Primary cutaneous cryptococcosis caused by Cryptococcus gattii VGII in a tsunami survivor from Thailand.

Skin and soft tissue fungal infections with Apophysomyces elegans, Fusarium solani, Cladophialophora bantiana have been reported in survivors from 2004 Indian ocean Tsunami. We report the first case of primary cutaneous cryptococcosis caused by Cryptococcus gattii VGII in a Tsunami survivor from Thailand.

Reversible cerebral vasoconstriction syndrome with increased intracranial pressure, probably related to altitude changes and windy winter travelling.

Reversible cerebral vasoconstriction syndrome (RCVS) has reversible multifocal narrowing of the cerebral arteries. Respiratory alkalosis in high altitude studies cause impairment of the central nervous system, presumably by cerebral vasoconstriction. A 54 year-old woman presented with a 1-week of throbbing headache around her forehead while travelling in moderately high altitude, during a windy winter. Sudden severe headache had progressed and developed bilateral lower visual fields defect along with mild weakness of her right leg on the next day. Magnetic resonance (MR) imaging revealed acute ischemic process at both occipital, parasagittal left parietal and right frontal area. MR venography was negative but MR angiography showed multifocal narrowing of both anterior and posterior circulations. Lumbar puncture revealed the opening pressure of 240 mmH2O but normal CSF profiles. Blood tests, including complete blood count, protein C, protein S, antithrombin III, high-sensitivity C-reactive protein, immunologic and antibody profiles were normal. Dexamethasone and low-molecular weight heparin were given because the intracranial vasculitis and cerebral venous thrombosis could not be ruled out. Visual fields and right leg problems had fully recovered on the second day and second week respectively. Prednisolone was discontinued at the fourth week. MR imaging and MR angiography were repeated in the sixteenth week and revealed old infarction at the left posterior parietal area but narrowing segment of arterial systems were no longer seen. There were a few previous reported cases of RCVS in Asian counties. The authors proposed that altitude changes from travelling to the moderately high altitude and cold windy winter weather were the predisposing factors for the attack of RCVS.

Adjunctive corticosteroid therapy in 149 grade II (non-shock) adult DHF patients: an analysis during January 2008-February 2010.

BACKGROUND: It is well known that immunopathogenesis play an important role in the development of severe complications in DHF. Since 2006, the authors have experience in giving immunomodulators to save life of many severe complicated adult DHF patients. This experience stimulates our interest on the benefit of adjunctive corticosteroid therapy in adult grade II DHF patients. OBJECTIVE: To find out whether there are some benefits of giving adjunctive corticosteroid therapy in adult grade II DHF patients. DESIGN OF THE STUDY: Retrospective analysis during January 2008-February 2010. MATERIAL AND METHOD: One hundred and forty nine adult grade II DHF patients were admitted at Vichaiyut Hospital. They were divided into 3 groups according to the different therapy designed by the responsible clinicians. Group 1 consisted of 59 cases who received full dose-short course of intravenous dexamethasone (4 milligram every 6 hours for 2-3 days). Group 2 consisted of 61 cases who received intermittent 4 milligrams intravenous dexamethasone only at febrile episode and group 3-29 cases did not received corticosteroid. All the patients were investigated similarly. Age, sex, symptoms and signs including daily hematologic studies (Hct, Wbc, differential count, platelet count) were recorded. Serum SGOT SGPT bilirubin, alkaline phosphatase and albumin BUN, creatinine were performed on admission and repeated as indicated. The parameter to measure the benefit of adjunctive corticosteroid included 1) severity of thrombocytopenia, 2) liver impairment, 3) the days of illness as determined by fever and 4) the length of the hospital days. RESULTS: The clinical severity of all the three groups were quite similar. There was no benefit of using adjunctive corticosteroid therapy in term of changing the severity of thrombocytopenia and liver impairment. However, the days of illness and the length of hospital days were shorter at 4.6 days and 3.7 days respectively in the group who received full dose, continuous-short course of dexamethasone intravenously. This is statistically significant when compared to the other two groups who had the longer total days of fever at 5.8 days and 6.03 days and the longer length of hospital days at 5.19 days and 4.5 days respectively (p < 0.05). CONCLUSION: Adjunctive corticosteroid by given full dose, continuous short course in grade II adult DHF reduced the course of illness (days of fever) and the length of hospital days. These findings indicated the benefit of using adjunctive corticosteroid therapy in grade II adult DHF patients.

Hemophagocytic syndrome in Dengue hemorrhagic fever with severe multiorgan complications.

A 46 year old woman who presented with severe multiorgans involvement including liver brain, cardio-pulmonary failure, gastrointestinal bleeding, progressive cytopenia, DIC and hemophagocytic syndrome during the convalescent phase of Dengue type II has been successfully treated primarily with pulse methyl prednisolone and high dose intravenous immunoglobulin G. The authors believe that HPCS are not infrequently seen with high mortality and recommended early diagnosis and treatment with the regimen. This is the first complete report of hemophagocytic syndrome in adult dengue hemorrhagic fever in Thailand. The literature of HPCS in DHF was reviewed and discussed.

EBV and hemophagocytic syndrome: analysis of 3 cases, with speculation on clinical features, therapy and role of EBV.

The authors report three patients diagnosed with EBV associated HPCS. The first case died of a fatal EBV infection. The second and third cases had primary disease of malignant lymphoma. In case 2, T cell lymphoma associated HPCS was diagnosed early. However, despite the aggressive treatment of HPCS and T-cell lymphoma, the patient died because of the refractory lymphoma. In case 3, HPCS and B malignant lymphoma were diagnosed at post mortem. EBV was found very late in all three cases. Case 1 and case 2 had a very high DNA-EBV load in blood. Case 3 demonstrated EBV-RNA encoded antigen (EBER) in lymph node by in situ hybridization technique. The clinical features of HPCS were analysed. Four early manifestations in these three cases were emphasized, namely fever, splenomegaly, progressive pancytopenia and impaired liver function test without severe jaundice. The authors stress the most important factor to save the life of the patients is to give early diagnosis and early proper management of HPCS as well as the etiologic diseases. The treatment of choice of early HPCS are pulse corticosteroid, IVIgG. Combination immunochemotherapy including pulse corsticosteroid, IVIgG, cyclosporin A, etoposide and plasma exchange should be given promptly in severe cases. From the present report, it indicates that the association of EBV with HPCS is not uncommon in Thailand. EBV is very important because it gives a very poor prognosis either by being an etiologic cause of HPCS or by association with ML with HPCS. Clinicians should be aware of EBV and recognize it early. The early treatment of EBV should helpfully changes the prognosis of the patients. The role of EBV on the occurrence of HPCS and T-ML is also discussed

Fatal myeloencephalitis following yellow fever vaccination in a case with HIV infection.

A 53 year old physically healthy man, unaware of any immunocompromised condition developed rapidly fatal myelomeningoencephalitis following a live-attenuated yellow fever vaccination. He was found to have asymptomatic HIV infection with high viral loads and low CD4 counts. This is the first reported case of such an incidence in the world literature. It is strongly suggested that in countries where HIV infection is endemic, an HIV blood test should be performed prior to the yellow fever vaccination and the vaccine should not be given to those immunocompromised persons.