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Abstract Background Anemia is a common clinical finding in HIV-infected patients and iron deficiency or redistribution may contribute to the development of low hemoglobin levels. Iron overload is associated with a poor prognosis in HIV and Hepatitis C virus infections. Iron redistribution may be caused by inflammation but possibly also by hepatitis C co-infection. We examined the prevalence of anemia and its relation to mortality in a cohort of HIV patients in a setting where injecting drug use (IDU) is a main mode of HIV transmission, and measured serum ferritin and sTfR, in relation to anemia, inflammation, stage of HIV disease, ART and HCV infection. Methods Patient characteristics, ART history and iron parameters were recorded from adult HIV patients presenting between September 2007 and August 2009 in the referral hospital for West Java, Indonesia. Kaplan-Meier estimates and Cox's regression were used to assess factors affecting survival. Logistic regression was used to identity parameters associated with high ferritin concentrations. Results Anemia was found in 49.6% of 611 ART-naïve patients, with mild (Hb 10.5 - 12.99 g/dL for men; and 10.5 - 11.99 g/dL for women) anemia in 62.0%, and moderate to severe anemia (Hb < 10.5 g/dL) in 38.0%. Anemia remained an independent factor associated with death, also after adjustment for CD4 count and ART (p = 0.008). Seroprevalence of HCV did not differ in patients with (56.9%) or without anemia (59.6%). Serum ferritin concentrations were elevated, especially in patients with anemia (p = 0.07) and/or low CD4 counts (p < 0.001), and were not related to hsCRP or HCV infection. Soluble TfR concentrations were low and not related to Hb, CD4, hsCRP or ART. Conclusion HIV-associated anemia is common among HIV-infected patients in Indonesia and strongly related to mortality. High ferritin with low sTfR levels suggest that iron redistribution and low erythropoietic activity, rather than iron deficiency, contribute to anemia. Serum ferritin and sTfR should be used cautiously to assess iron status in patients with advanced HIV infection.

Background: Dengue has emerged as one of the most important infectious diseases in the last five decades. Evidence indicates the expansion of dengue virus endemic areas and consequently the exponential increase of dengue virus infections across the subtropics. The clinical manifestations of dengue virus infection include sudden fever, rash, headache, myalgia and in more serious cases, spontaneous bleeding. These manifestations occur in children as well as in adults. Defining the epidemiology of dengue in a given area is critical to understanding the disease and devising effective public health strategies. Methodology/Principal Findings: Here, we report the results from a prospective cohort study of 4380 adults in West Java, Indonesia, from 2000–2004 and 2006–2009. A total of 2167 febrile episodes were documented and dengue virus infections were confirmed by RT-PCR or serology in 268 cases (12.4%). The proportion ranged from 7.6 to 41.8% each year. The overall incidence rate of symptomatic dengue virus infections was 17.3 cases/1,000 person years and between September 2006 and April 2008 asymptomatic infections were 2.6 times more frequent than symptomatic infections. According to the 1997 WHO classification guidelines, there were 210 dengue fever cases, 53 dengue hemorrhagic fever cases (including one dengue shock syndrome case) and five unclassified cases. Evidence for sequential dengue virus infections was seen in six subjects. All four dengue virus serotypes circulated most years. Inapparent dengue virus infections were predominantly associated with DENV-4 infections. Conclusions/Significance: Dengue virus was responsible for a significant percentage of febrile illnesses in an adult population in West Java, Indonesia, and this percentage varied from year to year. The observed incidence rate during the study period was 43 times higher than the reported national or provincial rates during the same time period. A wide range of clinical severity was observed with most infections resulting in asymptomatic disease. The circulation of all four serotypes of dengue virus was observed in most years of the study. [ABSTRACT FROM AUTHOR]

Background: Distortion of iron homeostasis may contribute to the pathogenesis of human immunodeficiency virus (HIV) infection and tuberculosis (TB). We studied the association of the central iron-regulatory hormone hepcidin with the severity of HIV and the association between hepcidin and other markers of iron homeostasis with development of TB. Methods: Three groups of patients were selected from a prospective cohort of HIV-infected subjects in Bandung, Indonesia. The first group consisted of HIV-infected patients who started TB treatment more than 30 days after cohort enrollment (cases). The second group consisted of HIV-infected patients who were matched for age, gender and CD4 cell count to the cases group (matched controls). The third group consisted of HIV-infected patients with CD4 cell counts above 200 cells/mm3 (unmatched controls). Iron parameters including hepcidin were compared using samples collected at cohort enrollment, and compared with recently published reference values for serum hepcidin. Results: A total of 127 HIV-infected patients were included, 42 cases together with 42 matched controls and 43 unmatched controls. Patients with advanced HIV infection had elevated serum hepcidin and ferritin levels. Hepcidin levels correlated inversely with CD4 cells and hemoglobin. Cases had significantly higher hepcidin and ferritin concentrations at cohort enrollment compared to matched controls, but these differences were fully accounted for by the cases who started TB treatment between day 31 and 60 after enrollment. Hepcidin levels were not different in those with or without hepatitis C infection. Conclusion: Iron metabolism is distorted in advanced HIV infection with CD4 cell counts correlating inversely with serum hepcidin levels. High serum hepcidin levels and hyperferritinemia were found in patients starting TB treatment shortly after cohort enrollment, suggesting that these parameters have a predictive value for development of manifest TB in HIV-infected patients. [ABSTRACT FROM AUTHOR]

