Treatment of cytomegalovirus (CMV) retinitis with intravitreous ganciclovir in HIV-infected children.

OBJECTIVES: To evaluate the efficacy, visual outcomes, and complications of intravitreous ganciclovir treatment in cytomegalovirus (CMV) retinitis in HIV-infected children. MATERIAL AND METHOD: The medical records of HIV-infected children who were screened for CMV retinitis from February 2002 to February 2005 were reviewed. The children with CD4+ < 15%, or with clinical category C would have complete ophthalmic examination every 3 months. Ganciclovir (4 mg/0.04 ml) was administered intravitreously to the eye with CMV retinitis every 2 weeks under general anaesthesia. After injection, fundi were examined immediately, 1 day, 14 days and every 2 weeks until the lesions were stable. RESULTS: Six (9 eyes) out of 45 children (13%) aged 2-12 years were found to have CMV retinitis. All CMV retinitis lesions were "cheese and ketchup like" (retinal hemorrhage and exudate) lesions and presented in the posterior pole. Bilateral CMV retinitis were found in 3 children. Intravitreous ganciclovir was injected in 4 children (5 eyes). The average number of intravitreous injections for each patient was 5.6 (3-7) times. All of the children received antiretroviral therapy and 3 children also received intravenous ganciclovir CMV retinitis lesions were improved in every eye. The visual acuity (VA) remained stable in 4 eyes, but endophthalmitis developed in one eye a few days after injection. The average duration of follow-up was 13.5 months (3-23 months). CONCLUSION: CMV retinitis was not uncommon. The authors found that intravitreous ganciclovir was effective but may cause complications. This treatment should be considered in a resource-limited setting.

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

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

Recurrent Campylobacter lari bacteremia in X-linked agammaglobulinemia: a case report and review.

X-linked agammaglobulinemia (XLA) is a primary immune deficiency disease with a B-cell defect. We present the first XLA patient who had recurrent Campylobacter lari bacteremia. High dose intravenous immunoglobulin combined with azithromycin once per week, and a complete avoidance of bacterial reservoirs may be helpful for the prevention of C. lari bacteremia.

Comparison of outcomes and efficiency between drawings of two blood samples and three blood samples for culture.

Health economic analysis is one of the strategies for healthcare provider or policy makers to make decision. Cost identification is the basic evaluation while cost minimization or cost benefit is a further step comparing the cost with the efficacious outcome. Ideally, the comparison between drawings of two blood samples and three blood samples for culture has to be done by prospective randomization to avoid selective biases as much as possible. In the situation of a cohort study like “Comparison of Outcomes and Efficiency between Drawings of Two Blood Samples and Three Blood Samples for Culture,” the reasons for taking two or three blood samples have to be clearly stated. Also, all the demographical data of subjects such as gender, age group, volume of each blood sample, duration between blood drawing and diagnosis have to be comparable and stated as much as possible. First blood specimens from table 1 and table 2 show the recovery rate of positive hemoculture which are summarized as follows. Although we could draw a conclusion that each subject has 11-12% chance to have positive first blood culture specimen, but drawing of two blood specimens were more contaminated (20.1%) than three blood specimens (8.3%). The evidence is clear and comparable. Regarding the calculation of Number Needed to Treat (NNT) of 56 cases or doing the third hemoculture will find one more case than only drawing two specimens, we had 10,264 specimens/year of two specimens and would miss 184 cases/that could be detected by the third hemoculture and just only one resulted this true infection. How many subjects responsible for the cost of over treat or under treat? How much is the cost of life and reputation of the hospital? Interpretation and conclusion in terms of monetary unit provide ultimate outcome as morbidity mortality.

Developmental screening by the Cognitive Adaptive Test/Clinical Linguistic and Auditory Milestone Scale (CAT/CLAMS) in HIV- infected children.

Bayley Scales of Infant Development (BSID) is considered to be a standard test for child development. The test requires experienced evaluator and is time consuming; therefore, it is not easy to apply in busy clinic. The Cognitive Adaptive Test/Clinical Linguistic and Auditory Milestone Scale (CAT/CLAMS) is an easy assessment method that has been demonstrated to correlate with BSID in many studies among normal and developmental delayed children, including in HIV-infected infants. We created a pilot system of CAT/CLAMS assessment applied to 16 HIV-infected infants ages 12-34 months. They were all in the normal range score of developmental quotient (DQ). However, longitudinal follow-up by CAT/CLAMS assessment is needed in these HIV-infected children. When DQ score is below 70 (assuming to be delayed development), the child should be evaluated by BSID. In this way delayed development can be screened easily and early developmental stimulation program can be implemented appropriately.

The first pediatric case of Staphylococcus aureus with heterogenous resistant to vancomycin endocarditis in Thailand.

