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Introduction: Calciphylaxis, otherwise known as calcium uremic arteriolopathy, is defined as calcium deposition around blood vessels in skin and fat tissue which occurs in 1-4% of patients with end-stage renal disease (ESRD). Calcium deposition in the esophagus is extremely rare;to date, there have been only 4 cases reported worldwide. We report the fifth case of esophageal mucosal calcinosis occurring in a young male with ESRD. Case Description/Methods: A 37-year-old Thai man with ESRD on peritoneal dialysis since 2005 presented with generalized weakness and odynophagia due to oral ulcers, resulting in poor PO intake. He denied drinking alcohol, illicit drug use, or smoking. On exam his abdomen was soft, non-distended, non-tender, without any guarding. Past medical history included hypertension and COVID-19 in January 2022. Laboratory tests revealed neutropenia and pancytopenia, hyperphosphatemia, and hypocalcemia. EGD revealed distal esophageal esophagitis and hemorrhagic erosive gastropathy. Biopsy showed ulcerative esophagitis with dystrophic calcification, consistent with esophageal mucosal calcinosis .No intestinal metaplasia was noted. Immunohistochemistry was negative for CMV, HSV1, and HSV2. The patient was treated with pantoprazole 40mg IV every 12 hours, Magic Mouthwash 5ml qid, and Carafate 10mg qid. He was transferred to a cancer center where he had a bone marrow biopsy formed which was negative. His symptoms resolved and the patient was discharged to home (Figure). Discussion(s): Esophageal mucosal calcinosis is extremely rare. It is due to a combination of factors involving acidosis and the phenotypic differentiation (and apoptosis) of vascular smooth muscle cells (VSMC) into chondrocytes or osteoblast-like cells. These changes, along with the passive accumulation of calcium and phosphate, induce calcification. Acidosis is well-known to promote inflammation of the arterial walls, releasing cytokines that induce vascular calcification. The benefits of treatment with sodium thiosulfate remain unclear. An ample collection of cases should help devise standardized treatment options and establish management guidelines for this condition.
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Background/Purpose: IgA vasculitis is the most common vasculitis affecting children. Vasculitis can be associated with the inflammatory process following infections, involving single or multiple organs. COVID-19 associated vasculitides have been reported variously, mostly Kawasaki-like features, livedo reticularis and rarely cutaneous small vessels vasculitis. Recently, there have been reports of IgA vasculitis following COVID-19 infection in children, although data among Asians are scarce. Method(s): Case report Results: We herein report a case of a previously healthy 6-year- old Thai boy with history of COVID-19 infection 4 weeks earlier, with only mild upper respiratory tract symptoms treated by a 5 day-course of favipiravir and supportive medication. He presented with rash over both lower limbs with difficulty to bear weight for a week. He denied fever, abdominal pain, nausea, vomiting, or any abnormal urinary symptoms. Physical examination revealed palpable purpura distributed on both lower legs with pain in his left foot and difficulty in bearing weight. His blood pressure was unremarkable for age at 97/67 mmHg. The initial investigations showed complete blood count with white cell count of 8.9 x 103/muL (neutrophils 47.3% and lymphocytes 42.4%), hemoglobin of 13.6 g/dL, which had no anemia for his age and platelet count of 297 x 103/muL. His urinalysis showed 2-3 red blood cells and 0-1 white blood cells per high power field without proteinuria and normal renal function. The erythrocyte sediment rate was 11 mm/hr and c-reactive protein was 3.9 mg/L, which were in normal range. He was diagnosed as IgA vasculitis and non-steroidal anti-inflammatory drug was prescribed to alleviate arthralgia of left foot. A week later, he revisited due to pain and swelling at his left scrotum. He was diagnosed as orchitis, one of the clinical manifestations of IgA vasculitis that can occur in boys. He had ongoing palpable purpura on the legs but pain at the left foot subsided. He then received oral prednisolone for the indication of orchitis at the dosage of 1 mg/kg/day with subsequent tapering for total duration of 3 weeks. All of his symptoms completely resolved. Conclusion(s): We present the interesting case of a Thai boy clinically diagnosed with IgA vasculitis following COVID-19 infection, having the clinical manifestations of palpable purpura, arthralgia, and orchitis. There are very limited data about post COVID-19- associated IgA vasculitis in children, especially in the Asian population. We would like to highlight this condition for physicians and to raise the awareness in the COVID-19 era.
