Impact of diabetes mellitus on clinical parameters and treatment outcomes of newly diagnosed pulmonary tuberculosis patients in Thailand.

BACKGROUND: To assess the clinical and laboratory parameters, response to therapy and development of antituberculosis (TB) drug resistance in pulmonary TB (PTB) patients with diabetes mellitus (DM) and without DM. METHODS: Using a prospective design, 227 of 310 new cases of culture-positive PTB diagnosed at the Queen Savang Vadhana Memorial Hospital and the Chonburi Hospital between April 2010 and July 2012 that met the study criteria were selected. Data regarding clinical and laboratory parameters, drug susceptibility and treatment outcomes were compared between PTB patients with DM and those without DM. To control for age, the patients were stratified into two age groups (< 50 and ≥ 50 years) and their data were analysed. RESULTS: Of the 227 patients, 37 (16.3%) had DM, of which 26 (70.3%) had been diagnosed with DM prior to PTB diagnosis and 11 (29.7%) had developed DM at PTB diagnosis. After controlling for age, no significant differences were found between the two groups regarding mycobacterium burden, sputum-culture conversion rate, evidence of multidrug-resistant tuberculosis, frequency of adverse drug events from anti-TB medications, treatment outcomes and relapse rate. The presenting symptoms of anorexia (p = 0.050) and haemoptysis (p = 0.036) were observed significantly more frequently in PTB patients with DM, while the presenting symptom of cough was observed significantly more frequently in PTB patients without DM (p = 0.047). CONCLUSIONS: Plasma glucose levels should be monitored in all newly diagnosed PTB patients and a similar treatment regimen should be prescribed to PTB patients with DM and those without DM in high TB-burden countries.

Immunofluorescence microscopy for the rapid diagnosis of melioidosis.

A direct immunofluorescent antibody test (DIF) was developed for the rapid diagnosis of melioidosis, a potentially fatal infection caused by Pseudomonas pseudomallei. In a clinical evaluation of 369 sputum, pus, or urine specimens from 272 patients with suspected melioidosis, the DIF had a sensitivity of 73% and a specificity of 99% compared with culture. Using this DIF, a confident diagnosis of melioidosis can now be made within two hours of admission to hospital, compared with the delay of two to four days required for culture results. Consequent early institution of specific antimicrobial therapy may help to save lives.

Latex agglutination for rapid detection of Pseudomonas pseudomallei antigen in urine of patients with melioidosis.

A latex agglutination test for the detection of Pseudomonas pseudomallei antigen in urine was evaluated for the rapid diagnosis of melioidosis. With unconcentrated urine, antigen was detected in only 18% of patients with melioidosis overall. However, when urine was concentrated 100-fold, antigen was detected in 47% overall and in 67% of patients with septicaemia or disseminated infection, in whom a rapid diagnosis is most important. The specificity of the test was 100%. These results compared favourably with an enzyme immunoassay. This latex agglutination test is a simple, rapid and highly specific method of diagnosing melioidosis, and will be particularly useful in areas with limited laboratory facilities.

Detection of Pseudomonas pseudomallei antigen in urine for the diagnosis of melioidosis.

An enzyme-linked immunosorbent assay using a fluorescein isothiocyanate (FITC)-anti-FITC amplification system, has been developed to detect Pseudomonas pseudomallei antigen in urine. The assay was evaluated in 135 patients with acute melioidosis, 194 hospitalized patients with other disorders, and 40 healthy controls. Antigen was detected in the urine of 123 (91%) patients with melioidosis. Urinary antigen was found in 85 (96%) of 89 patients with septicemic melioidosis, all six patients with P. pseudomallei urinary tract infection, and 32 (80%) of 40 patients with other localized infections. Antigen was not detected in the urine of 40 healthy individuals, but the urine of 16 (8%) of 194 hospitalized patients with diagnoses other than melioidosis gave a positive result. Of the false-positive results, 13 of 16 were associated with bacteriuria > or = 10(4) colony-forming units/ml. At a cutoff titer of 1:10, the sensitivity and specificity of the test were 81% and 96%, respectively. Enzyme immunoassay detection of urinary antigen is a valuable and rapid laboratory test for the early diagnosis of acute melioidosis.

Synergy of antithrombin III concentrate and antivenom in preventing coagulopathy in a rat model of Malayan pit viper envenoming.

