Measles in Thai adults: three case reports and management of contact cases.

We report on three adults (one nurse and two medical students) diagnosed as having measles. All the patients presented with fever, cough, conjunctival injection and rash. They contracted measles from pediatric patients who had been treated at Chulalongkorn Hospital in the previous two weeks. Physical examination revealed Koplik's spots on the oral mucosa and typical maculopapular rash. The diagnosis was confirmed by viral isolation. Measles IgG antibodies were measured in 36 medical students who were in close contact with patient 2 and measles vaccines were given. Thirty-three specimens had positive measles IgG, two had equivocal results and one had negative result. The student with negative measles IgG eventually developed measles (patient 3). Except for patient 2 and 3, no further cases of measles were seen among the contacts.

Typhoid glomerulonephritis in a child: a rare complication of typhoid fever.

We report a child with typhoid glomerulonephritis who presented with fever, gastrointestinal symptoms, edema, hypertension and abnormal urine findings including microscopic hematuria and proteinuria. Salmonella typhi resistant to ampicillin and cotrimoxazole was isolated from a blood culture. Renal biopsy was not performed. The child successfully treated with ceftriaxone.

Seroprevalence of hepatitis A virus antibody among children and young adults in Bangkok.

OBJECTIVE: To determine the prevalence of hepatitis A virus (HAV) antibodies in various age groups of healthy children and young adults who have not received the hepatitis A vaccine. METHOD: Blood samples were collected from 825 volunteers aged 1-30 years from a well baby clinic and five academic institutions in the Don Mueang area from 1998 to 1999. Serum samples were assayed for specific HAV IgG antibodies using a commercial enzyme-linked immunosorbent assay (ELISA) kit. RESULTS: The seropositivity rate (12.4% overall) in each age group was as follows: 1-3 years, 7.7 per cent; 4-7 years, 6.6 per cent; 8-11 years, 12.4 per cent; 12-15 years, 10.7 per cent and 16-30 years, 25.9 per cent. CONCLUSIONS: In the Don Mueang area of Bangkok, the majority of children (< 16 years) do not have natural immunity against HAV. The use of hepatitis A vaccine for this population should be considered. Pre-vaccination serologic screening for HAV IgG in children may not be worthwhile.

Intrapartum and neonatal zidovudine treatment in reduction of perinatal HIV-1 transmission in Bangkok.

OBJECTIVE: To evaluate the efficacy of zidovudine (ZDV) administered during labor and to the infants in the first 6 weeks of life in reduction of perinatal HIV-1 transmission. DESIGN: Open label clinical trial. SITE: King Chulalongkorn Memorial Hospital, Bangkok, Thailand. MATERIAL AND METHOD: One hundred asymptomatic, antiretroviral naive HIV-1 infected pregnant women who had either late or no prenatal care were recruited from the obstetric service of King Chulalongkorn Memorial Hospital, Bangkok, Thailand. They were given ZDV 300 mg orally every 3 hours during the intrapartum period until delivery. ZDV syrup 2 mg/kg orally every 6 hours were given to the infants immediately after birth for 6 weeks. Breast feeding was not allowed. Infant's blood for HIV-1 PCR test was obtained at age 1 day, and 1, 3 and 6 months. HIV-antibody test was determined at age 18 months. Infants with at least one positive HIV-1 PCR test performed at or after 1 month of age or positive HIV-antibody test at age 18 months were classified as HIV-1 infected infants. RESULTS: There were 100 healthy infants delivered without complication. Fourteen infants were excluded due to; 13 lost to follow-up and 1 drug intolerance. Of the remaining 86 infants who were followed-up, 27 infants (31.4%) did not receive intrapartum ZDV treatment and 9 infants were HIV-1 infected. The perinatal transmission rate was 10.5 per cent, (95% CI 3.9, 17.1). CONCLUSION: The result of this study suggests that intrapartum oral ZDV treatment in asymptomatic HIV-1 infected mothers together with ZDV treatment in the neonates for 6 weeks can reduce the rate of perinatal HIV-1 transmission. This regimen may be an alternative treatment for prevention of HIV-1 infection in infants born to HIV-1 seropositive mothers who have had either late or no prenatal care.

