for CDI, followed by PCR assay of tcdA and tcdB in samples with discordant results. Of the 91 adult patients (37 males and 54 females, mean age of 60.0 ± 19.5 years) with suspected CDI hospitalized at King Chulalongkorn Memorial Hospital, Bangkok, Thailand from December 2012 to February 2013, 22 were diagnosed with CDI by the gold standard PCR test for tcdA and tcdB, among whom 21 were positive by GDH EIA, accounting for a sensitivity of 95%. Of the 69 patients without CDI, GDH EIA was negative in 46 patients, accounting for a specificity of 67%. The positive predic- tive value (PPV), negative predictive value (NPV) and accuracy of GDH EIA was 48%, 98% and 74%, respectively, whereas sensitivity, specificity, PPV, NPV, and accuracy of cytotoxins A/B ELFA was 73%, 96%, 84%, 92% and 92%, respectively. Some 30% of specimens required the more expensive PCR assay. However, this two-step protocol detected 20% more patients with CDI than the currently used cytotoxins A/B ELFA method.

A case of invasive pulmonary infection caused by novel species of Perenniporia.

Perenniporia species, members of basidiomycetes, are known as decay fungi from wood of hardwood tree species. The clinical significance of these non-sporulating fungi from respiratory tract specimens is unknown. They have frequently been discarded as contaminants. There was only one case report of pulmonary fungal ball with positive culture for a Perenniporia species. We report herein a case of invasive pulmonary infection caused by the novel species of Perenniporia in a 44-year-old woman with active systemic lupus erythematosus who was successfully treated with voriconazole.

Catheter-related bloodstream infections caused by Trichosporon species.

Trichosporonosis is an emerging invasive opportunistic fungal infection in immunocompromised patients. We report 5 catheter related blood stream infections caused by Trichosporon species over a five-year period at King Chulalongkorn Memorial Hospital, Bangkok, Thailand. All the patients were immunocompromised, had received broad-spectrum antibiotics and had a central venous catheter or arterial line inserted for a mean duration of 16.2 days (range 10-30 days). Four patients developed disseminated infection and only 2 survived, giving a mortality rate of 60%. Because of the prevalence of Trichosporon catheter related blood stream infections at our institute, health care providers should have a high index of suspicion for Trichosporon species infections in patients with risk factors and prolonged presence of a central venous catheter.

Clinical Prediction Rules for In-Hospital Mortality Outcome in Melioidosis Patients.

BACKGROUND: Melioidosis, a disease induced by Burkholderia pseudomallei, poses a significant health threat in tropical areas where it is endemic. Despite the availability of effective treatments, mortality rates remain notably elevated. Many risk factors are associated with mortality. This study aims to develop a scoring system for predicting the in-hospital mortality from melioidosis using readily available clinical data. METHODS: The data were collected from Surin Hospital, Surin, Thailand, during the period from April 2014 to March 2017. We included patients aged 15 years and above who had cultures that tested positive for Burkholderia pseudomallei. The clinical prediction rules were developed using significant risk factors from the multivariable analysis. RESULTS: A total of 282 patients with melioidosis were included in this study. In the final analysis model, 251 patients were used for identifying the significant risk factors of in-hospital fatal melioidosis. Five factors were identified and used for developing the clinical prediction rules, and the factors were as follows: qSOFA ≥ 2 (odds ratio [OR] = 2.39, p= 0.025), abnormal chest X-ray findings (OR = 5.86, p < 0.001), creatinine ≥ 1.5 mg/dL (OR = 2.80, p = 0.004), aspartate aminotransferase ≥50 U/L (OR = 4.032, p < 0.001), and bicarbonate ≤ 20 mEq/L (OR = 2.96, p = 0.002). The prediction scores ranged from 0 to 7. Patients with high scores (4-7) exhibited a significantly elevated mortality rate exceeding 65.0% (likelihood ratio [LR+] 2.18, p < 0.001) compared to the low-risk group (scores 0-3) with a lower mortality rate (LR + 0.18, p < 0.001). The area under the receiver operating characteristic curve (AUC) was 0.84, indicating good model performance. CONCLUSIONS: This study presents a simple scoring system based on easily obtainable clinical parameters to predict in-hospital mortality in melioidosis patients. This tool may facilitate the early identification of high-risk patients who could benefit from more aggressive treatment strategies, potentially improving clinical decision-making and patient outcomes.