The effects of unrefined equine antivenom and antithrombin III (AT-III) concentrate on the coagulopathy induced by systemic envenomation by Malayan pit viper (Calloselasma rhodostoma; MPV) venom were investigated in a rat model. 37 rats received an intramuscular injection of MPV venom and serial blood samples were taken from the femoral vein for simple whole blood clotting tests and measurement of AT-III activity. 30 min after venom injection, treatment (antivenom, AT-III or both) was given intravenously. 6 rats were untreated and all developed uncoagulable blood and AT-III depletion 90-210 (median 180) min after venom injection. A combination of high dose AT-III concentrate (0.5 units/g) and antivenom (20 micrograms/g) prevented abnormal clotting (P less than 0.001), whereas AT-III alone, antivenom alone, or a combination of low dose AT-III (0.25 units/g) and antivenom did not (P less than 0.05). These results suggest that the coagulation abnormality in MPV envenomation is secondary to activation of the coagulation cascade at several levels, and that treatment with antivenom alone may not be sufficient to reverse or prevent this phenomenon.

Semi-quantitative measurement of Plasmodium falciparum antigen PfHRP2 in blood and plasma.

Plasmodium falciparum histidine rich protein 2 (PfHRP2) antigen was measured semi-quantitatively in whole blood, plasma, and supernatants and red blood cells of cultures in vitro using the dipstick ParaSight-F test and also by a quantitative antigen-capture enzyme-linked immunosorbent assay (ELISA). In vitro, PfHRP2 was secreted mainly during the second half of the asexual cycle with a marked rise during schizont development and rupture. The total PfHRP2 secreted before schizogony corresponded to approximately 4% of that contained in the red blood cells. In samples from 55 patients with acute falciparum malaria, the level of detection by ELISA corresponded to parasitaemias of 100/microL for whole blood and 1600/microL for separated plasma. Whole blood PfHRP2 levels were correlated significantly with admission parasitaemia (r = 0.76, P < 0.0001) and the stage of parasite development (r = 0.43, P < 0.01). Although whole blood PfHRP2 concentrations were higher in severe malaria, plasma concentrations of PfHRP2 were considerably higher in severe malaria (median titre 1:320, range zero to 1:1280) than in uncomplicated malaria (median titre 1:5, range zero to 1:80; P < 0.0001). The ratio of whole blood to plasma PfHRP2 was lower in severe than in uncomplicated malaria (median 4, range 0.25 to 256, versus 64, range 4 to 1280; P < 0.0001). With plasma samples the intensity of colour change on the dipstick correlated well with more precise measurement of optical density in the ELISA (r = 0.88, P < 0.0001). These results suggest that measurement of PfHRP2 in plasma could provide an alternative approach to the assessment of the parasite biomass, and thus prognosis, in severe malaria, and that this could be done simply by using the currently available dipsticks.

Activation of the coagulation cascade in falciparum malaria.

The incidence and progression of coagulation abnormalities were studied in 52 patients with acute falciparum malaria. The patients were prospectively divided into 3 groups; severe (parasitaemia greater than or equal to 5% or vital organ dysfunction), 12 patients; moderate (parasitaemia 1%- less than 5% without complications), 16 patients; and mild (parasitaemia less than 1%), 24 patients. No case died or developed clinical evidence of disseminated intravascular coagulation. Conventional indices of coagulation (prothrombin time, partial thromboplastin time, fibrinogen, fibrin degradation products) were usually within the normal range but reduced plasma concentrations of antithrombin III (AT-III) levels were noted in all groups, and the incidence was significantly higher in patients with severe and moderate malaria (83% and 81%) compared with the mild group (37%; P less than 0.005). Depletion of AT-III was associated with thrombocytopenia, decreased AT-III activity and elevated plasma concentrations of thrombin-antithrombin III complexes (P less than 0.01), confirming activation of the coagulation cascade and increased clotting factor consumption. AT-III levels returned to normal coincident with clinical improvement. Activation of coagulation is a common and sensitive measure of disease activity in acute falciparum malaria. It is not a specific feature, nor is there evidence to suggest it has a primary pathological role in severe infections.

Erythrocyte survival in severe falciparum malaria.

