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Purpose: Cytomegalovirus (CMV) retinitis can have debilitating impacts on quality of life (QOL), but few contemporary studies have characterized these ramifications. This study assessed the impact of CMV retinitis on vision-related QOL for those living with HIV/AIDS in Thailand., Methods: QOL was assessed as part of a prospective interventional cohort study of patients referred to a tertiary hospital in Thailand for CMV retinitis screening. A validated vision-related QOL questionnaire was administered at the baseline screening visit and at the 6-month study visit. Multivariable linear regression models were performed to determine the effect of CMV retinitis diagnosis on QOL score., Results: A total of 152 participants completed the QOL questionnaire at their initial clinic visit. At baseline, a diagnosis of CMV retinitis diagnosis was significantly associated with decreased QOL score: unilateral retinitis was associated with a 0.11 (95% CI: -0.26-0.03) decrement in QOL, and bilateral retinitis was associated with a 0.33 (95% CI: -0.51-0.16) decrement (joint P-value = 0.0009). For the 78 participants with a 6-month visit, changes in QOL from baseline were small and not significant. A diagnosis of CMV retinitis was still associated with decreased QOL score at 6 months (joint P -value = 0.03)., Conclusions: This study found that vision-related QOL was lower in those with CMV retinitis, especially with bilateral involvement, and did not improve after treatment among those with follow-up. These findings reinforce the debilitating clinical manifestations of this disease, and support efforts for earlier screening to detect CMV retinitis before impacts on QOL have occurred.

Background: Pneumonia remains the leading cause of death among children <5 years of age beyond the neonatal period in Thailand. Using data from the Pneumonia Etiology Research for Child Health (PERCH) Study, we provide a detailed description of pneumonia cases and etiology in Thailand to inform local treatment and prevention strategies in this age group., Methods: PERCH, a multi-country case-control study, evaluated the etiology of hospitalized cases of severe and very severe pneumonia among children 1-59 months of age. The Thailand site enrolled children for 24 consecutive months during January 2012-February 2014 with staggered start dates in 2 provinces. Cases were children hospitalized with pre-2013 WHO-defined severe or very severe pneumonia. Community controls were randomly selected from health services registries in each province. Analyses were restricted to HIV-negative cases and controls. We calculated adjusted odds ratios (ORs) and 95% CIs comparing organism prevalence detected by nasopharyngeal/oropharyngeal (NP/OP) polymerase chain reaction between cases and controls. The PERCH Integrated Analysis (PIA) used Bayesian latent variable analysis to estimate pathogen-specific etiologic fractions and 95% credible intervals., Results: Over 96% of both cases (n = 223) and controls (n = 659) had at least 1 organism detected; multiple organisms were detected in 86% of cases and 88% of controls. Among 98 chest Radiograph positive (CXR+) cases, respiratory syncytial virus (RSV) had the highest NP/OP prevalence (22.9%) and the strongest association with case status (OR 20.5; 95% CI: 10.2, 41.3) and accounted for 34.6% of the total etiologic fraction. Tuberculosis (TB) accounted for 10% (95% CrI: 1.6-26%) of the etiologic fraction among CXR+ cases., Discussion: More than one-third of hospitalized cases of severe and very severe CXR+ pneumonia among children 1-59 months of age in Thailand were attributable to RSV. TB accounted for 10% of cases, supporting evaluation for TB among children hospitalized with pneumonia in high-burden settings. Similarities in pneumonia etiology in Thailand and other PERCH sites suggest that global control strategies based on PERCH study findings are relevant to Thailand and similar settings., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc.)

Microsporidial myositis caused by Trachipleistophora hominis is a life-threatening and emerging microsporidiosis among immunocompromised hosts. This article reports a case of disseminated microsporidiosis caused by T. hominis in southern Thailand. The patient had HIV and presented at the clinic with incapacitating muscle pain. She was diagnosed with disseminated microsporidiosis. Molecular identification revealed the sequence of 18S ribosomal RNA gene involving sequences sharing 99% nucleotide identity with T. hominis from an Australian patient. To our knowledge, this is the first study to report the detection of T. hominis microsporidia in an HIV patient in Thailand.

Background: Mannose-binding lectin (MBL) plays a pivotal role in innate immunity; however, its impact on susceptibility to opportunistic infections (OIs) has not yet been examined in a natural history cohort of people living with HIV/AIDS., Methods: We used archived samples to analyze the association between MBL expression types and risk of major OIs including Pneumocystis jirovecii pneumonia (PCP), cryptococcosis, talaromycosis, toxoplasmosis, and tuberculosis in a prospective cohort in Northern Thailand conducted from 1 July 2000 to 15 October 2002 before the national antiretroviral treatment programme was launched., Results: Of 632 patients, PCP was diagnosed in 96 (15.2%) patients, including 45 patients with new episodes during the follow-up period (1006.5 person-years). The total history of PCP was significantly associated with low MBL expression type: high/intermediate (81/587, 13.8%), low (10/33, 30.3%) and deficient (5/12, 41.7%) (p = 0.001), whereas the history of other OIs showed no relation with any MBL expression type. Kaplan-Meier analysis (n = 569; log-rank p = 0.011) and Cox's proportional hazards model revealed that deficient genotype dramatically increased the risk of PCP, which is independent upon sex, age, CD4 count, HIV-1 viral load and hepatitis B and C status (adjusted hazard ratio 7.93, 95% confidence interval 2.19-28.67, p = 0.002)., Conclusions: Deficiency of MBL expression is a strong risk factor determining the incidence of PCP but not other major OIs., Competing Interests: The authors have declared that no competing interests exist.

