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The implementation of a laboratory information system (LIS) at the Hospital for Tropical Diseases in Thailand provides valuable medical resources, particularly for dengue. Hematocrit (Hct), which is often derived from hemoglobin (Hgb), is important in the diagnosis and management of dengue. This study aimed to evaluate the Hct value obtained from the LIS automated analyzer. We prospectively enrolled 163 hospitalized adults with dengue, for whom 1,141 real-time complete blood count (CBC) results were obtained via a hematology analyzer and updated in the LIS database. The median (interquartile range (IQR)) duration of analytic turnaround times (TATs) was 40.0 (30.0–53.0) minutes. Linear regression analysis indicated a significant relationship between Hgb and Hct with a coefficient of determination (Pearson’s R2) of 0.92 at red blood cell distribution width (RDW) ≤18, but Pearson’s R2 decreased to 0.78 at RDW >18. The Hct calculated from the three-fold conversion method and from the analyzer had a Pearson’s R2 of 0.92. At Hgb P value

Three patients diagnosed with severe COVID‐19 pneumonia received treatment with hydroxychloroquine combined with lopinavir, ritonavir, and favipiravir. Two patients diagnosed early, received tocilizumab when the pneumonia became severe and survived. The thrid patient was diagnosed late and received tocilizumab when the disease progressed to acute respiratory distress syndrome, and died., Tocilizumab could be used in patients with severe COVID‐19 pneumonia who did not show response to a combination of antiviral therapy. However, the use of a combination antiviral therapy should be further confirmed in clinical trials.

Three patients with COVID-19 pneumonia received treatment with hydroxychloroquine combined with lopinavir plus ritonavir and favipiravir. Two patients early diagnosed with COVID-19 pneumonia received tocilizumab at severe pneumonia diagnosed and survived. The third patient was late diagnosed and received tocilizumab when the disease progressed to ARDS, and passed away.

BACKGROUND Out-of-hospital cardiac arrest is an emergency that requires immediate management to save lives. However, some predictive scores for the immediate outcomes of patients with out-of-hospital cardiac arrest are difficult to use in clinical practice. AIMS This study aimed to identify predictors of sustained return of spontaneous circulation and to develop a predictive score. METHODS This prospective observational study evaluated sustained return of spontaneous circulation among out-of-hospital cardiac arrest patients in a Thai emergency department between July 2014 and March 2018. The baseline characteristics and prehospital and hospital findings were analysed. RESULTS Of 347 patients, 126 (36.3%) had sustained return of spontaneous circulation and 20 (5.8%) were discharged. Witnessed arrest (odds ratio = 2.9, 95% confidence interval 1.3-6.2), time from arrest to chest compression

Introduction Factors predictive for death from snake envenomation vary between studies, possibly due to variation in host genetic factors and venom composition. This study aimed to evaluate predictive factors for death from snake envenomation in Myanmar. Methods A prospective study was performed among adult patients with snakebite admitted to tertiary hospitals in Yangon, Myanmar, from May 2015 to August 2016. Data including clinical variables and laboratory parameters, management, and outcomes were evaluated. Multivariate regression analysis was performed to evaluate factors predictive for death at the time of presentation to the hospital. Results Of the 246 patients with snake envenomation recruited into the study, 225 (92%) survived and 21 (8%) died during hospitalization. The snake species responsible for a bite was identified in 74 (30%) of the patients; the majority of bites were from Russell's vipers (63 patients, 85%). The independent factors predictive for death included 1) duration from bite to arrival at the hospital >1 h (odds ratio [OR]: 9.0, 95% confidence interval [CI]: 1.1–75.2; P =0.04); 2) white blood cell counts >20 ×10 3 cells·μL -1 (OR: 8.9, 95% CI: 2.3–33.7; P =0.001); and 3) the presence of capillary leakage (OR: 3.7, 95% CI: 1.2–11.2; P =0.02). A delay in antivenom administration >4 h increases risk of death (11/21 deaths). Conclusions Patients who present with these independent predictive factors should be recognized and provided with early appropriate intervention to reduce the mortality rate among adults with snake envenomation in Myanmar.

Severe dengue is more prevalent in adults than in children. Our objectives were to determine the clinical presentations of dengue in adults and to identify predictive factors for severe dengue. A retrospective cohort study was performed in adults with dengue, as confirmed by a positive NS1 antigen test result. Patients were classified as with non-severe or severe dengue. A total of 357 patients were enrolled; 45.4% were men, with a median (interquartile range [IQR]) age of 27.9 (21.8-43.5) years. Of all patients, 28.3% had warning signs and 10.6% had severe dengue. Patients with severe dengue were significantly older (35.1 [26.2-50.6] vs. 26.7 [21.7-43.3] years, P = 0.010), immunocompromised (7.9% vs. 0.9%, P = 0.018), and had cough (29% vs. 16%, P = 0.046), hepatomegaly (10.5% vs. 3.1%, P = 0.050), impaired consciousness (5.3% vs. 0%, P = 0.011) or higher (IQR) alanine aminotransferase (ALT) level (151 [57-295] vs. 66 [37-114] U/L, P = 0.008). By multivariate analysis, having cough (odds ratio [OR], 8.07; 95% confidence interval [CI], 2.51-30.16, P = 0.001) and ALT>120 U/L (OR, 3.51; 95% CI, 1.11-11.14, P = 0.033) were predictors of severe dengue. Early recognition of risk variables may be important for healthcare providers to appropriately manage dengue patients.

