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Tuberculosis (TB), caused by Mycobacterium tuberculosis, is a major global public health issue. Southeast Asia contributes notably (44%) to global TB cases. Thailand is in the top 30 countries for [...]

Abstract Objective To study the association of workplaces and recent onset latent tuberculosis (LTB) in health care workers (HCW). Methods A case-control study was conducted at Srinagarind Hospital, Khon Kaen University, Thailand. We recruited HCW who had results of tuberculin test within 2 consecutive years from 2001–2008 and also had fixed workplaces (working hours more than 40 hours/week). Cases were subjects with tuberculin conversion, while controls were subjects with negative results of tuberculin test in two consecutive years. Tuberculin conversion was defined if a subject had a negative baseline tuberculin test and a positive tuberculin test in the next consecutive years. Baseline characteristics, workplaces (office, in-patient unit, out-patient unit, intensive care, operating room, and laboratory unit), tuberculosis related variables, and prevention strategies were studied. Multiple logistic regression analysis was used to identify predictors for tuberculin conversion. Results There were 624 subjects who met the criteria and 163 subjects had tuberculin conversion (26.1%; case group). The median age and male/female ratio of both groups were 39 years old and about 1:4. The cases group had higher percentage of subjects who worked at in- and out-patient department (30.7 vs 20.2 and 17.2 vs 12.2, respectively), had history of tuberculosis exposure in the past year (32.1 vs 16.1), and had history of prevention by any method and by surgical mask (49.4 vs 37.0 and 54.3 vs 38.3, respectively). Workings at in- and out-patient unit and history of tuberculosis exposure in the past year were significant predictors for tuberculin conversion (adjusted odds ratio and [95% confidence interval] of 1.99 [1.25–3.17], 1.91 [1.10–3.17], and 2.26 [1.47–4.96], respectively). Summary Workplaces in health care facilities do increase risks of LTB in HCW, particularly in in- and out-patient unit. Policy development regarding tuberculosis infection control programs focused on workplace prevention in health care facilities in Thailand is needed.

Multiple myeloma (MM) is a hematologic malignancy of plasma cell origin. Incidence of pleural effusion in multiple myeloma patients is approximately 6%. Myelomatous pleural effusions (MPE) are rare and occur in less than 1% of all MM cases. MPE is associated with advanced diseases, decreased survival time, and poor treatment response. In our case report, we describe a 59-year old man who presented with MPE at the initial diagnosis of MM. A diagnosis of MPE was reach through pleural fluid cytology and pleural tissue histology. The MPE had good response to initial dexamethasone without local therapy. [ABSTRACT FROM AUTHOR]

AbstractObjectiveData SourcesSelected StudiesResultsConclusionThis study investigated the utilization of nebulized budesonide for acute asthma and COPD exacerbations as well as for maintenance therapy in adults.We conducted a search on PubMed for nebulized budesonide treatment.Selecting all English-language papers that utilize Mesh phrases "asthma," "COPD," "budesonide," "nebulized," "adult," "exacerbation," and "maintenance" without temporal restrictions, and narrowing down to clinical research such as RCTs, observational studies, and real-world studies.Analysis of 25 studies was conducted to assess the effectiveness of nebulized budesonide in asthma (n = 10) and COPD (n = 15). The panel in Thailand recommended incorporating nebulized budesonide as an additional or alternative treatment option to the standard of care and systemic corticosteroids (SCS) based on the findings.Nebulized budesonide is effective and well-tolerated in treating asthma and COPD, with less systemic adverse effects compared to systemic corticosteroids. High-dose nebulized budesonide can enhance clinical outcomes for severe and mild exacerbations with slow systemic corticosteroid response. Nebulized budesonide can substitute systemic corticosteroids in some situations. [ABSTRACT FROM AUTHOR]

