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Background There have been reports concerning an association between human immunodeficiency virus (HIV) infection and autoimmune and rheumatic diseases. Objective The purpose of this study was to examine autoimmune and rheumatic manifestations in HIV-infected patients and their correlation with antinuclear antibody (ANA) tests. Methods The clinical and laboratory results of HIV-infected patients attending the Department of Dermatology, Siriraj Hospital, Bangkok, Thailand, from February 1999 to January 2000, were analyzed. Laboratory studies included serum CD4 lymphocyte count and ANA tests. Results Sixty-two patients were enrolled prospectively in the study. Myalgia was the most common clinical presentation (50%). Others included photosensitivity (on history) (39%), arthralgia (26%), vasculitis (18%), sicca complex (10%), arthritis (7%), and Reiter's syndrome (2%). A history of hair loss was given by 23% of patients. A positive ANA test was detected in 3%. No cases of systemic lupus erythematosus, scleroderma, or dermatomyositis were seen. Conclusions Autoimmune and rheumatic manifestations were not uncommonly detected in patients with HIV infection. HIV infection may sometimes mimic systemic lupus erythematosus clinically.

Background Deep fungal and higher bacterial skin infections occur fairly frequently in Thailand. Methods Cases with a provisional diagnosis of deep fungal and higher bacterial infections were prospectively collected from 1994 to 1997 in the Granuloma Clinic, Department of Dermatology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand. Demographic data, clinical manifestations, causative organisms, histologic features, treatment, and outcome were investigated. Results The total cases in a 4-year period numbered 27. The male to female ratio was approximately 1 : 1. Mycetoma was most common, followed by chromoblastomycosis. Actinomycetoma was similar in incidence to eumycetoma. The only causative organism that could be identified among the mycetoma cases was Cladosporium carrionii, which caused mycetoma of the buttock of an aplastic anemia patient at the site of bone marrow aspiration. Surgical treatment was recommended for eumycetoma. Chromoblastomycosis was caused by C. carrionii and F. compactum and responded well with itraconazole orally. Mycotic abscesses were found in four cases, basidiobolomycosis in two cases, and cutaneous nocardiosis in one case. Cotrimoxazole was recommended in the treatment of actinomycetoma, cutaneous nocardiosis, and basidiobolomycosis. Conclusions Localized, chronic, slow, progressive, and usually asymptomatic were the main cutaneous manifestations of deep fungal and higher bacterial skin infections. A skin biopsy for histologic study and culture identification should be performed in every suspected case. The causative organisms were found in the histologic sections of every case, but only about one-third were found by culture.

This prospective, double-masked, randomized study was performed in 14 centers throughout Asia (The Philippines and Thailand), Latin America (Mexico, Peru, Chile, and Venezuela), and Europe (Poland, Hungary, and the Czech Republic). Outpatients with acute mild-to-moderate skin and soft-tissue infections (cellulitis, impetigo, folliculitis, furunculosis and carbuncles without surgical incision, and skin wound infections from trauma) were randomly assigned to one of the following regimens for a total of 7 to 14 days: (1) clindamycin 150 mg four times daily (QID) (CLIN 150); (2) clindamycin 300 mg twice daily (BID) (CLIN 300); or (3) dicloxacillin 250 mg QID (DICLOX). Patients were assessed clinically and bacteriologically at the end of treatment and 2 to 3 weeks after treatment. Study variables included clinical and bacteriologic outcomes. No statistically significant differences in any of the study variables were noted between the treatment groups either at the end of therapy or at follow-up 2 to 3 weeks later. In addition, no statistically significant differences were noted between the three groups regarding adverse events; two patients in the CLIN 150 group had serious adverse events (cachexia due to malnutrition and allergic dermatitis), but both problems were treated and the patients completed the study. Based on these results, we conclude that the two regimens of oral clindamycin showed rates of clinical and microbiologic efficacy similar to those of the standard regimen of oral dicloxacillin.

Melasma is an acquired hyperpigmentary disorder commonly seen in Orientals. The pattern of pigmentary change in this condition is very characteristic and the diagnosis is usually evident to the patient. A number of pigmentary disorders mimicking melasma have been reported in Asian people. They include Riehl’s melanosis, pigmented actinic lichen planus, and acquired bilateral naevus of Otalike macules. Increased awareness of these pigmentary disorders should lead to the correct diagnosis.