Tenofovir disoproxil fumarate-associated nephrotoxicity in HIV-infected patients: a prospective controlled study.

OBJECTIVE: To evaluate all renal functions in patients receiving TDF and other nucleoside analogues. MATERIAL AND METHOD: A prospective controlled study evaluating glomerular and tubular functions was conducted in patients receiving either TDF- or AZT-containing antiretroviral therapy regimen between 2008 and 2009 at King Chulalongkorn Memorial Hospital, Bangkok, Thailand RESULTS: Of 51 patients, there were 39 and 12 patients, with the mean age of 40.03 +/- 7.7 and 37.2 +/- 7.6 years in the TDF and AZT groups. There was no diference between the two groups, except longer HIV infection duration, higher patient number with previous antiretroviral therapy and undetectable HIV RNA, and higher CD4 count in the TDF group. All and most patients had received lamivudine and a non-nucleoside analogue. The mean change of eGFR from the baseline to the six months of follow-up was +/-1.32 and +/- 5.88 mL/minute in the TDF and AZT groups. Proximal tubular dysfunction was not noted at three and six months of follow-up. However patients in the TDF group had lower serum phosphate and higher renal potassium loss than the AZT group at six months of follow-up (p = 0.08 and p = 0.09, respectively). No patients in the two groups with distal tubular dysfunctions were noted CONCLUSION: To our knowledge, this is the first prospective controlled study extensively evaluating all renal functions in patients receiving TDF andAZT There are no differences in the eGFR decline between the two groups during the six months of follow-up. However, a trend towards greater renal loss of potassium and phosphate is noted in the TDF group. A study with longer duration of follow-up is needed

Disseminated infection caused by novel species of Microsporidium, Thailand.

We describe a case of microsporidial myositis in a healthy man from Thailand. The small subunit rRNA sequence of this microsporidium is novel and has a close phylogenetic relationship with Endoreticulatus, a genus of lepidopteran microsporidia. Myositis could be caused by more genera of microsporidia than previously known.

A comparative study to determine the recovery rate of microorganisms of bloodstream infections: two versus three blood culture specimens.

OBJECTIVE: There has been a development of automated and continuous-monitoring blood culture systems that are more sensitive than conventional systems for the detection of microorganisms. Whether two or three blood culture specimens obtained during a 24-hour period using these automated systems achieving a higher recovery rate of microorganism remains to be determined. The present study was aimed to compare the recovery rates of microorganism of blood-stream infections (BSIs) using two and three blood culture specimens. MATERIAL AND METHOD: A prospective investigator-blinded study was carried out in patients who needed to have blood cultures in medicine wards and intensive care units as well as an emergency room of King Chulalongkorn Memorial Hospital, Bangkok, Thailand, between October 1, 2010 and March 31, 2011. Three blood culture specimens were obtained from each patient during a 24-hour period. Each specimen was inoculated into an aerobic bottle of blood culture broth (TREK Diagnostics, Cleveland, OH, US), and then incubated at 37 degrees C for seven days. RESULTS: Of 568 patients, there were 116 (20.4%) unimicrobial episodes with three blood cultures obtained during a 24-hour period. There were 70 (12.3%) and 46 (8.1%) episodes of true pathogen and contaminant, respectively. The recovery rates of true pathogen were 75.7% (53 isolates), 87.1% (61 isolates), and 100% (70 isolates) with the first, second, and third blood culture specimens, respectively (p < 0.05 between the recovery rate with the first two and the third blood culture specimens). There were 25 (35.7%), 38 (58.6%) isolates, and four (5.7%) of Gram-positive, Gram-negative bacteria, and fungi, respectively. Among 25 Gram-positive bacteria, Staphylococcus aureus was the most common isolate (10, 14.3%), followed by Streptococcus pneumoniae (5, 7.1%) and Enterococcus faecalis, Enterococcus faecium, coagulase-negative Staphylococcus (3, 10% each). Among 38 Gram-negative bacteria, Escherichia coli was the most common isolate (13, 18. 6%), followed by Pseudomonas aeruginosa (8, 11.4%), and Klebsiella pneumoniae (6, 8.6%). The sensitivity and specificity of the recovery rate of microorganisms using two blood culture specimens were 85.7% and 92.3%, respectively. The sensitivity and specificity of the recovery rate of microorganisms using three blood culture specimens were 100% and 90.8%, respectively. CONCLUSION: To the best of the authors'knowledge, the present study is the first prospective study to compare the recovery rate of microorganisms of BSIs between the two and three blood culture specimens using the VersaTREK blood culture system. Three blood culture specimens are required to achieve the recovery rate of more than 99%.

