Study on serum transcobalamin II in patients with murine typhus.

We measured the serum transcobalamin II in murine typhus- infected patients (n = 16) admitted to the Hospital for Tropical Diseases in 1996-1997, compared with healthy controls (n = 60). The results showed that the transcobalamin II (TCII) and total serum unsaturated vitaminB12 binding capacity (UBBC) in patients with murine typhus (2,126.5 pg/ml, range 1,262-4,568 and 3,771.5 pg/ml, range 1,576-6,763 pg/ml) were statistically significantly higher than normal subjects (987.5 pg/ml, range 678-2,000 pg/ml and 1,402 pg/ml, range 932-2,470 ml) (p<0.001). Serum TCII levels in patients (63%) were elevated during the febrile period and returned to normal post-treatment. These findings suggest that patients with murine typhus had stimulation of reticulo-endothelial system, spleen, mesenteric lymph nodes, liver and skin and then released TCII into the blood circulation. The elevation in TCII may be used for confirming a diagnosis of murine typhus.

Elevation of serum transcobalamin II in patients with scrub typhus.

Serum transcobalamin II levels were measured in scrub typhus patients. Eighteen out of fifty-two patients admitted to Maharat Nakhon Ratchasima Hospital were diagnosed with scrub typhus infection. The serum unsaturated vitamin B12 binding protein (UBBC) and total vitamin B12 binding protein (TBBC) levels in these patients were significantly higher than in normal subjects (p < 0.001). The mean serum transcobalamin II level in the typhus patients was also significantly higher than in the normal subjects (p=0.004). There was a significant correlation between serum TCII levels and typhus IgM or IgG titers (p < 0.05), but not to total IgM levels. These findings indicate that patients with scrub typhus had stimulation of the recticuloendothelial system as a result of a considerable increase in transcobalamin II levels.

The hematological status, plasma vitamin B12 and folic acid levels, and intestinal pathology in rats infected with Giardia lamblia.

The purpose of our study was to investigate the hematological status, vitamin B12 and folic acid absorption and intestinal pathology after Giardia lamblia infection in a rat model. Adult Wistar rats were assigned randomly to receive human giardia cysts orally in the amount of 5 x 10(5) or 1.0 x 10(6) cysts, or none in the controls. The results showed that all the rats injected with giardia cysts became infected. The cyst output in the infected rats varied considerably. In rats infected with 5.0 x 10(5) giardia cysts, the incubation period until cyst output was 10 days compared with 4 days in rats infected with the higher amount of 1.0 x 106 giardia cysts. The highest peaks for cysts output in these 2 groups were on days 4-33, which decreased gradually to days 40-58. The hematocrit and hemoglobin levels in the infected rats were statistically significantly lower than in the controls on days 16, 22, 33, and 37 post-infection (p < 0.05). A reverse relationship between giardia cyst output and hemoglobin concentration was found in the infected rats (p = 0.05). There were no significant differences in plasma vitamin B12 and folic acid levels between the infected rats and the control rats. No pathological changes were found in the small intestine of infected rats. These findings suggest that giardiasis did not affect the absorption of plasma vitamin B12 and folic acid but caused anemia in a rat model.

Septicemic melioidosis and meningitis: A case report.

Melioidosis predominantly affects the rice-farming community of north-eastern Thailand, and occurs mainly in patients with underlying diseases such as diabetes mellitus or chronic renal impairment. It may be asymptomatic or may present as acute septicaemic or chronic suppurative infection. Neurological involvement in melioidosis is uncommon. We report here on a patient with septicaemic melioidosis and meningitis. A 48-year-old man presented with a three-month history of fever, chillis and weight loss. He came from Udon Thani and was a known diabetic who had been on regular treatment for three years. Both Widal and Weil-Felix reactions were negative with normal X-ray of the chest. On the next day, the patient had severe headache with a stiff neck. The CSF contained elevated glucose and protein concentrations, polymorphonuclear cells and lymphocytes but revealed no growth on culture. Two days later, the patient developed a cough, dyspnoea with difficulty in swallowing. Culture frpm the blood and sputum yielded pure Burkholderia pseudomallei. The patient was treated with a combination of ceftriaxone and trimethoprim-sulphamethoxazle which was found to be sensitive in vitro. However, the patient died on day 7 of hospitalization. This case illustrate an urgent need for early diagnosis and identification of sensitive drugs for the treatment the melioidosis which is still quite common in north. Eastern Thailand.

