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Objective: To evaluate all renal functions in patients receiving TDF and other nucleoside analogues., Material and Method: A prospective controlled study evaluating glomerular and tubular functions was conducted in patients receiving either TDF- or AZT-containing antiretroviral therapy regimen between 2008 and 2009 at King Chulalongkorn Memorial Hospital, Bangkok, Thailand, Results: Of 51 patients, there were 39 and 12 patients, with the mean age of 40.03 +/- 7.7 and 37.2 +/- 7.6 years in the TDF and AZT groups. There was no diference between the two groups, except longer HIV infection duration, higher patient number with previous antiretroviral therapy and undetectable HIV RNA, and higher CD4 count in the TDF group. All and most patients had received lamivudine and a non-nucleoside analogue. The mean change of eGFR from the baseline to the six months of follow-up was +/-1.32 and +/- 5.88 mL/minute in the TDF and AZT groups. Proximal tubular dysfunction was not noted at three and six months of follow-up. However patients in the TDF group had lower serum phosphate and higher renal potassium loss than the AZT group at six months of follow-up (p = 0.08 and p = 0.09, respectively). No patients in the two groups with distal tubular dysfunctions were noted, Conclusion: To our knowledge, this is the first prospective controlled study extensively evaluating all renal functions in patients receiving TDF andAZT There are no differences in the eGFR decline between the two groups during the six months of follow-up. However, a trend towards greater renal loss of potassium and phosphate is noted in the TDF group. A study with longer duration of follow-up is needed

Objective: There has been a development of automated and continuous-monitoring blood culture systems that are more sensitive than conventional systems for the detection of microorganisms. Whether two or three blood culture specimens obtained during a 24-hour period using these automated systems achieving a higher recovery rate of microorganism remains to be determined. The present study was aimed to compare the recovery rates of microorganism of blood-stream infections (BSIs) using two and three blood culture specimens., Material and Method: A prospective investigator-blinded study was carried out in patients who needed to have blood cultures in medicine wards and intensive care units as well as an emergency room of King Chulalongkorn Memorial Hospital, Bangkok, Thailand, between October 1, 2010 and March 31, 2011. Three blood culture specimens were obtained from each patient during a 24-hour period. Each specimen was inoculated into an aerobic bottle of blood culture broth (TREK Diagnostics, Cleveland, OH, US), and then incubated at 37 degrees C for seven days., Results: Of 568 patients, there were 116 (20.4%) unimicrobial episodes with three blood cultures obtained during a 24-hour period. There were 70 (12.3%) and 46 (8.1%) episodes of true pathogen and contaminant, respectively. The recovery rates of true pathogen were 75.7% (53 isolates), 87.1% (61 isolates), and 100% (70 isolates) with the first, second, and third blood culture specimens, respectively (p < 0.05 between the recovery rate with the first two and the third blood culture specimens). There were 25 (35.7%), 38 (58.6%) isolates, and four (5.7%) of Gram-positive, Gram-negative bacteria, and fungi, respectively. Among 25 Gram-positive bacteria, Staphylococcus aureus was the most common isolate (10, 14.3%), followed by Streptococcus pneumoniae (5, 7.1%) and Enterococcus faecalis, Enterococcus faecium, coagulase-negative Staphylococcus (3, 10% each). Among 38 Gram-negative bacteria, Escherichia coli was the most common isolate (13, 18. 6%), followed by Pseudomonas aeruginosa (8, 11.4%), and Klebsiella pneumoniae (6, 8.6%). The sensitivity and specificity of the recovery rate of microorganisms using two blood culture specimens were 85.7% and 92.3%, respectively. The sensitivity and specificity of the recovery rate of microorganisms using three blood culture specimens were 100% and 90.8%, respectively., Conclusion: To the best of the authors'knowledge, the present study is the first prospective study to compare the recovery rate of microorganisms of BSIs between the two and three blood culture specimens using the VersaTREK blood culture system. Three blood culture specimens are required to achieve the recovery rate of more than 99%.