Staphylococcus aureus with reduced susceptibility to vancomycin has been reports worldwide. Here we report the first pediatric case of heterogeneous vancomycin intermediate resistance Staphylacoccus aureus (hVISA) causing endocarditis in Thailand. A 4 months old girl with truncus arteriosus type IV and ventricular septal defect developed methicillin-resistant S. aureus (MRSA) bacteremia and endocarditis after total repair operation. The patient did not respond to combination antimicrobial treatment including vancomycin. The strain was susceptible to trimethoprim-sulfamethoxazole and vancomycin by conventional antimicrobial susceptibily test. The vancomycin minimal inhibitory concentration by E-test was 2 microg/ml. The strain was judged to be possible heteroresistant when screening was done by one-point population analysis. The subsequent population analysis and testing for the emergence of mutants with reduced susceptible to vancomycin confirmed that this strain was hVISA. Despite the treatment with vancomycin, amikacin, rifampicin and cotrimoxazole, the patient died. hVISA should be suspected in MRSA infections that were refractory to vancomycin therapy could be due to. The emergence hVISA underscored the importance of the prudent use of antibiotics, the laboratory capacity to identify MRSA and hVISA and proper communication with treating clinicians, and the meticulous infection-control measures to prevent transmission.

Initiation of antiretroviral treatment with dual nucleoside reverse transcriptase inhibitors in human immunodeficiency virus-infected infants with less advanced disease in a resource-limited setting: a multi-center study in Thailand 1998-2000.

OBJECTIVES: To evaluate the feasibility, duration of efficacy, and outcome of therapy with dual nucleoside reverse transcriptase inhibitors (NTRI) initiated in HIV-infected infants with mild to moderate disease. MATERIAL AND METHOD: During 1998-2000, a multi-center prospective open-labeled operational study was conducted. Antiretroviral naôve HIV-infected infants were enrolled in seven hospitals to receive either zidovudine (AZT) plus lamivudine (3TC) or AZT plus didanosine (ddI). Infants who were in CDC stage "C3" were excluded from the study. RESULTS: Of the 88 infants, the mean age of treatment initiation was 6.8 months, and the mean initial CD4 was 1538 cells/mm3 (21.4%). The z-scores for weight and height increased after 4-8 months of treatment, and by the 24th month, were +0.89 and +0.69 higher than at enrollment. The CD4% peak increased at 8 months of treatment, by a mean increment of 4.19%, but decreased to the level of 1.08% above baseline by the 24th month of treatment. Three (3.4%) infants died, 11 (12%) had disease progression, 7 (8%) was prematurely discontinued from the study protocol due to poor compliance, and 37 (42%) were lost to follow-up. At the end of 24 months, all remaining 30 children were in stable condition with a chance of clinical and immunological stability of 34% and 68% by intention-to-treat and on-treatment analysis, respectively. CONCLUSION: Clinical and immunological benefit from dual NRTI was limited. Treatment of HIV-infected infant with mild to moderate disease in a resource-limited setting may have limited feasibility due to the high drop-out rate.

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

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

Diagnosis disclosure in HIV-infected Thai children.

BACKGROUND: Increasing number of children with perinatally acquired HIV-infection are now surviving into school age and adolescence. Disclosure of diagnosis to these children has become an important clinical issue. Clinical reports and studies from other countries suggest that a significant number of these children have not been told of their HIV status. The objective of this study was to assess diagnosis disclosure status of perinatally acquired HIV-infected Thai children. MATERIAL AND METHOD: Primary caregivers of 96 HIV-infected children aged 5 years and older were interviewed to assess the child disclosure status and the caregivers reasons to disclose or not to disclose the diagnosis to the child. The disclosed children were also interviewed to assess perception of their illness. RESULTS: Nineteen of 96 children (19.8%) had been told of their HIV diagnosis by their caregivers. The mean age of the disclosed children was 9.6 years. Eighty-four percent of the disclosed children reported perception of their illness as having HIV infection or AIDS. Common reasons for non-disclosing were concerns that the child was too young, that the child might be psychologically harmed, and that the child could not keep the secret. Of 77 non-disclosing caregivers, 54 reported that they plan to disclose HIV status to the children in the future. CONCLUSION: This study demonstrates that diagnosis disclosure was made in only 1/5 of HIV-infected children, and that most of the caregivers were reluctant in disclosing serostatus to the child. Development of an appropriate guideline for assisting the caregivers and the children to deal with the difficult disclosure process is needed.

A randomized study of 3 umbilical cord care regimens at home in thai neonates: comparison of time to umbilical cord separation, parental satisfaction and bacterial colonization.