Talaromyces marneffei is a fungal opportunistic infection usually seen in immunocompromised patients from eastern countries. In the US when examining HIV-patients for suspected fungal infections, laboratory serological tests guide therapy until cultures are available. We present the case of a 35-year-old HIV patient originally from Thailand in which urine lab results were positive for Blastomyces and Histoplasma antigen, but biopsy showed T. marneffei. Concomitantly the patient presented with hyponatremia which was deemed to be from SIADH. We present the first case of a patient with T. marneffei cross reactivity with Blastomyces, Histoplasma and SIADH due to pulmonary disease., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Importance: Cytomegalovirus (CMV) retinitis is a leading cause of blindness in many developing countries, likely the result of inadequate screening. Telemedicine screening for CMV retinitis instituted at the point of care for human immunodeficiency virus (HIV) infection may allow for earlier detection., Objectives: To determine the diagnostic accuracy of retinal photography in detecting CMV retinitis at the point of HIV care and to characterize the clinical manifestations of CMV retinitis detected through the screening program., Design, Setting, and Participants: We enrolled 103 participants from a population of 258 patients with HIV and a CD4 level of less than 100/μL treated at an HIV clinic in Thailand from June 2010 through June 2012. We captured mosaic fundus photographs through a dilated pupil using a digital fundus camera. An experienced on-site ophthalmologist masked to the results of the fundus images subsequently examined each eye with indirect ophthalmoscopy and recorded the clinical findings on a standardized form. Three remote graders evaluated each image for CMV retinitis., Intervention: Fundus photography and indirect ophthalmoscopy., Main Outcomes and Measures: Sensitivity and specificity of telemedicine relative to indirect ophthalmoscopy for diagnosis of CMV retinitis and clinical features of CMV retinitis lesions., Results: Sixteen patients (15.5%) were diagnosed as having CMV retinitis, of whom 5 (31%) had bilateral disease. Of the 21 eyes (10.2%) with CMV retinitis, 7 (33%) had visual symptoms. Retinitis lesions occupied less than 10% of the total retinal surface area in 13 of 21 eyes (62%) and did not involve the posterior pole (ie, zone 1) in 15 of 21 eyes (71%). Mean logMAR visual acuity in affected eyes was 0.41 (95% CI, 0.11-0.71; Snellen equivalent, 20/50 [95% CI, 20/25-20/100]). The mean sensitivity for the 3 remote graders in detecting CMV retinitis on fundus photography was 30.2% (95% CI, 10.5%-52.4%), and mean specificity was 99.1% (95% CI, 97.8%-100.0%). The CMV retinitis lesions missed by the remote graders (false-negative findings) were more likely to be small (P = .001) and located in the peripheral retina (P = .04)., Conclusions and Relevance: Patients undergoing screening at a clinic for HIV treatment had less extensive retinitis than patients in recent reports from an ophthalmology clinic. Retinal photography with the camera used in this study was not highly sensitive in detecting CMV retinitis but may identify disease with an immediate threat to vision. Improved accuracy will require a camera that can more easily image the peripheral retina.

Importance: Cytomegalovirus (CMV) retinitis continues to be a leading cause of blindness in many developing countries. Telemedicine holds the potential to increase the number of people screened for CMV retinitis, but it is unclear whether nonophthalmologists could be responsible for interpreting fundus photographs captured in a telemedicine program., Objective: To determine the accuracy of nonophthalmologist photographic graders in diagnosing CMV retinitis from digital fundus photographs., Design, Setting, and Participants: Fifteen nonexpert graders each evaluated 182 mosaic retinal images taken from the eyes of patients with AIDS who were evaluated at the Ocular Infectious Diseases Clinic at Chiang Mai University in Chiang Mai, Thailand., Main Outcomes and Measures: Graders diagnosed each image as CMV retinitis present, CMV retinitis absent, or unknown. The results from each grader were compared with those of an indirect ophthalmoscopic examination from an experienced on-site ophthalmologist as well as with the consensus grade given by a panel of CMV retinitis experts., Results: Relative to the on-site ophthalmologist, the sensitivity of remote CMV retinitis diagnosis by nonexpert graders ranged from 64.0% to 95.5% (mean, 84.1%; 95% CI, 78.6%-89.6%)), and the specificity ranged from 65.6% to 92.5% (mean, 82.3%; 95% CI, 76.6%-88.0%)). Agreement between nonexpert and expert graders was high: the mean sensitivity and specificity values of nonexpert diagnosis using expert consensus as the reference standard were 93.2% (95% CI, 90.6%-95.8%) and 88.4% (95% CI, 85.4%-91.1%), respectively. Mean intrarater reliability also was high (mean Cohen κ, 0.83; 95% CI, 0.78-0.87)., Conclusions and Relevance: The sensitivity and specificity of remote diagnosis of CMV retinitis by nonexpert graders was variable, although several nonexperts achieved a level of accuracy comparable to that of CMV retinitis experts. More intensive training and periodic evaluations would be required if nonexperts are to be used in clinical practice.

Purpose: To characterize the clinical manifestations of cytomegalovirus (CMV) retinitis in northern Thailand., Design: Prospective, observational, cross-sectional study., Methods: We recorded characteristics of 52 consecutive patients newly diagnosed with CMV retinitis at a tertiary university-based medical center in northern Thailand. Indirect ophthalmoscopy by experienced ophthalmologists was supplemented with fundus photography to determine the proportion of eyes with various clinical features of CMV retinitis., Results: Of the 52 patients with CMV retinitis, 55.8% were female. All were HIV-positive. The vast majority (90.4%) had started antiretroviral therapy. CMV retinitis was bilateral in 46.2% of patients. Bilateral visual acuity worse than 20/60 was observed in 23.1% of patients. Of 76 eyes with CMV retinitis, 61.8% had zone I disease and 21.6% had lesions involving the fovea. Lesions larger than 25% of the retinal area were observed in 57.5% of affected eyes. CMV retinitis lesions commonly had marked or severe border opacity (47.4% of eyes). Vitreous haze often was present (46.1% of eyes). Visual impairment was more common in eyes with larger retinitis lesions. Retinitis lesion size, used as a proxy for duration of disease, was associated with fulminant appearance (odds ratio, 1.24; 95% confidence interval, 1.01 to 1.51) and marked or severe border opacity (odds ratio, 1.36; 95% confidence interval, 1.11 to 1.67). Based on lesion size, retinitis preceded antiretroviral treatment in each patient., Conclusions: Patients seeking treatment at a tertiary medical center in northern Thailand had advanced CMV retinitis, possibly because of delayed diagnosis. Earlier screening and treatment of CMV retinitis may limit progression of disease and may prevent visual impairment in this population., (Copyright © 2012 Elsevier Inc. All rights reserved.)

This study identified causes of first hospitalization among perinatally acquired HIV-infected children at Chiang Mai University Hospital between 1989 and 2009. Data were stratified into three seven-year time periods: pre-Pneumocystis jiroveci pneumonia (PJP) prophylaxis, pre-antiretroviral therapy (ART) and ART period. Over the 21-year study period, 1121 children were hospitalized. The mean age at admission was 2.7 years and had become older over time. Of the 1121 hospitalization causes, 50.6% were AIDS-defining illnesses (ADIs), 48.1% were non-AIDS-defining illnesses (NADIs) and 1.3% were related to immune reconstitution syndrome. Types of ADIs changed over time: PJP and recurrent Salmonella septicaemia decreased, while mycobacterial infection and systemic fungal infection increased. For NADIs, bacterial infections, viral infections and gastrointestinal problems decreased, but haematological problems increased in the third period. Decline in the number of hospitalizations and mortality rate, increase in the mean age of hospitalized children, change in the distribution of specific illnesses and appearance of immune reconstitution syndrome were observed in the ART period.