Background:. Liposuction is the most common aesthetic surgical procedure performed globally. Some of the patients with normal weight who seek liposuction may suffer from body dysmorphic disorder (BDD). Leptin, which is mainly produced by adipose tissue, may be associated with this condition. The aim of this study was to determine the prevalence of BDD and leptin levels in patients with normal weight seeking liposuction. Methods:. Thirty-two nonobese women who sought liposuction were matched with 32 healthy volunteers by age and body mass index. Blood biochemistry, leptin levels, and BDD-Yale–Brown Obsessive-Compulsive Scale (BDD-YBOCS) questionnaires were evaluated and compared between the groups. Results:. Patients who underwent liposuction had significantly higher median (interquartile range) of total BDD-YBOCS scores than healthy volunteers [25 (22–27) versus 12 (8–20); P < 0.001]. Overall, 28 (87.5%) patients had total BDD-YBOCS scores of >20, whereas 10 (31.5%) volunteers had scores of >20. Patients with total BDD-YBOCS scores of >20 had significantly lower levels of serum leptin [12.43 (7.15–16.98) ng/ml versus 15.57 (9.59–22.28) ng/ml; P = 0.043]. Conclusions:. Patients who underwent liposuction had a significantly higher total score of BDD-YBOCS than healthy volunteers matched by sex, age, and body mass index. Subjects with higher BDD-YBOCS scores had significantly lower serum leptin levels.

Background Snakebite-related acute kidney injury (AKI) is a common community-acquired AKI in tropical countries leading to death and disability. The aims of this study were to (1) determine the occurrence of snakebite-related AKI, (2) assess factors at presentation that are associated with snakebite-related AKI, and (3) determine the outcomes of patients with snakebite-related AKI. Methods We conducted a prospective observational study of patients with snake envenomation at the three academic tertiary care hospitals in Yangon, Myanmar between March 2015 and June 2016. Patient data including baseline characteristics, clinical and laboratory findings, hospital management, and outcomes were recorded in a case report form. A stepwise multivariate logistic regression analysis using a backward selection method determined independent factors significantly associated with AKI. Results AKI was observed in 140 patients (54.3%), the majority of whom were AKI stage III (110 patients, 78.6%). AKI occurred at presentation and developed during hospitalization in 88 (62.9%) and 52 patients (37.1%), respectively. Twenty-seven patients died (19.3%), and 69 patients (49.3%) required dialysis. On multivariate logistic regression analysis, (1) snakebites from the Viperidae family (odds ratio [OR]: 9.65, 95% confidence interval [CI]: 2.42–38.44; p = 0.001), (2) WBC >10 × 103 cells/μL (OR: 3.55, 95% CI: 1.35–9.34; p = 0.010), (3) overt disseminated intravascular coagulation (OR: 2.23, 95% CI: 1.02–4.89; p = 0.045), (4) serum creatine kinase >500 IU/L (OR: 4.06, 95% CI: 1.71–9.63; p = 0.001), (5) serum sodium

Definitions of abnormal urine findings and electrolyte abnormalities. Table S2. Definitions of clinical parameters of snake envenoming according to the WHO 2010 guidelines. Table S3. Baseline characteristics and pre-hospital management among 258 adults with snakebite envenomation, Yangon, Myanmar, 2015–2016. Table S4. Clinical presentation among 258 adults with snakebite envenomation, Yangon, Myanmar, 2015–2016. Table S5. Laboratory parameters at presentation among 258 adults with snakebite envenomation, Yangon, Myanmar, 2015–2016. Table S6. Management and outcomes among 258 adults with snakebite envenomation, Yangon, Myanmar, 2015–2016. Table S7. Clinical parameters among 164 adults bitten by Viperidae or presenting the clinical syndrome of Viperidae (86 patients with acute kidney injury at presentation and 78 patients without acute kidney injury). Table S8. Laboratory parameters among 164 adults bitten by Viperidae or presenting the clinical syndrome of Viperidae (86 patients with acute kidney injury at presentation and 78 patients without acute kidney injury). Table S9. Management and outcomes among 164 adults bitten by Viperidae or presenting the clinical syndrome of Viperidae (86 patients with acute kidney injury at presentation and 78 patients without acute kidney injury). Table S10. Clinical parameters among 128 adults bitten by Viperidae or presenting the clinical syndrome of Viperidae (50 patients who developed acute kidney injury during hospitalization and 78 patients without acute kidney injury). Table S11. Laboratory parameters among 128 adults bitten by Viperidae or presenting the clinical syndrome of Viperidae (50 patients who developed acute kidney injury during hospitalization and 78 patients without acute kidney injury). Table S12. Management and outcomes among 128 adults bitten by Viperidae or presenting the clinical syndrome of Viperidae (50 patients who developed acute kidney injury during hospitalization and 78 patients without acute kidney injury). The supplementary tables provide additional data to help interpret the results of the study. (DOCX 92 kb)