Background: In Thailand, acute diarrhea is one of the most common problems among ambulatory patients at the outpatient department (OPD). Overuse of antibiotics is associated with increased rates of antibiotic-resistant bacteria, unnecessary increased cost of treatment, and significant incidence of adverse effects. In Thailand, how frequently antibiotic is prescribed in adult patients with acute diarrhea is not known., Material and Method: The authors performed a retrospective study in all adult patients with acute diarrhea attending at the OPD of King Chulalongkorn Memorial Hospital, Bangkok, Thailand between August 2009 and January 2010 as ambulatory basis. All data regarding epidemiology, clinical features, and treatment were evaluated., Results: There were 390 [255 females (65.4%) and 135 males (34.6%)] patients during the study period. There were 91 (23.3%) with inflammatory diarrhea and 209 (76.7%) patients with non-inflammatory diarrhea. Only 36 (9.2%) patients had stool examination and culture results. Of 13 (36.1%) patients with positive stool cultures, four (11.1%) patients had Vibrio parahaemolyticus, two (5.7%) patients each had non-O1 Vibrio cholerae, Cryptosporidium parvum, or Plesiomonas shigelloides and V. parahaemolyticus, and one (2.9%) patient each had P. shigelloides, P. shigelloides and Salmonella, or group D Salmonella. Three hundred fifty three (90.5%) and 37 (9.5%) patients were treated by residents and faculty staffs, respectively One hundred and seventy-six (45.1%) patients received antibiotics, which included norfloxacin (128 patients, 72.7%), ciprofloxacin (34, 19.3%), ceftriaxone and ciprofloxacin (6, 3.4%), ceftriaxone (5, 2.8%), ceftriaxone and norfloxacin (2, 1.1%), amoxicillin (1, 0.6%), and ofloxacin (1, 0.6%). One hundred and forty-eight of 353 (41.9%) residents and 28 of 37 (75.7%) faculty staffs prescribed antibiotics. According to the recommendations by WHO, the rate of overuse of antibiotics was 48.9% (86 of 176 patients)., Conclusion: There is a very high rate of overuse of antibiotics in Chulalongkorn Hospital. Both attributing physician- and patient-related factors should be evaluated before implementing an effective strategy to change prescribing behavior.

Background: Central nervous system (CNS) infections are among one of the most common complications in HIV-infected patients. The present study aimed to determine the etiologies, clinical features, treatment, and outcomes of all CNS infections in HIV-infected patients., Material and Method: A retrospective study was carried out in all adult HIV-infected patients with CNS infection who were hospitalized at King Chulalongkorn Memorial Hospital, Bangkok, Thailand, from January 1, 2007 to December 31, 2008. Medical records ofthe patients were identified by extensively searching the disease codes based on International Classification ofDiseases-10, all microbiological data, and all histopathological data., Results: One hundredforty eight patients were enrolled. There were 103 males (69.6%) with the mean age of 36.1 +/- 8.9 years (range 15 to 75 years). Among 93 patients with available data, the median and percentage of CD4 cell count during hospitalization were 64.0 cells/microlitre and 6% (range 1-684 cells/microlitre and 1-57%). Among 106 patients with known HIV infection, 67 patients (63.2%) had received antiretroviral therapy with the mean duration of 1.6 +/- 2.1 years. The most common CNS infection was cryptococcal meningitis (56 patients, 37.8%), followed by tuberculosis (53, 35.8%), toxoplasmosis (19, 12.8%), progressive multifocal leukoencephalopathy (6, 4.1%), varicella-zoster virus (VZV) meningitis (4, 2.7%), brain abscess (3, 2.1%), cytomegalovirus radiculomyelitis (2, 1.4%), pneumococcal meningitis (2, 1.4%), herpes simplex encephalitis, Epstein-Barr virus-related primary CNS lymphoma, and HIV-associated myelopathy (1 patient, each, 0.7%). Twenty-two patients died, accounting for the mortality rate of 14.9%. Of these 22 patients, tuberculous meningitis was the most common cause (9 patients, 16.9%), followed by cryptococcal meningitis (9, 16.1%), VZV encephalitis, Aspergillus brain abscess, herpes simplex encephalitis, and pneumococcal meningitis (1, 4.8% each)., Conclusion: To the authors' knowledge, this is the first comprehensive study in Thailand to investigate the etiologies, clinical manifestations, and outcomes of all CNS infections in AIDS patients. There are a high number of patients with tuberculosis and severe immunodeficiency in the present study. The authors' findings suggest an urgent need to actively search and treat most HIV-infected patients in the community before they become severely immunocompromised.