Background: Cervical cancer is one of the most common AIDS-related malignancies in Thailand. To prevent cervical cancer, The US Public Health Service and The Infectious Disease Society of America have recommended that all HIV-infected women should obtain 2 Pap smears 6 months apart after the initial HIV diagnosis and, if results of both are normal, should undergo annual cytological screening. However, there has been no evidence in supporting whether this guideline is appropriate in all settings - especially in areas where HIV-infected women are living in resource-constrained condition., Methods: To determine the appropriate interval of Pap smear screenings for HIV-infected Thai women and risk factors for subsequent abnormal cervical cytology, we assessed the prevalence, cumulative incidence and associated factors of cervical cell abnormalities (atypical squamous cell of undetermined significance or higher grades, ASCUS+) among this group of patients., Results: The prevalence of ASCUS+ was 15.4% at the first visit, and the cumulative incidence of ASCUS+ gradually increased to 37% in the first 3.5 years of follow-up appointments (first 7 times), and tended to plateau in the last 2 years. For multivariate correlation analysis, women with a CD4 count <350 cells/μL had a significant correlation with ASCUS+ (P = 0.043). There were no associations of subsequent ASCUS+ with age, pregnancy, contraceptive method, highly active anti-retroviral treatment, assumed duration of infection, or the CD4 count nadir level., Conclusion: There are high prevalence and cumulative incidence of ASCUS+ in HIV-infected Thai women. With a high lost-to-follow-up rate, an appropriate interval of Pap smear screening cannot be concluded from the present study. Nevertheless, the HIV-infected Thai women may require more than two normal semi-annual Pap smears before shifting to routinely annual cytologic screening.

Disseminated penicilliosis-an AIDS-indicator disease in Southeast Asian countries -but not Japan- is a systemic fungal infection caused by Penicillium marneffei. A 30-year-old HIV-positive Japanese man visiting Southeast Asia three months before admission and reporting fever, general fatigue, and enlarged lymph nodes lasting over one month was admitted for detailed tests. Blood culture and fine-needle aspiration lymph node biopsy a led to a diagnosis of disseminated penicillioisis, later cured by several anti-fungal agents. Caution is thus recommended regarding the possibility of this disease, given the large number of travelers visiting overseas, geographical proximity to Southeast Asia, and increasing numbers of HIV patients in Japan.

Background: The International Network for the Study of HIV-associated IRIS (INSHI) recently published criteria for tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) diagnosis. The performance of this definition and clinical manifestations of TB-IRIS were studied., Methods: Antiretroviral therapy-naive HIV/TB Thai patients receiving antituberculous therapy were enrolled during 2006-2007 and prospectively followed through 24 weeks of antiretroviral therapy. Patients were defined as having paradoxical TB-IRIS if they fulfilled the 'study definition' by French 2004 and were confirmed by an external reviewer. All were later compared by the classification according to 'INSHI-2008'., Results: For the 126 patients, median baseline CD4 cell count was 43 cells/microl and HIV-1 RNA was 5.9 log(10) Y copies/ml. Seventy-three (58%) had extrapulmonary/disseminated TB. Twenty-two (18%) and 21 (17%) fulfilled TB-IRIS criteria according to the study definition and INSHI-2008 definition, respectively. Two (2%) were diagnosed by study definition only and one (1%) by INSHI-2008 definition only. Twenty (16%) were concordantly diagnosed by both definitions and 103 (82%) were consistently negative. Eighteen (82%) had worsening of a preexisting site, whereas four (18%) had TB-IRIS in a new location. Lymph node enlargement (73%) and fever (59%) were common in TB-IRIS. Sensitivity and specificity of INSHI-2008 was 91% (95% confidence interval, 72-98%) and 99% (95% confidence interval, 95-99.8%), respectively. Positive predictive value was 95% and negative predictive value was 98%. By multivariate analysis, factors predicting TB-IRIS were extrapulmonary TB (odds ratio, 8.63) and disseminated TB (odds ratio, 4.17)., Conclusion: There was high concordance between the INSHI-2008 and French 2004 definition for TB-IRIS diagnosis in HIV/TB patients with relatively high rate of paradoxical TB-IRIS. This suggests that lack of HIV-1 RNA and CD4 cell count monitoring does not impede the ability to diagnose TB-IRIS.

Introduction: This study aimed to determine the prevalence and risk factors of drug-resistant tuberculosis (TB), and to develop a diagnostic algorithm for newly-diagnosed TB patients., Methods: This is a retrospective medical chart review of 290 patients who were diagnosed with bacteriological-proven pulmonary TB between 2000 and 2006 in Ramathibodi Hospital, Thailand. Patient characteristics, radiological and microbiological findings, as well as a history of previous TB disease and treatment, were included in the analysis of predictive factors of drug resistance. Predictive scores were derived from statistically significant factors at the cut-off point of the receiver-operating curve that yielded the best area under the curve., Results: The resistance rate to each of these drugs among 290 patients was: isoniazid, 6.9 percent; rifampicin, 4.5 percent; either isoniazid or rifampicin, 9.0 percent; and multidrug resistance, 2.4 percent. Far advanced TB was an independent risk factor for isoniazid resistance. Rifampicin resistance was associated with recurrent TB within six months after the completion of treatment and prior incomplete TB treatment. A drug-resistant TB predictive score of either isoniazid or rifampicin resistance was developed based on the aforementioned factors. The cut-off score of greater than or equal to 3 yielded the least error of classification in differentiating patients with the resistant strain from those with the susceptible strain at a sensitivity of 57.7 percent, a specificity of 67.8 percent, a positive predictive value of 15 percent and a negative predictive value of 94.2 percent., Conclusion: Our study suggested a drug-resistant TB predictive score for the exclusion of either isoniazid or rifampicin resistance, and provides a decisional guide for the clinician on whether to send a patient's respiratory specimen for sputum culture and drug susceptibility testing.