In this data article, we present Raman spectroscopy (RS) and surface-enhanced Raman spectroscopy (SERS) data obtained using an InVia Reflex confocal Raman microscope (Renishaw; Wotton-under-Edge, UK) and processed using WiRE™ 4.2 software. The data include RS and SERS spectra detected, after removal of albumin, from the serum proteome of tuberculosis (TB) patient categories and controls (active tuberculosis; ATB, latent tuberculosis; LTBI, TB-exposed persons with undetected infection; EC, healthy controls; HC) using 532 nm and 785 nm laser wavelengths for RS and 785 nm for SERS. The RS and SERS data had high reproducibility (SERS; R 2  = 0.988, RS at 785 nm; R 2  = 0.972, RS at 532 nm; R 2  = 0.9150). This data can be used for analysis of proteomic spectra based on RS and SERS for TB diagnosis and can also be compared to other populations. The spectral dataset based on normal, healthy control groups might be used as the control data for analysis of other diseases using RS and SERS approaches., (© 2019 The Author(s).)

Health-care workers (HCWs) are a high-risk population for acquiring Mycobacterium tuberculosis infection. Understanding the risk factors for latent tuberculosis infection (LTBI) could provide information to facilitate an appropriate tuberculosis (TB) control program. We aimed to determine the prevalence of, and risk factors for LTBI among HCWs in northeastern Thailand. Between 1 November 2013 and 30 September 2015, we examined 112 HCWs at Srinagarind Hospital, Khon Kaen Province in northeastern Thailand using the QuantiFERON®-TB Gold In-Tube (QFT) assay. Twenty-one [18.8%; 95% confidence interval (CI): 11.5- 26.0%] HCWs had a positive QFT result — all of whom were determined to have LTBI. The exposure risks and demographic data obtained from a questionnaire were compared between the 21 subjects who had a positive QFT assay and the 91 subjects who had a negative QFT assay. Multivariate analysis showed factors significantly associated with a positive QFT assay were: age ≥30 years (OR=18.88; 95%CI: 1.52-234.36), having worked as a nurse (OR=2.78; 95%CI: 1.19-6.49), having been employed at that job for ≥10 years (OR=8.78; 95%CI: 1.26-61.29) and having been exposed to known TB patients (OR=13.32: 95%CI: 1.61-110.04). Appropriate guidelines need to be developed, especially for these at-risk workers to prevent LTBI. These high-risk workers should also be considered for regular TB screening.

Nocardia thyroid abscess with pneumonia is a rare clinical presentation. We reported a liver transplant recipient with Nocardia thyroiditis and pneumonia after receiving high dose immunosuppressants to preserve his graft. The patient is a 50-year-old male who developed hepatitis C virus-related liver cirrhosis and received a liver transplant. Seven months post-transplantation the patient developed graft rejection, which was treated with 3 days pulse dose methyl-prednisolone followed by an increased dose of his tracolimus, mycophenolate and prednisolone. He presented to the hospital with a 2 week history of fever, tenderness in his anterior neck and dry cough. On admission his temperature was 39.5°C. The right wing of his thyroid gland was swollen to 3 cm in size, fluctuant and tender. On auscultation of his lungs there were fine crepitations and increased vocal resonance in the right middle lung field. On laboratory testing, a complete blood count (CBC) revealed leukocytosis (19,900/mm3) with neutrophils (97%). A chest X-ray showed an patchy infiltrates and round circumscribed densities in the superior segment of the right lower lobe of his lung. A CT scan of his neck revealed a diffusely enlarged right wing of the thyroid gland, 3.8 cm in diameter that had an abnormal hyposignal area. A CT of his chest revealed consolidation of the superior segment of the right lower lobe and necrotic right paratracheal lymph nodes with inflamed strap muscles. Fine needle aspiration of the right lobe of thyroid gland was performed. Modified acid-fast bacilli (MAFB) staining showed partially acid-fast beaded branching filamentous organisms and a culture grew out Nocardia asteroides. He was treated with trimethoprim-sulfamethoxazole for 6 months. He improved clinically and his chest X-ray also cleared.