Background: Infections cause substantial morbidity and morbidity in neutropenic patients. In King Chulalongkorn Memorial Hospital, Gram-negative bacteria remained the most common causative pathogen of febrile neutropenia in all three studies conducted before 2002. However, Gram-positive bacteria have become more commonly isolated etiologic pathogens, and the incidence of fungal infection has been increasing since 2005., Objective: Determine the infectious etiology of fever in neutropenic patients at King Chulalongkorn Memorial Hospital, Bangkok, Thailand., Material and Method: A retrospective chart review of all medical records of febrile neutropenic patients hospitalized at Department of Medicine between January 1 and December 31, 2006 in accompanying with microbiologic, radiologic, and serologic results was analyzed., Results: There were 125 patients (61 males and 64 females) and 172 episodes of febrile neutropenia with a mean age of 46.5 +/- 18.5 years (range: 15-81 years). The three most common primary diseases associated with neutropenia were acute myeloid leukemia, non-Hodgkin's lymphoma, and acute lymphoblastic leukemia (36.6%, 33.1%, and 10.5%). Infections could be documented microbiologically and clinically in 84 episodes (48.8%), and primary bacteremia or fungemia was the most common cause of infection (40.5%). Gram-negative bacteria were the most frequently isolated pathogens (63.9%), followed by Gram-positive bacteria (29.9%) and fungi (6.2%). Escherichia coli (46.8%) and coagulase-negative Staphylococcus (27.6%) were the most common isolates among Gram-negative and Gram-positive bacteria, respectively. Among 53 episodes (30.8%) of bloodstream infections, Gram-negative bacteria were the most commonly isolated pathogens (38 episodes, 71.7%), followed by Gram-positive bacteria (19 episodes, 35.8%) and Candida tropicalis (1 episode, 1.9%). Surprisingly, invasive mold infections were noted in eight episodes (5, 1, and 2 episodes of proven, probable, and possible infections, respectively). The overall mortality was 19.2%., Conclusions: Although Gram-negative bacteria are the most common etiology of fever in neutropenic patients, the occurrence of infections caused by coagulase-negative Staphylococcus and molds has been increasing in comparison with the observations from previous studies in King Chulalongkorn Memorial Hospital. To authors knowledge, the present study is the first in Thailand to determine the occurrence of invasive fungal infections using the standard criteria recommended by EORTC/MSG.

We describe the first case of typhoid spondylodiscitis in Southeast Asia, and the literature were also reviewed. A 57-year-old diabetic Thai man who presented with a one-month course of progressive low back pain associated with paraparesis and bowel-bladder dysfunction. Examination revealed local tenderness over T12 area, spastic paraparesis, impaired pinprick sensation up to T12 level, and loose anal sphincter tone. Magnetic resonance imaging showed spondylodiscitis of T11 and T12 and epidural abscess causing spinal cord compression. T11 and T12 laminectomy, T11/12 discectomy, and debridement of epidural abscess were performed, and the cultures of the pus grew Salmonella Typhi. He was treated with intravenous ciprofloxacin for three weeks and was discharged from the hospital with oral ciprofloxacin and trimethoprim-sulfamethoxazole for another five months of treatment. The patient was doing well when last seen two months after discontinuation of antimicrobial treatment. In addition, a total of ten cases of typhoid spondylitis/spondylodiscitis were reviewed.