Objective: To determine the underlying cause of the brain lesions in adult HIV patients referred for CT scan at Ramathibodi Hospital and to evaluate accuracy of CT for the diagnosis of the brain lesion., Material and Method: Data from first CT scan of the brain of 195 adult HIV patients at Ramathibodi Hospital were reviewed The final diagnoses from medical records were assessed followed by CSF analysis, pathological report, and therapeutic treatment. The accuracy of the CT brain was evaluated using sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV)., Results: One hundred ninety five adult seropositive patients for HIV underwent CT scan of the brain, 59% were HIV encephalopathy (HIVE), 22% toxoplasmosis, 9% cryptococcoma, 5% tuberculous meningitis, 4% tuberculoma, 3% progressive multifocal leukoencephalopathy (PML), 2% lymphoma, and 1% normal. In non-specified causes (from CT scan), 33% were meningitis, 4% cerebritis, and 5% infarction. CT was found to have high sensitivity, specificity, PPV, and NPV for toxoplasmosis (92%, 96%, 86%, and 98%, respectively)., Conclusion: HIV encephalopathy was the most common finding of adult HIV brains. Toxoplasmosis was the most common opportunistic parenchymal brain lesion in adult HIV brains. CT was the modality of choice for diagnosis and exclusion of toxoplasmosis, but it cannot determine the cause of disease showing meningitis pattern.

Purpose: To determine the aetiology and clinical characteristics of patients with uveitis in a tertiary ophthalmology centre in northern Thailand., Methods: Standard ophthalmological examination and laboratory screening blood tests were performed in 200 consecutive new patients with uveitis. Patients were classified according to the location and aetiology of the uveitis. Specific clinical characteristics were recorded., Design: Prospective case series., Results: The case series included 106 male and 94 female patients with a mean age of 38 years. HIV-associated uveitis was noted in 31% (62/200), and included mostly patients with cytomegalovirus retinitis (85%, 53/62). In the non-HIV group, the most common anatomical type was anterior uveitis (34%, 47/138). Infectious uveitis was diagnosed in 22% (30/138) of non-HIV patients, and toxoplasmosis was the most common infection (12/138, 8.7%). The most common non-infectious clinical entities were Vogt-Koyanagi-Harada disease (20%, 22/108) and HLA-B27-associated acute anterior uveitis (9%, 10/108)., Conclusions: The spectrum of uveitis in northern Thailand included 27% of HIV-infected patients with cytomegalovirus retinitis. Causes of non-HIV uveitis were similar to those often observed in the Far East, but the specific prevalences of these disorders were distinct from that found in India and Japan.

Background: Epidemiology and clinical features of newly diagnosed HIV-infected patients vary and depend on period of time and geographical area., Methods: A retrospective review was conducted in adults with positive HIV antibody testing between January and December 2006 at a university hospital setting., Results: Prevalence of HIV infection was 1.0%. There were 221 patients with a median age of 35.5 (range, 15.8-72.3) years, and 57% were males. The most common risk of HIV acquisition was heterosexual (63.8%). The most common reason for HIV testing was preoperative screening (41.2%). Of all, 52.9%, 37.1%, and 10% were diagnosed as AIDS, asymptomatic, and symptomatic patients, respectively. Median CD4 count at HIV diagnosis was 260 (range, 6-1284) cells/mm(3). AIDS-defining illnesses were found in 35.7%. Overall mortality rate was 1.8%., Conclusions: More than half of newly diagnosed HIV-infected patients have advanced HIV disease and are unaware of their HIV status. These results reflect inadequate education of HIV risks and voluntary HIV testing in Thailand.

We describe a case of disseminated Penicillium marneffei in a human immunodeficiency virus (HIV)-positive Italian man who stayed for 4 years in Chiang Ray province, northern Thailand. A review of the literature shows that penicilliosis, although unusual, may represent an emerging opportunistic infection among HIV-positive people traveling to endemic areas.

Introduction: Histoplasmosis and penicilliosis are infections caused by the dimorphic fungi, Histoplasma capsulatum and Penicillium marneffei, respectively. The aim of this study was to compare the clinical presentation, laboratory and radiologic findings and outcome of these infections at Srinagarind Hospital, Khon Kaen, Thailand., Methods: The medical records of patients who had positive cultures for Histoplasma capsulatum and Penicillium marneffei during 1996-2002 were reviewed. The data were compared and analyzed by the Chi-square and Fisher's exact tests., Results: There were 32 and 36 medical records of patients with H. capsulatum and P. marneffei infection, respectively, available for review. The most common underlying disease of patients with histoplasmosis and penicilliosis was acquired immunodeficiency syndrome (AIDS), which accounted for 90.6% and 91.7%, respectively. The most common clinical findings in both infections were fever, weight loss, cough, anemia, lymphadenopathy, hepatomegaly and splenomegaly. Frequencies of skin lesions were not statistically different between either group (P=0.20). Laboratory findings were similar between the two infections, except hyperbilirubinemia, which was more common in the penicilliosis group (P=0.02). There were similar abnormal X-ray findings in both groups with interstitial infiltration the most common abnormality., Conclusions: Histoplasmosis and penicilliosis had similar clinical presentations, laboratory findings and chest X-ray abnormalities. Itraconazole is recommended as secondary prophylaxis in HIV-infected patients who have histoplasmosis or penicilliosis.

Objective: To identify the magnitude of ocular complications in HIV infection in Chiang Mai, and determine the signs or symptoms that indicate the risk factors for developing ocular complications in HIV-positive patients, Method: A prospective study was carried out in newly diagnosed HIV-positive patients seen in the Ocular Infectious Disease Clinic of Maharaj Nakorn Chiang Mai Hospital from March 1, 2000 through February 28, 2001. A complete ophthalmic examination was performed on each patient together with a systemic evaluation of present illness and current medications., Results: Three-hundred and ninety-five HIV-positive patients were seen for ophthalmic evaluation. Of these, 90 were in stage A (asymptomatic), 84 were in stage B (symptomatic), and 221 were in stage C (AIDS). Ocular complications were found in 44.6 per cent of the patients. Cytomegalovirus (CMV) retinitis was the most common ophthalmic complication (33%). Other ocular complications included cotton wool spot (8%), uveitis (4%), optic neuropathy (3%), and keratoconjunctivitis sicca (2%). The clinical presenting symptoms, which were the indicators for ocular complications and CMV retinitis, included chronic cough, oral thrush, chronic diarrhea, weight loss, wasting, and skin disorders. Ocular symptoms, which indicated a high risk of developing CMV retinitis, included flashing, floaters, and scotoma., Conclusions: Ocular complications are common in HIV-positive patients. CMV retinitis, which is a major vision-threatening problem, represented the most common finding. It is recommended that HIV-positive patients should have their eyes examined regularly, particularly when they have the clinical presenting symptoms previously mentioned. The patients should also notice early symptoms of CMV retinitis, which includes flashing, floaters, and scotoma.