Background: The effectiveness of directly observed therapy (DOT) on TB treatment outcome has been debated and different findings regarding different DOT practices and settings were demonstrated. Methodology: The observational study was conducted in new sputum smear and culture positive pulmonary TB patients at Queen Savang Vadhana Memorial Hospital and Chonburi Hospital, Chonburi province, Thailand during April 2010 and July 2012. The aim of this study was to evaluate the effect of family based DOT toward sputum culture conversion. Sputum AFB smear, culture and drug susceptibility test were performed at the time of diagnosis, the second and the fifth month of treatment. Baseline characteristic, clinical and laboratory parameters, treatment regimens and adverse events were recorded. Descriptive statistics were applied as appropriate. Results: Proportion of patients with illiteracy, visual alteration and hepatitis was significantly higher in family based DOT group (p=0.026, p=0.011 and p=0.031). Sputum smear and culture conversion at 2 and 5 months after treatment were not significantly different between family based DOT and self administer groups. Patients in both group achieved over 90% cure rate without significant difference (p=0.262). Conclusions: Continuing patient education, counseling and AEs monitoring should be incorporated into family based DOT to achieved successful outcome. DOT can be interfered by many factors. Therefore appropriate implementing of DOT can enhance effectiveness of DOT toward patient adherence and further achieve success in TB treatment and control.

Summary Background To assess the clinical and laboratory parameters, response to therapy and development of antituberculosis (TB) drug resistance in pulmonary TB (PTB) patients with diabetes mellitus (DM) and without DM. Methods Using a prospective design, 227 of 310 new cases of culture-positive PTB diagnosed at the Queen Savang Vadhana Memorial Hospital and the Chonburi Hospital between April 2010 and July 2012 that met the study criteria were selected. Data regarding clinical and laboratory parameters, drug susceptibility and treatment outcomes were compared between PTB patients with DM and those without DM. To control for age, the patients were stratified into two age groups (

Background Currently, there are no biomarkers that can predict the incidence of dengue shock and/or organ failure, although the early identification of risk factors is important in determining appropriate management to reduce mortality. Therefore, we sought to determine the factors associated with dengue shock and/or organ failure and to evaluate the prognostic value of serum procalcitonin (PCT) and peripheral venous lactate (PVL) levels as biomarkers of dengue shock and/or organ failure. Methodology/Principal Findings A prospective observational study was conducted among adults hospitalized for confirmed viral dengue infection at the Hospital for Tropical Diseases in Bangkok, Thailand between October 2013 and July 2015. Data, including baseline characteristics, clinical parameters, laboratory findings, serum PCT and PVL levels, management, and outcomes, were recorded on pre-defined case report forms. Of 160 patients with dengue, 128 (80.0%) patients had dengue without shock or organ failure, whereas 32 (20.0%) patients developed dengue with shock and/or organ failure. Using a stepwise multivariate logistic regression analysis, PCT ≥0.7 ng/mL (odds ratio [OR]: 4.80; 95% confidence interval [CI]: 1.60–14.45; p = 0.005) and PVL ≥2.5 mmol/L (OR: 27.99, 95% CI: 8.47–92.53; p, Author Summary Dengue is a major global health concern, particularly in tropical countries, and affects all age groups. Mortality rates among patients who have been hospitalized with severe dengue are 1.6–10.9%, and death in adults is mainly due to the development of dengue shock and organ dysfunction. In states of poor tissue circulation or shock, lactate is produced. Additionally, procalcitonin is a highly specific biomarker of systemic inflammation. Therefore, we assessed whether procalcitonin and peripheral venous lactate could be used to predict the incidence of dengue shock and/or organ failure in patients with dengue. Our study showed that a combination of serum procalcitonin levels ≥0.7 ng/mL and peripheral venous lactate levels ≥2.5 mmol/L at admission could discriminate between patients who did and did not develop shock and/or organ failure, with high sensitivity and specificity. These parameters may therefore be useful as prognostic biomarkers. Our results suggest that serum procalcitonin is indicative of an extensive early inflammatory response, which may occur during the systemic phase of dengue. Peripheral venous lactate may be produced as a result of the poor tissue circulation that precedes dengue shock. Our findings may help clinicians to predict dengue shock and/or organ failure earlier to reduce in-hospital mortality.