Invasive pneumococcal infection and drug-resistant Streptococcus pneumoniae in Thai children.

Sixty-eight children with systemic Streptococcus pneumoniae infection were identified by hospital chart review between 1986-1997. The age distribution varied from 2 days to 15 years, with a mean age of 3.3 years. There were 35 boys and 33 girls. Four clinical entities included 30 cases of meningitis, 20 cases of pneumonia, 10 cases of peritonitis and 8 cases of septicemia/bacteremia. Forty patients (58.8%) had underlying diseases. Seventeen patients (25.0%) developed early complications and the mortality rate was 8.8 per cent. The percentage of susceptible isolates to penicillin, chloramphenicol, cefotaxime/ceftriaxone, ciprofloxacin, imipenem and vancomycin were 69.6, 91.3, 100.0, 87.2, 100.0 and 97.1 per cent, respectively. There were six cases of drug-resistant S. pneumoniae (DRSP) infection; 3 cases of meningitis, one case of pneumonia, one case of infective endocarditis and one case of purpura fulminans. Our data indicate that S. pneumoniae infection is relatively serious and life-threatening. There is a trend of increasing prevalence of invasive pneumococcal and DRSP infections.

Primary dengue infection: what are the clinical distinctions from secondary infection?

To determine the magnitude of the problem posed by primary dengue infection in children and the distinctive clinical clues that may differ from those with secondary infection, 996 children serologically diagnosed with dengue infection and admitted to the Department of Pediatrics, Chulalongkorn Hospital, Bangkok, Thailand between 1988 and 1995 were retrospectively reviewed. One hundred and thirty-nine cases (14.0%) were serologically proved to be primary dengue infection. Of these, 72 were males and 67 were females, with a mean age of 4.8 years. Common manifestations by order of frequency included fever (97.8%), hepatomegaly (71.9%), vomiting (59.0%), decreased appetite (55.4%), coryza (52.5%), drowsiness (39.6%), diarrhea (34.5%), rash (33.8%), abdominal pain (23.0%) and seizure (15.8%). The mean duration of fever before admission was 4.6 days. Common sites of bleeding were skin (41.7%), mucous membrane (14.4%) and the gastrointestinal tract (12.2%). Clinical diagnosis was categorized into dengue fever (22.3%), dengue hemorrhagic fever (60.4%) and dengue shock syndrome (17.3%). Three patients (2.2%) died. Compared with the children with secondary dengue infection (n=139), children with primary dengue infections tended to be younger, presented more commonly with coryza, diarrhea, rash and seizure; and less commonly with vomiting, headache and abdominal pain (p < 0.05). The maximal hematocrit level, the mean difference between maximal and minimal hematocrit values and the maximal percentage of neutrophils were significantly lower in the study group, whereas the maximal percentage of lymphocytes was significantly higher. Dengue fever was more common and dengue shock syndrome was less common in the study group (p < 0.05). This study has emphasized that primary dengue infection is not uncommon and is less severe than secondary infection. Clinical presentations and laboratory findings are somewhat different between the two conditions.

Childhood cryptococcosis: an increasing problem in the era of AIDS.

The authors reported 8 children with cryptococcosis from King Chulalongkorn Memorial Hospital from 1991 to 2000. Five patients were older than five years. The two common underlying diseases were HIV/AIDS (5 cases) and systemic lupus erythematosus (2 cases). Seven cases had been observed in the past four years, four of these in 2000. One patient developed disseminated disease and two patients died. In the era of HIV/AIDS and due to the fact that HIV-infected children are tending to live longer, we may encounter a higher occurrence of this opportunistic fungus in children.

Seroprevalence of Epstein-Barr virus infection in Thai children.