Serum transcobalamin II level in a malarial patient with ceftriaxone-induced haemolyic anaemia.

Cephalosporins have rarely been reported as the cause of immune haemolytic anaemia (IHA). The case history of a patient who had elevated serum transcobalamin II (TCII) levels due to a ceftriaxone-induced haemloytic anaemia is presented in this study. The patient was admitted because of high fever due to P.falciparum. The fever subsided after treatment with anti-malarial drugs. However, two days later, the fever recurred and ceftriazone was given. On the next day, the patient had haemolysis with haemoglobinuria and renal insufficiency which resolved after withdrawal of the drug. Serum TCII levels were elevated during the haemolytic episode and the period of renal impairment. The mechanisms of increased serum TCII are probably due to the acute haemolysis and nephrotoxicityinduced by ceftriaxone, leading to the impaired catabolism and clearance of TCII. Therefore, intravascular THII survival is prolonged. Resulting in elevated serum TCIIlevels.

Persistently elevated serum transcobalamin II in a patient with reactive haemophagocytic syndrome.

A 24-year-old man was admitted to the hospital with a history of prolonged fever, peripheral blood neutropenia and bone marrow showing benign haemophagocytic histiocytosis. He presented with symptoms and manifestations over a brief duration until death, with the progressive development of multi-organ dysfunction. His serum TCII levels were persistently elevated throughout the disease duration in the hospital. Available evidence indicates that macrophages, mononuclear cells and histiocytes can produce TCII. Serum TCII levels in patients with reactive haemophagocytic syndrome are therefore elevated due to the increased be helpful in making the diagnosis in these patients.

Effect of chloroquine on serum vitamin B12 and its binding proteins in patients with plasmodium vivax.

Chloroquine (CQ) is widely used as an antimalarial agent. It is accumulated in the lysosomes of various types of cells and inhibits the intralysosomal degradation of a wide range of proteins. CQ is found to interfere with vitamin B12 transportation in vitro and in the experimental animal. The present study was performed in order to determine such interference in humans receiving CQ. Serum vitamin B12 and vitamin B12 binding proteins were determined in 13 patients with P.vivax, both before and after receiving six tablets and 10 tablets of CQ. There were no significant differences between serum vitamin B12, UBBC, TBBC and TC values in patients before and after taking 6 tablets of CQ. A slight but not significant decrease in serum vitamin B12 and a significant increase in serum TCII were found after taking 10 tablets of CQ. The low serum vitamin B12 could be due to the effect of CQ on prevention of lysosomal degradation of intrinsic factor, leading to the accumulation of IF-B12 in the intestinal mucosa. As CQ also inhibits the intracellular degradation of TCII, therefore, more TCII levels are synthesized and secreted from various organs by the feedback mechanism. All these findings indicated the CQ had some effects on vitamin B12 absorption and transportation. However, these effects were relatively unsevere for the required dose of CQ in the treatment of P.vivax malaria.

Increased circulating levels of transcobalamin II in typhoid fever.