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Background: Patients with SLE are at high risk of COVID-19 infection due to the disease itself and to steroids and immunosuppressive treatments. COVID-19 vaccine is crucial for reducing the severity and spread of the virus. However, vaccine hesitancy is a significant barrier to infection control. Accurate vaccine information contributes to increased vaccine acceptance. There is a lack of research on vaccine hesitancy and educational interventions in patients with SLE. Objective(s): The current study determines the prevalence and reasons for vaccine hesitancy in patients with SLE. Additionally, we evaluate the effectiveness of educational interventions. Method(s): This prospective study enrolled 305 patients with SLE between July and December 2021. The data included demographics, disease activity as measured by the Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2 K), and medication. A score of >4 on the SLEDAI-2 K or >3 on the modified SLEDAI-2 K indicated active disease. Each patient completed a vaccination questionnaire before receiving the COVID-19 vaccination. We identified vaccine hesitancy rate and three main concerns regarding efficacy, side effects, and disease interference. Vaccine information was then provided, including the risks and benefits of vaccination following a standardized guideline. During the follow-up, the first vaccination was documented as vaccination acceptance. The factors associated with vaccine hesitancy were investigated using multivariate analysis. A P-value of 0.05 was considered statistically significant. Result(s): The majority of patients (94.4%) were female, with an average age of 46.6 years and a disease duration of 13.5 years. A mean period between follow-ups was 18.8 weeks. Half of patients (50.2%) had a low level of education. Only 23% of patients had active disease. Steroids and immunosuppressive treatment were 57.4 and 42.0%, respectively. COVID-19 vaccine hesitancy was observed in 86 (28.2%) of patients, with 36 (11.8%) refusing vaccination and 50 (16.4%) remaining indecisive. Concerns regarding the vaccination's efficacy were stated by 24.3 percent of all patients, 70.2 percent concerning side effects, and 70.5 percent about the vaccine exacerbating SLE activity. The educational intervention boosted vaccination acceptance from 71.8% to 94.1% in patients who were previously hesitant to vaccination. Low level of education was the only factor associated with vaccine hesitancy (P = 0.018). Conclusion(s): COVID-19 vaccine hesitancy is low in Thai patients with SLE. Most individuals are concerned about the vaccine's adverse effects and negative impact on SLE activity. Patients with a low level of education are prone to exhibit vaccine hesitancy. Appropriate vaccine education significantly increases vaccination acceptability.
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Objectives: Mitragyna speciosa (commonly known as kratom) has both opioid and stimulant-like effects. Recently, Thailand decriminalized the possession and sale of kratom, led to people in many areas earned income selling Kratom at a time of widespread unemployment due to COVID-19. Here, we report a patient with post-Covid syndrome who developed mixed cholestatic-hepatocellular liver injury secondary to kratom. Materials and Methods: A 23-year-old Thai man was seen for evaluation of fatigue and nausea, followed soon after with pruritus, dark urine and jaundice. The patient had no known underlying disease but had been treated with mild COVID-19 pneumonia in the past 2 months. He reported taking kratom recreationally for 2 weeks as a treatment for his post-COVID insomnia. Kratom was bought from his friend and used as a homemade iced cocktail called ''4 9 100'' that consists of Coca-Cola, tea made from boiled kratom leaves, and diphenhydramine-containing cough syrup which has been popular in Southernmost provinces of Thailand. On workup, his total bilirubin was noted to be 10.6 mg/dL, aspartate aminotransferase was 642 U/L, alanine aminotransferase 1,635 U/L. Extensive workups including viral etiologies was negative. Abdominal ultrasound revealed only fatty liver without cirrhosis. Results: The patient had been managed conservatively for 5 days in the hospital. Urine toxicology screening confirmed the presence of only mitragynine. At two weeks later, serum total bilirubin was decreased to 1.5 mg/dL, aspartate aminotransferase was 112 U/L, alanine aminotransferase 404 U/L. He was in a stable condition and normalized liver function tests at 3 months after discharge. Conclusion: There is growing evidence that kratom is safe if used as pure kratom products or brewed herbal decoction in small doses and for a limited period of time. However, the polydrug patterns of kratom use could lead to severe liver injury.
