Inferior vena cava stenosis and pancreatic ascites complicating chronic calcific pancreatitis: a case report.

A 19-year-old Thai male, who was a regular drinker, presented with massive ascites, back pain and leg edema for four months. On examination there was obvious clinical evidence of an inferior vena cava obstruction. Inferior vena cavography showed narrowing of the hepatic portion of IVC with collateral circulation. Surgical dilatation of the inferior vena cava was performed. The ascites were diagnosed four months later as pancreatic ascites with a very high ascitic amylase level. Computerised axial tomography and endoscopic retrograde pancreatography showed evidence of chronic calcific pancreatitis and pseudocyst. After further medical treatment, ascites and inferior vena cava stenosis subsided which was confirmed by repeated vena cavography, computerised axial tomography and magnetic resonance imaging. The cause of inferior vena cava stenosis and clinical obstruction in this case most likely resulted from phlebitis secondary to pancreatitis. The etiology of chronic calcific pancreatitis in this case might be alcoholic abuse and/or nutritional tropical pancreatitis. Inferior vena cava stenosis and associated pancreatic ascites complicating chronic calcific pancreatitis has not been previously reported in Thailand.

Evaluation of two screening tests for human leptospirosis.

Leptospirosis is prevalent in Thailand but its diagnosis depends primarily on clinical awareness. Serodiagnosis is of great assistance in the diagnosis of leptospirosis but in Thailand microagglutination (MA) is the only serodiagnosis available. MA is not rapid and it is used mainly in the referent laboratory. In addition, its roles in early diagnosis are rarely available. Rapid screening serological test which is sensitive early in the infection is needed. Latex agglutination (LA), indirect hemagglutination (IHA) were developed and evaluated in 100 MA positive sera and 200 blood donors. Later on, IHA and LA were compared with MA in 30 patients with a clinical picture compatible with leptospirosis. IHA and LA had sensitivities of 94 and 98 per cent respectively in MA positive sera. The specificity of IHA and LA in 200 blood donors was 99 and 100 per cent respectively. The study in 30 patients showed that LA and IHA were definitely more sensitive than MA test in sera collected within two weeks after the onset of fever. LA is also one of the most rapid tests for leptospirosis. With either LA or IHA human leptospirosis will be diagnosed more readily and more accurately.

Opisthorchis viverrini infection in rural and urban communities in northeast Thailand.

The prevalence and intensity of liver-fluke (Opisthorchis viverrini) infection were investigated among 559 patients who were born in, and had lived all their lives in, either the rural or urban northeastern Thailand. 344 (79.4%) of 433 rural dwellers were infected compared with only 69 (54.8%) of 126 urban dwellers (P less than 0.005). The intensity of infection, and the reported level of consumption of koi-pla, a favourite dish of local inhabitants prepared from uncooked freshwater fish which often contains viable metacercariae, were greater among rural dwellers than their urban counterparts (P less than 0.05 to P less than 0.005). Infection due to O. viverrini appears to be mainly a rural problem strongly associated with the habit and frequency of eating koi-pla.

Spontaneous Vibrio vulnificus peritonitis and primary sepsis in two patients with alcoholic cirrhosis.

Two patients with alcoholic cirrhosis were seen on two separate occasions for fever, swollen legs, petechial hemorrhage, purpura, and cutaneous bullae. One patient ate oysters 2 days before the onset of illness. Vibrio vulnificus, a lactose-positive halophilic vibrio, was isolated from the ascitic and cutaneous fluid in both cases, and from the blood in one of the two cases. Both isolated strains were sensitive to the antibiotics given to the patients from the beginning; however, both patients died, one from septicemic shock and the other from massive esophageal variceal hemorrhage. Autopsies in both patients revealed alcoholic cirrhosis, hemorrhagic necrosis of the terminal ileum, intraalveolar hemorrhage, petechial hemorrhage in the peritoneum, and nonspecific acute inflammation of the dermis with vasculitis. Physicians should consider V. vulnificus in the differential diagnosis of cirrhotic patients with sepsis, primary skin lesions, and spontaneous bacterial peritonitis with or without history of recent oyster ingestion.

Opisthorchis viverrini infection and cholangiocarcinoma. A prospective, case-controlled study.

During a prospective, 24-mo case-controlled study, 551 patients from northeastern Thailand were independently evaluated for Opisthorchis viverrini infection, hepatobiliary tract disease, and hepatic carcinoma to determine whether there was any association between hepatic carcinoma and O. viverrini infection. Stool examination by the formalin-ether concentration method revealed O. viverrini ova in 389 (70.6%) patients. Of the 551 patients, 72 (13.1%) had both clinical and laboratory evidence of hepatobiliary tract disease, chronic liver disease, or hepatic carcinoma, alone or in combination. Of these 72 patients, 28 (38.9%) had a liver biopsy that revealed cholangiocarcinoma in 7 patients with O. viverrini ova in their stools, and in 4 patients without. In another patient with ova in the stool combined hepatocellular carcinoma and cholangiocarcinoma was found. In the 4 patients with cholangiocarcinoma who had no O. viverrini ova in their stools, ova were detected in the bile fluid aspirated from the intrahepatic biliary tree during exploratory laparotomy. An additional patient with clinically suspected cholangiocarcinoma and O. viverrini ova in stool had a left supraclavicular lymph node biopsy specimen taken that revealed metastatic adenocarcinoma; this adenocarcinoma was interpreted as compatible with cholangiocarcinoma. Cholangiocarcinoma, therefore, was found only in patients with O. viverrini ova in stool or in the intrahepatic biliary tree. Statistical analysis revealed that patients with known O. viverrini infection had a higher incidence of cholangiocarcinoma than did patients without such infection (X2 test, p less than 0.05).

Consistency of fecal egg output in patients with Opisthochiasis viverrini.

Counts of Opisthorchis eggs in two samples of feces arbitrarily taken 0-21 days apart from each of 209 patients from northeastern Thailand were carried out by Stoll's dilution technique. Based on the number of eggs/mg feces, each patient was classified as uninfected, lightly infected (less than 1 egg/mg), moderately infected (1-10/mg), heavily infected (greater than 10-50/mg), or very heavily infected (greater than 50/mg). The intensity of infection for each of the 209 individuals as shown by first and second counts was compared. Of the 209 individuals, 150 (71.8%) remained within the same egg excretion category, with all but five (2.4%) of the remainder being in an adjacent category. Statistical analysis showed no effect of variation in interval between stool counts on the accuracy or consistency of replicate counts.

Intrahepatic cholestasis and cutaneous bullae associated with glibenclamide therapy.

Intrahepatic cholestasis and cutaneous bullae associated with glibenclamide therapy are described in a 61-year-old diabetic patient who presented wit hypoglycaemic coma. These features have not previously been reported as side effects of glibenclamide therapy, but intrahepatic cholestasis may occur with chlorpropamide, a similar sulphonylurea agent. The mechanism of this cholestasis is not clear at present.