Many previous studies have shown that serum transcobalamin II (TCII) is usually elevated in patients with a stimulated and proliferative reticuloendothelial system resulting from such diseases as multiple myeloma, systemic lupus erythrematosus, dermatomyositis, rheumatoid arthritis and Gaucher’s disease. As reactive macrophage hyperplasia with monocytosis also occurs in patients with typhoid fever, we therefore studied TCII in these patients. The mean value of serum TCII was significantly higher in the typhoid patients’ group, and 15 out of 35 patients had serum TCII values over 2,000 pg/ml. There was no relationship between serum TCII and white blood count, haemoglobin or haematocrit values. The increased serum TCII level in typhoid patients was possibly due to increased synthesis by the proliferative mononuclear cells derived from reticuloendothelial tissue in various organs such as the spleen, liver and mesenteric lymph nodes. This supposition is supported by a previous report that TCII is synthesized in part by mouse peritoneal macrophages, as well as by human monocytes and macrophages which produced and secreted considerable amounts of TCII into the medium. Findings of increased serum TCII in typhoid patients therefore add a new area of information which has never been studied before.

Idiopathic hypereosinophilic syndrome: A case report.

Eosinophilia is quite common in Thailand due to the high prevalence of parasitic diseases. A study in 1993-1994 showed that 41% of patients with different parasitic infections had eosinophilia. We report herein a patient with idiopathic hypereosinophilic syndrome (HES). A 23-year-old man was admitted to the hospital with a 1.5 month history of chest pain and dyspnea on exertion. He had symptoms and signs of congestive heart failure. His peripheral blood revealed eosinophils 42% (8.4 x 109/1) with many hypogranulated and vacuolated eosinophils. Bone marrow aspiration showed a hypercellular marrow with eosinophils 10% and plasma cells 5-10%. Chest x-ray showed cardiomegaly and an echocardiography revealed pericardial effusion. As this patient had eosinophilia, signs and symptoms of cardiac involvement and lack of evidence for parasitic, allergic or other causes of eosinophilia, a diagnosis of idiopathic HES was made. Treatment with prednisolone resulted in the improvement of congestive heart failure and the eosinophil count returned to normal. A prompt diagnosis and treatment are needed in patents with this syndrome.

Tropical pyomyositis: A case report.

Tropical pyomyositis is an inflammatory condition of skeletal muscles, usually associated with infection with microbials. As this disease is quite rare in Thailand, we report here a 20-year-old man, a Burmese immigrant in Bangkok for 5 months, who presented with fever, malaise, luecocytosis, elevated sedimentation rate, anemia and a tender mass on his right back. Ultrasonography revealed a mass with abscess suggested tropical pyomyositis and was confirmed by open surgery. Pus was sterile. After treatment with cloxacillin for 24 days, the abscess healed and the patient was discharged and has been followed for 4 months with no recurrence of pyomyoistis. Tropical pyomyositis should be considered and differentiated from viral infection, osteomyelitis and visceral abscesses in the tropical countries.

Salmonella choleraesuis bacteremia associated with The Acquired Immunodeficiency Syndrome (AIDS).

Multiple opportunistic infections are characteristic of the acquired immunodeficiency syndrome (AIDS). An emerging problem with salmonella infection among patients with AIDS is increasing. We report here 3 patients with AIDS who presented with fever and were found to be bacteremia due to serotypes of Salmonella choleraesuis. As this serotype rarely occurs in normal hosts in Thialand, finding the infection in patients with AIDS indicate that these patients are at high risk. It suggests that AIDS patients with prolonged febrile illness should be investigated for salmonella infection.

Elevated serum transcobalamin II levels in patients with prolonged fever.

Serum transcobalamin II levels were determined in 70 patients with prolonged fever. Twelve patients were found to have elevated serum TCII levels, i.e., 8 patients with salmonellosis, 3 patients with scrub typhus and 1 patient with pyrexia of unknown origin. There were no relationships between serum TCII levels and white blood cells, lymphocytes or monocytes. The possible mechanism producing increased serum TCIII levels in patients with salmonellosis and scrub typhus is the increased synthesis and release of TCII by the proliferative mononuclear phagocytic cells of the reticuloendothlial tissues such as spleen, liver, bone marrow and lymph nodes. This study gives the additional data that elevated serum TCII may occur not only in inflammatory disorders, autoimmune diseases, lymphoproliferative disorders, malignant histiocytosis and neoplasms, but also in infection with salmonellosis and scrub typhus.