A definitive marker determining the bacillary load of Mycobacterium tuberculosis (MTB), the causative agent of tuberculosis (TB), and hence disease severity, is required for patient monitoring and management. In this study, the association among T-cell responses based on the interferon-gamma release assay (IGRA) and the tuberculin skin test (TST), the sputum acid-fast bacilli (AFB) grade and types of radiological lesions were analyzed in new cases of pulmonary TB patients (n = 54) at Srinagarind Hospital, Khon Kaen, Thailand between September 1, 2012 and March 31, 2014. It was found that infiltrative and cavitary lesions from chest radiographs were associated with high sputum AFB grade (p = 0.048). T-cell responses from both IGRA and TST were not correlated with sputum AFB grade. Neither IGRA nor TST was correlated with the bacillary load as defined by AFB grade and chest radiographs. Patients with cavitary lesions on chest radiographs tended to have high IFN-γ concentrations and large TST indurations. In addition, TB patients with previous BCG vaccination showed significantly higher IFN-γ induction compared to the non-vaccinated group (p = 0.001). This study showed T-cell responses based on both IGRA and TST were not correlated with AFB grade and chest radiograph. In areas of high rates of BCG vaccination, as in Thailand, the BCG may affect IGRA and TST interpretations.

Objective: To study treatment outcomes of new and previously-treated smear positive pulmonary TB according to current WHO guideline 2010 and factors related to treatment success at Srinagarind Hospital., Material and Method: Adult patients who had smear-positive pulmonary TB treated at Srinagarind Hospital between January 2005 and December 2010 were enrolled in the present study., Results: Over a 6-years period, 322 patients (272 new and 50 previously-treated cases) were diagnosed smear positive pulmonary TB. The mean age was 48.85 (SD 17.9) years and the male to female ratio was 1.8:1. The mean duration of symptoms in the previously-treated group was longer than the new cases (2.39 vs. 1.99 months, p = 0.38). Symptoms, underlying diseases, HIV status, and organ involvement between these two groups were not different. Two-thirds (72.1% of patients) had cough, 35.4% had fever and 20.5% weight loss. Twenty-three percent of cases had underlying DM and 7.8% were HIV positive. Disseminated TB was found in 18.9% of cases. The mean duration of treatment in new cases was 6.88 months vs. 11.20 months in previously-treated cases. The common regimens for new cases included 2IRZE/4IR (72.8%) and 2IRE/7IR (19.1%) vs. 2IRZE/4IR (62%), 2IRE/7IR (12%), and other regimens for MDR patients (6%) among the previously-treated cases. However in previously-treated group IRZES/IRZE/IRE (p = 0.001), second-line drugs (p = 0.002), and MDR regimens (p < 0.001) were statistically more common treatments than in the new cases group. About 60% of cases were treated at TB clinic. The success rate among new cases who had completed treatment at Srinagarind Hospital was higher than for previously-treated ones (94.8% vs. 86.4%; p = 0.04). Among previously-treated cases (n = 50); 24 were defaulters, 19 were relapses, and seven were failures. For the defaulted and relapsed cases, patients usually received the IRZE/IR or IRZES/IRZE/IRE regimens. On the other hand, for failure cases, patients usually received the second-line drugs or MDR regimens. The overall success rate in defaulted cases was 87.6%, vs. 68.4% who relapsed and 57.1% who failed (p = 0.067). For new cases, the isolations found DR-TB 3.6% and MDR-TB 0%. For previously-treated cases, the isolations found DR-TB 16.67% and MDR-TB 6.25%. The only one factor related to successful outcomes was treatment at TB clinic (adjusted OR 2.01, 95% CI 1.18-3.43)., Conclusion: Previously-treated pulmonary TB had less success rate than new cases. Culture and susceptibility for previously-treated group were recommended before starting treatment. Treatment at TB clinic improved treatment outcomes.