This prospective study was designed to compare the efficacy and safety of itraconazole oral solution with those of clotrimazole troche in the treatment of oropharyngeal candidosis in acquired immunodeficiency syndrome (AIDS) patients. Patients were excluded if they had been treated with any antifungal agents 2 weeks prior to the study entry, were pregnant or nursing, or had significant liver disease. Twenty-nine patients (20 men and nine women), with a mean age of 32 years (15–62 years), were randomly, observer-blind treated with clotrimazole troche (10 mg, five times daily) or itraconazole oral solution (100 mg/10 mL, twice daily) for 1 week. Clinical and mycologic assessment were carried out on four consecutive days, in week 1, week 2, and week 4 after the start of treatment. Clinical evaluation was assessed by a scoring method (0–3, absent to severe) as follows: soreness, change in taste, erythema, removable white plaque, and extent of lesions. Mycologic assessment was performed by KOH preparation and fungal culture. Global evaluation, which is a summary of clinical and mycologic assessment at the end of treatment, was classified as cure (all signs and symptoms resolved with no evidence of infection), improvement (decrease in clinical score without complete resolution), or failure (lack of improvement or further deterioration). (Pons V, Greenspan D, Debruin M. Therapy for oropharyngeal candidiasis in HIV-infected patients: a randomized, prospective multicenter study of oral fluconazole versus clotrimazole troches. J Acquir Immune Defic Syndr 1993; 6: 1311–1316.) Global evaluation at week 2 and week 4 was made in terms of no relapse or relapse. Any intercurrent medical events, whether human immunodeficiency virus (HIV)-related or not, were recorded. An intention-to-treat analysis was employed. Data were analyzed using the chi-squared test, Mann–Whitney U-test, and Student's t-test.

Atopic dermatitis is a chronic inflammatory skin disorder, for which it is difficult to obtain epidemiologic findings. In a previous study, we suggested the following diagnostic criteria for atopic dermatitis in the adult Thai population: visible flexural dermatitis, a history of flexural dermatitis, a rash of more than six months duration and visible dry skin. However these criteria were not validated against physicians' diagnoses. In the present study, we validated these diagnostic criteria for atopic dermatitis in the Thai population in a clinical setting. A case-controlled study was performed on a total of 259 patients; 33 subjects with active atopic dermatitis, 26 with inactive atopic dermatitis, 100 controls presenting with an inflammatory skin disorder other than atopic dermatitis and 100 controls without any skin disease. Each patient was examined according to the above criteria. Sensitivity, specificity, relative value, positive predictive value, and negative predictive value were calculated for each individual criterion and for composite criteria. Our data confirmed that in order to achieve satisfactory sensitivity and specificity for diagnosing atopic dermatitis in Thai people older than 13 years, a patient must have a history of flexural dermatitis plus two or more of the other mentioned criteria.

Acquired bilateral nevus of Ota-like macules (Hori's nevus) is a dermal pigmented lesion commonly seen in middle-aged women of Asian descent. The Q-switched ruby laser (QSRL) has been used successfully to treat a variety of benign pigmented lesions. Multiple, sequential treatments are typically required for complete clearance of the dermal pigmented dermatoses.The purpose of this study was to determine the efficacy of QSRL in the treatment of Hori's nevus and the beneficial effect of epidermal ablation using the scanned carbon dioxide (CO(2)) laser before QSRL.A total of 13 women from Thailand with Hori's nevus were randomly treated with the scanned CO(2) laser followed by QSRL on one side of their face, and QSRL alone on the other side. The same fluence of QSRL was used on both sides in individual patients. The treatment response was objectively evaluated by measuring the melanin index using a Mexameter (CourageKhazaka Electronic GmbH, Köln, Germany), and subjectively assessed by the patients before treatment and 3 and 16 months after treatment. Adverse sequelae of the treatment and the patients' tolerance were also evaluated at the same follow-up visit.The 3- and 16-month posttreatment melanin index was significantly decreased compared with that of pretreatment on both treated sites and this corresponded to the patients' subjective evaluations. The response rate, defined as "the percentage of reduction in melanin index," was significantly higher on the sides treated with scanned CO(2) laser followed by QSRL, compared with the sides irradiated with QSRL alone at both follow-up visits. At the 3-month follow-up, the most common adverse effect was hypopigmentation, found in 15% (2 of 13) of the patients on the sites treated with QSRL alone, and on the sites treated with scanned CO(2) laser followed by QSRL (8%, 1/13). Erythema was observed in 15% (2/13) of the patients only on the sites that received combination treatment. However, no adverse sequelae were observed at the 16-month posttreatment follow-up.Epidermal ablation with scanned CO(2) laser before the use of the pigment-specific laser may be an effective technique for increasing therapeutic efficacy in the treatment of dermal pigmented dermatoses.

A rare simultaneous occurrence of multicentric Castleman's disease, non-Hodgkin's lymphoma, and Kaposi's sarcoma was diagnosed in a 70-year-old man who presented with fever, polyarthralgia, weight loss, vascular purpura, anemia, generalized lymphadenopathy, and hepatosplenomegaly. He had no risk of HIV infection and serological tests for HIV were negative twice, but a low number of T-cells and a reversed CD4/CD8 ratio were observed. During hospitalization, he developed Kaposi's sarcoma at the right sole. Lymph node biopsies revealed multicentric Castleman's disease together with a large B-cell lymphoma, which showed monotypic IgM-lambda lymphocytes. To our knowledge, this is the first report in which systemic manifestations of all three diseases occurred simultaneously prior to any specific treatment. The altered immune status and human herpesvirus-8 infection might have played a role in the pathogenesis of this occurrence.