As part of the continuing national antimicrobial surveillance, the national antimicrobial resistance surveillance thailand (NARST), data of all clinical isolates of Streptococcus pneumoniae were collected from 28 hospitals in Thailand from 2000 to 2005. Epidemiological and microbiological data were obtained and analyzed using the WHONET software program. Among all isolates tested for antimicrobial susceptibility, the rates of penicillin resistance were constantly high, ranging from 42.4% in 2000 to 47.7% in 2005. The third-generation cephalosporin resistance rate, determined by Epsilon test (E-test) in 10% to 15% of all isolates each year, ranged from 2.1% to 8.4%. The rates of erythromycin resistance ranged from 24.2% to 30.3%. Surprisingly, one isolate in 2005 was resistant to levofloxacin. The rates of multi-drug resistance ranged from 14.8% to 34.3%. In conclusion; the present (NARST) study documents remarkable increase of penicillin, erythromycin, and multi-drug resistance rates in Thailand, especially among isolates from the North, the Center, the East, and Bangkok; from university hospitals; from young children; and from non-sterile specimens.

In this overview, the authors summarize the antimicrobial susceptibility patterns of important Gram-positive bacteria from the National Antimicrobial Resistance Surveillance Thailand (NARST) program between 2000 and 2005 as well as the clinical implications. This collaborative network program was funded by the World Health Organization, and involved 33 hospitals throughout Thailand. There are rising trends of drug-resistant S. pneumoniae (DRSP), ampicillin-resistant enterococci, but a constant occurrence of methicillin-resistant S. aureus (MRSA) was noted during this period. The rates of penicillin and erythromycin resistances of S. pneumoniae were constantly high, ranging from 42.5% to 47.7% and 24.6% to 31.1%, respectively, whereas the rates of cefotaxime resistance were quite low, ranging from 2.1% to 8.4%. The rates of multidrug-resistant (MDR) S. pneumoniae ranged from 14.8% to 34.3%. Of all S. aureus isolates, MRSA comprised 24% to 27%, and vancomycin resistance rates of these MRSA isolates ranged from 0.1% to 0.8%. The antimicrobial resistance rates of methicillin-susceptible S. aureus isolates were very low. The rates of ampicillin and high-level gentamicin resistances of E. faecium from 2000 to 2005 have been significantly increasing from 52% to 84.1%, and from 46.9% to 75%, respectively, but vancomycin resistance was stable at the rates between 0.4% and 1.9%. In conclusions, antimicrobial resistance rates of important Gram-positive bacteria have been increasing in Thailand. All local, national, and international surveillance data will help to set the strategic plan for control and treatment of these resistant organisms. Appropriate and accurate microbiological procedures regarding the collection and transportation of clinical specimens as well as the identification of these emerging resistant organisms are urgently needed, in collaboration with other concerned sectors.

Objective: To determine the prevalence, clinical epidemiology, and antimicrobial susceptibility of Pseudomonas aeruginosa in Thailand from 2000 to 2005., Material and Method: Using WHONET data from 28 hospitals participating in the National Antimicrobial Resistance Surveillance Thailand (NARST) program, all data were reviewed and analyzed for the prevalence, clinical epidemiology, and antimicrobial susceptibility of clinical isolates of P. aeruginosa from 2000 to 2005., Results: During the six-year surveillance, the prevalence of P. aeruginosa in clinical isolates was constant among 28 hospitals. The most common sites of isolation included sputum, pus, and urine. The most active antimicrobials were netilmicin (88% to 90.8%), cefoperazone/sulbactam (85.1% to 89.5%), imipenem (84.6% to 87.2%), and meropenem (84.5%). The resistance to ceftazidime was very high, ranging from 24.6-27.4%. The prevalence of multidrug-resistant (MDR) P. aeruginosa (resistance to amikacin, ciprofloxacin, and ceftazidime) was constant. Some hospitals in Central and Eastern regions had the prevalence of MDR up to 20% to 30% of the isolates., Conclusion: According to NARST data, the antimicrobial resistance rates of P. aeruginosa remains constant with the exception of relatively high rates in ceftazidime. The prevalence of MDR P. aeruginosa is generally low with a moderately high prevalence in some hospitals.