Summary Background The emergence of highly pathogenic avian influenza H5N1 viruses has raised concerns about their pandemic potential. Vaccination is the most effective way of preventing influenza. In this study, we investigated the safety and immunogenicity of an avian H5N2 live attenuated influenza vaccine (LAIV H5N2) in healthy Thai adults and its priming immune responses with an H5N1 inactivated vaccine boost. Methods This study was done at the Vaccine Trial Centre at Mahidol University, Bangkok, Thailand and was divided into two parts. Part 1 consisted of a randomised, double-blind, placebo-controlled trial done over 18 months. We randomly assigned (2:1) healthy Thai adults aged 18–49 years with a computer generated randomisation sequence (blocks of six) to receive either two intranasal doses (0·25 mL per nostril) of LAIV H5N2 (101 participants) or placebo (51 participants) 21 days apart. For part 2, an open-label trial was done in which previously vaccinated participants (40 from LAIV H5N2 group and 20 placebo) were given one intramuscular dose (0·5 mL) of H5N1 booster vaccine. Participants, investigators, and site-study workers were blinded from randomisation. Immune responses after subsequent immunisation were evaluated using haemagglutination-inhibition and microneutralisation assays and circulating follicular T-helper cells and plasmablast cells were measured in serum and whole blood. The trials are registered with ClinicalTrials.gov, numbers NCT01841918 and NCT02229357. Findings Between Feb 4, 2013, and Feb 28, 2013, 256 individuals were screened, of whom 152 participants were enrolled in part 1 of this study. LAIV H5N2 vaccine was well tolerated. Viral shedding was detected in only six (6%) of 101 participants in the vaccine group 1 day after the first vaccination and in and two (2%) of 98 participants in the group after the second vaccination. There was no serious adverse event in both groups. 51 (50%) of 101 participants in the vaccine group and 28 (55%) of 51 in the placebo group reported at least one adverse event. 80 (84%) of 95 events in the vaccine group and 32 (78%) of 43 events in the placebo groups were reportedly suspected adverse events, probably related to the vaccine; however, most were mild in nature. After two doses of vaccine, 13 (13%) of 100 participants in the vaccine group had an increase in haemagglutination-inhibition titre of more than four-fold and four (4%) of 100 vaccinees developed a rise in neutralisng antibody titre of more than four-fold. 1 year later, after a booster with an inactivated H5N1 vaccine (part 2), 39 (98%) of 40 participants who had previously been vaccinated with LAIV H5N2 had an increase in haemagglutination-inhibition titre of greater than four-fold as early as day 7 compared with three (15%) of 20 participants in the placebo group. Peak geometric mean titre (GMT) for haemagglutination-inhibition antibodies in the previously LAIV H5N2 vaccinated group (566·89 [95% CI 436·97–735·44]) were significantly higher than among those who previously received placebo (25·49 [11·82–54·96]; p

SUMMARY: Background: Patients on dialysis are at high risk of acquiring viral hepatitis infections. However, there were only few data from Thailand. The aim of the present study was to assess the prevalence, incidence and associated risk factors of viral hepatitis infections among dialysis patients. Methods: A retrospective study was conducted to evaluate 5179 medical records of dialysis patients from the Thailand Renal Replacement Therapy Registry. Results: In 2002, the seroprevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) infections were 6.3% (n = 2454) and 4.8% (n = 2167), respectively. HBV and HCV seroprevalence became 6.5% (n = 2585) and 4.3% (n = 2399) in 2003. The incidence of HBV and HCV infections were 1.5 and 2.4 cases per 1000 patient-years, respectively. Logistic regression analysis showed that age and gender were significant risk factors for HBV infection, but not for HCV infection. Conclusion: In Thailand, it was not uncommon for dialysis patients to acquire viral hepatitis infections. However, our prevalence is similar to reports from some other South-East Asian countries.

Background Dengue is the most common mosquito-borne viral disease in humans. Recently, there has been an epidemic shift of dengue from mainly affecting children to affecting more adults with increased severity. However, clinical factors associated with severe dengue in adults have varied widely between studies. We aimed to identify the clinical factors associated with the development of severe dengue according to the World Health Organization (WHO)’s 2009 definition. Methods We conducted a prospective study of adults with dengue admitted to the Hospital for Tropical Diseases in Bangkok, Thailand, from October 2012 to December 2014. Univariate and stepwise multivariate logistic regression analyses were performed. Results Of the 153 hospitalized patients with confirmed dengue viral infections, 132 (86.3 %) patients had non-severe dengue including dengue without warning signs (7 patients, 5.3 %) and dengue with warning signs (125, 94.7 %). The rest (21, 13.7 %) had severe dengue including severe plasma leakage (16, 76.2 %), severe organ involvement (16, 76.2 %), and severe clinical bleeding (8, 38.1 %). Using stepwise multivariate logistic regression, clinical factors identified as independently associated with the development of severe dengue were: (1) being >40 years old (odds ratio [OR]: 5.215, 95 % confidence interval [CI]: 1.538–17.689), (2) having persistent vomiting (OR: 4.817, CI: 1.375–16.873), (3) having >300 cells per μL of absolute atypical lymphocytes (OR: 3.163, CI: 1.017–9.834), and (4) having lactate levels ≥2.0 mmol/L (OR: 7.340, CI: 2.334–23.087). In addition, increases in lactate and absolute atypical lymphocyte levels corresponded with severe dengue (p

