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.

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.

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.

The analysis of 46 fatal snake bite cases in Thailand.

In order to identify aspects of snake bite treatment which could be improved, 46 well-documented cases of fatal snake bite (mortality rate = 2.8%) from 15 provincial hospitals throughout Thailand were selected for analysis (1,626 bites in 84 hospitals). Bungarus candidus and Calloselasma rhodostoma were each responsible for 13 deaths, Naja kaouthia for 12, Vipera russelli for seven and Bungarus fasciatus for one. Major causes of death were respiratory failure and complications of prolonged mechanical ventilation following Elapidae bites; shock, intracranial haemorrhage, complications of local wound necrosis including tetanus, and renal following Viperidae bites. Analysis of these patients’ clinical management revealed the following factors contributing to fatal outcome : inadequate dose of antivenom (15 cases), inappropriate specificity of antivenom (12 cases), inadequate mechanical ventilation (10), late arrival at hospital after traditional treatment (10 cases), artificial ventilation not attempted despite respiratory failure (8), inadequate treatment of hypovolemia including tetanus (6), obstruction of endotracheal or tracheostomy tube (5) and transfer between hospital (5), the treatment of snake bite must be directed both to medical staff and potential patients, particularly the high risk groups in rural areas. This study was supported in part by the Wellcome Trust of Great Britain under the Wellcome-Mahidol University, Oxford Tropical Medicine Research Programme.