Erythrocyte survival was studied in 17 Thai patients (10 males, 7 females; aged 13-57 years) with severe falciparum malaria. To ensure radioisotopic labelling of cells before bone marrow recovery and survival analysis under near-steady state conditions, 51Cr labelling of autologous erythrocytes was performed at the time of admission (0 h) and calculation of mean cell lifespan (MCL) was based on semilogarithmic plots of corrected counts from 60 h onwards. Five patients received blood transfusions, all within 48 h of admission. The overall mean (+/- S.D.) MCL was short (44.1 +/- 21.7 days). Nontransfused patients had similar MCL values (43.6 +/- 20.4) to those of transfused patients (45.5 +/- 27.3 days, p greater than 0.8). Patients with and without palpable splenomegaly had MCL values which were not significantly different (54.1 +/- 28.8 vs. 37.2 +/- 12.3 days respectively, p greater than 0.1). There was no association between admission haematocrit or peripheral parasitaemia and MCL (p greater than 0.2 in each case), but there was an inverse correlation between total serum bilirubin and MCL (r = -0.49, p less than 0.025). There is accelerated destruction of non-parasitised erythrocytes in severe malaria resulting in a mean MCL that is half that found previously in healthy Thai volunteers (89.6 +/- 13.1 days, p less than 0.001) and significantly shorter than that reported previously in Thai patients with uncomplicated P. falciparum infections studied after parasite clearance (56.8 +/- 10.2 days, p less than 0.05).

Antithrombin III and antivenom reversal of coagulopathy in rats envenomated with Malayan pit viper venom.

The therapeutic effects of antithrombin III (AT-III) and unrefined equine antivenom in the treatment of coagulopathy induced by Malayan pit viper (Calloselasma rhodostoma) venom were assessed in 42 adult Wistar rats. Following intramuscular venom injection (2 micrograms/g body weight), serial blood samples were taken from the femoral vein for measurement of whole blood clotting time and AT-III activity. There was progressive depletion of AT-III and blood ceased to clot a mean (S.E.) of 164 (8.3) min after venom injection. Coagulopathy was reversed by a high dose antivenom (10 micrograms/g) or a lower dose of antivenom (5 micrograms/g) in combination with AT-III (> or = 0.1 U/g; P < 0.01) but not 5 micrograms/g antivenom or AT-III alone. Following successful treatment, the mean plasma AT-III activity remained above 90%. In this animal model, systemic envenomation by the Malayan pit viper causes uncoagulable blood associated with AT-III consumption. The dose of antivenom required to reverse this coagulopathy can be reduced by half by the addition of AT-III sufficient to maintain blood concentrations within the normal range.

The hyaluronidase activities of some Southeast Asian snake venoms.

The hyaluronidase activities of venoms of snakes indigenous to Southeast Asia were investigated. With the exception of the venom of the Malayan krait Bungarus candidus, the elapid venoms had either little or no hyaluronidase activities, whereas the viperid venoms possessed considerable activity. A component of Russell's viper venom with hyaluronidase activities had a mol. wt of approximately 14,000. Neither MP4, a monoclonal antibody raised against the purified Russell's viper venom hyaluronidase toxin, nor a monospecific polyclonal antivenom neutralized the hyaluronidase activities of this purified hyaluronidase component of crude Russell's viper venom. The Russell's viper venom hyaluronidase activities was labile on heating and storage. The significance of these observations to envenomation and antivenom production is discussed.

Gnathostoma larva migrans among guests of a New Year party.

An outbreak of Gnathostoma larva migrans occurred among guests of a New Year's party in Chachoengsao, Thailand. Nine people who consumed a raw fish dish called 'Hu-sae' contracted the disease. Five of them developed gastro-intestinal symptoms consisting of nausea, vomiting, abdominal cramps and diarrhea as early as within the first 24 hours, while in the other four, symptoms started on the following day. After the initial symptoms pertaining to the gut, malaise, chest discomfort, cough, myalgia, weakness, itching and migratory swellings were experienced. Eosinophilia was demonstrated in every patient with a mean (+/- SE) count of 5,516 +/- 1,010 cells/cu mm. Detection of antibody against aqueous extracts of G. spinigerum adult antigen using an enzyme-linked immunosorbent assay showed a titer of 1:1,600 or greater in every patients except one who had a titer of 1:400 (positive greater than or equal to 1:400). This outbreak illustrates the high attack rate when heavily infected fish are consumed.

Hepatitis B problem in Thailand.