Background: Much controversy exists as to whether cephalosporin treatment is appropriate for infections caused by ESBL-producing organisms because no randomized controlled studies have been performed., Objective: Evaluate the therapeutic outcomes of ceftriaxone treatment in acute pyelonephritis caused by ESBL-producing Escherichia coli, Klebsiella pneumoniae, or Proteus mirabilis., Material and Method: The authors performed a prospective study in female patients hospitalized with acute pyelonephritis caused by ESBL-producing or ESBL-nonproducing E. coli, K. pneumoniae, or P. mirabilis in four hospitals in Thailand from 2004 to 2006. The clinical and microbiological outcomes were evaluated at 72 hours after empirical ceftriaxone treatment., Results: One hundred eleven patients with the mean age of 65.29 years participated in this study. There were no differences in demographic and clinical characteristics and laboratory data between the ESBL-producing and ESBL-nonproducing groups except the higher rates of previous antibiotic use and urinary tract infection; and the lower frequency of costovertebral angle tenderness in the ESBL-producing group. Both clinical (65% and 93%) and microbiological (67.5% and 100%) responses at 72 hours after ceftriaxone treatment were poorer in the ESBL-producing group than in the ESBL-nonproducing group (p < 0.0002)., Conclusion: To the authors' knowledge, this is the first prospective study to evaluate the outcomes of ceftriaxone treatment in acute pyelonephritis caused by ESBL-producing Enterobacteriaceae. The present study confirms that acute pyelonephritis in the female patients caused by ESBL-producing strains could not be treated with ceftriaxone.

Background: Currently, in established antibiotic era, there is a widespread and increasing use of broad-spectrum antibiotics. Clostridium difficile, one of the troublesome intruders, flourishes when normal gut flora is altered by antibiotics. C. difficile is recognized as a frequent and leading cause of antibiotic-associated diarrhea and colitis. It causes substantial morbidity and mortality in hospitalized patients., Objective: The present study was aimed at determining patient characteristics, clinical features, treatment, and outcomes of C. difficile-associated disease (CDAD) in hospitalized patients at King Chulalongkorn Memorial Hospital, Bangkok, Thailand., Material and Method: From 2002 to 2005, 88 patients with positive latex immunoassay for C. difficile toxin A were identified. Data from medical records of 56 patients were available for analysis., Results: Of 56 patients, there were 28 males and 28 females, with the mean age of 47.39 years (range: 4 months to 93 years). 50 (89.3%) patients had underlying illnesses with hematological malignancies (14 patients, 25%) and solid tumors (15 patients, 26.8%) being the most common. All patients had a history of antibiotic use including current (17 patients, 30.4%), recent (16 patients, 28.6%), or both current and recent uses (23 patients, 41.1%). Cephalosporins and carbapenems were the two most commonly prescribed antibiotics. 25 (44.6%) patients were receiving either omeprazole or ranitidine. 12 (21.4%) patients had received chemotherapy within two months before CDAD diagnosis. Of 50 stool specimens examined, only 26 (52%) had white or red blood cells. Colonoscopy was performed in only three patients, and pathological findings revealed non-specific colitis. Oral metronidazole, intravenous metronidazole, and vancomycin were prescribed for CDAD treatment in 38 (67.9%), 4 (7.1%), and 2 (3.6%) patients, respectively. 8 (14.3%) patients had no specific treatment, and the offending antibiotic was not discontinued in three of them. An overall initial response rate was 66.7%. 2 patients relapsed after metronidazole treatment., Conclusion: The present study is the first in Southeast Asia to describe the decreased initial response rate of metronidazole treatment of CDAD. The reasons for this relatively poor response in the presented patients need to be determined in a future study.

