Angiotensin converting enzyme inhibitor induced cough: experience in Siriraj Hospital.

With the increasing use of angiotensin converting enzyme inhibitors (ACEI) in the treatment of hypertension, particularly in diabetic patients, and heart failure, an annoying cough has frequently been observed. According to the post marketing surveillance studies, the prevalence of cough associated with ACEI was only 0.1-4 per cent. However, many recent studies have observed a very much higher frequency. To examine the incidence and pattern of cough associated with the usage of ACEI (C-ACEI) in a Thai population, mixed retrospective and prospective studies were performed in hypertensive patients who attended the out-patient department, Siriraj Hospital between December 1999 and August 2000. A thousand cases who had used or have been using ACEI were studied. C-ACEI was present in 179 cases of 760 retrospective studied cases (23.6%) and 75 cases of 240 prospective studied cases (31.3%). Cough was typically described as irritative (93.8% retrospectively and 98.7% prospectively, p = 0.05) and nocturnal in onset (74.9% retrospectively and 80% prospectively, p = 0.12), and usually appeared within the first 4 weeks of treatment (41.3% retrospectively and 46.7% prospectively, p = 0.43). Patients who received a full dosage of ACEI did not have to posses an increasing risk of C-ACEI. There was no difference in the prevalence of C-ACEI among types of ACEI, except cilazapril and quinapril which were found to be higher than enalapril in the retrospective study (p < 0.0001 and p = 0.002, respectively). Types of study were shown to influence the prevalence of C-ACEI. Prospective studies yielded a higher rate of C-ACEI than retrospective ones.

Is blood pressure adequately controlled in general medicine clinics?

To determine how well elderly-essential-hypertensives (EHT) were managed at the general medicine (GM) clinics at Siriraj Hospital when compared to those at the hypertension (HT) clinic. Adequacy of BP management (ADBP) was considered when DBP < 85 mmHg in diabetic patients with HT or < 90 mmHg in non-diabetic EHT. Sixty-seven and 63 cases were enrolled from the GM and HT clinics respectively from mid June to mid July 1999. Percentage of ADBP cases (69.8 vs 49.3%, p = 0.02, OR = 2.4, 95%CI = 1.2-4.9) were significantly higher in patients at the HT-clinic compared to that of the GM-clinic. Physicians' unwillingness to change the number or dosage of drugs when target BP was not achieved was found to be an independent risk factor that contributed to poor BP control of patients from both clinics (p = 0.003, OR = 9.7, 95%CI = 2.2-44.4). In conclusion, the BP of those EHT at GM-clinics was not adequately controlled compared to that of the HT-clinic. Methods to improve normalization of BP were proposed.

Surgery and anesthesia for pheochromocytoma--a series of 40 operations.

Pheochromocytoma is a catecholamine-producing tumor which can be life-threatening. A series of 40 operations in 39 pheochromocytoma patients at a tertiary hospital in Thailand from 1976 to 1997 was reported. The patients were 30 females and 9 males; aged 7-73 years. One man had 2 operations 5 years apart. The most common symptoms and signs were palpitation, headache and hypertension. Preoperative management consisted of control of blood pressure and restoration of intravascular volume by using prazosin, an alpha adrenergic blocker. New imaging techniques have improved the ability to localize the tumors; 20 were found in the right adrenal glands, 14 in the left, 1 patient had bilateral tumors, 4 in Organs of Zuckerkandl and 1 patient had metastatic liver nodules. The operative procedures were 39 laparotomies and 1 laparoscopic surgery. The surgical and anaesthetic procedures were presented, and nitroprusside was used to control intraoperative blood pressure. Removal of tumors was successful in all cases except for 1 mortality due to injury of the liver and massive blood loss. Other complications were postoperative pulmonary edema and renal vein thrombosis. One patient had MEN type 2 and five cases were malignant. Pheochromocytoma can be cured by surgery, but cooperation among surgeons, anesthesiologists and internists is very important.

Exchange transfusion in severe falciparum malaria.

Malaria associated with complications or a fatal outcome is caused by Plasmodium falciparum. The mortality due to this disease is parallel to the degree of parasitemia. Successful use of exchange blood transfusion as a therapeutic adjunct for this infection was reported. The rationale for this form of therapy is based on (1) rapid reduction in parasite load by exchange transfusion, (2) removal of toxic substances and (3) reducing microcirculatory sludging. We describe here thirteen cases of severe falciparum malaria treated with infusion of quinine dihydrochloride and exchange transfusion 2,320-8,000 ml of whole blood. We observed that the greatest reduction in the average circulating infected red blood cells, from 20.7 per cent to 9.3 per cent, seemed to occur early in the first 2,000 ml of blood exchange and the parasitemia often reduced to 5.1 per cent in patients who had 4,000 ml of blood exchange. In order to reduce the initial parasitemia to 5 per cent by exchange transfusion, we suggest the volume of exchange transfusion should be 2,000 ml for average parasitemia 10 per cent, 4,000 ml for parasitemia > 20 per cent and 2,000-4,000 ml for parasitemia 10-20 per cent.

Diencephalic epilepsy resembling pheochromocytoma: a first reported case in Thailand.

A 31 year old hypertensive patient suffered from a fluctuation of blood pressure. Pheochromocytoma was suspected because of the clinical history, and extremely labile blood pressure but did not respond to therapy with alpha adrenergic blocking agent and normal excretion rates of catecholamine and vanilly mandelic acid (VMA). An enlarged left adrenal gland from computerized tomographic scan was found. So left adrenalectomy was performed and the result was consistent with cortical adrenal hyperplasia. Fluctuation of blood pressure still occurred after surgery with the symptoms of epigastric oppression and focal epileptic attack of the left arm. Epileptic potential waves were seen during hyperventilation from electroencephalogram but showed normal magnetic resonance imaging computerized tomographic scan of the brain. Diencephalic epilepsy was diagnosed and treated with anticonvulsant (carbamazepine) and eventually all of the symptoms including labile blood pressure subsided.

Scrub typhus in suburban Bangkok: first cases.

Three patients, two of whom had eschars, were admitted with fulminant febrile disease suggestive of scrub typhus. Elevated IgG and IgM to Rickettsia tsutsugamushi were detected in all three by IFA. The cases lived in widely separated areas of western Bangkok where fruit trees are grown and claimed not to have left the areas of their homes during the estimated incubation periods. A field survey collected rodents, treeshrews, and mites fro around the homes of each case. R. tsutsugamushi was isolated from one rat and known vector species of mites were found. These are the first confirmed cases of scrub typhus transmission in Metropolitan Bangkok. It is suggested that typhus incidence around Bangkok may be substantial but has been unreported because of widespread self-medication with antibiotics and the difficulties of laboratory diagnosis.