Antibiotic prescription for adults with acute diarrhea at King Chulalongkorn Memorial Hospital, Thailand.

BACKGROUND: In Thailand, acute diarrhea is one of the most common problems among ambulatory patients at the outpatient department (OPD). Overuse of antibiotics is associated with increased rates of antibiotic-resistant bacteria, unnecessary increased cost of treatment, and significant incidence of adverse effects. In Thailand, how frequently antibiotic is prescribed in adult patients with acute diarrhea is not known. MATERIAL AND METHOD: The authors performed a retrospective study in all adult patients with acute diarrhea attending at the OPD of King Chulalongkorn Memorial Hospital, Bangkok, Thailand between August 2009 and January 2010 as ambulatory basis. All data regarding epidemiology, clinical features, and treatment were evaluated. RESULTS: There were 390 [255 females (65.4%) and 135 males (34.6%)] patients during the study period. There were 91 (23.3%) with inflammatory diarrhea and 209 (76.7%) patients with non-inflammatory diarrhea. Only 36 (9.2%) patients had stool examination and culture results. Of 13 (36.1%) patients with positive stool cultures, four (11.1%) patients had Vibrio parahaemolyticus, two (5.7%) patients each had non-O1 Vibrio cholerae, Cryptosporidium parvum, or Plesiomonas shigelloides and V. parahaemolyticus, and one (2.9%) patient each had P. shigelloides, P. shigelloides and Salmonella, or group D Salmonella. Three hundred fifty three (90.5%) and 37 (9.5%) patients were treated by residents and faculty staffs, respectively One hundred and seventy-six (45.1%) patients received antibiotics, which included norfloxacin (128 patients, 72.7%), ciprofloxacin (34, 19.3%), ceftriaxone and ciprofloxacin (6, 3.4%), ceftriaxone (5, 2.8%), ceftriaxone and norfloxacin (2, 1.1%), amoxicillin (1, 0.6%), and ofloxacin (1, 0.6%). One hundred and forty-eight of 353 (41.9%) residents and 28 of 37 (75.7%) faculty staffs prescribed antibiotics. According to the recommendations by WHO, the rate of overuse of antibiotics was 48.9% (86 of 176 patients). CONCLUSION: There is a very high rate of overuse of antibiotics in Chulalongkorn Hospital. Both attributing physician- and patient-related factors should be evaluated before implementing an effective strategy to change prescribing behavior.

Central nervous system infections in HIV-infected patients hospitalized at King Chulalongkorn Memorial Hospital.