HBV infection is hyperendemic in Thailand. Approximately 5 million Thais are chronic HBV carriers. The prevalence of HBV markers in general population varies from 40-60%. Approximately 10-20% of children between the ages 1-5 years have serologic evidence of HBV infection and this prevalence increases with age reaching a plateau of 40-60% by age 20. High risk groups are household contacts of HBsAg carriers and babies born to HBsAg positive mothers. Approximately 75% of the babies born to HBsAg & HBeAg positive mothers become HBsAg positive at 3 months after birth. A few studies showed that the HBV prevalence of hospital personnel and other high risk groups is similar to that of the general population. The prevalence of chronic HBsAg carrier varies from 5-10% and is highest among age groups 10-30 years. Primary hepatocellular carcinoma (PHC) is the first and third most common cancer among Thai males and females, respectively. Approximately 35%-75% of PHC in adults are HBsAg positive. Histological studies showed that 47.3% of cryptogenic cirrhosis, 58%-66% of PHC and 35%-85% of cryptogenic cirrhosis with PHC were HBsAg positive. Studies on Hepatitis B immune globulin and Hepatitis B vaccine revealed a 70% and 56%, respectively, reduction in the HBsAg prevalence of infants born to HBsAg and HBeAg positive mothers. More epidemiologic, clinical and laboratory studies on HBV infection are being carried out by groups of scientists and investigators in the Ministry of Public Health and many medical schools. A national committee has been appointed to plan strategy for controlling HBV.

Studies on the chemotherapy of human opisthorchiasis: II. Clinical trial of niclofolan.

A clinical trial of Niclofolan on human opisthorchiasis was carried out in 60 patients admitted to the Hospital for Tropical Diseases. Two dosage regimen, 2 mg and 3 mg per kg body weight repeated after a 72 hour interval was administered to 31 and 4 patients respectively. Comparative evaluation with the placebo group of 25 patients was made by the Stoll count on day 20, 40 and 60 after treatment. On day 60 percentage egg reduction of the treated and the placebo groups were similar. Mild and transient side effects such as nausea, anorexia, myalgia and arthralgia were recorded in all 3 groups but more severe in the higher dosage group. In this study, Niclofolan failed in reducing the egg production of Opisthorchis viverrini.

Albendazole stimulates outward migration of Gnathostoma spinigerum to the dermis in man.

Human gnathostomiasis is characterized by space-occupying inflammatory lesions and/or hemorrhage as a result of the migration of, very often, a single larva of Gnathostoma spinigerum. Intermittent cutaneous migratory swellings occurring over years is the most common manifestation and the rare cerebral invasion may be fatal. There are currently no effective anthelminthics for this infection. During a double-blind randomized placebo control trial evaluating the efficacy of albendazole in cutaneous gnathostomiasis at a dosage of 400 mg twice daily for two weeks, it was observed that gnathostome larvae tended to migrate outward as a result of the treatment so that they could be recovered by excisional biopsy or by picking with a needle. In the placebo-treated group (N = 40), no such migration was observed during the 8,470 patient-days of follow-up while in the albendazole-treated group (N = 41) there was one worm in an excisional biopsy done on day 16 and two worms were removed from the skin by the patients themselves on days 8 and 0. Assuming that the period of drug exposure of the gnathostomes was the 14 days of albendazole administration plus another washout period of 7 days (equivalent to 20 half-lives of the active detectable metabolite), the total patient-days of albendazole exposure was 830. The rate of outward migration of gnathostomes in the drug treated group (3 per 830 patient-days) was significantly (p < 0.0001) higher than in the placebo group (0 per 8,470 patient-days).(ABSTRACT TRUNCATED AT 250 WORDS)

Cutaneous manifestations in HIV positive patients.

Cutaneous manifestations are common clinical findings among HIV positive patients. The causes may be bacteria, viruses, fungi and other non-infectious agents. This study was conducted at the Pramongkutklao Hospital skin clinic to determine the frequency distribution of cutaneous manifestations in HIV positive patients. A total of 147 patients with HIV seropositivity were recruited and divided into a retrospective group and a prospective study group. For the retrospective study, hospital records of 129 patients who attended from January 1995 to November 1998 were recruited. The prospective study was carried out from November 1998 to January 1999 and 18 patients were recruited. Cutaneous finding among patients in the two studies were evaluated. There were ten common cutaneous manifestations observed in the retrospective and prospective study including pruritic papular eruptions (PPE) (51.2%, 50%), oral candidiasis (16.7%, 21.7%), herpes zoster (10.9%, 5.6%), oral hairy leukoplakia (10%, 5.6%), unclassified eczema (9%, 11.1%), urticaria (5.6%, 3.1%), seborrheic dermatitis (4.7%, 16.7%), folliculitis (4.7%, 5.6%), prurigo simplex (4.7%, 5.6%), and Steven-Johnson syndrome (3.9%, 0%). However, the distribution of cutaneous manifestations in the two studies were not significantly different. These findings may be useful as baseline data for common cutaneous manifestations in HIV positive patients.