Background: Urinary tract infection (UTI) is common in spinal cord injured patients. The authors investigated the epidemiology of bacteria associated with UTI to select an appropriate antibiotic for empirical treatment of UTI before obtaining a bacterial culture., Objective: To determine the prevalence, as well as the causative bacteria and their susceptibility pattern of urinary tract infection in spinal cord injured patients hospitalized to the Rehabilitation Center, Thai Red Cross Society, Samutprakarn, Thailand from January 2001 to December 2005., Material and Method: A retrospective chart review of 76 spinal cord injured patients., Results: Of all spinal cord injured patients, there were 50 males and 26 females, with the average age of 44.70 years. The average length of hospitalization was 104.5 days. 71.2% of the patients needed intermittent catheterization for bladder drainage, and only 2.7% had suprapubic cystostomy. None of patient had indwelling catheterization. Forty-six patients had 68 episodes of UTI (60.52%). Eighteen patients had recurrent UTI (14 patients had two episodes and four patients had three episodes). E. coli was the most common isolated pathogen (74.36%) followed by K. pneumoniae (12.82%), E. faecalis (5%) and P. mirabilis (5%). Most gram-negative pathogens were susceptible to amikacin and third generation cephalosporins. The susceptibility of these organisms to cotrimoxazole, amoxicillin/clavulanate, and ciprofloxacin were in the range of 34.6-60.0%, 44.0-50.0% and 25.9-50.0%, respectively., Conclusion: Urinary tract infections were commonly observed among spinal cord injured patients in the presented institution. E. coli was the most common isolated pathogen. Surprisingly, most gram-negative pathogens were resistant to cotrimoxazole, amoxicillin/clavulanate, and ciprofloxacin. An antibiotic of choice for UTI in our patients should be aminoglycoside or third generation cephalosporins.

Background: The most common endocrine disorder in patients with human immunodeficiency virus (HIV) is adrenocortical dysfunction. The prevalence of adrenal insufficiency in patients with AIDS is unclear; partly due to different tests, doses of adrenocorticotrophic hormone (ACTH), and criteria used. In addition, there is controversy regarding the assessment of adrenal insufficiency in patients with and without critical illness., Objective: To help clarify the prevalence of adrenal insufficiency in patients with AIDS both in critical and non-critical illness, the authors compared the prevalence based on the high-dose ACTH stimulation test., Material and Method: There were 26 patients with AIDS (19 males and 7 females) with a mean age of 33.6 years (range: 22-46 years). Twelve and 14 patients were in critical and non-critical illness, respectively., Result: Overall, the prevalence of adrenal insufficiency was 19.2% (5 of 26) and 30.8% (8 of 26) when a peak stimulated cortisol level of < 18 microg/dL and < 25 microg/dL was defined, respectively. The prevalence was 8.3% and 28.6% in critically and non-critically ill patients; respectively, when a peak stimulated cortisol level of < 18 microg/dL was defined. Finally, when a peak stimulated cortisol level of < 25 microg/dL was defined, the prevalence was 16.7% and 42.9% in critically and non-critically ill patients, respectively., Conclusion: Adrenal insufficiency in patients with AIDS is more prevalent than those without HIV infection, no matter what criteria of cortisol response after ACTH test are defined An adrenal testing should be performed in all hospitalized patients with AIDS, both in critical and non-critical illness.

The authors describe the first case of Salmonella serogroup D gas-forming femoral osteomyelitis and pyomyositis in a 51-year-old man with non-Hodgkin lymphoma. The patient was successfully treated with surgical debridement as well as clindamycin plus ceftriaxone, and then switched to ciprofloxacin. However, he eventually died due to multidrug-resistant Acinetobacter baumannii pneumonia. In addition, five cases of Salmonella gas-forming pyomyositis in the literature were reviewed.