Of the 169 human immunodeficiency virus (HIV)-infected children being cared for at Siriraj Hospital from January 1998 to September 2000, 10 had Mycobacterium avium complex (MAC) infection; seven had disseminated disease and three had MAC pneumonia. Nine children were in the advanced stage of HIV disease at the time of diagnosis with the median CD4 count of 7 cells/mm3 and 127 cells/mm3 and the median age of 65 months and 63 months in disseminated MAC and MAC pneumonia respectively. None of these children had received prior chemoprophylaxis. Common clinical findings included prolonged fever, weight loss, lymphadenopathy, hepatosplenomegaly, diarrhea, anemia and leukopenia. The outcome of MAC infection was poor, with a mortality rate of 60 per cent. In in vitro susceptibility testing, clarithromycin was the least resistant drug. With the incidence rate of 2.15 per 100 person-years, the high rate of antimicrobial resistance, and the poor outcome, primary chemoprophylaxis for MAC infection in conjunction with effective antiretroviral therapy should be considered for Thai children in the advanced stage of HIV infection.

Persons with advanced human immunodeficiency virus (HIV)-1 infection are susceptible to disseminated mycobacterial infections. In the United States, most such infections are caused by Mycobacterium avium or M. intracellulare (i.e., M. avium complex [MAC]). In less developed countries, M. tuberculosis is equally or more prevalent than MAC in persons with HIV-1 infection. Other mycobacterial species have been reported to cause disseminated infection in HIV-infected persons, including Simiae-Avium (SAV) group mycobacteria. SAV group organisms share characteristics of M. avium and M. simiae. Although disseminated (i.e., the isolation of a mycobacterial species from the blood) infection with M. simiae has been reported in HIV-infected persons, another distinct species within the SAV group, M. triplex, was characterized in 1996. Two cases of disseminated infection caused by M. triplex have been reported in HIV-1-positive persons. This report describes four HIV-infected patients from Bangkok, Thailand, and Lilongwe, Malawi, who were infected with SAV group organisms. Because different mycobacterial species are not susceptible uniformly to antimycobacterial agents, accurate identification of mycobacterial species causing an infection is crucial for directing appropriate therapy.

The prevalence of Cryptosporidium in 156 HIV-infected Thai patients who had acute diarrheal illness at Bamrasnaradura Infectious Diseases Hospital, was studied. This cross-sectional study was performed from March to August in year 2001. The patients ranged in age from 1 month-65 years old. A stool sample from each subject was stained to find the oocysts by modified Ziehl Nelson carbolfuchsin staining. According to the present study, a diagnosis of Cryptosporidium parvum infection was found in 20 patients (11 males and 9 females). The prevalence of cryptosporidiosis in the present series was 12.8 per cent (10.0% in males and 19.1% in females). This infection rate between males and females was not significantly different. Comparing this prevalence to a report in the previous 5 years in the same hospital, the same high rate can be seen.

Setting: Chiang Rai Hospital, Chiang Rai Province, the epicentre of the human immunodeficiency virus (HIV) in Thailand., Objective: To describe the health seeking behaviour among tuberculosis (TB) patients, to measure patient and provider delays and to analyse factors determining these delays., Design: All patients aged over 15 years with new smear-positive pulmonary TB detected in Chiang Rai Hospital (n = 557) were interviewed using a structured questionnaire., Results: The median patient delays for HlV-positive and HIV-negative patients and those whose HIV status was unknown were 10, 15 and 15 days respectively, while provider delays were respectively 7, 7.5 and 10 days. HIV-positive patients suffered more symptoms and had a shorter patient's delay. Risk factors of long patient delay (>21 days) included being HIV-negative, having no health insurance, hill tribe ethnicity, no previous visits to the hospital, and borrowing money for hospital visits. Multivariate logistic analysis suggested that being married or widowed and being HIV-positive led to the shortest patient delay. Provider delay was significantly longer in female patients than male patients., Conclusion: Although patient and provider delays were favourably short, certain specific groups require further attention. Hill tribe people should be targeted to improve accessibility to TB treatment. Active case-finding services for people known to be HIV-positive should be encouraged. The reasons for the longer provider delay in female patients require further investigation.

The objectives of this study were to determine levels of oral yeasts in Thai people at different stages of HIV infection compared with HIV-negative controls, to identify factors associated with the levels of oral Candida, and to determine whether the levels of the organism can be used as a predictive clinical marker in HIV-infected individuals. One hundred and eighty HIV-infected heterosexual persons and intravenous drug users (IVDUs) were enrolled (152 men, 28 women). Eighty-three HIV-free subjects from the same population were included as controls (48 men, 35 women). Oral yeasts were isolated in 103 HIV-infected subjects (57.2%) and 36 HIV-negative controls (43.3%). The mean number of colony forming units (CFU) of oral Candida in the first group was 1.9x10(4) CFU/ml (range 2.2x10(2)-4.0x10(6) CFU/ml), which was significantly different statistically when compared with 1.7x10(3) CFU/ml (range 4.0x10(2)-1.2x10(5) CFU/ml) in the control group (P=0.0000). The following factors are significantly associated statistically with the levels of oral Candida among the subjects (P<0.05): age, stage of HIV infection, total number of lymphocyte cell count, risk group, nutritional status, general health status, weight loss, type of oral lesions and number of oral lesions and number of sites affected. The study revealed that HIV serostatus, stage of HIV infection, and the occurrence of oral lesions among HIV-infected subjects may be predicted by the levels of oral Candida (P<0.05). By using a cut-off point of 2.0x10(3) CFU/ml, the sensitivity and predicitve values of the level of oral Candida on the HIV serostatus was higher than that based on the culture positivity results alone, although the specificity was similar. These findings suggest that, in conjunction with some other clinical signs and laboratory findings, the levels of oral Candida may be used as a predictive marker of disease in HIV infection.