ELISA for immunodiagnosis of human gnathostomiasis.

An ELISA for immunodiagnosis of human gnathostomiasis using a crude water extract of third-stage larvae of G. spinigerum as antigen, and alkaline phosphatase labelled goat antihuman IgG in the indicator system was developed and evaluated. At the titre of 1:400 and above positive results were observed in 100% of 4 parasitological confirmed and 10 eosinophilic meningo-encephalitis (EME) typical of gnathostomiasis cases, 56% of 160 cutaneous migratory swelling cases, 33% of 24 cases with EME typical of A. cantonensis infections, 23% of 92 cases with other parasitic infections and 1.5% of blood donors. The overall sensitivity was 59% and specificity 84%. The predictive value was 77%. The results indicated that ELISA is potentially useful for immunodiagnosis of gnathostomiasis but improvement of sensitivity and specificity is needed.

Adherence of human eosinophils to infective filariform larvae of Necator americanus in vitro.

Eosinophilia is common in hookworm infection but the interaction between eosinophils and the larval stage of the parasite is poorly understood. The present study was conducted to test the ability of the eosinophils to adhere to infective filariform larvae of Necator americanus in vitro. Adherence of eosinophils to the larvae was found to be serum dependent. Antibody facilitated eosinophil adherence but this was maximal in the presence of complement. The adherence was greatly diminished by EGTA treated normal human serum (NHS) and was completely abolished when NHS was treated with either EDTA or heat-inactivation, suggesting that the process can be facilitated through complement activation via the alternative pathway. As with other nematodes, the surface of hookworm larvae appeared to be both antigenic and complement-activating. Although it is not known whether eosinophil adherence has any larvicidal effect, the present study demonstrated for the first time a definite interaction between human eosinophils and hookworm filariform larvae.

Clinical trial of flubendazole on hookworm, Trichuris trichiura and Ascaris lumbricoides infections.

Flubendazole, a parafluoro analoque of mebendazole, was given to 89 service men with hookworm, Trichuris trichiura and Ascaris lumbricoides infections. The drug was given either as two doses of 300 mg at 12 hour interval (regimen A) or as two doses of 300 mg at 24 hour interval (regimen B). At four weeks follow-up the mean percentage egg reduction for hookworm was 88% and 96% in regimen A and B respectively. There were too few cases of Trichuris and Ascaris infection to allow comparison of the two regimens, but flubendazole appeared to be as effective and the single day regimen more convenient than difetasone for trichuriasis and levamisole for ascariasis. Side effects were few, mild and transient.

Prevalence of cytomegalovirus antibodies among various age groups of Thai population.

The prevalence of CMV antibody in various groups of Thai population was studied. Pregnant women and young children had been infected with CMV more than the other studied groups. Children of both sex had equal chance of getting CMV infection while the risk of CMV infection in adult between male and female was significantly difference (p < 0.001). Pregnant women had higher chance to get CMV infection than normal women. Prevalence of CMV antibody at present was similar to previous studies.

Immune responses following killed whole vibrio-B subunit oral cholera vaccine in human volunteers.

Immunogenicity of killed whole vibrio and B subunit oral cholera vaccines in American and Thai volunteers were analysed in terms of significant rise of antibody titre. Three doses of 2 x 10(11) killed vibrios and 5 mg of cholera toxin B subunit were given at two-week intervals. There were no differences in the percent of volunteers with significant rise of serum immunoglobulin G and secretory immunoglobulin A (sIgA) to cholera toxin. However, the percent with significant rises of serum antibody to whole cell V. cholerae Inaba measured by vibriocidal titre and serum immunoglobulin G, and secretory immunoglobulin A to lipopolysaccharide (LPS) measured by ELISA in American volunteers were significantly different from those in Thai volunteers (89% VS 45%, 68% VS 9% and 53% VS 0%, respectively) (p less than 0.05).