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.

Nitrendipine in treatment of hypertension.

Twenty-three mild and moderate essential hypertensive patients, 3 males and 20 females without any complications were given nitrendipine or Baypress, a new calcium antagonist, 10-20 mg once daily for 23 weeks. The blood pressure of all 23 patients was significantly reduced (p = less than 0.01) in both systolic and diastolic blood pressures. No serious side effects were observed. There were only headache (4 cases), palpitation (2 cases), and paroxysmal ventricular contraction (1 case). No hematological, urinalysis and biochemical changes of kidney and liver functions, fasting blood sugar, cholesterol and triglyceride except for sodium and potassium which were raised and weight reduction was observed. All patients tolerated the drug very well. We conclude that, nitrendipine is safe and suitable for management of mild and moderate uncomplicated essential hypertension.

Multicentre isradipine dose-confirmation study in Thai patients with hypertension.

Isradipine is a new calcium antagonist of the dihydropyridine type, with marked vasodilator activity and minimum negative inotropic effects. It is a potent antihypertensive drug when given as monotherapy. This was a single-blind multicentre study consisting of 2 weeks' placebo pretreatment and 8 weeks' treatment with isradipine. After the placebo period, 90 patients aged 36 to 65 (mean 52) years with mild to moderate hypertension and diastolic blood pressures (DBPs) of greater than 95 to 114 mm Hg, were started on isradipine 1.25mg twice daily for 4 weeks. The dosage for the next 4 weeks was increased to 2.5mg twice daily if the DBP was greater than 90mm Hg. At the end of the study 72 of 90 patients (80%) had achieved a reduction in DBP greater than or equal to 10mm Hg and, of these, 48 (53%) had DBPs of less than or equal to 90mm Hg. This study confirms that isradipine 2.5mg twice daily is effective and well tolerated in the treatment of Thai patients with mild to moderate essential hypertension.

Differential diagnosis of eosinophilic meningitis.

Meningitis - infection o f the meninges - can be attributed to a variety o f agents, including bacteria, protozoa and some helminths. In helminth infections, but rarely in protozoal infections, eosinophilia is a common sign. Thus eosinophilic meningitis (EOM) is typically associated with certain helminth infections in which nervous system involvement occurs. Among the most important of these are ongiostrongyliosis, gnathostomiasis, porogonimiasis and cysticercosis (see Fig. 1). Here, Nibha Jaroonvesoma discusses the key distinctions between such infections.

Intestinal absorption studies in Fasciolopsis buski infection.

The intestinal absorption of carbohydrate, fat, protein and vitamin B12, serum vitamin B12, serum and red cell folate levels were performed in 10 patients harbouring F. buski. No disturbance of carbohydrate, fat and protein absorption was observed but vitamin B12 absorption was found to be slightly lower than normal in 8 out of 10 patients, and serum vitamin B12 was also lower than normal in 4 out of 9 patients. Red cell and serum flolate levels were within the normal limits. Histological study of jejunal biopsy was normal in 7 out of 8 patients.

ELISA testing in cases of clinical angiostrongyliasis in Thailand.

The sera from 116 Thais admitted to Nakhon Ratchasima hospital in northeastern Thailand with eosinophilic meningitis were tested for antibodies to Angiostrongylus cantonensis by ELISA. Ninety-six percent of the sera were considered positive with ELISA values exceptionally high for most patients. The clinical aspects of the disease are also presented. The ELISA test is considered to be of value in the diagnosis of the disease but tests for the antigen would provide a more definitive diagnosis.

Studies on paragonimiasis: treatment with mebendazole, emetine with mebendazole and praziquantel.

One hundred cases of paragonimiasis from Saraburi province, Thailand were studied with respect to epidemiology, clinical manifestations, radiography and treatment. Highly endemic areas were Cha-om and Sum-pugpaew villages in Kang-koy district. The ratio of male to female was 48:52. Uncooked crabs and shrimps are the second intermediate hosts of Paragonimus. Hemoptysis and chronic cough were the main symptoms; with crepitations and rhonchi in both lungs. There was no specific changes in chest X-rays of the lungs, except in cases of hemoptysis where changes in pulmonary vessels were observed. Tomograms of the lungs provided 100% accuracy and confirmation of diagnosis of pulmonary paragonimiasis. Praziquantel 25 my/kg body weight three times a day for 2 days gave a cure rate of 90%, mebendazole plus emetine hydrochloride gave a cure rate of 70% and mebendazole alone was not effective.

Primary amoebic meningoencephalitis: a first reported case in Thailand.

A case of primary amoebic meningoencephalitis caused by Naegleria, from Sisaket province of Thailand is first reported. A 5-year old Thai with boy a history of swimming in a pond along a rice field before the onset of this illness, was admitted to the provincial hospital for chief complaints of headache, high fever, vomiting and drowsiness for 4 days. On admission he had convulsions and became comatosed with signs of meningeal irritation. The cerebrospinal fluid was similar to pyogenic meningitis but numerous amoebae were found and identified as Naegleria sp. Unfortunately, specific treatment was not administered promptly, the patient died 3 days after admission.

Single-day drug treatment of amebic liver abscess.

This double-blind trial was initiated to test, in a controlled study, the value of single-day drug treatment of amebic liver abscess. Patients were treated with 2 g either of ornidazole or tinidazole, two newly developed 5-nitroimidazole derivatives, given in two equal doses during the course of 1 day. A success rate of over 94% in the 72 patients from both treatment groups who were followed up for 6 months demonstrates the efficacy of the single-day drug treatment.

Treatment of Opisthorchis viverrini with mebendazole.

Thirty-six hospitalized Thais (21 males, 15 females, 9 to 63 years of age) with Opisthorchis viverrini infection were treated with mebendazole in dosages of 20 mg/kg body weight for 4 weeks and 30 mg/kg body weight for 3 or 4 weeks. The drug was found to be effective when given in dosages of 30 mg/kg body weight for 3 to 4 weeks only a few eggs being found in the stool of one of 27 persons at 3 or 4 weeks post-treatment. In follow-up examination at 6 months, only two of 15 persons available were positive. These could have been reinfection, however. Side effects were essentially absent, except one person who vomited on the first day of treatment. The drug could be used in a mass treatment campaign because of effectiveness, low toxicity, and action against other helminthic infections.

Leucocyte migration agarose test to study cell-mediated immunity in amoebiasis.

The leucocyte migration agarose test (LMAT) was used to measure quantitatively the magnitude of cell-mediated immunity (CMI) in 35 patients with amoebic liver abscess and 22 healthy controls. LMAT was positive in 65.7% and 85.7% of patients with amoebiasis in the presence of 200 microgram and 400 microgram of the amoeba extract respectively, whereas the test in all 22 healthy controls was negative. Time course studies showed that within 10 days after the onset of clinical illness, only 1 of 4 patients was positive. Thereafter the percentage positivity was raised, especially when 400 microgram antigen was used. Maximum CMI response was apparent between 31-60 days after the onset of clinical illness. The indirect haemagglutination (IHA) test showed that all patients and 5 of 22 healthy controls were positive. These was no correlation between IHA titers and the magnitude of LMAT reaction.

Closure of intrahepatic hepatoportal arteriovenous fistula. Review and case report.

An intrahepatic hepatoportal arteriovenous fistula was discovered incidentally at the time of visceral angiography in a hypertensive patient. The patient had had a blunt abdominal trauma 7 years prior to her present hospitalization. No bruit or thrill was found on her abdomen. There was no clinical evidence of portal hypertension. Selective celiac angiography performed 44 days later showed that the arteriovenous fistula had closed. Previous reports of this anomaly are reviewed.