OBJECTIVE: To compare time to cord separation, parental satisfaction and bacterial colonization, among 3 regimens of cord care at home. STUDY DESIGN: Randomized controlled trial. MATERIAL AND METHOD: Term infants were randomly assigned based on cord care regimens at home: 1) triple dye, 2) alcohol, and 3) no antiseptic agent. Timing of cord separation, and parental satisfaction were evaluated during the first month of age. RESULTS: 185 infants were recruited. Time to cord separation in infants of group I was significantly longer than in group 2 (p = 0.036) and group 3 (p = 0.003). The satisfaction scores of group I were significantly lower than those of group 2 and group 3. 180 culture specimens were performed and positive in all but none had omphalitis. CONCLUSION: Triple dye delayed time to cord separation and was less satisfactory. The authors conclude that using alcohol or dry clean could be alternative ways of umbilical cord care at home.

Modified boosted – p24 antigen can predict HIV-1 RNA viral load (Ampiclor HIV-1 Monitor).

Objective : To evaluate the prediction of HIV-1 RNA viral load (Ampiclor) in log_copies per ml by each level of modified boosted-p24 antigen in log_ fg per ml. , Methods : 283 plasma samples were collected and blindly determined the HIV-1 RNA Amplicor Monitor, Roche as standard test with modified boosted p24 antigen assay. Likelihood ratio positive analyses of multiple levels of p24 were calculated as well as the post-test probability in predicting the amount of virus (log_copies/ ml). Results: Subject were between 18 to 73 years old with the range of virus 1.75 to 5.92 log-copies per ml. By the calculation of likelihood ratio positive and positive predictive value, it was demonstrated that modified boosted p24 antigen (Ag in log-fg per ml) might predict the viral load (VL in log-copies per ml) as follow. Ag 2.0-3.0 log-fg per ml corresponding to 2.0 or lower log-copies per ml VL Ag 3.0-3.5 log-fg per ml corresponding to 2.5 or lower log-copies per ml VL Ag 3.5-4.0 log-fg per ml corresponding to 3.5 or lower log-copies per ml VL Ag 4.0-over log-fg per ml corresponding to 4.5 or lower log-copies per ml VL Conclusions: In countries with limited financial resources, the modified p24 antigen may be clinically applied in antiretroviral management programmes, instead of the HIV-1 RNA Amplicor Monitor, Roche.

Diagnosis of dengue infection using various diagnostic tests in the early stage of illness.

In order to elucidate the usefulness of various tests in the early course of dengue infection, in terms of diagnosis and correlation with clinical severity, blood specimens were collected every 48 hours on 3 occasions from patients with clinical suspicion of dengue infection with fever for less than 4 days. Viral isolation was attempted by mosquito inoculation (MI), tissue culture inoculation (TC), and reverse transcriptase polymerase chain reaction (RT-PCR). Antibodies were detected by hemagglutination inhibition test (HI), an in-house-ELISA (IH-ELISA), and an ELISA by MRL diagnostics Clinical data were collected from the time of enrollment to complete recovery. Of the 40 patients enrolled, 31 were diagnosed as dengue infection and confirmed by either serology or viral isolation. Of these, 12 had primary infection and 19 had secondary infection. Dengue fever occurred in 9 cases. Dengue viruses were isolated from 28 out of 31 patients, and dengue hemorrhagic fever was diagnosed in 22 patients. Viral serotypes identified by viral isolation, and RT-PCR were concordant: DEN1 was isolated in 8, DEN2 in 13, DEN3 in 5, and DEN4 in 2 patients. Viral isolation yielded positive results on blood collected before the 5th day of fever. MI was more sensitive than TC. RT-PCR was less sensitive than viral isolation during the early days of fever, but became more sensitive after the 5th day of fever. RT-PCR was able to detect virus up to day 7-8 of fever, even after defervescence, and in the presence of antibody. During the febrile stage, serological diagnosis on blood samples taken 48 hours apart was carried out by HI, IH-ELISA, and MRL-ELISA, facilitating diagnosis in 3 (10%), 21 (67%), and 27 (87%) of patients, respectively. All of the patients with secondary infection were diagnosed by MRL-ELISA before defervescence. By the 8th day of fever, a serological diagnosis aided to diagnose in 9 (29%), 29 (93%), and 31 (100%) of patients by HI, IH-ELISA, and MRL-ELISA, respectively.

Breakthrough neurological manifestation during appropriate antituberculous therapy of miliary tuberculosis.

We report a 20-month-old girl with miliary pulmonary tuberculosis and normal neurological findings. While on treatment with isoniazid, rifampicin, pyrazinamide, and ethambutol for 1 month, she developed weakness of the lower extremities without meningism or altered consciousness. A computerized tomogram revealed tuberculomas and basal arachnoiditis. The cerebrospinal fluid findings were compatible with tuberculous meningitis. She responded well to systemic corticosteroids.

High CD4+ T-cells percentage and/or low viral load are predictors of 1-5 years survival in HIV-1 vertically infected Thai children.