Salmonella infection in patients with plasmodium falciparum malaria.

Patients with P.falciparum malaria infection are unusually susceptible to a variety of infectious diseases. There is an increased incidence of salmonella infection and bacteremia in patients with malaria. The objective of the present study was to report 3 patients with P.falciparum malaria infection in association with salmonellosis. These patients presented with fever and their blood smears revealed P.falciparum. They were treated with anti-malarial drugs. The malarial parasites disappeared from the peripheral blood, however, the fever persisted or recurred within a few days. Blood cultures grew S.choleraesusis, S.enteritidis and S.paratyphi A, respectively. These patients were treated successfully with antibiotics. Blood cultures should therefore be performed in all patients with P.falciparum malaria whose fever persists after treatment with antimalarial drugs.

A case with acute myelofibrosis and acute promyelocytic leukemia.

A 65-year-old man was admitted to a provincial hospital repeatedly over a period of years with a history of weakness, tiredness and progressive anemia. One occasion a bone marrow aspiration was found to contain normal marrow elements. On admission four months later, the patient was pale with pitting edema on both legs. His liver was barely palpable and the spleen was palpable 2 cm below the costal margin. He was anemic and peripheral blood showed anisopoikilocytosis, burr cells, ovalocytes and macrocytosis. The platelet level was very low, with some giant cells. The white blood cell count was normal, with some immature granulocytes. Bone marrow biopsy confirmed the diagnosis of acute myelofibrosis. The patient had very high levels of serum vitamin B12 and vitamin B12 binding proteins, especially transcobalamin I. After treatment with blood transfusion and prednisolone, his white cell count increased considerably. He died nine days after admission because of bronchopneumonia. This patient is an example of the simultaneous occurrence of acute myelofibrosis and acute promyelocytic leukemia that can terminate as acute myeloblastic or other stem – cell leukemia.

Salmonellosis in a patient with abdominal aortic aneurysm.

A 62 year-old man was admitted to the hospital with a history of fever and abdominal pain for 3 days. Four years ago, he has previously been treated for ischemic heart disease, hypertension and diabetes mellitus. CT scan of the abdomen revealed a partially thrombosed atherosclerotic aneurysm of the abdominal aorta. Hemoculture grew out Pseudomonas aeruginosa. After treatment with ciprofloxacin for 10 days, the abdominal pain and fever recurred. One week later, a blood culture grew out Salmonella group B. Ampicllin was given intravenously, however, the fever still persisted. On day 32 of admission, the patient went into shock with bleeding in the gastro-intestinal tract. The patient died on the next day despite blood transfusion. This patient represented an atheroscloerotic aneurysm of the abdominal aorta with salmonella infection and subsequent rupture.

Excessively high serum vitamin B12 level in patients with a provisional diagnosis of megaloblastic anemia.

High serum vitamin B12 level has been reported in patients with liver diseases ad some hematological disorders. It has been observed that some patients diagnosed as megaloblastic anemia have high serum vitamin B12 with low serum unsaturated vitamin B12 binding capacity (UBBC). The objective of the present study was to investigate in these patients. A retrospective study in 9 patients with a provisional diagnosis of megaloblastic anemia showed extraordinarily high serum vitamin B12 with very low UBBC. Their past history showed that these patients were treated with 1,000 g vitamin B12 intramuscularly 10-24 hours before serum samples were taken for vitamin B12 determination. Study in another 3 patients showed that within 12 hours after a single injection of 1,000 g cyanocobalamin, their serum vitamin B12 raised considerably with an extremely low UBBC level. These findings indicated that the injected vitamin B12 saturated all transcobalamins and then exceeded to bind to other serum proteins such as albumin and gamma globulin. Serum vitamin B12 was maintained at a very high level with a very low unsaturated vitamin B12 binding capacity. Therefore the past history of receiving vitamin B12 must be exactly known in any patients who were taken blood sample for vitamin B12 determination.

