Epidemiology of HIV infection among prostitutes in the Philippines.

Between 1985 and 1987, examinations for human immune deficiency virus (HIV) antibody were done on 25,392 prostitutes working in 64 cities throughout the Philippines. The country-wide seropositivity rate among prostitutes based on this sample was 0.8/1,000. Of the HIV cases, 85% were working in just two cities whose prostitute populations comprised 50% of the total sample. The average incidence rate for the same two cities after 1 year was 2.3/1,000. HIV antibody-positive women were enrolled in a case-control study to determine demographic and epidemiologic risk factors. This study involving 34 HIV-positive prostitutes and 61 randomly selected negative control prostitutes did not reveal any risk factors related to sexual or other types of behavior. A history of genital warts, a history of abnormal vaginal discharge, and cytomegalovirus antibody were significantly more frequent in the HIV-positive cases than in the controls; however, by logistic regression analysis, only an abnormal vaginal discharge was independently associated with HIV infection. Absence of any evidence of transmission by blood transfusion or i.v. drug abuse suggests that HIV was introduced by the heterosexual route.

Bites by the Philippine cobra (Naja naja philippinensis): prominent neurotoxicity with minimal local signs.

We studied 39 patients envenomed by the Philippine cobra (Naja naja philippinensis). Neurotoxicity occurred in 38 cases and was the predominant clinical feature. Respiratory paralysis developed in 19 patients, and was often rapid in onset--in 3 cases apnea occurred within 30 min of the bite. There were 2 deaths, both in patients who were moribund upon arrival at the hospital. Three patients developed necrosis, and 14 individuals with systemic symptoms had no local swelling. Both cardiotoxicity and reliable nonspecific signs of envenoming were absent. Bites by the Philippine cobra produce a distinctive clinical picture characterized by severe neurotoxicity of rapid onset and minimal local tissue damage.

Bites by the Philippine cobra (Naja naja philippinensis): an important cause of death among rice farmers.

We investigated mortality from cobra (Naja naja philippinensis) bite among Filipino rice farmers. Village records in one area were examined and we conducted a careful survey in this and two additional areas among inhabitants at varying risk for snakebite. The death rate from cobra bite was estimated to be as high as 107.1 deaths per 100,000 population per year at one site. Most victims were young (median age 17) and 98% were males. Only 8% of the victims studied reached a hospital. The confirmed death rate averaged 53.8/100,000 for the three populations.

Nonresolution of an amebic liver abscess after parasitologic cure.

A 43-year-old Filipino male was admitted to a Manila hospital with a 1 month history of epigastric pain and fever, and was found to have a palpable epigastric mass. Computerized tomography revealed a large hepatic abscess which serologically was shown to be amebic. Chemotherapy resulted in clinical cure and an initial reduction in size of the liver abscess. However, resolution of the abscess cavity did not occur, and on closed needle aspiration, 80 cc of characteristic amebic pus was recovered. Parasitological cure without complete repair of the abscess cavity itself raises questions concerning the potential danger of clinically silent residua and the role of therapeutic aspiration in the management of amebic liver abscesses.

Tourniquet application after cobra bite: delay in the onset of neurotoxicity and the dangers of sudden release.

The effects of tourniquet application were prospectively studied in 36 hospitalized patients who developed neurotoxic symptoms after bites by the Philippine cobra (Naja naja philippinensis). Tourniquets had been applied in 94% of cases and delayed the onset of symptoms. Four patients were asymptomatic prior to the release of their tourniquet and in 11 patients symptoms worsened precipitously. Most importantly, 4 patients developed complete respiratory paralysis requiring artificial ventilation on its removal. Medical personnel seeing patients after a possible cobra bite should remove any tourniquet very gradually with both specific therapy and ventilatory support at hand. We recommend tourniquet application in the Philippines only after the bite of a definitely identified cobra and when removal can take place under controlled hospital conditions.

Amodiaquine less effective than chloroquine in the treatment of falciparum malaria in the Philippines.

Amodiaquine was compared to chloroquine in two groups of Filipino patients with uncomplicated falciparum malaria. Every patient received 25 mg/kg of base orally given over three days. In a hospital study, all eight patients receiving chloroquine cleared their parasitemia by day 6, but six of eight patients receiving amodiaquine failed to clear parasitemia and in four patients there was no response at all (RIII resistance); this difference was significant (P less than 0.01). In a village based study, there was initial clearing of parasitemia in each patient. However, recrudescent infection occurred in all five patients receiving amodiaquine (RI resistance). Five of six falciparum infections were sensitive to chloroquine, while parasitemia reappeared in one patient. In this village, resistance to amodiaquine was significantly more common than resistance to chloroquine (P less than 0.05). To our knowledge, this is the first report of amodiaquine being substantially worse than chloroquine in the treatment of Plasmodium falciparum infection.