In tuberculosis endemic areas, patients with sputum positive for acid-fast bacilli (AFB) are usually diagnosed and treated for pulmonary tuberculosis. The diagnosis of nontuberculous mycobacteria (NTM) lung disease is often ascertained only after lung disease progression occurs, increasing the risk of severe morbidity and mortality. We conducted a matched case-control study among a prospective cohort of 300 patients with newly diagnosed AFB-positive sputum in Thailand during 2010-2012. We compared clinical and laboratory parameters and outcomes among patients with pulmonary tuberculosis, NTM lung disease and NTM colonization. A mycobacterial culture was performed in all patients. Ten patients with NTM lung disease were compared to 50 patients with pulmonary tuberculosis and 10 patients with NTM colonization. The presence of diabetes mellitus or human immunodeficiency virus infection, were associated with NTM lung disease (p = 0.030). Patients with NTM lung disease had a significantly lower body weight prior to treatment (p = 0.021), a higher body weight change from baseline (p = 0.038), and were more likely to have cavitations on chest radiograph (p = 0.033) than those with NTM colonization. In tuberculosis endemic areas, mycobacterial identification should be performed among patients with impaired immune function. NTM lung disease treatment should be considered in patients with NTM sputum isolates who have a history of significant weight loss or cavitations on chest radiography.

Malaria is a common parasitic disease in tropical countries, causing one to two million deaths every year. To establish the new biomarker, we analyzed plasma miRNAs obtained from 19 malaria patients and 19 normal subjects, using reverse transcription-based quantitative polymerase chain reaction (RT-qPCR). The average levels of plasma miR-451 and miR-16 were significantly lower in malaria patients, (8.9-fold; p

A retrospective study was conducted by reviewing medical records of 323 adult patients hospitalized with dengue infection at the Hospital for Tropical Diseases, Bangkok, Thailand between 2006 and 2010 in order to determine factors associated with severe clinical manifestations of dengue. Of 323 patients, 95 (29.4%) had dengue fever (DF) and 228 (70.6%) had DHF, which were categorized as grade I (67 patients, 29.4%), grade II (62 patients, 27.2%), grade III (95 patients, 41.7%) and grade IV (4 patients, 1.8%) following 1997 WHO definitions. Using the revised 2009 WHO definitions, 233 patients (72.1%) had non-severe dengue infection and 90 patients (27.9%) had severe dengue infection. Of the 233 patients with non-severe dengue infection, 193 (82.8%) were classified as having non-severe dengue infection with warning signs and 40 (17.2%) were classified as having non-severe dengue infection without warning signs. Using stepwise multivariate logistic regression analysis, having a hematocrit2% above the reference range [odds ratio (OR) 3.235; 95% confidence interval (CI) 1.807-5.793] or having an alanine aminotransferase level120 IU/l (OR 1.896; 95% CI 1.018-3.531) were associated with having DHF grades II-IV, whereas female gender (OR 2.042; 95% CI 1.143-3.648) or having a mean arterial pressure80 mmHg (OR 2.275; 95% CI 1.302-3.975) were associated with severe dengue. These findings may help clinicians to determine patients at risk for severe manifestations of dengue infection, which could lead to proper management of these cases.

A retrospective study was conducted by reviewing 459 medical records of adult treatment naive HIV patients who received a fixed dose combination of GPO-VIR-S (stavudine, lamivudine and nevirapine) or GPO-VIR-Z (zidovudine, lamivudine and nevirapine) at Ramathibodi Hospital in Bangkok, Thailand during 2002-2009 following Thai National Treatment Guideline for adults with HIV. The aim of this study was to assess the association between the baseline CD4 cell count and outcome. The median CD4 cell count at baseline, 6, 12 and 102 months were 102 cells/microl, 213 cells/microl, 274 cells/microl and 423 cells/microl. The virologic response (p=0.327), virologic rebound (p=0.626), adverse effects of anti-retroviral therapy (ART) (p=0.976), switching to other ART (p=0.245), occurrence of immune reconstitution inflammatory syndrome (IRIS) (p0.05) and occurrence of drug resistance (p=0.952) were not significantly associated with baseline CD4 count. The Kaplan-Meier estimate showed the median time (95% CI) to achieve virologic response was 10.4 (9.8-11.0) months and the median time to achieve virologic rebound was 30.0 (21.6-38.4) months after initiation of ART. Analysis showed the median time to achieved virologic response (p=0.401) and virologic rebound (p=0.562) were not significantly associated with the baseline CD4 count. This study shows the outcome after onset of ART did not vary by baseline CD4 cell count.

