Rabies 2007: perspective from Asia.

Rabies remains a public health problem in many parts of the less developed world. Much is known about the virology, pathophysiology, epidemiology, and methods for control but this knowledge is not applied in many countries. Thailand has been on the frontline of efforts to conduct research in rabies for almost a century, starting with Dr. Leopold Robert from the Institute Pasteur of Paris. He was invited by the Thai King in 1913 to develop a research and production facility for rabies vaccine and snake antivenins which later became the Queen Saovabha Memorial Institute. Thai physicians, scientists and nurses, jointly with some notable expatriate colleagues, were then responsible for major advances in rabies vaccine development, rational application of preand postexposure prophylaxis and better understanding of immunology and pathophysiology of this dread disease. They not only discovered new scientific principles but also cost-benefit methods for their application and set the foundation for the work conducted in Thailand during the next two decades. Many concepts developed by Thai scientists have been incorporated into WHO and US-CDC rabies management guidelines. This is an overview of significant developments during the past two decades [1-8].

Enteric fever-like illness caused by infection with citrobacter amalonaticus.

'Enteric fever' is a potentially fatal, severe systemic disease, which is encountered worldwide. Traditionally, enteric fever refers to a bacteremic illness caused by members of certain Salmonella serotypes, notably: Salmonella typhi, a Gram-negative bacterium, and to a lesser extent, Salmonella paratyphi A, B and C. In addition, other non-salmonella organisms may produce a syndrome clinically indistinguishable from "enteric fever". Brucella sp., Campylobacter sp., Edwardsiella tarda, Enterobacter Cloacae, Escherichia coli, Klebsiella pneumoniae, Providencia alcalifaciens, Pseudomonas sp., Serratia marcescens, Francisella sp. and Yersinia pp have been identified in enteric fever This is, to the best of the authors' knowledge, the first case of Citrobacter to be reported presenting as enteric fever in a normal host in Thailand.

Intratesticular injection of a balanced zinc solution for permanent sterilization of dogs.

Five male mature dogs with normal sex organs and normal pre-study semen evaluation received intratesticular injections of a sterile solution of balanced zinc gluconate. Semen without sperm could be collected on days 26, 30, 35 and 51 from 4 dogs. The dogs achieved penile erection but no ejaculation before these days. There were no significant adverse effects and no change in the dog behavior during the time that they were observed. Histopathological findings documented virtually complete fibrosis of seminiferous tubules and Leydig cells on days 60 and 75. This preliminary study concludes that balanced zinc gluconate may be used to sterilize dogs.

Paradigm shift in rabies control: a system approach.

Government centered approach in rabies prevention and control has not led to rabies safe community, both in urban and rural areas. Government services and organizations should recognize that only joint collaboration among households and community can lead to a successful rabies control mission. Dog owners should have been more actively involved in the prevention and solving of rabies problem. Promotion and support of government organizations should aim to strengthen the communities to become self reliance in diseases control and health care services. Only by strengthening community roles result in a more sustainable community disease control program.

Streptococcus suis meningitis in Thailand.

Streptococcus suis may be the second most common cause of adult streptococcal meningitis. The clinical and epidemiological data of S. suis meningitis are occasionally reviewed. To date, there have been only two large case series from Hong Kong and the Netherlands. We describe twelve cases of S. suis meningitis who were admitted to Chulalongkorn University Hospital, Bangkok, during a 6-year period between 1997 and 2002. A comparative review of case reports of S. suis meningitis in Thailand, Hong Kong, and the Netherlands is presented and revealed no significant differences between the three series. However, the cases from Thailand and Hong Kong had a significantly greater number of associated skin and soft tissue infections. Clinically, S. suis meningitis may appear acute or with a more chronic course.

The rabies epidemic on Flores Island, Indonesia (1998-2003).

Flores is an isolated previously rabies-free Indonesian island which has been experiencing a canine rabies outbreak which resulted in at least 113 human deaths. It started with the importation of three dogs from rabies endemic Sulawesi in September of 1997. Local authorities responded with massive killing of dogs starting in early 1998. Approximately 70% of the dogs, in the district where rabies had been introduced, were killed during that year, yet canine rabies still exists on Flores at this time (June 2004). Approximately 50 percent of dog bite cases and human deaths were in children under 15 years of age. Between 1998 and the end of 2002, 3,389 post-exposure rabies treatments were provided and none of the treated subjects died. Almost all patients were given the Thai Red Cross intradermal rabies postexposure treatment regimen using tissue culture rabies vaccine. A small but unknown number of patients with very severe exposures also received equine rabies immune globulin. This occurrence indicates that even massive culling of the dog population, without an intensive vaccination campaign of the survivors, will not arrest an outbreak even if it occurs on a small island.

Hydatid disease of the liver: the first indigenous case in Thailand and review of the literature.

The authors describe the first indigenous case of hepatic hydatid disease in Thailand. A 58-year-old female presented with progressive right upper quadrant abdominal discomfort over a 6-month period. Ultrasonography and computed tomography showed a solitary cystic lesion 11 x 12 x 13 centimeter in size at the left lobe of the liver. She had never been abroad and had no livestock exposure. The first operation was complicated by spillage of the parasite which required a combination of albendazole and praziquantel and a second operation for intracystic instillation of hypertonic saline solution. Unfortunately, uncontrolled generalized seizures developed due to severe hypernatremia. She never regained consciousness and expired 3 weeks after admission. In addition, the authors also reviewed previous reports of hydatid disease in Thailand. To date, only 9 cases have been reported since 1932.

