Disseminated intravascular coagulation findings in 100 patients.

A retrospective study of 100 patients with disseminated intravascular coagulation from 1993 to 1997 is reported. Forty-five patients were neonates with a mean age of 12.6 days and 55 patients were infants, children and adolescents with a mean age of 6 years and 3 months. Most of them (91.5%) had complicated underlying conditions which included congenital anomalies, prematurity, malignancy, hematological and various diseases. Additionally, every patient had triggering conditions commonly identified as gram-negative septicemia. Bleeding and thromboembolic manifestations were found in 59.4 per cent and 19.8 per cent, respectively. The laboratory findings revealed red blood cell fragmentation, 89.6 per cent and thrombocytopenia, 85.8 per cent. Natural anticoagulants were studied in a few cases and revealed low levels of antithrombin III and protein C. The prompt effective management included treatment of underlying diseases, identification and relief of triggering conditions, correction of thrombocytopenia and coagulopathy, and fully supportive care. The overall case-fatality rate was 41.6 per cent which was not correlated with age, underlying diseases, triggering conditions, manifestation of bleeding, thromboembolism or shock, and exchange transfusion. However, a significant lower case-fatality rate was found in patients with positive culture (25%) as compared to those with sepsis and negative culture (51.7%) (p = 0.044). In addition, the febrile neutropenic patients, who showed good response to the administrated granulocyte-colony stimulating factor (G-CSF), survived from the DIC.

Effect of antibiotic order form guiding rational use of expensive drugs on cost containment.

New injectable antimicrobial agents are generally costly and broad-spectrum. Overusage results in unnecessary economic loss and multi-drug resistant organisms. Effective strategies for decreasing costs without compromising patient care are required. This study aimed to evaluate the economic impact of a system using an antimicrobial order form to assist rational usage of expensive antimicrobial agents. The study was performed during 1988-1996 at a 900-bed, tertiary-care, medical school hospital in Bangkok. The target drugs were 3 costly, broad-spectrum antibacterial drugs, namely imipenem, vancomycin, and injectable ciprofloxacin. The restriction of these 3 drugs was started in 1992 and was extended to netilmicin and ceftazidime in 1995. A filled antimicrobial order form (AOF) was required by pharmacists before dispensing the drugs. The AOF guided the physicians to give explicit information about anatomic diagnosis, etiologic diagnosis, and suspected antimicrobial resistance patterns of the organisms. It also contained information about indications of the restricted drugs. The filled forms were audited daily during working days by the chairman of The Hospital Antibiotic Committee. Feedback was given to the prescribers by infectious disease specialists at least twice a week. The strategy was endorsed by the executive committee of the hospital. Impact of AOF without endorsement, audit and feedback, was evaluated in 1996. The expenditures of the drugs were adjusted to the average admitted patient-days per fiscal year of the study period. The system with endorsement was well accepted and could be maintained for 4 years. The adjusted expenditures per year of the 3 restricted antibiotics were 1.41-1.87 million baht less (22-29%) in 1992-1994 than the pre-intervention year 1991. The cost reduction of imipenem and injectable ciprofloxacin could also be maintained for 1995 but not vancomycin for which use increased. The costs of these 3 restricted drugs increased very sharply (69%) in 1996 when there was loss of endorsement and capacity to perform auditing and feed back by infectious disease specialists. The system did not work with ceftazidime which was commonly used for febrile neutropenia and nosocomial infections.

Randomized controlled trial of dexamethasone in infectious croup.

Infectious croup is a common and an important cause of upper airway obstruction in young children. Despite its frequency and potentially serious nature, there is still no definite conclusion regarding the beneficial effect of corticosteroid. A randomized controlled study on the effects of dexamethasone in infectious croup was conducted at the Department of Pediatrics, Ramathibodi Hospital between January 1985 and September 1986. Thirty-two patients, 2-37 months old, were included in this study. Fourteen patients received dexamethasone (0.5 mg/kg/dose daily for 3 days) and eighteen patients were the control group. The dexamethasone group had significantly lower croup scores at 48 hour (p < 0.05), shorter hospital course (p < 0.005) and lower incidence of endotracheal intubation (p < 0.05) than the control group. Five patients in the control group required endotracheal intubation. Complications included four episodes of pneumonia, one episode of sepsis, and one bacterial tracheitis. Pneumonia and sepsis occurred only in the control group. We concluded that dexamethasone therapy decrease the severity of infectious croup and the risk of complications.

Naegleria meningomyeloencephalitis.

A case of primary amebic meningoencephalitis (PAM) with severe spinal cord involvement was documented in a 12 year-old boy from Samut Prakan Province, Thailand. This is the first reported case of Naegleria meningomyeloencephalitis in Thailand. He had a history of swimming in the canal nearby his house prior to the fever, headache and convulsion which rapidly progressed into a comatose state. PAM was only detected at post-mortem. The findings included suppurative exudates and necrosis of the olfactory bulbs and the basal parts of the frontal, temporal lobes, pons, cerebellum, medulla and the spinal cord. Numerous Naegleria trophozoites were present in the brain and spinal cord. Foci of neuronal degeneration and demyelination were noted.

Hepatopathy-thrombocytopenia vs infection-induced hemophagocytic syndrome in Wilms' tumor: a case report.

A 3-year-old boy with Wilms' tumor, post operative left nephrectomy stage, had HTS on day 99 of the combined chemotherapy which lasted for more than 20 days. He had severe respiratory distress due to a moderate amount of ascites and marked pleural effusion. Because of high fever, thrombocytopenia and marked hemphagocytosis in the bone marrow, he received IVIG for 2 days. Normal platelet count and markedly decreased pleural fluid were attained within 3 days. He subsequently tolerated full doses of combined chemotherapeutic agents with an additional one (doxorubicin). In cases of HTS, IAHS should be suspected. The bone marrow should be done and treatment accordingly so that there is no need to decrease, the dosage of chemotherapeutic agents afterwards.