Chloroquine and quinine: a randomized, double-blind comparison of efficacy and side effects in the treatment of Plasmodium falciparum malaria in the Philippines.

Chloroquine (25 mg/kg over 3 d) was compared to quinine (10 mg/kg 3 times daily for 5 d) in 20 adult Filipino males with uncomplicated Plasmodium falciparum malaria in a double-blind, randomized trial. Asexual parasitaemia was cleared in all patients, with no statistically significant difference (P = 0.13) in the rate of clearance between the chloroquine-treated patients (76.1 +/- 29.3 h) and those receiving quinine (60.3 +/- 12.5 h). The duration of fever was also comparable (chloroquine 46.3 +/- 24.7 h; quinine 43.2 +/- 20.0 h; P = 0.76) and 40% of patients in each treatment group experienced mild side effects. Chloroquine, however, is cheaper and easier to administer. In vitro results were strikingly different. P. falciparum parasites from 4 quinine-treated patients were all sensitive to this compound in vitro, whereas 4 of the 5 isolates from the chloroquine group were resistant. Further comparisons of these two antimalarials are indicated, especially in cerebral malaria, and drug use policies should be based on clinical and parasitological response to treatment.

Comparison of Tensilon and antivenom for the treatment of cobra-bite paralysis.

We prospectively compared the ability of anti-venom and edrophonium (Tensilon) to improve paralytic symptoms in 8 patients envenomed by the Philippine cobra (Naja naja philippinensis). Twenty, 50 or 100 ml of Philippine cobra antivenom were administered in a double-blind fashion by constant intravenous infusion over 30 min. Even the largest dose of antivenom failed to produce marked improvement within 2 h, though enzyme-linked immunosorbent assays and neutralization tests demonstrated that it possessed high titres of anti-neurotoxin antibodies. Tensilon given at 2 h was significantly more effective than antivenom at increasing the duration of upward gaze (78 +/- 28 vs 43 +/- 26 sec, P less than 0.001), and either completely reversed or markedly decreased paralysis in every patient. The Tensilon test should be given to all patients with paralytic envenoming by cobras, and anticholinesterases administered to those with a positive response.

A serologic survey of rice-field leptospirosis in Central Luzon, Philippines.

Although human cases of leptospirosis have been reported from the Philippines, there is a lack of data on its prevalence. We therefore surveyed three rice-farming villages for the presence of leptospiral antibody. Out of 155 sera tested, 63 (43.6%) tested positive using the standard microagglutination test. Antibodies were more frequent in men than women (48 vs. 31%, respectively, p less than 0.01), and less common in the elderly. Exposure to leptospires occurs frequently in rice farmers, and leptospirosis is likely to be an underdiagnosed cause of both mild and severe febrile illness in the Philippines.

Sexual behavior of Filipino female prostitutes after diagnosis of HIV infection.

A study of female prostitutes in Manila who tested positive for human immunodeficiency virus (HIV) antibody ascertained demographic and sexual behavior information following diagnosis. Counselling alone did not appear to have a major impact on the sexual behavior of the HIV positive women since most continued to work as prostitutes. Switching from high risk to low risk jobs in bars is not effective in preventing HIV positive women from engaging in prostitution. Revoking work permits is only effective if enforced with adequate follow up. Alternative job training programs may offer a viable approach.

Intestinal parasites in dogs and cats from the district of Évora, Portugal.

Intestinal parasites, both helminths and protozoa, are commonly found in domestic animals, and the possible transmission of enteric parasites from dogs and cats to humans may constitute a global potential health risk worldwide. In the present study, we analysed 148 stool samples from dogs (n=126) and cats (n=22) collected from animal shelters and veterinary clinics, in the district of Évora, Portugal. Microscopic examination confirmed that Giardia was the most frequent parasite in the studied population (34/148; 23%). Other parasites such as Ancylostoma sp., Isospora spp., Toxocara, Trichuris spp., Toxascaris and Toxoplasma were also found. Furthermore, molecular characterization of Giardia duodenalis analysis targeting the small subunit ribosomal RNA (ssu-rRNA) was performed revealing the presence of host-specific (C and D) and zoonotic assemblages (A and B). This work points out to the importance of protozoan parasites in companion animals, and reanalyses the need for parasite prophylaxis.

Limulus lysate positivity and Herxheimer-like reactions in leptospirosis: a placebo-controlled study.