Objective: To quantify the admission mortality, pathogens,factors related to mortality, length of hospital stay, and healthcare costs in adult hospitalized pneumonia in Thailand, Material and Method: The data on hospitalized pneumonia for the 2010 fiscal year extracted from the three main health insurance coverage schemes in Thailand (the Social Security System (SSS), the Medical Welfare System (MWS), and the Civil Servant Medical Benefit System (CSMBS)) were analyzed, Results: Adult hospitalized pneumonia admissions numbered 136,696, with mortality rate 9.63%. The mortality increased with increasing age, 15.49% for age > 80 years. Influenza virus was the major etiology for 19 to 25 years old (49.30%) with low mortality (1-2%). S. pneumoniae and typical pathogens were found in every age group. The mortality rate for S. pneumoniae increased with age, viz. 0%, 1.96%, 5.56%, 7.02%, 6.98%, and 24.24% for 19 to 25, 26 to 40, 41 to 60, 61 to 70, 71 to 80, and 81+ years old. The mortality rate from C. pneumonia was about 10% and high among the younger age group. Gram-negative bacilli and Staphylococcus caused high mortality (about 20 to 35%), especially in the older age group. The major risk factors for increasing mortality were: elderly (OR 3.46, 95% CI 3.27-3.77), alcoholic liver disease (OR 3.26, 95% CI 2.85-3.72), cirrhosis (OR 3.45, 95% CI 2.93-4.08), heart disease (OR 2.47, 95% CI 2.38-2.56), ischemic heart disease (OR 2.21, 95% CI 2.07-2.36), renal failure (OR 5.26, 95% CI 5.07-5.49), and cerebrovascular disease (OR 3.62, 95% CI 3.43-3.82). The median length of hospital stay was four days (IQR, 3-7 days) and the median cost of treatment per admission was US$ 256.63 (IQR, US$ 147.81-531.21). Complications such as acute respiratory failure, acute respiratory distress syndrome (ARDS), septicemia, shock, and acute renal failure made hospital stays two to three days longer and costs three to seven times higher than no complications., Conclusion: The mortality from pneumonia among the elderly was high, especially for those over 80 and with multiple medical co-morbidities.

Abstract. Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) have an impact on health care costs and mortality. The aim of this study was to identify the causative agents, antibiotics prescribed, cost of treatment and drug resistance trends among HAP and VAP patients at a tertiary-care hospital in northeastern Thailand during 2008 and 2009. The incidences of HAP in 2008 and 2009 were 0.7/1,000 and 0.55/1,000 hospital days, respectively. The incidences of VAP in 2008 and 2009 were 13.6/1,000 and 12.6/1,000 ventilator days, respectively. About 70% of HAP were caused by Pseudomonas aeruginosa, Acinetobacter baumannii, and Klebsiella pneumoniae; and 70% of VAP were caused by A. baumannii, P. aeruginosa, and K. pneumoniae. The ranking in the causative agents of HAP and VAP was not different, but more antimicrobial resistant organisms were seen in 2009. More than half of the costs of nosocomial infection treatment in 2008 and 2009 were the costs for HAP and VAP, 16.8 and 17.5 million Baht, respectively. Fewer A. baumannii and P. aeruginosa isolates were sensitive to carbapenems. Only one-fifth of A. baumannii isolates were sensitive to cefoperazone/sulbactam. The only two antimicrobial agents with consistently good activity against A. baumannii were tigecycline (approximately 85%) and colistin (approximately 99%). Fifty-seven point six percent of P. aeruginosa isolates were sensitive to ceftazidime, 72.4% were sensitive to piperacillin/tazobactam, 95.9% were sensitive to netilmycin and 99.2% were sensitive to colistin. Forty-seven percent of K. pneumoniae isolates were extended spectrum beta-lactamase and sensitive to carbapenems. Methicillin-resistant S. aureus was the cause of 6-7% of HAP/VAP cases in our study.