Disseminated Burkitt's lymphoma in a child with AIDS.

Rarity of HIV-associated disseminated lymphomas in children initiated this report. The patient was an 18-month-old girl who had a history of chronic cervical lymphadenopathy since 6 months of age. She was first seen because of rapid enlargement of an inguinal lymphnode. The bone marrow aspirate was compatible with Burkitt's lymphoma, L3 cell-type. She was treated with chemotherapy without satisfactory success. She developed neurological involvement of lymphoma. Accidental sharp injury which contaminated her blood, in a medical personnel leaded to having her blood tested for anti-HIV and it was found positive. Her mother had positive anti-HIV presumably acquired from blood transfusion after an abortion in early 1988. It occurred before the donated blood was compulsively tested for anti-HIV. She died at the age of 24 months.

Intradermal hepatitis B virus immunization: immunogenicity and reactogenicity.

Mass immunization of hepatitis B virus (HBV) vaccine in adults is frequently demanded. However the high cost of conventional immunization is an obstacle to the provision of this vaccine. We investigated the serological response and adverse reactions following administration of a low-dose (1 or 2 micrograms of yeast-derived HBV vaccine (HB-VAX II, Merck, Sharp and Dohme) intradermally in young adults. Each 1 ml dose of the vaccine contained 10 micrograms of HBsAg protein. The study population included 58 female volunteers, aged 20-33 years, who were serologically-negative for HBV. They were alternately allocated to 1 microgram or 2 micrograms intradermal dose given by 2 experienced nurses as one or two 0.1 ml injections. Doses were given at 0, 1, and 6 months. Anti-HBs concentration was tested by enzyme-immunoassay on their sera obtained at 1, 6, and 7 months after the first dose. Positive seroconversion (anti-HBs greater than 10 IU/1) at 7 months was found in 90% (95% CL 79%, 100%) of the 1 microgram group and 96% (95% CL 89%, 100%) of the 2 micrograms group. Local reaction, a transient pigmented macule with an underlying nodule, was found in most volunteers but did not bother them. Intradermal HBV immunization could be an alternative strategy for mass immunization in young adults.

Plasma prostacyclin (PGI2) in dengue hemorrhagic fever.

Dengue hemorrhagic fever (DHF) is an epidemic viral disease. The exact mechanism attributable to platelet and vascular dysfunctions is still obscure. Plasma 6-keto-PGF1a (6KPGF1), the stable metabolite of PGI2 was determined in 60 DHF patients and in 11 non-DHF (NDHF) patients with fever of over 38.5 degrees C to compare with that of 33 normal children (NC) in the same age group (2-15 years). Among 60 DHF patients, 32 had blood obtained during impending shock, whereas blood samples of the remainder were taken during normotension. Their plasma 6 KPGF1 values (mean +/- SE) were 201.06 +/- 12.42 and 132.87 +/- 13.08 pg/ml respectively. All patients had serology positive for acute dengue viral infection. The plasma 6 KPGF1 (mean +/- SE) of 33 NC and 11 - NDHF subjects were 149.82 +/- 4.93 and 108.69 +/- 14.53 respectively. The plasma 6KPGF1 levels of 32 DHF patients with impending shock were significantly higher than those of 28 normotensive DHF patients (p less than 0.005), 33 NC (p less than 0.005) and 11 - NDHF patients (p less than 0.005). However the levels in 28 normotensive DHF patients are not statistically different from the values of 33 NC and 11 - NDHF patients. It is concluded that there is a tendency of excessive PGI2 production in DHF patients during hypotensive crisis.

Failure of norfloxacin to eradicate intestinal colonization of non-typhoidal salmonella in infants.

Infant colonization with non-typhoidal Salmonella (NTS) is common and eradication is problematic. Oral norfloxacin has promising properties for solving this problem, though it has potential toxicity to infants. The drug has been available in Thailand since 1987. Since then, some infants who had diarrhea or NTS colonization were treated with oral norfloxacin 15-20 mg/kg/day for 3-5 days on individual physician's judgement. This observational study was performed in infants and children who had NTS in stool, seen at Ramathibodi hospital from September 1987 to February 1988, in order to give preliminary information. Sixteen of 48 infants received oral norfloxacin treatment. Nine infants had established failure of NTS eradication from follow-up rectal swab cultures. Five infants did not have follow-up rectal swab culture, and two had negative culture once on day 7 after treatment. Considering that 7 infants who did not have evidence of bacteriologic failure were free from colonization, the excretion rate during the first two weeks could be estimated as 56 per cent which is not less than the natural history of this disease. This observation suggests failure of oral norfloxacin, 15 mg/kg/day given in 2 divided doses for 3 days, in eradication NTS colonization in infants.

Primary amoebic meningoencephalitis in Thailand: report of a case and review literatures.

Primary amoebic meningoencephalitis (PAM) which is caused by free-living amoeba, Naegleria fowleri, is a rare disease. We report the fifth case in Thailand in order to add more information. The patient was a previously healthy 4 1/2-year-old girl from Nakhon Pathom province. For several weeks before this illness she had swum in a water supply canal. She developed high fever with change in consciousness. Her cerebrospinal fluid contained numerous Naegleria fowleri which grew in culture media and mice inoculation. She did not respond to treatment with intravenous and intraventricular amphotericin B, and oral rifampicin. She died on the fifth day of illness. Water sample from the canal also grew N. fowleri. All five reported cases in Thailand were reviewed. It was found that none of them had been exposed to a common source. Four of the five cases were male, and four cases occurred during the summer months, March to May. These findings agree with worldwide information.