BACKGROUND: Central nervous system (CNS) infections are among one of the most common complications in HIV-infected patients. The present study aimed to determine the etiologies, clinical features, treatment, and outcomes of all CNS infections in HIV-infected patients. MATERIAL AND METHOD: A retrospective study was carried out in all adult HIV-infected patients with CNS infection who were hospitalized at King Chulalongkorn Memorial Hospital, Bangkok, Thailand, from January 1, 2007 to December 31, 2008. Medical records ofthe patients were identified by extensively searching the disease codes based on International Classification ofDiseases-10, all microbiological data, and all histopathological data. RESULTS: One hundredforty eight patients were enrolled. There were 103 males (69.6%) with the mean age of 36.1 +/- 8.9 years (range 15 to 75 years). Among 93 patients with available data, the median and percentage of CD4 cell count during hospitalization were 64.0 cells/microlitre and 6% (range 1-684 cells/microlitre and 1-57%). Among 106 patients with known HIV infection, 67 patients (63.2%) had received antiretroviral therapy with the mean duration of 1.6 +/- 2.1 years. The most common CNS infection was cryptococcal meningitis (56 patients, 37.8%), followed by tuberculosis (53, 35.8%), toxoplasmosis (19, 12.8%), progressive multifocal leukoencephalopathy (6, 4.1%), varicella-zoster virus (VZV) meningitis (4, 2.7%), brain abscess (3, 2.1%), cytomegalovirus radiculomyelitis (2, 1.4%), pneumococcal meningitis (2, 1.4%), herpes simplex encephalitis, Epstein-Barr virus-related primary CNS lymphoma, and HIV-associated myelopathy (1 patient, each, 0.7%). Twenty-two patients died, accounting for the mortality rate of 14.9%. Of these 22 patients, tuberculous meningitis was the most common cause (9 patients, 16.9%), followed by cryptococcal meningitis (9, 16.1%), VZV encephalitis, Aspergillus brain abscess, herpes simplex encephalitis, and pneumococcal meningitis (1, 4.8% each). CONCLUSION: To the authors' knowledge, this is the first comprehensive study in Thailand to investigate the etiologies, clinical manifestations, and outcomes of all CNS infections in AIDS patients. There are a high number of patients with tuberculosis and severe immunodeficiency in the present study. The authors' findings suggest an urgent need to actively search and treat most HIV-infected patients in the community before they become severely immunocompromised.

Huge cutaneous abscess and severe symptomatic hypercalcaemia secondary to Mycobacterium kansasii infection in an immunocompetent patient.

Mycobacterium kansasii is among the most common non-tuberculous mycobacteria causing human infections. Apart from pulmonary infection, the most common infection caused by M. kansasii is skin and soft tissue infection, and it is very rare in immunocompetent people. In this report, we present a case of a huge cutaneous abscess caused by M. kansasii A 63-year-old man living in Bangkok presented with progressive pain at the left lateral chest wall for 3 weeks and altered mentation for a few days. Examination revealed a non-tender fluctuated cutaneous mass 20×10 cm in size. An aspiration of the mass yielded 50 mL pus with many positive acid-fast bacilli. Mycobacterial PCR was positive for M. kansasii with culture confirmation. There was severe hypercalcaemia. The treatment included surgical drainage, and medical treatment consisted of isoniazid, rifampicin, ethambutol and levofloxacin, along with adequate hydration and calcitonin for hypercalcaemia. The patient gradually improved and was discharged 12 days after hospitalisation.

Native Valve Infective Endocarditis Caused by Histoplasma capsulatum in an Immunocompetent Host: The First Case in Asia and Literature Review in Asia and Australia.

BACKGROUND: Infective endocarditis caused by the dimorphic fungus Histoplasma capsulatum is extremely rare, occurring predominantly in individuals with prosthetic heart valves and HIV infection. To our knowledge, no case of H. capsulatum native valve endocarditis has been reported in Asia. Methodology. A descriptive study was carried out at King Chulalongkorn Memorial Hospital, Bangkok, Thailand, in 2020. RESULTS: A previously healthy 34-year-old man developed fever, umbilicated skin lesions, oral ulcers, hoarseness of voice, severe weight loss, and progressive dyspnea over the course of one week. Facial umbilicated papules, nodular ulcers in his tongue and palate, a diastolic rumbling murmur at the mitral valve, diffuse fine crackles in both lungs, and engorged neck veins were detected during the examination. Skin scraping of the facial lesion revealed both extracellular and intracellular yeasts with buddings, 2-4 µm in size on Wright's stain. Transthoracic echocardiography demonstrated a left ventricular ejection fraction of 54 percent, severe rheumatic mitral stenosis, and multiple oscillating masses in the anterior mitral valve leaflet ranging in dimension from 1.5 to 2.4 cm. The HIV antibody test was negative. H. capsulatum endocarditis was diagnosed, and liposomal amphotericin B was administered. Due to cardiogenic shock, emergency open-heart surgery was conducted one day after admission. However, he died of multiorgan failure four days after the operation. The skin and vegetation cultures finally grew H. capsulatum after 1 week of incubation. CONCLUSIONS: To date, there has been handful of cases of H. capsulatum native valve endocarditis in non-HIV-infected patients. We report herein the first case in Thailand. Umbilicated skin lesions, especially combined with oral mucosal lesions, are a clinical clue that leads to the correct diagnosis of the causative organism.