Medical residency training in the US: important considerations.

The United States attracts medical scholars from abroad. However, the previously open-armed welcome extended to medical residents in America no longer exists for a variety of reasons. A series of barriers based on high educational standards and a rigid system of testing scientific and clinical skills and communication abilities, now tend to eliminate many applicants. Added to this is that American medical colleges now produce a near adequate number of new graduates and that foreign trained residents are often relegated to less desirable programs. These may not provide the level of training expected by the applicant. Less attractive programs are also less likely to enhance the scholar's chances of gaining an academic career and professional recognition on returning home. Applicants for residencies in the US should now be aware that only the best are likely to gain entrance to highly desired posts and to quality fellowships after completing a residency in America. All of this should be weighed against the stress and high costs that are now entailed in obtaining postgraduate medical training in America. This study endeavors to summarize what a young doctor should know about the application process for an American residency position and what he might expect from it.

Clinical spectrum of hepatic tuberculosis: comparison between immunocompetent and immunocompromised hosts.

BACKGROUND: Hepatic tuberculosis has been reported in normal and immunocompromised hosts. However, no published comparisons between these two groups of subjects with hepatic tuberculosis have been found. The aim of this study was to compare the clinical manifestations, biochemical tests, radiologic features and pathological findings of hepatic tuberculosis in immunocompromised and immunocompetent patients. METHOD: The authors reviewed retrospectively 20 patients with hepatic tuberculosis admitted between January 1993 and October 2000 to Chulalongkorn University Hospital, Thailand. There were 12 immunocompromised patients (10 HIV-infected males, 1 systemic lupus erythematosus (SLE) male, 1 SLE female) and 8 immunocompetent patients (6 males, 2 females). The clinical manifestations, biochemical tests, radiologic features and pathological findings were compared between these 2 groups. The diagnosis of Mycobacterium tuberculosis (M. tb) was the combination of a demonstrated organism in hemo- or specimen culture, histopathology (positive acid fast bacilli) and rapid identification of M. tb from nested polymerase chain reaction (nPCR) assay based on amplification of the IS 6110 insertion sequences. RESULTS: The clinical features were similar in both groups with fever, weight loss and hepatomegaly as the main manifestations. The biochemical findings were also similar but the alkaline phosphatase (ALP) was significantly higher in the immunocompromised group (p < 0.001). Hepatomegaly and diffuse increased echogenicity were common in both groups. Ascitis and calcifications were found more commonly in the immunocompetent subjects, although the differences were not statistically significant. Non-caseating granuloma without detection of acid fast bacilli was a common finding in both groups. The nested PCR assay increased the sensitivity from 49 per cent to 86 per cent compared to the regular PCR assay but specificity was 100 per cent in both techniques. The mortality was significantly higher in immunocompetent patients (p < 0.05) due to the extreme age and severe coexisting diseases. CONCLUSION: Fever, weight loss, hepatomegaly, disproportionate elevation of ALP and reverse A/G ratio were common in hepatic tuberculosis. A disproportionate elevation of ALP was significantly higher in the immunocompromised hosts. Nested PCR assay showed good sensitivity and specificity in the diagnosis of this disease.

Streptococcus suis infection in Thailand.

This is a retrospective study of Streptococcus suis infection in humans submitted to the National Streptococcal Referrence Center of Thailand from 1994 to 2001. There were 11 men and 6 women whose mean age was 46.24 years (range 1 month to 75 years). Among the men, two had known occupational and behavioral exposure to pork or meat products. Among the women, one was a butcher and three were housewives. Half of the patients had underlying diseases. One patient had congenital hydrocephalus, three patients had rheumatic heart disease and three were alcoholics. Two of these patients had a history of skin injury before infection. Nine patients had evidence of acute bacterial meningitis, four patients had infective endocarditis, two had the sepsis syndrome and two suffered from pneumonia and spontaneous bacterial peritonitis. The authors suspected that many cases are not reported particularly where pig-rearing or pork consumption are common. In the absence of an effective vaccine, prevention by public health surveillance is important. Prompt treatment of any cuts and wounds among pork-handlers is a sensible precaution. Furthermore, a high index of suspicion and early detection in order to identify and apply effective antimicrobial agents is necessary to successfully treat S. suis infection.

Risk of rabies after mammal bites in Thai children.

The data were collected by questionnaire at the Outpatient Department of Chulalongkorn University Hospital, Bangkok Thailand. This study revealed that 52 per cent of children had pet mammals in their home of which 67 per cent were dogs. 23.6 per cent of these children gave at least one history of a mammal bite inside (53.4%) or outside (46.6%) their house. Mammal bites of children could be found at all ages. However, most were in the age group of 10-14 years (42.3%), and 5-9 years (39.7%). The most common site of injury was on the legs (56.6%) and hands (30.7%). 31.7 per cent and 68.3 per cent of the bitten children incurred WHO category II and III potential rabies exposures (moderate and severe). 61.9 per cent had performed wound cleansing on each bite injury site and 34 per cent did not. 72 per cent of the children who had mammal bites received no post-exposure rabies treatment and 85.7 per cent did not make any effort to capture or observe the animal who had bitten them. Only 10.6 per cent observed the animals for 10 days or more. It was concluded that children are at considerable risk of mammal bites and that they are not receiving optimal care in this canine rabies endemic region and that 50 per cent of human rabies cases in Thailand were in children under 15 years of age.