A hospital-based cross-sectional survey was conducted in Bhumibol Adulyadej Hospital, Bangkok, Thailand between January and December 1997 to study the seroprevalence of anti-EBV IgG antibody in previously healthy hospitalized children aged 0-15 years. Of 589 cases, there were 327 boys and 262 girls with a mean age of 3.9 years. The seroprevalence of EBV infection was 50.4, 72.8, 92.3, 96.6 and 97.6 per cent in children at the age range of 0-2, 3-5, 6-8, 9-11 and 12-14 years, respectively. After excluding infants below 6 months of age, the total seroprevalence rate was 68.4 per cent. The age of children with positive anti-EBV IgG antibody was significantly higher than that of children with negative antibody. Children who were reared at home had lower seroprevalence rates. In conclusion, seroprevalence of EBV infection increased with advancing age and reached 90 per cent or more after 6 years of age.

Seroprevalence of Epstein-Barr virus antibody among children in various age groups in Bangkok, Thailand.

There are no current data on previous Epstein-Barr virus (EBV) infections in different age groups of Thai children. This study was conducted to determine the prevalence of anti-EBV IgG antibody in healthy children of various age ranges in Bangkok, Thailand. Between June and December 1998, blood samples were collected from 425 volunteers aged 6 months to 15 years who attended a well baby clinic in the northern suburban part of Bangkok, Thailand. Serum samples were assayed for specific anti-EBV IgG antibodies using a commercial enzyme-linked immunosorbent assay kit. The percentage of children with positive anti-EBV IgG antibody increased with advancing age. The overall seropositivity rate was 72.7%. Children with anti-EBV IgG antibody were significantly older than those without the antibody. Seronegative children were reared at home significantly more frequently than seropositive children. These seroopidemiologic data will guide calculation of the appropriate age for administration of an EBV vaccine to children, when it becomes available.

Neurological manifestations in dengue patients.

To determine the frequency and the natural history of neurological manifestations of dengue infection in Thai children, 1,493 children diagnosed with dengue infection by serology and admitted to the Department of Pediatrics, Chulalongkorn Hospital, Bangkok, Thailand from 1987 to 1998 were reviewed from prospectively recorded medical charts. There were 80 children identified with neurological manifestations, an incidence of 5.4% of all dengue patients. Of these, there were 41 males and 39 females, with ages ranging from 3 months to 14 years. They were categorized into 20 cases of dengue fever, 26 cases of dengue hemorrhagic fever and 34 cases of dengue shock syndrome. All cases experienced the neurological manifestations during the febrile stage of the illness. The patients were classified into an encephalitic group (called "dengue encephalopathy") (42), a seizure group (35) and a miscellaneous group (3). Encephalitic patients presented with alteration of consciousness (83.3%), seizure (45.2%), mental confusion (23.8%), nuchal rigidity (21.4%), spasticity of limbs (9.5%), positive clonus (4.8%), hemiplegia (2.4%) and positive kernig (2.4%), and were older than those in the other groups. Patients in the seizure group presented with seizure (100%) and positive clonus (2.9%). Abnormal laboratory findings included hyponatremia, abnormal liver enzymes and CSF pleocytosis. Dengue IgM and dengue PCR were not demonstrated in 16 CSF specimens. An autopsy finding of a child in the encephalitic group showed histologic evidence of encephalitis, the only case of confirmed dengue encephalitis in this study. One patient with encephalitic symptoms suffered from long-term neurological sequelae. The overall mortality rate was 5%. In conclusion, neurological manifestations including seizure and encephalopathy in children with dengue are not uncommon whereas dengue encephalitis is a rare entity.

Short course zidovudine maternal treatment in HIV-1 vertical transmission: randomized controlled multicenter trial.