This paper reviews the use of the fluoroquinolone antibiotics in the management of sexually transmitted diseases (STD) in Southeast Asia. Numerous clinical trials performed in the region have shown that the quinolones are highly effective for treating uncomplicated gonorrhoea. Norfloxacin 800 mg, ofloxacin 400 mg, ciprofloxacin 250 mg, and pefloxacin 400 mg in single oral doses have yielded excellent clinical results. Overall cure rates were greater than 95%, with full eradication of penicillinase-producing Neisseria gonorrhoeae in all studies. Strains of gonococci resistant to the quinolones have already emerged and should be closely monitored. However, this has not become a serious problem to date, as large scale evaluation has shown that the quinolones remain highly efficacious for the treatment of gonorrhoea. These antibiotics in single doses are not effective for postgonococcal urethritis (PGU); therefore, concomitant use of an antichlamydial regimen for all patients with gonorrhoea is recommended. The quinolones are also highly effective for chancroid. Excellent results, with cure rates approaching 100%, were achieved with single oral doses of ciprofloxacin 500 mg, norfloxacin 800 mg, and ofloxacin 400 mg. Widespread use of these drugs in STD treatment regimens may be one of the main factors causing a dramatic decline in the number of cases of chancroid seen in recent years. Ofloxacin in variable dosages for a period of 10 to 21 days was found to be effective in nongonococcal urethritis (NGU). However, when compared with the tetracyclines, it is less cost effective and can thus be regarded as an alternative treatment for NGU.

An emerging trend in medical tourism is the flow of patients from developed countries seeking treatment in developing nations. Medical tourism seemingly acts as a valve for capacity limitations and cost escalation at home. In contrast to the prevailing view that developing countries mainly offer a price advantage, we argue that the underlying success factor for the sustainable competitiveness of a healthcare destination is neither price nor medical quality, but patient-centred, highly personalised service quality. This conclusion is based on a comprehensive narrative analysis of the lived experiences of patients from developed countries who receive invasive medical procedures at one of the largest private hospitals in Thailand, which has been described as emblematic for the trend of internationalisation of healthcare and a model that many other hospitals in Asia follow. We find that, while a low price might initiate interest in medical treatment abroad, return visits are built on profound patient satisfaction, and even bonding, to doctors and nurses. Successful health destinations need to provide foreign patients unexpectedly pleasant experiences through organisational innovations and service quality based on superior patient?doctor?nurse relationship.

Background. Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are potentially life-threatening illnesses that have often been linked to drug exposure. Methods. We looked retrospectively for all cases of SJS and TEN that were admitted to Siriraj Hospital between 1981 and 1990 to determine the drug etiology. Results. Fifty-eight cases of SJS and 20 cases of TEN were identified. Eight patients initially had an SJS-like aspect, which subsequently evolved into TEN. A culpable drug was determined in 60 patients (77%). The mean time from first drug administration to onset of SJS or TEN was 6.8 ± 6.5 days (range, 1 to 28 days). A longer incubation period was observed with thiacetazone (10.5 ± 5.6 days), phenytoin (12 ± 8.5 days), and carbamazepine (11.3 ± 3.4 days). Conclusions. The culprit drugs included the following: antibiotics, 32 cases (penicillin, sulfonamides, tetracycline, erythromycin); anticonvulsants, nine (phenytoin, carbamazepine, barbiturates); antitubercular drugs, eight (thiacetazone); analgesics, four (acetylsalicylic acid, fenbufen); sulfonylurea, two; allopurinol, one; and others, four. The most frequent underlying diseases justifying the ingestion of one or more drugs in our patients were infections (52.7%), followed by pulmonary tuberculosis (10.8%), and by seizures (8.1%). The total mortality rate was 14%; 5% for SJS, and 40% for TEN. Mortality was not affected by the type of drug responsible.

Context: Atopic dermatitis is a common disease that is diagnosed by use of Hanifin, Lobitz and Rajka's criteria based on patient history and clinical features. However these criteria are not suitable for population-based studies. Aims: The purpose of this study is to develop a minimum list of diagnostic criteria for atopic dermatitis that is sensitive, specific, reproducible, noninvasive, applicable to adult Thai population and easy to perform in population-based studies. Settings and Design: This study was conducted at Department of Dermatology, Faculty of Medicine Siriraj Hospital Mahidol University, Bangkok, Thailand. Materials and Methods: The new cases of typical mild to moderate atopic dermatitis and exactly age-matched and sex-matched controls presenting with an inflammatory skin disease other than atopic dermatitis were selected from Department of Dermatology, Faculty of Medicine Siriraj Hospital. Each subject was examined with reference to 31 clinically diagnostic features of atopic dermatitis proposed by Hanifin and Rajka. One hundred and forty patients (70 cases and 70 controls) were studied. Statistical Analysis Used: Sensitivity and specificity of each criterion was calculated using the dermatologist's diagnosis as the standard. Regression techniques were then used to derive a minimum set of diagnostic criteria. Results: Using multiple logistic regression techniques, a minimum set of diagnostic criteria for atopic dermatitis was derived: visible flexural dermatitis, history of flexural dermatitis, duration of rash >6 months and visible dry skin. Conclusions: A minimum list of diagnostic criteria for atopic dermatitis was derived that should be of use in Thai population-based studies.