We conducted a retrospective study of patients with severe falciparum malaria to determine factors associated with malarial acute renal failure (MARF). We reviewed 262 medical records of adults hospitalized with severe falciparum malaria in Thailand from 2004 to 2008. The incidence of MARF in our study population was 44% (115/262); 75% (86/115) of these had MARF on admission and 25% (29/115) developed MARF during hospitalization. The majority of MARF patients presented in a hypercatabolic state (62%, 68/109) and were non-oliguric (48%, 55/115) or oliguric (44%, 51/115). Forty-six percent of MARF patients (53/115) required renal replacement therapy for a median duration of 4.5 days. Patients with MARF had significantly higher complication rates (p0.001), longer duration of hospitalization (p0.001) and a higher case fatality rate (p = 0.001). Using stepwise multiple logistic regression analysis by backward selection method, factors associated with MARF were advanced age [odds ratios (OR); 95% confidence intervals (CI) 1.037 (1.011-1.063), p = 0.005], being, referred from another hospital [2.876 (1.447-5.714), p = 0.003], an elevated total bilirubin level [(1.168 (1.101-1.241), p0.001], requiring inotropic drugs [4.879 (2.255-10.557), p0.001] and developing a hospital acquired infection [3.425; 1.406-8.343, p = 0.007]. Clinicians should be aware of these factors associated with MARF.

Hemorrhage is an important complication in dengue infection, but early predictors of clinically significant bleeding are undefined. This study aimed to determine clinical factors on admission associated with Type I bleeding, defined as gastrointestinal bleed, hematuria and menorrhagia, among adult patients with dengue infection. We carried out a retrospective study among 277 patients aged15 years with serologically-confirmed dengue infection admitted to the Hospital for Tropical Diseases, Bangkok, Thailand during 2006-2009. Female gender (p0.001), vomiting (p=0.05), severe thrombocytopenia (platelet count25 x 10(9)/l; p=0.007), high absolute lymphocyte count (ALC500; p=0.05) and high aspartate aminotransferase level (AST200; p=0.02) were significantly associated with hemorrhage on univariate analysis. Multivariate analysis revealed variables associated with bleeding were female gender [odds ratio (OR) 14.5; 95% confidence interval (CI) 0.16-0.56, p0.001], thrombocytopenia (OR 4.7; 95%CI 0.13-0.9, p=0.03) and ALC500 (OR 5.7; 95%CI 1.17-4.99, p=0.02). These data identify patients at high risk for developing clinically significant bleeding with dengue infection.

The Leptospira immunoglobulin M enzyme-linked immunosorbent assay (IgM ELISA) has been recommended for the rapid diagnosis of leptospirosis in endemic areas. We conducted a retrospective case-control study of 218 patients (109 leptospirosis cases confirmed by Leptospira culture and/or microscopic agglutination test and 109 control patients with acute febrile illness) to evaluate the diagnostic accuracy of a commercial IgM ELISA (Panbio) in northeast Thailand. Paired serum samples taken on admission and at least 10 days after the onset of symptoms were tested. Using the cutoff value recommended by the manufacturer (11 Panbio units), sensitivity and specificity of IgM ELISA on paired sera were 90.8% and 55.1%. A receiver operating characteristic curve was used to determine the optimal cutoff value. This was 20 Panbio units, which gave a sensitivity and specificity of 76.1% and 82.6%, respectively, on paired sera. We conclude that using either cutoff value, the accuracy of IgM ELISA is limited in our setting.

Generic fixed dose combination stavudine (d4T), lamivudine (3TC) and nevirapine (NVP), named GPO-VIR is recommended in the HIV treatment guidelines for Thailand. The long term effectiveness and adverse effects of this drug combination for the treatment of HIV were evaluated in an ambispective study at Bamrasnaradura Infectious Diseases Institute, Nonthaburi Province, Thailand from March 2002 to January 2006. A total of 152 adult treatment naive HIV patients who had received at least 12 months of GPO-VIR were enrolled. The median (IQR) CD4 cell count increased from 23 (8-94) cells/microl at baseline to 126 (38-180), 136 (98-189), 199 (141-255) and 334 (243-414) cells/microl at 3, 6, 12 and 24 months (p0.001), respectively. The median (IQR) percentage of body weights increased from baseline by 3.0% (0.3-6.3), 6.2% (2.2-9.3), 7.3% (3.9-10.9) and 8.1% (3.4-11.9) at 3, 6, 12 and 24 months, respectively and then remained at a plateau until the end of the 3-year study. The occurrence of new opportunistic infections decreased significantly (p0.001) with GPO-VIR treatment. Drug resistance occurred in 5 cases (3.3%) with a median (IQR) time of 18.0 (16.5-32.5) months to occurrence. Adverse effects included hypercholesterolemia (43.2%), lipodystrophy (35.5%), hypertriglyceridemia (25%), hypertension (13.1%), peripheral neuropathy (11.9%), hyperlactatemia (2.6%) and lactic acidosis (1.3%). Thirty-six patients (27%) switched from GPO-VIR to other anti-retroviral drugs regimens due to lipodystrophy. This study showed GPO-VIR had clinical and immunological benefits, but one-third of patients had adverse effects.

