Mycotic aneurysm caused by Burkholderia pseudomallei with negative blood cultures

We describe a case of bacterial aortitis caused by Burkholderia pseudomallei. This patient presented with prolonged fever and hoarseness of voice. Aneurysm removal with Dacron graft replacement was performed, followed by a prolonged course of antibiotics. The patient has progressed satisfactorily without recurrence of symptoms. Previous case reports are summarized.     

Basal ganglia and brainstem encephalitis, optic neuritis, and radiculomyelitis in Epstein-Barr virus infection

The neurologic complications of Epstein-Barr virus (EBV) infection are rare. We describe a healthy adult with acute EBV meningoencephalomyeloradiculitis. The clinical manifestations, a serologic study, and a dynamic change of EBV DNA in the cerebrospinal fluid with spontaneous recovery confirmed the diagnosis of EBV infection of the nervous system. In addition, we provide other clinical clues for suspicion of EBV infection in patients with encephalitis. These include bilateral basal ganglia and brainstem lesions on magnetic resonance imaging, optic neuritis, or involvement of all levels of the nervous system.     

Immunological response to hepatitis B vaccination in patients with AIDS and virological response to highly active antiretroviral therapy

Previous studies showed that an immunological response to hepatitis B virus (HBV) vaccination in patients with AIDS was lower than in the normal population. However, those with virological response to highly active antiretroviral therapy (HAART) may have a normal immunological response to HBV vaccination. In our study, patients with AIDS who had a virological response to HAART and no immunity to HBV received 3 doses of HBV vaccine (20 microg of Engerix-B(R)) on d 0, 30, and 180. Anti-HBs level was measured 1 month after complete vaccination. Of 28 patients, overall response rate to vaccination was 71.4%. The responder group had a significantly higher CD4 count at 1 month after complete vaccination than the non-responder group (466.95+/-146.94 and 335+/-112.62 cells/microl, p =0.035). The patients receiving efavirenz-containing HAART had better response than those without efavirenz-containing HAART (p =0.030). The responder group had received a longer duration of HAART. In conclusion , to our knowledge, ours is the first prospective study to determine the immunological response to HBV vaccination in all patients with AIDS who had maintained the virological response after receiving HAART throughout the study period. Patients with AIDS and virological response to HAART have a good immunological response to HBV vaccination.     

Impact of self‐monitoring of salt intake by salt meter in hypertensive patients: A randomized controlled trial (SMAL‐SALT)

Salt intake over reference level would result in elevated blood pressure (BP) and long‐term morbidity. Salt meter is a device used to detect sodium content in daily food. This study aimed to evaluate the efficacy of salt‐meter addition to dietary education. The authors conducted a randomized‐controlled trial in hypertensive patients with uncontrolled BP (systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg). Patients were randomized to receive salt meter plus dietary education (group A) or education only (group B), and followed up for 8 weeks. The primary endpoint was change in 24‐h urinary sodium excretion. Changes in BP, salt taste sensitivity, cardio‐ankle vascular index (CAVI) were also analyzed. There were total number of 90 patients who had complete follow‐up, 45 in each group. Mean age was 62.9 years and 53% were females. Mean baseline 24‐h urine sodium was 151.6 mmol/24 h and mean SBP and DBP were 152.8 and 83.4 mmHg, respectively. Baseline characteristics were similar between two groups. At 8 weeks, mean change in urine sodium were –31.83 mmol/24 h and 0.36 mmol/24 h in group A and group B, respectively (p = .006). Mean decrease in BP were SBP, 14.44 versus 8.22 mmHg (p = .030), and DBP 5.53 versus 1.93 mmHg (p = .032). The salt sensitivity was improved more in group A. There was no different between change in CAVI. From this study, salt meter in conjunction with dietary education, for self‐monitoring of salt intake is superior to education alone in hypertensive patients, and provided better blood pressure control. Salt meter should be considered in uncontrolled hypertensive patients.     

There is need for antigen-based rapid diagnostic tests to identify common acute tropical illnesses

Enteric fever, typhus, leptospirosis, dengue, melioidosis, and tuberculous meningitis present urgent diagnostic problems that require experience and clinical judgment to make early evidence-based management decisions. Basic and applied research dealing with reliable antigen-based diagnostics has been published and confirmed for several of these infections. This should have initiated commercial production but has not. Established international firms see little profit in such diagnostic kits since they would be used in poor countries with little prospects for return of investment capital. We attempt to illustrate this issue, using common causes of acute febrile illnesses in the Southeast Asian region. We believe that rapid diagnostic technology could prevent significant delay in starting appropriate therapy, reduce hospital expenses, and even save lives.     