Myositis Caused by Trachipleistophora hominis in a Person With Human Immunodeficiency Virus: The First Case in Thailand.

BACKGROUND: To date, cases of extraintestinal micro-sporidiosis have been increasingly reported in both otherwise healthy and immunocompromised individuals. Among them, microsporidial myositis is very rare. To the best of our knowledge, this is the first report of microsporidial myositis caused by Trachipleistophora hominis in a patient with human immunodeficiency virus (HIV) in Thailand. CASE REPORT: A Thai man with HIV presented with fever and muscle pain at both anterior thighs and left arm for 3 months. Muscle biopsy was performed, and pathology exhibited neutrophil infiltration and focal aggregations of microsporidial spores. The 18S ribosomal RNA sequence revealed the species of this microsporidium as T hominis, and albendazole of 800mg/day was initiated. He gradually improved, and was discharged home 6 weeks after hospitalization. CONCLUSIONS: To the best of our knowledge, this is the first report of microsporidial myositis caused by Trachipleistophora hominis in a person with HIV in Thailand.

A comparison of the efficacy of normal saline and Savlon solutions in periurethral cleaning to reduce catheter-associated bacteriuria: A randomized control trial.

OBJECTIVE: Catheter-associated urinary tract infection (CAUTI) is a common nosocomial infection. However, there has been no randomized control trial (RCT) comparing the efficacy of periurethral cleaning solutions for reducing CAUTI. This study aimed to compare the efficacy of normal saline solution (NSS) and Savlon solution. METHODS: A non-inferiority cross-over RCT was conducted to compare the 2 solutions by the incidence of significant bacteriuria (SB) on day 5 after Foley catheterization. Patients admitted to a tertiary referral hospital from June 2018 to August 2019 participated in the study. The acceptable prespecified non-inferiority margin was 10%. RESULTS: There were 265 and 275 patients in the NSS and Savlon groups, respectively. The incidence of CAUTI was 2.65/1000 catheter-days, and the median duration of catheterization was 5 days (IQR 4, 7). There was no significant difference between the incidence of SB in the NSS and Savlon groups, as indicated by the adjusted difference of 0.6 (95% CI: -3.1-4.2). CONCLUSION: This study was the first RCT in patients from multiple hospital units to compare the efficacy of the 2 solutions in the periurethral cleaning process. The study demonstrated non-inferiority of NSS to Savlon solution. THAI CLINICAL TRIALS REGISTRY STUDY ID: TCTR20180518001.

Vascular pythiosis caused by Pythium aphanidermatum: the first case report in Asia.

BACKGROUND: Pythium, soil-borne plant pathogens, are in the class Oomycetes. They are not true fungi, but are related to diatom and algae. There are two human pathogens including P. insidiosum and P. aphanidermatum. To date, only one case of pythiosis caused by P. aphanidermatum has been reported. We present herein the first case of P. aphanidermatum vascular pythiosis in Asia. CASE PRESENTATION: A 47-year-old Thai woman, living in North Thailand, with ß thalassemia/hemoglobin E presented with acute recurrent arterial insufficiency of both legs. Emergent embolectomy with clot removal was performed. The pathology of the clot exhibited noncaseous granulomatous inflammation with many fungal hyphal elements. PCR identified P. aphanidermatum with 100% identity. Final diagnosis is vascular pythiosis. Unfortunately, the patient eventually expired after treatment with itraconazole, terbinafine, azithromycin, and doxycycline. CONCLUSIONS: To date, only one case of pythiosis caused by P. aphanidermatum has been reported. We present herein the first case of P. aphanidermatum vascular pythiosis in Asia.

The first report of kidney transplantation in a human immunodeficiency virus-positive recipient in Thailand and literature review: Encouragement for developing countries in Southeast Asia.