Jarisch-Herxheimer reactions are characteristic of some spirochetal diseases and have been reported in leptospirosis, but their pathogenesis and relationship to endotoxin remain unclear. Serial limulus amebocyte lysate assays (LAL) for endotoxin were performed on 40 patients with proven leptospirosis who were monitored for reactions after receiving either intravenous penicillin (24) or saline placebo (16). No Herxheimer-like reactions were observed, although 78% of patients had at least one positive LAL. Serum creatinine, serum bilirubin, and white blood cell counts were significantly higher (P less than .01) in simultaneously drawn LAL-positive specimens than in negative ones. Delayed hepatic clearance of endotoxin due to liver dysfunction may explain the high LAL positivity rate, since assay results correlated with severity of disease but not with the presence or absence of spirochetes. Fear of a Herxheimer-like reaction should not dissuade clinicians from administering antibiotics to patients with leptospirosis.

Skeletal and cardiac muscle involvement in severe, late leptospirosis.

Information is lacking on the prevalence and severity of cardiac and striated muscle injury in late leptospirosis, and it is unclear whether patients with one type of myositis are at increased risk of developing another. Therefore, 38 patients with severe, late Weil's disease were evaluated for heart and skeletal muscle involvement: 37% had myositis and 39% had abnormal electrocardiograms (ECGs). First-degree atrioventricular heart block and changes suggestive of acute pericarditis were the most common ECG findings. Two patients had transient pericardial friction rubs, but neither pericardial effusion, shock, nor congestive heart failure occurred. Cardiac involvement was not associated with skeletal muscle injury (P = .35), although both manifestations were correlated with severity of disease. Thus, ECG changes and myositis were prominent features of late Weil's disease but cardiac morbidity was not.

Hepatic parenchymal dysfunction in Schistosoma japonicum infection.

Decompensated liver disease was investigated in 94 unselected Filipino patients sequentially hospitalized with Schistosoma japonicum infection. Liver damage was objectively scored from 3 (none) to a maximum of 10 (severe damage with encephalopathy) using a modified Pugh-Child grading system. Liver parenchymal dysfunction occurred in 52% of patients and was severe in 21% (hepatic encephalopathy or markedly prolonged prothrombin time). Severity scores were higher in patients with previous gastrointestinal bleeding (7.3 vs. 5.1; P less than .001) and were inversely correlated with admission hematocrit (r = -.60; P less than .001). Ultrastructural analysis revealed abnormalities of Disse's space--the site of blood-hepatocyte exchange. Praziquantel achieved 100% parasitologic cure, but none of the 27 patients followed up for a mean of 9.6 months after receiving it had resolution of liver damage. Liver parenchymal dysfunction is a common problem in hospitalized schistosomiasis patients and persists after parasitologic cure.

Praziquantel pharmacokinetics and side effects in Schistosoma japonicum-infected patients with liver disease.

Praziquantel undergoes extensive first-pass hepatic biotransformation, but there is little information on its disposition or toxicity when administered to patients with liver disease. To define the influence of liver disease on the pharmacokinetics of praziquantel, we administered it orally to 30 patients with proven Schistosoma japonicum infection whose liver disease was carefully assessed as being severe, moderate, or absent. Both the peak plasma concentration of praziquantel and the bioavailability (measured as the area under the plasma concentration time curve) were significantly greater in the two groups of patients with liver disease (P less than .005), as were the concentrations of the two identified metabolites of praziquantel. Mild side effects were associated with high peak concentrations of praziquantel, but a syndrome of severe abdominal pain followed by bloody diarrhea was not. Our results indicate that the side effects and bioavailability of praziquantel are increased in the presence of liver disease.

Placebo-controlled trial of intravenous penicillin for severe and late leptospirosis.

The effect of a 7-day course of intravenous penicillin (6 million units/day) on severe, advanced leptospirosis was examined in a randomised, placebo-controlled, double-blind trial involving 42 patients. Every measurable aspect of the disease was favourably affected by penicillin. Fever lasted more than twice as long in the placebo group (11.6 [SD 8.34] days vs 4.7 [4.19] days, p less than 0.005), and by the fourth day after starting penicillin more than half the treatment group, but only 1 of 19 in the placebo group, were afebrile (p less than 0.005). Creatinine rises persisted more than thrice as long in the patients receiving only placebo (8.3 [8.46] days vs 2.7 [1.90] days; p less than 0.01). Penicillin also shortened the hospital stay and prevented leptospiruria. Intravenous penicillin should be given to patients with severe leptospirosis, even if therapy can be begun only late in the course of their disease.