Serum transcobalamin II in childhood histiocytosis syndromes.

It has been shown in a previous report that an extreme high serum TCII level was found in patients with malignant histiocytosis and patients with proliferative histiocytosis. The objective of the present study was to Langerhans cells histiocytosis and 6 patients with malignant histiocytosis. Serum TCII levels in both groups of patients were not significantly different from those of normal subjects. Furthermore, serum vitamin B12 and other transcobalamins levels were also within the normal limits. These findings do not support the results reported earlier in adult patients either with malignant histiocytosis or with proliferative histiocytosis. The suggestion that determination of TCII may be a useful indicator of activity and size of the macrophage/histiocyte system is therefore not proved in childhood histiocytosis syndromes.

Differential diagnosis of myelofibrosis from polycythemia vera and chronic myelogenous leukemia by vitamin B12 determination.

Myelofibrosis (MF) has a close pathogenic relationship to polycythemia vera (PV), chronic myelongenous leukemia (CML) and primary thrombocythemia (PT). Sometimes, clinical, hematological and radioisotopic studies in these patients cannot give a definite diagnosis. As serum vitamin B12 and vitamin B12 binding proteins in patients with PV and CML show their own specific pattern. It would be of interest to see whether these determinations could separate MF from PV and CML. Serum vitamin B12 and vitamin B12 binding proteins were determined on 6 patients with MF. It was found that serum vitamin B12, UBBC and TBBC levels were elevated. Both TCI and TCIII were increased while TCII decreased. A shift to the left of the increased granulocytes in MFR resulted in an increased TCI synthesized by the myelocytes and metamyelocytes while in PV, the increased number of granulocytes, most of which are mature granulocytes is characterized by increased serum TCII resulting in a reverse ratio of TCI/TCIII. In CML, serum vitamin B12, UBBC, TCI and TCII are much more sharply elevated than those of MF. Therefore determination of serum vitamin B12 and vitamin B12 binding proteins with other hematological, bone marrow and clinical studies could be used for a differential diagnosis of MF from PV or CML.

Serum folate and vitamin B12 levels in chronic alcoholics.

Anemia is common in alcoholics. Folate deficiency occurs commonly in association with the chronic use of alcohol. The incidence of folate deficiency in chronic alcoholic patients varies considerably from country to country. The purpose of the present study was to report the incidence of folate and vitamin B12 deficiencies in Thai chronic alcoholics. Serum folate and vitamin B12 levels were determined in 75 chronic alcoholics as well as in 80 apparently healthy Thai subjects. The mean Hb, Hct and serum folate levels were significantly lower in the alcoholics. Thirty-five percent and 84 percent had serum folate levels lower than 3 ng/ml and 6 ng/ml, respectively. On the other hand, the mean value of serum vitamin B12 in the alcoholic patients was significantly elevated, with 49 percent of them having serum vitamin B12 over 1,000 pg/ml. These findings indicated that the incidence of folic acid deficiency in the chronic alcoholics was quite high, which was probably due to dietary deficiency, folate malabsorption and interference by alcohol in folate metabolism. All these patients had a tendency to have a high serum vitamin B12 level, probably as a result of the increased release of vitamin B12 from storage in the injured liver.

Folates and vitamin B12 status in patients with multiple myeloma.

Serum and red cell folate, serum Vitamin B12 and Vitamin B12 binding proteins were multiple myeloma. Half of these patients were anaemic with a predominant macrocytic type. Altogether 17 and 33 percent had low serum and red cell folate levels, respectively. Low serum Vitamin B12 level was found in one third of these patients. Both TCI and TCIII increased while TCII decreased, while was different from the previous report of extremely elevated TCII in some patients with multiple myeloma. There was a direct relationship between serum Vitamin B12 and saturation of TCI. These finding indicated that folic acid and Vitamin B12 deficiency were relatively common in patients with multiple myeloma. The possible mechanisms of these vitamins deficiency were discussed in this paper.