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RATIONALE: Evidence shows poor adherence to data-supported strategies for reducing morbidity and mortality in ICU patients receiving mechanical ventilation globally. Best practice management relies on training all members of the interprofessional ICU team, each with complementary roles in patient management. While simulation is an effective tool for training in these skills, its availability in many parts of the world is limited. We present here a novel, two phase, train-the-trainer, interprofessional and multicultural “Best Practice for Management of Ventilated ICU Patients” simulation based curriculum for Thai critical care education leaders to improve mechanical ventilation training. METHODS: In phase one (OHSU Cohort), two groups of nine nurses and one ICU physician representing experts in critical care and education participated in a week-long, immersive, train-the-trainer course consisting of didactic, simulation, and in-situ immersive sessions focused on best practice management of ICU patients receiving mechanical ventilation. Nineteen participants completed the 33 question pre-test and post-test and course evaluation. In phase two (Thai Cohort), participants from phase one returned to Thailand and implemented ventilator education in-situ, using the same pre-/post-test to assess knowledge. 41 participants completed on-site training and assessment prior to the onset of the COVID-19 pandemic. RESULTS: OHSU Cohort: The mean pre-test knowledge score was 58.4%±13.2% with a mean improvement to 82.5%±11.6%, after completion of the course. The greatest improvements were seen in the core concept areas of respiratory physiology (58.5%), and advanced/disease specific concepts (60.4%). Participants had a high level of satisfaction with 90% rating the course as “excellent” and <90% reporting that the course “greatly improved” their understanding of best practices and comfort in managing mechanical ventilation. The Thai cohort had a mean baseline score of 45.4%±15.0%, and demonstrated a 54.8% improvement after training, with mean post-test score of 70.3%±19.1%,p<0.05. This cohort also saw the greatest improvement in respiratory physiology (58.5%) and advanced/disease specific concepts (77.2%), p<0.05. CONCLUSION: Our novel, two-phase, interprofessional, multicultural, simulation-based train-the-trainer curriculum was both feasible and effective in improving education in best practice management of the mechanically ventilated patient and may be a useful model for improving the care of ICU patients across the world.
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Objective: NA Background: Due to the COVID-19 pandemic, Thailand has started its vaccination program since February 2021. After the launch of the mass vaccination with CoronaVac, there were reports of patients who suffer unusual hemiparesis across the country. We report the first case of a patient who suffered transient focal neurological deficit mimicking stroke following CoronaVac vaccination. However, instead of an ischemic stroke, motor aura was suspected. Design/Methods: A 24 year-old Thai female presented with left hemiparesis fifteen minutes after receiving CoronaVac. She also had numbness of her left arm and legs, flashing lights, and headaches. On physical examination, her BMI was 32.8. Her vital signs were normal. She had moderate left hemiparesis (MRC grade III), numbness on her left face, arms, and legs. Her weakness continued for 5 days. Results: A brain CT scan was done showing no evidence of acute infarction. Acute treatment with aspirin was given. MRI in conjunction with MRA was performed in which no restricted diffusion was seen. A SPECT was performed to evaluate the function of the brain showing significant hypoperfusion of the right hemisphere. The patient gradually improved and was discharged. Conclusions: In this study, we present the first case of stroke mimic after CoronaVac vaccination. After negative imaging studies, stroke is unlikely to be the cause. Asymmetrical abnormal functional imaging study showing multifocal hypoperfusion on the right could represent the ongoing neurological deficits. Therefore, we believed that it might be due to cortical spreading depression, in which motor aura could be responsible. The uniqueness in our case is the prolongation of weakness that we think might be due reverberating spreading depression wave. The cause is unknown, but we proposed that aluminum found to enhance the vaccine that could disrupt the Glutamate - Nitric oxide - cGMP pathway leading to the prolongation of motor aura.
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Background: The coronavirus disease 2019 (COVID-19) pandemic has become one of the biggest challenges to individual health and the public health system worldwide. COVID-19 morbidity and mortality are increasing, impacting almost every country including Thailand. This study used the Health Belief Model (HBM) as a framework to examine the intention of unvaccinated people living in northern Thailand to receive COVID-19 vaccines. Methods: This cross-sectional study was conducted during October and November 2021. A total of 1,024 participants who are currently living in four northern provinces of Thailand, Chiang Mai, Chiang Rai, Lamphun, and Phayao, were recruited to participate in the study. The questionnaire was developed using an HBM structure to obtain information about the perceived severity, perceived susceptibility, self-efficacy, perceived benefits and barriers, cues to action, and preventive behaviors relating to COVID-19 vaccination and the decision to become vaccinated. Multiple linear regression was used to analyze the data. Results: The unvaccinated participants were an average of 44.45 ± 16.63 years of age and more than half were women (54.5%). The COVID-19 preventive behavior score used perceived severity (B = 0.26), self-efficacy (B = 0.51), perceived benefits and barriers (B = 0.11), and cues to action (B = 0.18) after adjusting for age, underlying disease, and body mass index (R 2 = 42.5%). The COVID-19 vaccination decision score was positively correlated with perceived severity (B = 0.13), perceived susceptibility (B = 0.25), perceived benefits and barriers (B = 0.21), and cues to action (B = 0.27) after adjusting for underlying disease (R 2 = 38.7%). Discussion: The results demonstrated the usefulness of using the HBM structure to understand individual intention to receive a COVID-19 vaccine. Communities should consider a COVID-19 health campaign and programs that use the HBM model as a framework for altering perceptions and beliefs about the COVID-19 vaccine and improving vaccination rates among unvaccinated people in rural northern Thailand.