Thailand experienced its first case of AIDS in 1984. Approximately 800,000 Thais were infected with HIV in 1995 and 1 million Thais became infected by the year 2000. There have been 5 major epidemic waves: among male homosexuals (started 1984-5), intravenous drug users (started 1988), female commercial sex workers (started 1989), male clients (started 1990), and housewives and the newborn (started 1991). Approximately 96 per cent of HIV-1 infected Thais carried recombinant subtype A/E, the rest carried B'. In a male seroconvertors cohort of 235 cases, median time to show CD4 <200 cells/microL was 6.8 years. Five years survival was significantly lower than that of the other subtype B seroconvertors study, i.e., 82 per cent compared to 90 per cent. Interestingly, 13.5 per cent of seronegative Thais showed homozygous SDF1-3'A polymorphism, which suggests that approximately one-tenth of Thais may become long-term non-progressors after HIV-1 infection. Primary HIV infection syndrome is rare among Thai patients (1.1%). In contrast, it was 50-90 per cent in Western cohorts. In early symptomatic patients, one-third developed pruritic pappular eruptions (PPEs). In advanced stage, disseminated tuberculosis, Pneumocystis carinii pneumonia (PCP), cryptococcosis, and esophageal candidiasis are commonly found. In Northern Thailand, however, Penicillium marneffei infection or penicillosis is more common than cryptococcosis. The recent understanding of HIV pathogenesis suggests that HIV eradication is unlikely to be achievable with current strategies. Several National HIV treatment guidelines including the Thai guideline have been recommended treatment with triple antiretroviral regimen when patients become symptomatics or CD4+ <200. Current development of antiretroviral therapy which includes new agents, new formulas, and pharmacokinetic enhancements, is directed to better potency, higher genetic resistant barrier, less pill burden, and once a day dosing. These will ultimately improve the adherence and the long-term effectiveness of antiretroviral treatment. In reality, however, although the cost of triple regimen is dramatically declining, many patients still can not afford it. Primary prophylaxis and early diagnosis and treatment of opportunistic infection should be considered in patients with CD4+ <200 cells/microL. Modified short course ZDV studies and donation campaigns for preventing mother-to-child transmission, clinical trials to investigate the best use of expensive anti HIV medications in a poor resource setting have been or are being conducted. Nine phase I/II HIV-1 vaccine trial protocols have been or are being tested. A phase III trial of gp120 subtype B/E (AIDSVAX, VaxGen) was started in 1999, a total of 2,500 volunteers will be enrolled, and interim analysis is planned for August 2002. Thai investigators are also participating in pre-clinical development of recombinant BCG and DNA vaccines. Multidisciplinary and multi-level approaches, both by the government and private sectors, have had a positive impact on the HIV epidemic as shown by the declining seroprevalence of HIV infection in Thai male conscripts, and of major sexually transmitted diseases in men. Nevertheless, more effort at the grass roots level is needed to ensure further success and sustainability of the control of the HIV epidemic in Thailand.

The authors reported 8 children with cryptococcosis from King Chulalongkorn Memorial Hospital from 1991 to 2000. Five patients were older than five years. The two common underlying diseases were HIV/AIDS (5 cases) and systemic lupus erythematosus (2 cases). Seven cases had been observed in the past four years, four of these in 2000. One patient developed disseminated disease and two patients died. In the era of HIV/AIDS and due to the fact that HIV-infected children are tending to live longer, we may encounter a higher occurrence of this opportunistic fungus in children.

Toxoplasmosis in an immunocompromised host was not documented in Thailand until 1992 when HIV/AIDS infection became pandemic. Patients with toxoplasmic encephalitis and cerebral abscess were recorded, particularly from the northern part of the country. However, data on the prevalence of the disease in HIV/AIDS patients is not yet available. In this study the authors determine the prevalence of T. gondii antibody in HIV persons. During a two-year period 312 serum samples of which 190 were HIV positive and the remaining samples were negative for HIV were tested. In the HIV positive group, 44 samples (23.2%) were positive for toxoplasma IgG antibody, whilst in the HIV negative group 36 samples (29.5%) were positive. All antibody titres found were not higher than 1:64. There is no significant difference of toxoplasma IgG antibody in HIV positive and HIV negative persons (p = 0.25). Among the HIV positive and T. gondii antibody positive group, 19 out of 44 persons (43.2%) had symptoms and signs of acute toxoplasmosis involving the eye and/or the central nervous system. Due to the high reactivation rate, the authors propose that all HIV-infected persons should be tested for T. gondii antibody and prophylactic treatment of opportunistic infection from T. gondii should be considered in those with positive results.

We examined 91 children under the age of 13 years with definite HIV infection born to HIV-seropositive women. The clinical spectrum of HIV infection in children younger than 13 years who are born to HIV-infected mothers was revised in 1994 into four clinical categories: category N (not symptomatic), category A (mildly symptomatic), category B (moderately symptomatic), and category C (severely symptomatic). Mucocutaneous manifestations were found in 47 (51.6%) of these children. The prevalence of mucocutaneous manifestations in categories A, B, and C were 4%, 62%, and 75%, respectively. The mucocutaneous manifestations in patients in categories B and C were significantly more common than in those category A (p < 0.001). The most common finding was oral candidiasis (36.3%). Drug rash, pruritic papular eruption, herpes zoster, cutaneous candidiasis, Penicillium marneffei infection, and herpes simplex virus stomatitis were found in 6.6%, 5.5%, 4. 4%, 3.4%, and 2. 2% of patients, respectively. All three patients who had disseminated P. marneffei infection were in category C.

Toxoplasma gondii has been recognized as an important cause of morbidity and mortality among immunocompromised persons. The diagnosis of T. gondii infection is most often based on serological tests results. Serological diagnosis can be limited in AIDS patients because of depressed antibody responses. Fifty serum samples were used in this study to investigate serological evidence of toxoplasmosis in HIV positive Thai patients by Platelia kit, the commercial enzyme-linked immunosorbent assay (ELISA) in which the membrane protein p-30 is the predominant antigen and immunoblot technique (IB). Sera of HIV positive Thai patients with Toxoplasma infection recognized the same antigenic component, the 32 kDa antigenic band, as is recognized by Toxoplasma positive sera from immunocompetent patients and it may represent a specific marker for diagnosis of Toxoplasma infection in HIV positive Thai patients.

Objective: To characterize the clinical spectrum of disease and immune status of adult HIV-1-infected patients in Bangkok., Design: Cross-sectional survey of hospital admissions., Methods: From November 1993 through June 1996, demographic, clinical, and laboratory data were collected from HIV-infected inpatients (> or =14 years old) at an infectious diseases hospital., Results: Of 16,717 persons admitted, 3112 (18.6%) were HIV-seropositive, 2261 of whom were admitted for the first time. Of 2261, 1926 (85.2%) were male, 1942 (85.9%) had been infected heterosexually or by means not related to drug use, 319 (14.1%) were injection drug users (IDUs), and 1553 (68.7%) had AIDS. The most common AIDS-defining conditions were extrapulmonary cryptococcosis (EPC; 38.4%), tuberculosis (TB; 37.4%), and wasting syndrome (WS; 8.1%). IDUs were more likely (p < .05) to have TB or WS but less likely (p < .05) to have EPC or Pneumocystis carinii pneumonia than patients with no history of injection drug use. Lymphocyte counts were measured for 2047 (90.5%) patients; 81.8% had < or =1500 lymphocytes/microl., Conclusion: These HIV-infected patients were admitted with severe immunosuppression. Cryptococcosis and TB are major problems and differ in prevalence among IDUs and persons infected sexually. Clinical and immunologic information is critical in improving the lives of HIV-infected persons in Asia through prevention, treatment, and prophylaxis.