Patients with human immunodeficiency virus infection are at risk of chronic kidney disease and end-stage renal disease. Human immunodeficiency virus infection impedes patients' accessibility to transplantation in Thailand and other developing countries in Southeast Asia, where the burdens of human immunodeficiency virus infection and chronic kidney disease are rapidly increasing. We report the successful kidney transplantation in a human immunodeficiency virus-positive recipient in Thailand and provide brief information about the current knowledge of human immunodeficiency virus medicine and transplantation that are needed for conducting kidney transplantations in such patients. Patient selection and evaluation, the choice of antiretroviral therapy, immunosuppressive regimens, and infectious complications are reviewed and discussed. The aim is to encourage kidney transplantation in end-stage renal disease patients with well-controlled human immunodeficiency virus infection, especially in countries where the prevalence of human immunodeficiency virus infection is high and the accessibility to transplantation is still limited.

Causative pathogens of fever in neutropenic patients at King Chulalongkorn Memorial Hospital.

BACKGROUND: Infections cause substantial morbidity and morbidity in neutropenic patients. In King Chulalongkorn Memorial Hospital, Gram-negative bacteria remained the most common causative pathogen of febrile neutropenia in all three studies conducted before 2002. However, Gram-positive bacteria have become more commonly isolated etiologic pathogens, and the incidence of fungal infection has been increasing since 2005. OBJECTIVE: Determine the infectious etiology of fever in neutropenic patients at King Chulalongkorn Memorial Hospital, Bangkok, Thailand. MATERIAL AND METHOD: A retrospective chart review of all medical records of febrile neutropenic patients hospitalized at Department of Medicine between January 1 and December 31, 2006 in accompanying with microbiologic, radiologic, and serologic results was analyzed. RESULTS: There were 125 patients (61 males and 64 females) and 172 episodes of febrile neutropenia with a mean age of 46.5 +/- 18.5 years (range: 15-81 years). The three most common primary diseases associated with neutropenia were acute myeloid leukemia, non-Hodgkin's lymphoma, and acute lymphoblastic leukemia (36.6%, 33.1%, and 10.5%). Infections could be documented microbiologically and clinically in 84 episodes (48.8%), and primary bacteremia or fungemia was the most common cause of infection (40.5%). Gram-negative bacteria were the most frequently isolated pathogens (63.9%), followed by Gram-positive bacteria (29.9%) and fungi (6.2%). Escherichia coli (46.8%) and coagulase-negative Staphylococcus (27.6%) were the most common isolates among Gram-negative and Gram-positive bacteria, respectively. Among 53 episodes (30.8%) of bloodstream infections, Gram-negative bacteria were the most commonly isolated pathogens (38 episodes, 71.7%), followed by Gram-positive bacteria (19 episodes, 35.8%) and Candida tropicalis (1 episode, 1.9%). Surprisingly, invasive mold infections were noted in eight episodes (5, 1, and 2 episodes of proven, probable, and possible infections, respectively). The overall mortality was 19.2%. CONCLUSIONS: Although Gram-negative bacteria are the most common etiology of fever in neutropenic patients, the occurrence of infections caused by coagulase-negative Staphylococcus and molds has been increasing in comparison with the observations from previous studies in King Chulalongkorn Memorial Hospital. To authors knowledge, the present study is the first in Thailand to determine the occurrence of invasive fungal infections using the standard criteria recommended by EORTC/MSG.

Typhoid spondylodiscitis: the first reported case in Southeast Asia and review of the literature.

We describe the first case of typhoid spondylodiscitis in Southeast Asia, and the literature were also reviewed. A 57-year-old diabetic Thai man who presented with a one-month course of progressive low back pain associated with paraparesis and bowel-bladder dysfunction. Examination revealed local tenderness over T12 area, spastic paraparesis, impaired pinprick sensation up to T12 level, and loose anal sphincter tone. Magnetic resonance imaging showed spondylodiscitis of T11 and T12 and epidural abscess causing spinal cord compression. T11 and T12 laminectomy, T11/12 discectomy, and debridement of epidural abscess were performed, and the cultures of the pus grew Salmonella Typhi. He was treated with intravenous ciprofloxacin for three weeks and was discharged from the hospital with oral ciprofloxacin and trimethoprim-sulfamethoxazole for another five months of treatment. The patient was doing well when last seen two months after discontinuation of antimicrobial treatment. In addition, a total of ten cases of typhoid spondylitis/spondylodiscitis were reviewed.