A multicenter randomized, double blind, placebo-controlled clinical trial was conducted to evaluate the effectiveness of a short course of oral zidovudine (ZDV) treatment in HIV-1 infected pregnant women, starting at 38 weeks of gestation plus ZDV infusion during labor until delivery, to reduce HIV-1 vertical transmission in non-breast fed infants. One hundred and eighty two asymptomatic antiretroviral naïve HIV-1 infected pregnant women were enrolled. Each patient was randomly allocated into either the ZDV or placebo group. The ZDV group received 250 mg ZDV orally twice a day initiated at 38 weeks' gestation until the onset of labor. During the intrapartum period, ZDV infusion at the rate of 2 mg/kg was administered within the first hour and then continuously infused at the rate of 1 mg/kg/h until delivery. The placebo group received an identical capsule during pregnancy and normal saline infusion during labor until delivery. HIV-1 transmission was documented by nested polymerase chain reaction in infants at birth and at 1, 3 and, 6 months of age. The estimated HIV-1 vertical transmission rate was 14.9 per cent (95% CI = 11.1 to 18.7) and 16.3 per cent (95% CI = 12.3 to 20.9) in ZDV and placebo group, respectively (p > 0.05). The short course ZDV in antiretroviral naïve pregnant women initiated at 38 weeks' gestation plus intrapartum ZDV infusion without treatment in the infants was not effective to prevent HIV-1 vertical transmission.

Intrapartum zidovudine infusion alone failed to reduce both maternal HIV-1 viral load and HIV-1 infection in infant.

A pilot clinical trial to assess the efficacy of intrapartum zidovudine (ZDV) infusion alone in the reduction of maternal viral load and its potential role in preventing vertical transmission of HIV-1. Twenty six, asymptomatic antiretroviral naïve HIV-1 infected pregnant women who had no prior antenatal care and were in labor were enrolled. Each patient received ZDV infusion at the rate of 2 mg/kg within the first hour. ZDV was then continuously infused at 1 mg/kg/h until delivery. Maternal plasma HIV-1 RNA prior to the commencement of ZDV infusion and within an hour after delivery were measured. HIV-1 transmission was documented by nested polymerase chain reaction in infants at six months of age. Median maternal plasma HIV-1 RNA prior to the ZDV infusion and after delivery was 29,401 and 32,555 copies/ml respectively, (p>0.05). The estimated HIV-1 transmission rate was 19.2 per cent (95% CI = 4-34). This result suggested that in asymptomatic HIV-1 infected pregnant women who were antiretroviral naïve and had no prior antenatal care, intrapartum ZDV infusion alone failed to reduce maternal HIV-1 viremia and the transmission rate of HIV-1.

Immune responses to measles immunization and the impacts on HIV-infected children.

This prospective cohort study was conducted to determine the seroconversion rate and the pattern of antibody response to measles vaccine administered at age 9 months in HIV infected and non-infected children born to HIV-1 seropositive mothers. Thirty children born to HIV-1 seropositive mothers and 3 born to HIV-1 seronegative mothers were recruited. One single dose of Schwarz strain of measles virus vaccine (Rouvax) was given to every child at 9 months of age. Clinical status and measles antibody levels were evaluated at the time just before vaccination, 2 and 12 weeks post-vaccination. Antibody was measured by an enzyme immunoassay commercial kit (Enzygnost, Dade Behring Manufacturer, Germany). Children were classified into 3 groups, groups 1 and 2 were children with and without HIV infection respectively. Group 3 children were those born to HIV-1 seronegative mothers. Of the 33 enrolled children, 16, 14 and 3 were classified as groups 1, 2 and 3 respectively. Four children, 2 of each, in groups 1 and 3 did not complete the study. Group 3 was excluded due to the small number of children recruited. There was no short term complication and no measles infection noted during the course of study. None of the children had pre-existing antibodies. The median (range) of CD4 count and CD4/CD8 ratio measured at the time of vaccination were statistically different between groups 1 and 2 children. Group 2 children had better antibody response than group 1 in terms of seroconversion rate and median of antibody levels at 12 weeks post-vaccination. Only 7 of 29 children (24.1%) had detectable measles antibodies at 2 weeks post-vaccination. A decrease in antibody was noted in 2 symptomatic HIV infected children as their disease had progressed. Various potential predictors of measles vaccine responses in HIV infected children including CD4 count and CD4/CD8 ratio were not statistically different between the responders and non-responders. All 4 asymptomatic HIV infected children were responders. This study demonstrated that all of the children had already lost their maternal acquired antibodies at age 9 months. HIV infected children had a poorerantibody response to measles vaccine than the non-infected children.