Background: Identification of dengue patients at risk for progressing to severe disease is difficult. Significant plasma leakage is a hallmark of severe dengue infection which can suddenly lead to hypovolemic shock around the time of defervescence. We hypothesized that the detection of subclinical plasma leakage may identify those at risk for severe dengue. The aim of the study was to determine the predictive diagnostic value of serial ultrasonography for severe dengue. Methodology/Principal Findings: Daily bedside ultrasounds were performed with a handheld ultrasound device in a prospective cohort of adult Indonesians with dengue. Timing, localization and relation to dengue severity of the ultrasonography findings were determined, as well as the relation with serial hematocrit and albumin values. The severity of dengue was retrospectively determined by WHO 2009 criteria. A total of 66 patients with proven dengue infection were included in the study of whom 11 developed severe dengue. Presence of subclinical plasma leakage at enrollment had a positive predictive value of 35% and a negative predictive value of 90% for severe dengue. At enrollment, 55% of severe dengue cases already had subclinical plasma leakage, which increased to 91% during the subsequent days. Gallbladder wall edema was more pronounced in severe than in non-severe dengue patients and often preceded ascites/pleural effusion. Serial hematocrit and albumin measurements failed to identify plasma leakage and patients at risk for severe dengue. Conclusions/Significance: Serial ultrasonography, in contrast to existing markers such as hematocrit, may better identify patients at risk for development of severe dengue. Patients with evidence of subclinical plasma leakage and/or an edematous gallbladder wall by ultrasonography merit intensive monitoring for development of complications. Author Summary: Dengue virus infection ranges from a mild febrile illness to severe illness. Severe dengue is mainly characterized by transient plasma leakage, which may lead to a sudden onset of shock around the time of defervescence. Severe bleeding and organ impairment are less common features of severe dengue. In clinical practice it is difficult to predict which dengue patient will develop severe complications. Commonly used laboratory markers indicating plasma leakage—such as hematocrit—are rarely of clinical benefit. In contrast, ultrasonography can directly visualize plasma leakage. Because ultrasonography is not routinely used due to financial and logistical limitations, we used a more affordable handheld ultrasound device for daily bedside follow up, which had similar results as conventional ultrasonography. This study shows that a substantial proportion of mildly ill patients already had small amounts of plasma leakage before severe complications developed and—most importantly—that these patients had an increased risk for progression to shock compared to patients without plasma leakage. We conclude that ultrasonography can help to identify dengue patients at risk for shock and that patients with ultrasonographic evidence of plasma leakage should be monitored more carefully for circulatory status to timely recognize and possibly prevent shock. [ABSTRACT FROM AUTHOR]

Objectives: Dengue fever may manifested without or with warning sign (DWOWS or DWS) and severe dengue (SD) (WHO 2009). DWOWS can be distinguished from DWS if there is plasma leakage that can be showed by changes in plasma (increased hematocrite) or detecting ascites or pleural effusion by USG. Standard abdominal ultra-sound examination (USG) could found plasma leakage, but this equipment is costly and impractical in daily use. In this study we examined the role of pocket USG device to detect plasma leakage as alternative to ordinary USG. Methodology: Dengue fever patients are included prospectively in HSH since March 2011 until March 2012, examined appropriately to confi rm and classify dengue disease. Pocket USG (P02742, 3.5 Mhz, Signos, Australia) was used to fi nd ascites, pleural efusion or thickened gallbladder wall (defi ned as wall thickness >0.35 cm). Examined bedside on hospitalized day 1, 3 and 5 for every patients. Analysis was conducted assessing contribution of this USG examination to detect of plasma leakage in comparison with increased hematocrite. Results: Sixty nine dengue patients were enrroled with characteritis as, fever median duration of 6-7 days, 31 male (45%) with a mean±SD age of 33±15 years. Hct increase (as indicator of plasma leakage) has detected in 22 (31.9 %) of the group. Pocket USG detected ascites in 12 (17.4%), pleural efusion 10 (14.5%). GBT in 22 (31.9%), and pericholecystic fl uid in 5 (7.2%) of the patients. Fluid accumulation mostly detect in median day of fever 6 (range 3-8) days. Overall, fl uid accumulation as plasma leakage was detected by USG in 27 (39.1%) where as hematocrite increased were found in 22 (31.9%) (p<0.05). GBT were compared to hematocrite for severe dengue (SD), (p<0.01, OR 64.50, 95% CI 9.54-436.20). In comparison with standard USG accuracy was reasonably well. Based on these, we can clasify dengue patient into 42 (60.9%) DWOWS, 22 (31.9%) DWS and 5 (7.2%) SD. Conclusion: Pocket USG allows detection of plasma leakage including GBT related to severity of dengue infection more sensitive than Hct. Because of its portability, it can be used bedside and in emergency room rapidly. [ABSTRACT FROM AUTHOR]