Cerebral venous sinus thrombosis has been reported to be associated with various systemic illnesses and infections, including severe malaria. We report here a 43 year-old Thai male presenting with fever and seizures. He was diagnosed as and treated for severe falciparum malaria. After gaining consciousness he developed focal neurological signs and evidence of increased intracranial pressure. Magnetic resonance imaging (MRI) and magnetic resonance venography (MRV) of the brain revealed a mid-superior sagittal sinus thrombosis with venous infarction. Investigations for other infections and thrombophilia were negative. The patient denied anticoagulant treatment. The clinical status and radiologic findings improved gradually. Physicians who care for malaria patients need to be aware of this rare complication when a malaria patient presents with focal neurological signs.

In a retrospective study of 1415 patients aged 15 and over, we determined the incidence of clinically important hyponatraemia and hypokalaemia in adults with uncomplicated malaria. On admission, serum concentrations of sodium (135–145 mmol/L) and potassium (3.5–5.0 mmol/L) were found outside these reference ranges in 81% of patients. Severe hypokalaemia (K+ 100 mg/dL) were all independent factors ( P < 0.001). Other independent predictors for hypokalaemia were Plasmodium vivax infection, female gender; and for hyponatraemia, P. falciparum infection, male gender, concentrations of G-6-PD and serum bicarbonate.

To determine the efficacy, safety and tolerability of an alternative short-course, artemisinin-based combination therapy for acute uncomplicated Plasmodium falciparum malaria, we compared Artequick®–a fixed-dosed combination of artemisinin (80 mg), piperaquine (400 mg), and primaquine (4 mg), per tablet–with a standard regimen of artesunate-mefloquine. A total of 130 patients were randomly assigned to treatment with an orally administered, once-daily, 3-day regimen of either Artequick® (Group A: 3.2 mg/kg/day of artemisinin, 16 mg/kg/day of piperaquine, and 0.16 mg/kg/day of primaquine) or artesunate-mefloquine (Group B: artesunate, 4 mg/kg/day, with mefloquine, 8 mg/kg/day). Patients receiving each regimen had a rapid clinical and parasitological response. All treatments were well tolerated, and no serious adverse effects occurred. No significant differences were found in fever- and parasite-clearance times between the two study groups. The 28-day cure rates were similarly high, at 98.5% and 100%, in groups A and B, respectively. We conclude that Artequick® was as effective and well tolerated as artesunate-mefloquine and could be used as an alternative treatment for multidrug-resistant Plasmodium falciparum malaria in Southeast Asia.

Plasmodium falciparum is a major cause of severe malaria in Southeast Asia, however, there is limited information regarding clinical factors associated with the severity of falciparum malaria from this region. We performed a retrospective case-control study to compare clinical factors and outcomes between patients with severe and non-severe malaria, and to identify clinical factors associated with the requirement for intensive care unit (ICU) admission of patients with severe falciparum malaria among hospitalized adults in Southeast Asia. A total of 255 patients with falciparum malaria in the Hospital for Tropical Diseases in Bangkok, Thailand between 2006 and 2012 were included. We identified 104 patients with severe malaria (cases) and 151 patients with non-severe malaria (controls). Patients with falciparum malaria with following clinical and laboratory characteristics on admission (1) referrals, (2) no prior history of malaria, (3) body temperature of >38.5°C, (4) white blood cell counts >10×10(9)/µL, (5) presence of schizonts in peripheral blood smears, and (6) albumin concentrations of

Chloroquine remains the drug of choice for the treatment of vivax malaria in Thailand. Mixed infections of falciparum and vivax malaria are also common in South-East Asia. Laboratory confirmation of malaria species is not generally available. This study aimed to find alternative regimens for treating both malaria species by using falciparum antimalarial drugs. From June 2004 to May 2005, 98 patients with Plasmodium vivax were randomly treated with either artemether-lumefantrine (n = 47) or chloroquine (n = 51). Both treatments were followed by 15 mg of primaquine over 14 days. Adverse events and clinical and parasitological outcomes were recorded and revealed similar in both groups. The cure rate was 97.4% for the artemether-lumefantrine treated group and 100% for the chloroquine treated group. We concluded that the combination of artemether-lumefantrine and primaquine was well tolerated, as effective as chloroquine and primaquine, and can be an alternative regimen for treatment of vivax malaria especially in the event that a mixed infection of falciparum and vivax malaria could not be ruled out.

