Pulmonary edema in cerebral malaria patients in Thailand.

Pulmonary edema is a serious complication of falciparum malaria that usually occurs in association with cerebral malaria, acute renal failure, high parasitemias, or delayed antimalarial treatment. From 1993 to 1996, 120 adult patients admitted to the intensive care unit of the Bangkok Hospital for Tropical Diseases were enrolled in a prospective study to assess the combination of artesunate and mefloquine for the treatment of cerebral malaria. Twenty-five patients (21%) presented with pulmonary edema and a majority developed complications in other organs as well, especially acute renal failure. In most patients (19 of 25), pulmonary edema was noted on the first day of admission and was associated with higher parasitemias and levels of acidemia, than in patients without pulmonary edema. Ten of the 25 patients diagnosed with pulmonary edema developed signs consistent with adult respiratory distress syndrome (ARDS). The mean central venous pressure when pulmonary edema was diagnosed was markedly lower in ARDS than in non-ARDS patients, supporting the argument that fluid imbalance is not essential for malaria-induced lung injury. Seven of 10 patients with ARDS died, 5 within 24 hours of admission, but there were no deaths in the 15 pulmonary edema patients without ARDS. Early diagnosis and prompt treatment remain important principles to reduce the morbidity and mortality associated with complicated falciparum malaria. This report emphasizes that ARDS, when concurrently occurs, is a poor prognostic clinical indicator in cerebral malaria.

The course of clinical COPD in Thailand.

Spirometry and outcome of 96 cases who were clinically diagnosed as having COPD were studied. Ninety-two cases had significant airway obstruction. Of these 92 cases, initial bronchodilator responses were evaluated in 73 cases. Twenty-six cases were responders (CRAO), while 47 cases were nonresponders (COPD). The average median survival of the whole group was 4 years and 5-year survival was 30 per cent. The annual change in FEV1 in both COPD and CRAO group were fluctuating, with a tendency to decrease in the former and increase in the latter. Spirometric parameters were found to be different between the survivors and nonsurvivors, these included initial PFEV1, PFVC, PFEF 25-75 per cent and postbronchodilator FEV1 and FEF 25-75 per cent. Inspite of the differences, an initial response to bronchodilator could not predict a better outcome for CRAO as compared to COPD. It was concluded that most clinical COPD who had progressive symptoms had significant airway obstruction and shorter survival. Due to fluctuating FEV1 during the course, the initial spirometry and degree of bronchodilator response were not accurate enough to predict subsequent outcome. Long-term follow-up on spirometry and response to bronchodilator should be individually evaluated.

The compromised host and pulmonary infiltration: a prospective study.

If immediate sputum examination does not result in a diagnosis, broad spectrum antibiotics should be administered while awaiting cultures. Three days later, if the patient deteriorates and has a negative hemoculture, bronchoalveolar lavage should be done before open lung biopsy or antifungal drugs are considered. We have demonstrated that rational empiric therapy in immunosuppressed patients with pneumonia is beneficial. Diagnostic tests must be performed so that treatment can be modified later when the etiological agent has been identified.