Giardia lamblia, a flagellate protozoan is a protozoa, frequently associated with diarrhea in AIDS patients (adults and children). Transmission occurs via the fecal-oral route by ingestion of infectious cysts in contaminated food or drinking water. Giardia lamblia can cause diarrhea and intestinal malabsorption in both AIDS and non-AIDS patients. The prevalence rate of diarrhea caused by Giardia lamblia in AIDS patients is higher than in those without AIDS, due to humoral immune defect in AIDS patients. The most common symptoms are abdominal distress, watery diarrhea and weight loss. The clinical symptoms in AIDS patients are similar to those in non-AIDS patients. Diagnosis may be made by identifying either cysts or trophozoites in a stool sample, duodenal biopsy and aspirate. Metronidazole is the common drug of choice. Relapse may be found in AIDS patients. At present there is no vaccine. Prevention requires proper handling, good hygiene and treatment of water used for AIDS patients.

Infections caused by nontuberculous mycobacteria (NTM), although rare in immuno-competent individuals, can potentially produce problems in immunocompromised patients such as those with acquired immunodeficiency syndrome (AIDS). In this study, hemocultures for mycobacteria using radiometric BACTEC 13A media were taken from 334 patients with known human immunodeficiency virus infection admitted to four referral hospitals with fever of unknown site of infection and negative blood cultures for pathogenic bacteria. The mycobacterial hemocultures were positive for Mycobacterium avium complex (MAC) in 58 patients (17.4%) and positive for Mycobacterium tuberculosis in 34 patients (10.2%). The results of this study have proved that MAC infection, indeed, exists among Thai AIDS patients. The prevalence of MAC infection in Thailand is very high and comparable to that in the western countries. Physicians taking care of AIDS patients in Thailand should be aware of potential MAC infection, particularly in advanced cases. Considering the high prevalence of infection, primary prophylaxis against MAC infection in advanced AIDS patients is recommended.

Penicillium marneffei has emerged as an important opportunistic pathogen in HIV-infected patients in Southeast Asia. We report the first 5 cases of P. marneffei diagnosed in Singapore. All the patients were HIV-infected and were either Thai nationals or had frequently travelled to Thailand. Fever, weight loss, anaemia and papular skin lesions were common clinical manifestations in our patients, all of whom had the organism isolated from blood. Skin biopsy specimens showed histological evidence of P. marneffei in 2 patients. In 1 patient each, the organism grew in cultures of specimens from bone marrow and respiratory secretions. Amphotericin B therapy followed by itraconazole were used in 3 of our 5 patients and was associated with good clinical response and outcome.

Diarrheal disease and its associated morbidities occur frequently in patients infected with human immunodeficiency virus (HIV) and may be associated with a decreased quality of life. We studied the spectrum of symptoms, measures of nutritional status, and the enteric pathogens associated with diarrheal disease in a group of 24 patients infected with HIV in Bangkok, Thailand compared with a group of 19 patients infected with HIV without diarrhea cared for at the same clinic. Patients with diarrhea appeared to have more advanced disease by CD4 cell counts and complained more frequently of symptoms such as anorexia, gas, and bloating than patients without diarrhea. Patients with diarrhea had a tendency toward a lower nutritional status, as measured by body mass index and mid arm circumference. Stool culture and examination revealed that enteric pathogens including Salmonella species and Cryptosporidium parvum sporidia were recovered at equal frequencies in patients with and without diarrhea (27% of the patients with diarrhea and 25% of the patients without diarrhea). Microsporidia was identified in one patient with diarrhea. It was not possible to identify a pathogen in 73% of the patients with diarrhea and 75% of the patients without diarrhea, suggesting that additional agents or factors may be responsible for the diarrheal symptoms in the patients with diarrhea. More extensive studies to identify potentially treatable pathogens in HIV-infected patients with diarrhea in Thailand are warranted and further attempts to better define the syndrome of pathogen-negative diarrheal disease in patients infected with HIV might result in the development of more targeted interventions in these patients.

Thirteen strains of Histoplasma capsulatum were isolated from clinical specimens, including those from AIDS patients, in Thailand. Random amplified polymorphic DNA (RAPD) analysis with three different PCR primers showed that the DNA fingerprint patterns of the Thai isolates were very similar to each other and homogeneous, with only one exceptional strain, although the patterns were clearly different from those of a reference North American strain with all primers tested. Although the difference in the DNA fingerprinting patterns was minor, Thai isolates could be classified into two to four groups. A common PCR band (about 700 bp) in the patterns of all H. capsulatum strains was extracted, and its DNA sequence was determined. A new PCR primer set for the identification of H. capsulatum species was developed based on this sequence information. This primer set was 100% successful in the identification of the reference strain as well as all Thai isolates. The results of specificity tests of the primer set for the identification of the fungus are also discussed.

Two imported cases of Penicillium marneffei infection in Belgium are reported. Both patients are Thai women co-infected with HIV. P. marneffei infection should be suspected in immunocompromised patients originating or travelling from South-East Asia with unexplained fever (> 38 degrees C), weight loss, a generalised lymphadenopathy, hepatomegaly, splenomegaly, skin lesions, cough and anaemia. Diagnosis is made by culture and/or histopathological examination. Mild to moderate infections are treated with itraconazole 400 mg/day as first choice. Amphotericin B parenteral therapy may be required for seriously ill patients. Maintenance therapy with itraconazole 200 mg/day is necessary to prevent relapses.

Primary laryngeal cryptococcosis was reported in a 42-year-old man with AIDS. The patient also had pulmonary tuberculosis and hydropneumothorax as a complication. Serological tests and/or cultures from blood, CSF, urine and pleural fluid were all negative for cryptococcus. He was successfully treated with oral fluconazole for 8 weeks to clear the infection and remained clear in the follow-up period 9 months after treatment.

Penicillium marneffei is a common cause of opportunistic fungal infection in patients with AIDS in Thailand. The diagnosis of penicilliosis is easily made when typical skin lesions appear but is frequently missed in their absence. We therefore attempted to identify noncutaneous indicators of P. marneffei infection in order to provide early curative treatment. We recognized a characteristic syndrome in six AIDS patients with penicilliosis involving primarily the liver but not the skin who presented with fever of short duration, hepatomegaly, and markedly elevated serum alkaline phosphatase levels. The diagnosis was confirmed by demonstrating the causative organism in the liver or in the blood. Increased awareness of hepatic penicilliosis and more-rapid diagnostic methods are needed to reduce the high mortality rate associated with this syndrome. P. marneffei is predominantly an Asian pathogen, but as a result of international travel, the need for increased awareness of penicilliosis is worldwide.