In acute uncomplicated falciparum malaria, there is a continuum from mild to severe malaria. However, no mathematical system is available to predict uncomplicated falciparum malaria patients turning to severe malaria. This study aimed to devise a simple and reliable model of Malaria Severity Prognostic Score (MSPS). The study was performed in adult patients with acute uncomplicated falciparum malaria admitted to the Bangkok Hospital for Tropical Diseases between 2000 and 2005. Total 38 initial clinical parameters were identified to predict the usual recovery or deterioration to severe malaria. The stepwise multiple discriminant analysis was performed to get a linear discriminant equation. The results showed that 4.3% of study patients turned to severe malaria. The MSPS = 4.38 (schizontemia) + 1.62 (gametocytemia) + 1.17 (dehydration) + 0.14 (overweight by body mass index; BMI) + 0.05 (initial pulse rate) + 0.04 (duration of fever before admission) - 0.50 (past history of malaria in last 1 year) - 0.48 (initial serum albumin) - 5.66. Based on the validation study in other malaria patients, the sensitivity and specificity were 88.8% and 88.4%, respectively. We conclude that the MSPS is a simple screening tool for predicting uncomplicated falciparum malaria patients turning to severe malaria. However, the MSPS may need revalidation in different geographical areas before utilized at specific places.

Liver function tests were performed in 61 vivax, 54 malariae and 15 ovale malaria patients who were admitted to Bangkok Hospital for Tropical Diseases between 2001 and 2004. The objective of the study was to evaluate changes in hepatic biochemical indices before and after treatment with artemisinin derivatives. On admission and prior to treatment, hepatic dysfunction was found among the 3 groups. Serum liver function tests and physical examinations were performed weekly during the 28-day follow-up period. Initially elevated serum bilirubin and diminished albumin returned to normal within 2 weeks of treatment. Serum alkaline phosphatase and aminotransferases returned to within normal limits within 3 weeks. We conclude that patients with Plasmodium vivax, P. malariae and P. ovale infections had slightly elevated serum bilirubin, aminotransferase and alkaline phosphatase levels, and hypoalbuminemia. These minor abnormalities returned to normal within a few weeks after treatment with therapies based on artemisinin derivatives.

We conducted a study to compare the safety and tolerability of anti-relapse drugs elubaquine and primaquine against Plasmodium vivax malaria. After standard therapy with chloroquine, 30 mg/kg given over 3 days, 141 patients with P. vivax infection were randomized to receive primaquine or elubaquine. The 2 treatment regimens were primaquine 30 mg once daily for 7 days (group A, n = 71), and elubaquine 25 mg once daily for 7 days (group B, n = 70). All patients cleared parasitemia within 7 days after chloroquine treatment. Among patients treated with primaquine, one patient relapsed on day 26; no relapse occurred with elubaquine treatement. Both drugs were well tolerated. Adverse effects occurred only in patients with G6PD deficiency who were treated with primaquine (group A, n = 4), whose mean hematocrit fell significantly on days 7, 8 and 9 (P = 0.015, 0.027, and 0.048, respectively). No significant change in hematocrit was observed in patients with G6PD deficiency who were treated with elubaquine (group B, n = 3) or in patients with normal G6PD. In conclusion, elubaquine, as anti-relapse therapy for P. vivax malaria, was as safe and well tolerated as primaquine and did not cause clinically significant hemolysis.

Peripheral gangrene, characterized by distal ischemia of the extremities, is a rare complication in patients with falciparum malaria. Patients with this complication have generally undergone early amputation of the affected areas. In this report, we describe 3 adult Thai patients presented at the Hospital for Tropical Diseases, Bangkok, with high grade of fever ranged 6-9 days, jaundice, acute renal failure, respiratory failure, alteration of consciousness and shock. Two patients had gangrene developed at the lower extremities on day 1 of hospitalization and 1 patient had gangrene developed on day 3. Blood smears revealed hyperparasitemia with Plasmodium falciparum. These patients were diagnosed as having severe malaria with peripheral gangrene. The resolution of gangrene was successfully achieved by treatment with artesunate and conservative treatment in 2 of 3 cases.

Background Dengue is the most common mosquito-borne viral disease in humans. However, the sensitivities of warning signs (WSs) for identifying severe dengue in adults are low, and the utility of lactate levels for identifying severe dengue in adults has not been verified. Therefore, we aimed to evaluate the diagnostic accuracy of using peripheral venous lactate levels (PVL), as well as WSs established by the World Health Organization, for identifying severe dengue. Methods We prospectively evaluated individuals hospitalized for dengue who were admitted to the Hospital for Tropical Diseases in Thailand between May 2013 and January 2015. Blood samples to evaluate PVL levels were collected at admission and every 24 h until the patient exhibited a body temperature of