Background: Nontuberculous mycobacteria (NTM) can cause infections in both human immunodeficiency virus (HIV)-infected and HIV-noninfected patients. The incidence of NTM infections has been increasing since the acquired immunodeficiency syndrome (AIDS) epidemics. However, the epidemiologic and clinical data of NTM infections in Thailand are limited., Objective: Determine the epidemiology, clinical manifestations, treatment, and outcome of NTM infections in King Chulalongkorn Memorial Hospital from January 2000 to December 2003., Material and Method: One hundred and fourteen patients had positive NTM cultures; however, complete medical records were available in only 103 (90.3%) patients., Results: There were 71 (68.9%) HIV-infected patients, and 38 (87%) of them had the CD4 counts of < 200 cells/microL (range 4-360). Among HIV-infected patients, the most common previous opportunistic infections included tuberculosis (36.6%), Pneumocystis jirovecii pneumonia (25.3%), cryptococcal meningitis (15.5%), penicilliosis (5.6%), and cytomegalovirus infection (5.6%). Most patients presented with prolonged fever (67%), chronic cough (54.4%), lymphadenopathy (52.4%), weight loss (50.5%), or chronic diarrhea (31%). The clinical manifestations included disseminated (17.4%) and localized (82.6%) infections. The localized infection included pulmonary infection (82.3%), followed by gastrointestinal infection (34.1%), skin infection (12.9%), lymphadenitis (8.2%), genitourinary tract infection (2.4%), central nervous system infection (2.4%), and keratitis (1.2%). Mycobacterium avium complex (MAC) was the predominant species (48.5%), followed by M. kansasii (19.4%), and rapidly growing mycobacteria (16.4%). Diffuse reticular infiltration was most commonly observed on chest radiography (53.4%). Abnormal laboratory findings included anemia (48.5%), hyponatremia (42.7%), and elevated alkaline phosphatase (39.8%). The overall mortality rate was 34.8% (45.9% and 11.1% in HIV- and HIV-noninfected patients)., Conclusion: A diagnosis of NTM infection requires a high index of suspicion in patients especially with AIDS or immunocompromised status who present with prolonged fever, with or without organ-specific symptoms and signs. Therefore, clinical specimens must be sent for mycobacterial cultures for a definite diagnosis, a determination of the species of NTM, and an appropriate management. In addition to four standard antituberculous drugs, clarithromycin should be added for the treatment of MAC in patients with AIDS who presented with disseminated opportunistic infections before obtaining the microbiologic results.

Objectives: Invasive aspergillosis (IA) is among the most common invasive fungal infections in neutropenic patients with hematological disorders in the authors' institution, King Chulalongkorn Memorial Hospital (KCMH), Bangkok, Thailand Previous studies have reported the Aspergillus galactomannan enzyme immunosorbent assay (GMEIA) may be a useful diagnostic tool for IA. The authors evaluated the performance of the GM EIA for the diagnosis and monitoring of the course of IA in KCMH., Material and Method: The authors prospectively performed the study from June 2002 to January 2004 in a consecutive series of adult neutropenic patients with hematological disorders who were at risk for developing IA. During hospitalization, serum galactomannan levels were measured once or twice weekly using the Platellia Aspergillus EIA test kit. The sensitivity and specificity of the GM EIA were calculated according to the proportion of patients with true and false positive and negative tests., Results: There were 50 treatment episodes in 44 patients with 5 proven, 12 probable, and 33 possible or no IA. The cutoff GM index of > 0.75 was determined with a sensitivity of 94.1% and a specificity of 78.8%. There was a close relationship between clinical outcome and the kinetics of GM indices., Conclusion: The GM EIA is a useful diagnostic toolfor the diagnosis and monitoring of the course oflA in the presented institute.

Brucellosis remains a major zoonotic disease worldwide. It has never been reported at King Chulalongkorn Memorial Hospital (KCMH). The authors describe the first case of brucellosis in KCMH, and also review all previous reports in Thailand. The presented case was a 52-year-old Thai man, living in Phetchabun Province, who was diagnosed with idiopathic pulmonary fibrosis two years prior to admission. He presented with prolonged fever, dry cough, weight loss of eight kg over three months, hepatosplenomegaly, and pancytopenia. Blood and bone marrow cultures grew Brucella melitensis at 72 hours of incubation. A slide agglutination (Rose Bengal) test was also positive for Brucella antibody. He had been exposed to contaminated placenta of his goats that had spontaneous abortion in the past few months before his illness. The patient was successfully treated with gentamicin, doxycycline, and rifampicin. Clinicians should have a high index of suspicion when evaluating patients presenting with prolonged fever and having an exposure risk of brucellosis.