A case of Invasive pulmonary infection caused by novel species of Perenniporia

Perenniporia species, members of basidiomycetes, are known as decay fungi from wood of hardwood tree species. The clinical significance of these non‐sporulating fungi from respiratory tract specimens is unknown. They have frequently been discarded as contaminants. There was only one case report of pulmonary fungal ball with positive culture for a Perenniporia species. We report herein a case of invasive pulmonary infection caused by the novel species of Perenniporia in a 44‐year‐old woman with active systemic lupus erythematosus who was successfully treated with voriconazole.     

KRAS Mutation in Pediatric Intracranial Germ Cell Tumors

Background: Intracranial germ cell tumors (IGCTs) are rare, highly curable neoplasms. KRAS is a gene in the KIT/RAS signaling pathway, and KRAS mutations have been reported in patients diagnosed with IGCTs. Objectives: To describe the clinicopathologic and molecular features of KRAS mutation and the treatment outcome of children diagnosed with IGCTs. Methods: Patients diagnosed with IGCTs at the Department of Pediatrics, King Chulalongkorn Memorial Hospital from 2007 to 2016 were retrospectively reviewed. DNA was extracted from formalin-fixed, paraffin-embedded tissue and used for molecular study. Mutations in codons 12, 13, and 61 of the KRAS gene were detected using the cobas® KRAS mutation test and pyrosequencing. Results: Eighteen patients were diagnosed with IGCTs (11 males and 7 females): nine with germinomas and nine with non-germinomatous GCTs (NGGCTs). The age range of the patients was 5–14 years (median 10.5 years). Elevated markers were revealed in approximately 25% of the patients. Four patients (two with germinomas and two with NGGCTs) had leptomeningeal involvement. All patients underwent tumor biopsy and received neoadjuvant chemotherapy. Radiotherapy was administered in 16 patients, and craniospinal radiation was administered only in patients with leptomeningeal metastasis. With a median follow-up of 26 months, overall survival was 88.9% in the patients with germinomas and 37% in the patients with NGGCTs. Mutation of the KRAS gene was detected using pyrosequencing in one patient. The mutation located at codon 61, with frequency 38.3% units, nucleotide substitution CAA > CTA, and amino acid substitution, was Q61L. The patient carrying the mutant gene was diagnosed with germinoma with cerebrospinal fluid metastasis and eventually died from treatment-related toxicity. Conclusion: Our study revealed the treatment outcomes of IGCTs in Thai children. The metastatic germinoma patient with KRAS codon 61 mutation had a poor outcome, supporting that Q61L has a clinical correlation with IGCTs.     

Case Report: Autochthonous Visceral Leishmaniasis in a Human Immunodeficiency Virus (HIV)-Infected Patient: The First in Thailand and Review of the Literature

We report a case of visceral leishmaniasis in a human immunodeficiency virus (HIV)-infected 37-year-old Thai fisherman who presented with nephritonephrotic syndrome, fever, anemia, and thrombocytopenia. Bone marrow biopsy revealed many amastigotes within macrophages. Kidney biopsy showed membranoproliferative glomerulonephritis. Polymerase chain reaction (PCR) and nucleotide sequence analysis of the internal transcribed spacer 1 of the small subunit ribosomal RNA gene in blood and kidney biopsy specimens showed Leishmania species previously described in a Thai patient with visceral leishmaniasis. Only four autochthonous cases of leishmaniasis have been reported in Thailand since 1996. To the best of our knowledge, this is the first report of autochthonous visceral leishmaniasis in an HIV-infected Thai. With an increasing number of patients with autochthonous leishmaniasis in association with the presence of potential vector, it remains to be determined whether this vector-borne disease will become an emerging infectious disease in Thailand.Leishmaniasis is a vector-borne infection caused by an obligate intracellular protozoon, Leishmania sp., which is transmitted by phlebotomine sandflies.^1–3 It occurs worldwide in tropical and subtropical regions including the Middle East, India, China, Africa, and southern and central America. Thailand is not a known endemic area for leishmaniasis. Most imported cases were reported between 1960 and 1986 in Thai workers returning from the Middle East.^4,5 The first reported indigenous patient with leishmaniasis was a 3-year-old girl living at Suratthani Province of southern Thailand in 1996.⁶ Several autochthonous cases with leishmaniasis were recently seen in northern, central, and southern Thailand.^7–9 Interestingly, these patients were from provinces where a potential sandfly vector has never been reported.^10–12 We describe the first report of visceral leishmaniasis in a human immunodeficiency virus (HIV)-infected patient and review all previous reports of autochthonous cases of leishmaniasis in Thailand.