Safety and immunogenicity of Bacillus Calmette-Guerin vaccine in children born to HIV-1 infected women.

This prospective cohort study was conducted to determine the complication of Bacillus Calmette-Guerin (BCG) vaccination given to newborn infants born to HIV-1 seropositive mothers and to compare the tuberculin reaction 9 months after BCG vaccination between HIV-1 infected and non infected children. Two hundred and twenty-three infants with BCG immunization at birth were examined. No BCG complication was noted. Tuberculin skin tests were performed on 126 children (56.5%). Eleven of them were excluded because of failure to have skin tests read at 48 hours. Of the 115 infants enrolled to this study, 15 (13%) had no BCG scar and 50 (43.5%) had no tuberculin reaction. Twenty-six children were classified as group 1 or HIV-1 infected children and 89 children were group 2 or HIV-1 non infected. Group 1 children had a smaller tuberculin skin response (X+SD) than group 2 (1.15 +/- 2.82 vs 4.64 +/- 4.29 mm; p < 0.0001). Mean weight + SD of group 1 children was also significantly less than those in group 2 (8,013 +/- 741 vs 8,540 +/- 984 g; p < 0.05). The proportion of children with non reactivity to the tuberculin test, a negative tuberculin test and no BCG scar in group 1 was significantly higher than that in group 2 (76.9% vs 33.7%, 92.3% vs 52.8% and 36.4% vs 6.7% respectively; p < 0.0001 for all). But, the proportion of non reactivity to the tuberculin test in children with or without BCG scar of each group was not different (p > 0.05). Positive tuberculin tests were 7.7% and 47.2% in group 1 and 2 respectively. None of the children with positive tuberculin tests had clinical evidence of tuberculosis. The findings of this study indicate that BCG vaccine given to newborn infants of HIV-1 seropositive mothers is safe. Although tuberculin skin responses of HIV-1 infected children are less than those of HIV-1 non-infected children, it is possible that BCG vaccine might protect these children from developing severe tuberculosis.

A dengue shock patient with negative serology and polymerase chain reaction (PCR) tests.

A 6-month-old Thai girl presented with clinical manifestations of dengue shock syndrome (DSS) with encephalopathy and urinary tract infection. Serology and PCR tests were negative whereas dengue virus type 2 was isolated. In cases of highly suspected dengue infections, viral isolation should be done even when serological and PCR tests are negative.

Dengue infection with central nervous system manifestations.

A prospective observational study was conducted over a seven years period to determine the clinical and laboratory findings of dengue patients with central nervous system manifestations. Thirty serologically confirmed dengue infected patients with central nervous system manifestations were seen at the Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok and at Songkhla Hospital, Songkhla, Thailand. The age ranged between 3 months and 14 years with a mean age of 6.2 years. Seventeen were boys and thirteen were girls. The central nervous system manifestations included alteration of consciousness 76.7%, seizures 63.3%, pyramidal tract signs 36.7%, meningeal signs 30% and headache 26.7%. Eleven patients had primary while 19 had secondary dengue infection. Cerebrospinal fluid examination showed lymphocytic pleocytosis in 6 out of 28 patients while presence of anti-dengue IgM antibodies was detected in 2 out of 19 specimens of cerebrospinal fluid tested. Two patients died, autopsy was done on one patient and examination of the brain was compatible with viral encephalitis.

Severe shigellosis in childhood.