Rapidly growing mycobacteria (RGM) have emerged as important human pathogens that can cause a variety of diseases. Thirty isolates of the pathogenic RGM were recovered from patients who attended King Chulalongkorn Memorial Hospital during 1997 and 2003. There were 16 isolates of Mycobacterium chelonae, ten isolates of M. fortuitum and four isolates of M. abscessus. Clinical data was available in only nine patients (five males and four females) including six M. chelonae, two M. abscessus, and one M. fortuitum. The mean age was 37 years (range: 13-62 years). The associated conditions were present in five patients including two diabetes, one HIV infection, one pregnancy, one SLE and one chronic renal failure. A wide spectrum of clinical features was observed. These included two chronic pulmonary infections, two post-traumatic wound infections, two disseminated infections, one lymphadenitis, one keratitis and respiratory colonization. AFB staining was positive in six patients (66.67%). The MIC of one M. chelonae and one M. abscessus were determined by Epsilon test. For M. chelonae, the MIC of clarithromycin, amikacin, ciprofloxacin, sulfamethoxazole and imipenem were 0.25, 2.0, 1.00, > 64, and 0.54 microg/ml, respectively. For M. abscessus, the MIC of clarithromycin, amikacin, ciprofloxacin, tetracycline and sulfamethoxazole were 0.016, 0.016, 0.038, > 16 and 0.002 microg/ml, respectively. Six of eight patients (75%) were initially treated with four first-line antituberculous drugs (isoniazid, rifampicin, pyrazinamide and ethambutol) before obtaining the culture result. Of these, three patients with pulmonary and disseminated infections improved after a prolonged course of these combinations. The patients improved after switching to specific anti-RGM antibiotics. One patient died after 10 months of therapy of four anti-tuberculous drugs. One patient with post-traumatic wound infection was cured with surgical debridement and dicloxacillin. One patient improved after treatment as acute bronchitis with oral amoxicillin. An extensive review of the literature of RGM infections in Thailand is also presented.

Adenovirus (AdV) infections are prevalent in bone marrow transplant patients, usually associated with significant morbidity and mortality. Hemorrhagic cystitis (HC) is a major complication mainly attributed to this virus. The authors report a case of AdV HC in a myelodysplastic patient undergoing peripheral blood stem cell transplantation. The diagnosis was confirmed by positive urine AdV antigen using indirect immunofluorescence assay. The patient gradually improved after adequate hydration, supportive treatment and reduced dose of cyclosporine, and was discharged on the ninth day of hospitalization. To the authors' knowledge, this is the first case of AdV HC in stem cell transplantation in Southeast Asia.

Leiomyosarcomas of the central nervous system are extremely rare; however they are becoming more prevalent in immunocompromised patients. The authors present MRI (Magnetic Resonance Imaging) of six cases of pathological proved leiomyosarcomas of the central nervous system in patients infected with human immunodeficiency virus. MR images of 4 cases of intraspinal leiomyosarcoma showed lobulated masses expanding multilevel of neural foramina with extradural and intradural extension, giving dumbbell appearance which mimic neurofibroma. Two cases of intracranial leiomyosarcoma revealed a mass at the left cavernous sinus involving prepontine cistern in one case and two lesions in the other case showing masses with dural based appearance at the region of the planum sphenoidale and the posterior aspect of the falx cerebri which mimiced a meningioma. The leiomyosarcoma should be included in the differential diagnosis of extra-axial CNS lesions in HIV-infected patients.

The authors describe the first indigenous case of hepatic hydatid disease in Thailand. A 58-year-old female presented with progressive right upper quadrant abdominal discomfort over a 6-month period. Ultrasonography and computed tomography showed a solitary cystic lesion 11 x 12 x 13 centimeter in size at the left lobe of the liver. She had never been abroad and had no livestock exposure. The first operation was complicated by spillage of the parasite which required a combination of albendazole and praziquantel and a second operation for intracystic instillation of hypertonic saline solution. Unfortunately, uncontrolled generalized seizures developed due to severe hypernatremia. She never regained consciousness and expired 3 weeks after admission. In addition, the authors also reviewed previous reports of hydatid disease in Thailand. To date, only 9 cases have been reported since 1932.