OBJECTIVE: Enrolling pediatric HIV children into the clinical trial of when to initiate antiretroviral therapy is a crucial ethical issue. CD4+ T-cells percentage and/or viral load were able to identify potential cases of survival through 5 years of age. METHOD: HIV infected cohort from 1992 to 1994 from Children's and Siriraj Hospitals were followed from 1 through 5 years of age. The outcome was survival or death. The predictors were CD4 percentage and viral load (without age and clinical status adjustment). RESULT: 16 of 35 (45.71%) of the cohort survived through 5 years of age. The probability of survival increased to almost 100 per cent either with CD4+ T-cells percentage of over 22 or viral load of less than 500,000.

The prevalence of prostate cancer screening in Thai elderly.

PROBLEM: Prostate cancer is the most common cancer in elderly men in Western countries. In the future, it may be an important problem in Thailand. At present, there is no evidence about the prevalence and the outcome of screening in this disease. OBJECTIVES: To determine the prevalence of prostate cancer in elderly Thai men and to identify the most appropriate screening method for detection of prostate cancer in Thailand. MATERIAL AND METHOD: 928 elderly men from communities around Siriraj Hospital were evaluated for prostate cancer by Digital Rectal Examination (DRE) and/or Prostate Specific Antigen (PSA). Transrectal ultrasound guided biopsy (TRUS-Bx) which is the gold standard for definitive diagnosis was performed in cases with an abnormal DRE and/or PSA. If biopsy could not be performed, intermittent follow-up with DRE and/or PSA were recommended. RESULT: The prevalence of prostate cancer in Thai elderly men in the urban community was more than 0.75 per cent and the prevalence of abnormal DRE and PSA was 8.7 and 17.3 per cent respectively. The Positive Predictive Value (PPV) of both tests was 60 per cent and higher than the PPV of an individual test. A screening program for prostate cancer starting with DRE may be more cost effective. CONCLUSION: The prevalence of prostate cancer, abnormal DRE and abnormal PSA in Thai elderly men were more than 0.75, 8.7 and 17.3 per cent respectively which are comparable to the prevalence in Western countries. It is important that we take an interest in this disease.

Benign prostatic hyperplasia in elderly Thai men in an urban community: the prevalence, natural history and health related behavior.

PROBLEM: Although benign prostatic hyperplasia (BPH) is a common disease in elderly Thai men the prevalence in the community and its natural history is unknown. OBJECTIVES: To determine the prevalence of symptomatic BPH and its natural history. To determine the health related behaviors which have an impact on the voiding symptoms. MATERIAL AND METHOD: 879 elderly men aged > or = 60 years from communities around Siriraj Hospital were studied. The International Prostate Symptom Scores (IPSS) and Quality of Life (QOL) scores were evaluated in the participants at the beginning of the study and 1 year later. The overall assessment, complications and health related behaviors were also evaluated. RESULT: The prevalence of symptomatic BPH in the community was 41.3 per cent. In terms of overall assessment at 1 year follow-up, symptomatic BPH patients (IPSS 8-35), the rate of "improved", "same" and "worse" was 10.6, 70.2 and 19.2 per cent respectively. The complication rate was about 10 per cent. Three quarters of the elderly men had health related behavior at risk. CONCLUSION: The prevalence of symptomatic BPH was high. Its natural history was unpredictable and some BPH symptoms may be influenced by their behaviors.

Transcutaneous bilirubinometry: Effect of postnatal age and serum bilirubin concentration.

Transcutaneous bilirubinometry (TcB) is a new diagnostic tool for neonatal hyperbilirubinemia. It can be used as a screening tool to identify full-term infants who require serum bilirubin determination. In Thai infants, it yields a positive prediction with serum bilirubin. The correlation coefficient was 0.8. The best correlation was obtained when serum bilirubin was over 15 mg/dl. The postnatal age of the infant affects the accuracy of TcB measured at the forehead. We recommend TcB be measured at the forehead during the first three days of life.

Breast feeding: The survey in paediatric out-patients.

Two thousand and seventeen guestionnaires were collected from 4 regional university hospitals in Bangkok (Siriraj), Chiengmai, Khon Kaen and Songkhla during November-December 1987. No difference was found in the proportion of the babies who were breast fed (at least for 1 month after birth) and those who were bottle fed among these hospitals. Although almost 80 percent of those babies were breast fed, the figure was lower than that in the community survey, 94 percent in 1984.

Antimicrobial agents in URI preliminary study.

A preliminary study of 606 children with upper respiratory tract infection, aged under 12 years was carried out at the out-patient clinic of Department of Paediatrics, Siriraj Hospital. It revealed the use of oral antimicrobial agents in 83 per cent of the cases. Most of the antimicrobial agents were prescribed for 3 days be either staff or residents or externs. More tendency of antimicrobial agents prescription was found in the pharyngitis group.