Background: Anemia is a common clinical finding in HIV-infected patients and iron deficiency or redistribution may contribute to the development of low hemoglobin levels. Iron overload is associated with a poor prognosis in HIV and Hepatitis C virus infections. Iron redistribution may be caused by inflammation but possibly also by hepatitis C co-infection. We examined the prevalence of anemia and its relation to mortality in a cohort of HIV patients in a setting where injecting drug use (IDU) is a main mode of HIV transmission, and measured serum ferritin and sTfR, in relation to anemia, inflammation, stage of HIV disease, ART and HCV infection., Methods: Patient characteristics, ART history and iron parameters were recorded from adult HIV patients presenting between September 2007 and August 2009 in the referral hospital for West Java, Indonesia. Kaplan-Meier estimates and Cox's regression were used to assess factors affecting survival. Logistic regression was used to identity parameters associated with high ferritin concentrations., Results: Anemia was found in 49.6% of 611 ART-naïve patients, with mild (Hb 10.5 -12.99 g/dL for men; and 10.5-11.99 g/dL for women) anemia in 62.0%, and moderate to severe anemia (Hb < 10.5 g/dL) in 38.0%. Anemia remained an independent factor associated with death, also after adjustment for CD4 count and ART (p = 0.008). Seroprevalence of HCV did not differ in patients with (56.9%) or without anemia (59.6%). Serum ferritin concentrations were elevated, especially in patients with anemia (p = 0.07) and/or low CD4 counts (p < 0.001), and were not related to hsCRP or HCV infection. Soluble TfR concentrations were low and not related to Hb, CD4, hsCRP or ART., Conclusion: HIV-associated anemia is common among HIV-infected patients in Indonesia and strongly related to mortality. High ferritin with low sTfR levels suggest that iron redistribution and low erythropoietic activity, rather than iron deficiency, contribute to anemia. Serum ferritin and sTfR should be used cautiously to assess iron status in patients with advanced HIV infection.

Aim: To investigate the hematologic manifestation and the relationship of the abnormalities with mortality., Methods: We examined hematologic data from 10 Avian influenza patients in Hasan Sadikin Hospital Bandung between November 2005 and March 2007., Results: The mortality rate was 70%. Anemia was found in 30% (3 of 10 patients). Leukopenia was found in 60% (6 of 10 patients. Lymphopenia and neutropenia were found in 50% (4 of 8 patients) and 62.5% (5 of 8 patients). Sixty percent (6 of 10 patients) had thrombocytopenia. Anemia was not correlated with mortality (OR=0.08). Leukopenia, neutropenia and lymphopenia were correlated with mortality (OR=5, OR=8 and OR=12, respectively). Thrombocytopenia was also correlated with mortality (OR=5)., Conclusion: Leukopenia, neutropenia, lymphopenia and thrombocytopenia were common findings among avian influenza patients in Hasan Sadikin Hospital. Decreased white blood cells and platelets were correlated with mortality.

A prospective study of dengue fever (DF) and dengue hemorrhagic fever (DHF) was conducted in a cohort of adult volunteers from two textile factories located in West Java, Indonesia. Volunteers in the cohort were bled every three months and were actively followed for the occurrence of dengue (DEN) disease. The first two years of the study showed an incidence of symptomatic DEN disease of 18 cases per 1,000 person-years and an estimated asymptomatic/ mild infection rate of 56 cases per 1,000 person-years in areas of high disease transmission. In areas where no symptomatic cases were detected, the incidence of asymptomatic or mild infection was 8 cases per 1,000 person-years. Dengue-2 virus was the predominant serotype identified, but all four serotypes were detected among the cohort. Four cases of DHF and one case of dengue shock syndrome (DSS) were identified. Three of the four DHF cases were due to DEN-3 virus. The one DSS case occurred in the setting of a prior DEN-2 virus infection, followed by a secondary infection with DEN-1 virus. To our knowledge, this is the first report of a longitudinal cohort study of naturally acquired DF and DHF in adults.