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Background: COVID-19 clinical manifestations range from asymptomatic to severe disease. Prior immune responses to human coronaviruses may affect individual responses to SARS-CoV-2. We surveyed coronavirus responses pre-pandemic in individuals from Kenya, Nigeria, Tanzania, Uganda and Thailand;81% were people living with HIV. Methods: Specimens were screened for SARS-CoV-2 Spike S2 subunit IgG responses. Selected samples were tested using a bead-based immunoassay that profiled the specificity, isotype and subclass of antibody responses to coronavirus, flavivirus and HIV antigens. Wilcoxon rank sum tests were performed to compare responses across antigens and participant group. Results: We screened 1,875 samples (one per individual) collected between 2013 and October 2019: 1,630 samples were from Africa (87%) and 245 from Thailand. 6.99% of participants (n=131, 116 from Africa (89%) and 15 from Thailand) showed responses above the naïve signal threshold and were further tested. Using a signal to noise ratio of >10 as a cut-off value, 44, 27 and 42 samples showed IgG responses to the Spike protein of SARS-CoV-2, SARS-CoV-1 and MERS-CoV respectively, while 7, 9 and 4 samples showed responses to Nucleocapsid for these same antigens. Some individuals had higher responses than those seen in SARS-CoV-2 convalescent individuals. We found a strikingly different pattern of reactivity in Africa compared to Thailand (Figure 1). Antibody responses were significantly higher in the African participants compared to Thai participants across antigens corresponding to SARS-CoV-2 (p<0.001), SARS-CoV-1 (p<0.001) and MERS-CoV (p<0.01). Similar patterns were seen for IgG subclasses, IgA and IgM. The difference was less pronounced for the four endemic coronaviruses, nonetheless anti-Spike responses were significantly higher in African participants for HKU1 and OC43 (p≤0.018). In addition, mapping responses to 21 flavivirus antigens showed the highest reactivity in Thailand and in Nigeria. Conclusion: Our serosurvey of pre-pandemic samples showed that there were significantly higher antibody responses against coronaviruses, including SARS-CoV-2, in Africa than in Thailand. Profiling flavivirus responses showed that the difference between the two regions was not due to a higher background reactivity across African samples. Further analysis is needed to explain pre-pandemic SARS-CoV-2-like antibody responses among African participants and explore implications for geographic diversity in disease severity.
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Background: Coronavirus disease 2019 (COVID-19) pandemic is a critical situation since 2020. Its outbreak occurs across the world. A national policy is to promote self-protection behavior including hand wash, wearing mask, and physical distancing. However, evidence on determinants of the behavior in Thai people is limited. This study aimed to identify determinants of COVID-19 self-protection behavior in Thai people. Design and Method: A cross-sectional survey was undertaken in January 2021. An online questionnaire was developed under the Health Belief Model (HBM). Participants who often or always behave COVID-19 self-protection was considered as proper self-protection behavior. Data was collected through social medias. Results: A total of408 participants was included. Of those, 92 participants (22.5%) were male with the average age of 32.3±11.5 years. A total of 158 participants (38.7%) has proper self-protection behavior. Based on HBM, perceived threat [odds ratio (OR)=1.40, 95%CI 1.01–1.92], perceived barriers (OR=0.51, 95%CI;0.36–0.71), and perceived self-efficacy (OR=6.77, 95%CI;3.60–12.72) were significantly associated with self-protection behavior. Conclusion: One-third of participants have proper COVID-19 self-protection behavior. Perceived self-efficacy is the strongest determinant of COVID-19 self-protection behavior followed by perceived threat and perceived barriers.