Setting: Chiang Rai, the northernmost province of Thailand, where extensive human immunodeficiency virus (HIV) transmission has resulted in a rapid increase in tuberculosis., Objective: To assess the utility of tuberculin and anergy skin testing to identify latent Mycobacterium tuberculosis infection in HIV-infected persons., Design: A cross-sectional study and analysis were conducted to examine reactivity to tuberculin and two control antigens (mumps and candida) in HIV-negative and HIV-positive blood donors and female sex workers., Results: HIV-positive persons had markedly decreased tuberculin reactivity; 14%, 19%, and 40% had an induration of > or = 10 mm, > or = 5 mm, > or = 2 mm, respectively, while 51% of 525 HIV-negative persons had an induration of > or = 10 mm (P < 0.001). Mumps and candida positivity (reactions of > or = 3 mm) were found in 94% and 78% of HIV-negative persons compared with 72% and 61% of HIV-positive persons, respectively (P < 0.001). Although HIV-positive persons had markedly less tuberculin reactivity even at higher CD4+ cell counts (> 400 cells/microL), reactivity to mumps and candida was present in more than half of HIV-positive persons with low CD4+ cell counts (< or = 200 cells/microL). Reaction to control antigens did not predict tuberculin reactivity., Conclusion: In this setting, tuberculin and anergy skin testing have a low predictive value in detecting M. tuberculosis infection in HIV-infected persons, and therefore such testing has a limited role in identifying HIV-infected persons who may benefit from tuberculosis preventive therapy programs.

Setting: Patients were recruited from Siriraj, Bamrasnaradura, and Central Chest Hospitals, the three major hospitals responsible for tuberculosis patients in Bangkok, Thailand, and vicinity., Objective: To evaluate a new rapid serologic test, the MycoDot test, for diagnosis of tuberculosis (TB)., Design: The study was conducted as a cross-sectional survey. A total of 594 patients were tested with the MycoDot test. This included 142 human immunodeficiency virus (HIV) seropositive patients with active TB, 144 HIV seronegative patients with active TB, 153 HIV seropositive controls, and 155 HIV seronegative controls., Results: The sensitivity of the MycoDot test for detection of TB was 40.1% in HIV seropositive patients, compared with 63.2% in HIV seronegative patients (P < 0.001). If only patients with laboratory proven TB were evaluated, the sensitivity was 40.6% in seropositive and in 70.8% seronegative patients. The sensitivity of the MycoDot test was similar in TB patients with pulmonary and extra-pulmonary disease. The sensitivity of the test in patients with CD4 counts > or = 200 cells/mm3 was significantly higher than in those with CD4 counts < 200 cells/mm3. The specificity of the test was 97.4%, and was identical in HIV seropositive and seronegative individuals., Conclusion: The MycoDot test had a higher sensitivity for the diagnosis of TB among HIV seronegative than HIV seropositive patients. Although the MycoDot test has a less than optimal sensitivity, the test specificity approaches 100%. It may be useful in patients with suspected TB and negative smears and in extra-pulmonary TB.

Eight sera from culturally-proven cases of penicilliosis marneffei and their corresponding isolates were examined for circulating antibody(ies) and antigen, and exoantigens, respectively, using a microimmunodiffusion (MID) test. Two of the 8 sera produced strong precipitins (1-2) when reacted against control Penicillium marneffei antigen (5-week-old shaken cultures at 25 C) in the presence of control rabbit anti-P. marneffei serum. Five of the 8 sera produced a strong precipitin line when reacted against control hyperimmune serum to P. marneffei. These five sera, and one additional serum, which tested negative for antibody to P. marneffei, demonstrated the presence of antigen by reacting only against the anti-P. marneffei serum. Serological evaluations of the sera revealed that the MID test is capable of detecting antibody and antigen in AIDS patients having penicilliosis marneffei infections. Exoantigen analysis of the 8 P. marneffei isolates, which were previously identified using the conventional and time-consuming macro- and micro-morphological characteristics, showed the presence of 1 to 4 specific exoantigens in MID. With the exoantigen analysis, the identity of all of the isolates was confirmed as P. marneffei. Our studies indicated that the serological tests are useful for detecting circulating antibody and/or antigen in patients' sera, and that the exoantigen test is reliable for confirming the identity of P. marneffei cultures.

A prospective study was designed to investigate the causes of chronic diarrhea in AIDS patients in Thailand. Forty-five patients from Bamrasnaradura Infectious Diseases Hospital were enrolled. Extensive investigations included multiple stool examinations for ova and parasites, using the stool formalin-ether concentration method, stool culture, stool acid-fast bacilli (AFB) stain, stool modified AFB stain, esophagogastroduoscopy with duodenal aspirate and biopsy, and colonoscopy with biopsy. Biopsied specimens were examined with H&E, Giemsa, Gram, Periodic acid Schiff, and AFB stains. Definitive causes were found in 29 patients (64.4%). Of these 29, 7 patients were found to habor more than 1 pathogen (15.5%). The most commonly found enteric pathogen was Cryptosporidium parvum (20.0%). Less frequently found pathogens were Mycobacterium tuberculosis (17.8%), Salmonella spp. (15.5%), Cytomegalovirus (11.1%), Mycobacterium avium intracellulare (6.6%), Strongyloides stercoralis (4.4%), Giardia lamblia (4.4%), Cryptococcus neoformans (2.2%), Histoplasma capsulatum (2.2%), Campylobacter jejun (2.2%), and Cyclospora cayetanensis (2.2%). Salmonella spp., Mycobacterium tuberculosis, and Mycobacterium avium intracellulare infections were shown to be more common in Thailand than in African countries.

Disseminated infection with the fungus Penicillium marneffei is one of the most common opportunistic infections in human immunodeficiency virus (HIV) disease in northern Thailand. We report the clinical, laboratory and therapeutic features of 21 human immunodeficiency virus-infected children with disseminated P. marneffei who were prospectively followed. Significant clinical and laboratory features included generalized lymphadenopathy (90%), hepatomegaly (90%), body temperature > 38.5 degrees C (81%), papular skin lesions with central umbilication (67%), splenomegaly (67%), failure to thrive (52%), severe anemia (hemoglobin < 60 g/liter) (43%) and thrombocytopenia (platelet count < 0.5 x 10(11)/liter) (21%). The response rate in patients who were treated with appropriate antifungal therapy (amphotericin B, fluconazole or ketoconazole) was 82%. No relapse was observed in patients given ketoconazole prophylactically. Skin lesions, usually papules with central necrotic umbilication, provide the most significant clue to the diagnosis. Early diagnosis based on finding P. marneffei in the skin smear or lymph node provides the basis for prompt administration of antifungal therapy and improved outcome.