A prospective study was performed on 20 bacteriologically proven pediatric cases of severe shigellosis admitted to the Department of Pediatrics, Chulalongkorn Hospital during March 1989 to March 1990. Fourteen patients were male and six were female. Shigella B was found in 85% and Shigella D in 15% of cases. The major indications for admission were convulsions and dehydration. Fifteen per cent of cases had underlying malignancies and 42.1% had malnutrition. Most patients had a peak of fever between 39.5 and 40.5 degrees C, serum sodium between 128-144 mEq/l. Mild acidosis was detected in 45% and moderate acidosis in 30% of cases. There were no statistical differences in peak of fever and serum sodium between patients who had convulsion and who did not. Shigellemia was found in one case who also had underlying neuroblastoma. One patient died due to necrotizing enterocolitis, septic shock and renal failure. Most of the organisms found resisted to ampicillin and trimethoprim-sulfamethoxazole (TMP-SMX). However, TMP-SMX was prescribed in most immunocompetent patients and they recovered well. All of three patients with underlying malignancy responded well to ceftriaxone.

Seroprevalence of cytomegalovirus infection in children.

A hospital-based cross-sectional survey was conducted in Bhumibol Adulyadej Hospital between February and May 1997 to study the seroprevalence of cytomegalovirus (CMV) infection in hospitalized infants. Of 83 cases, 46 were boys and 37 girls, with the mean age of 11.87 months. The seroprevalence of CMV infection was 80.95, 61.90, 80.95 and 70.00% in infants at the age range of 0-6, 6-12, 12-18 and 18-24 months respectively. After excluding infants below 6 months of age, the seroprevalence rate was 70.97%. The family income of infants with positive CMV antibody was significantly lower than that of infants with negative results. There were no statistical correlations between seroconversion and age, sex, number of children in family and place of child rearing.

Safety and immunogenicity of a Haemophilus influenzae type B polysaccharide-tetanus toxoid conjugate vaccine combined with diphtheria, tetanus and pertussis vaccines in Thai infants.

A randomized, open, multicenter trial was conducted to determine the safety and immunogenicity of a Haemophilus influenzae type b polysaccharide-tetanus toxoid (PRP-T) conjugate vaccine combined with tetanus, diphtheria and pertussis (DTP) vaccine in 271 Thai infants born to mothers immunized against tetanus during pregnancy. Infants were immunized at approximately 2, 4 and 6 months of age with these vaccines. To determine if elevated levels of anti-tetanus toxin antibodies suppressed the anti-PRP antibody response, a second group of infants were immunized with PRP complexed with outer membrane proteins of Neisseria meningitidis (Pedvax HIB) in one limb at 2 and 4 months of age and DTP vaccine in the other limb at 2, 4 and 6 months of age. A third group of infants received only DTP vaccine at 2, 4 and 6 months of age. The occurrence of both local and systemic adverse reactions were comparable in all 3 groups. The geometric mean anti-tetanus antibody titer was > 1 IU/ml at baseline. Approximately 1 month after the administration of the third dose of vaccine, 98.5%, 99.3% and 9.7% of the children immunized with DTP+Pedvax HIB, DTP-PRP-T or DTP possessed > or = 0.15 microgram of anti-PRP antibody per ml. No child in the DTP group achieved > or = 1 microgram/ml while 74.2% and 89.3% did so after immunization with DTP+Pedvax HIB, or DTP-PRP-T, respectively (p < 0.05). Immune responses to diphtheria, tetanus and pertussis antigens were similar in all vaccine groups. These results demonstrate that elevated tetanus antibody titers do not diminish the anti-PRP antibody response following immunization with a PRP-T conjugate combined with DTP vaccine.

Perinatal HIV infections in Thailand.

A collaborative study group of researchers from seven hospitals from all regions of Thailand was formed to collect information on children born to HIV-infected mothers since the beginning of the first hospital case until the end of June 1994. The study conducted to verify the status of perinatal transmission of HIV infection in Thailand showed a rapid increase in HIV seropositivity among Thai mothers with vertical transmission rates varying between 25% in Rayong and 42% in Chiang Rai Hospitals, respectively. The majority of children with symptomatic HIV infection had clinical presentations of delayed growth development, pneumonia, diarrhea, oral candidiasis, lymphadenopathy, hepato-splenomegaly. Cases of Penicillium marneffei infection were found only at Chiang Rai Prachanukroh Hospital. The ages at which diagnosis of HIV disease was made were mostly within the first year of life. One third of children with AIDS died during the period of study.