Drug-resistant tuberculosis is a major public health problem. The aim of this study was to assess the local susceptibility patterns of Mycobacterium tuberculosis and clinical outcomes of drug resistant tuberculosis (DR-TB) at Srinagarind Hospital, a tertiary care center in northeastern Thailand. Between January 2004 and December 2008, 1,052 patients had culture-proven M. tuberculosis infections at Srinagarind Hospital. M. tuberculosis was resistant to isoniazid (2.3%), rifampicin (2.8%), ethambutol (3.8%), streptomycin (2.1%), kanamycin (0.7%) and ofloxacin (1.9%). The occurrences of multi-drug resistant tuberculosis (MDR-TB) and extensively drug resistant tuberculosis (XDR-TB) were 1.2% and 0.38%, respectively. Of the 65 DR-TB patients, complete medical records were found for 55. The male to female ratio was 2.2:1. The mean age was 50 years. Thirteen patients had MDR-TB. The duration of symptoms in the MDR-TB group was longer than the non-MDR-TB group, 11.6 months vs 2.6 months, respectively. Half of MDR-TB and one-third of non-MDR-TB patients had a previous history of being treated for tuberculosis. Nearly 20% of cases were HIV positive. Mono-drug resistance was initially treated with standard first-line drugs (CAT 1). The clinical course was more likely to be worse during the maintenance phase if there was resistance to rifampicin. Whenever there was resistance to two, three or four drugs, the antituberculosis drugs were prescribed based on susceptibility patterns. Only 30% of patients with MDR-TB and XDR-TB responded to treatment. Culture and sensitivity testing for M. tuberculosis cases is recommended in patients at high risk for DR-TB, such as patients previously treated for tuberculosis and those HIV positive.

The authors present a case of right pleural effusion complicated by chronic pancreatitis. The patient was a 33-year-old man, who had progressive dyspnea with massive right pleural effusion for 2 months. He suffered significant weight loss of 10 kilograms but had no fever. Previously, he had a history of excessive alcohol consumption and chronic epigastrium pain for 2 year. At first, he was treated as tuberculous pleural effusion according to exudative lymphocytic pleural effusion. Diagnosis was delayed because of no abdominal symptoms at the time of admission. Chronic pancreatic pleural effusion was later diagnosed by calcified pancreas and suspected pseudocyst on CT chest included upper abdomen in addition with high pleural fluid amylase. ERCP was done followed by an operation. After operative procedure of pancreatic stone removal and sump drainage, serum amylase decreased and right intercostal drainage could be removed. The overall clinical presentation was improved and he was advised to stop drinking alcohol.

We investigated the charts of 381 new smear-positive tuberculosis patients at Khon Kaen Medical School during 1997-2001 using World Health Organization definitions to evaluate associations among treatment success or failure (defaulted, failed, died, or not evaluated) and tuberculosis clinic contact, demographics and clinical characteristics of the patients. Multinomial logistic regression was used for three-category outcome analysis: treatment success, transferred-out and clinical treatment failure. The treatment success and clinical treatment failure rates were 34.1% and 34.4%, respectively. About 46.5% and 85.8% of patients missed appointments at the tuberculosis clinic in the treatment success and treatment failure groups, respectively. The results show that patients who were absent from the tuberculosis clinic were 5.95 times more likely to have clinical treatment failure than treatment success, having adjusted for the effect of transfering-out and the effect of the treatment regimen and the sputum conversion status (adjusted odds ratio = 5.95; 95% CI: 2.99 to 11.84). The review showed that absence from the tuberculosis clinic was an independent risk factor for clinical treatment failure. We recommended that all new smear-positive tuberculosis patients should be followed closely at a tuberculosis clinic.

To determine the prevalence, risk factors and clinical outcomes of penicillin-resistant S. pneumoniae (PRSP) in community-acquired pneumonia (CAP), a cross-sectional study was conducted between January 1995 and December 2004 at Srinagarind Hospital, Khon Kaen, Thailand. Patients hospitalized with CAP and culture proved to be S. pneumoniae were included. PRSP was found in 22 of 64 (34.4%) patients. The MIC levels of penicillin non-susceptible strains ranged between 0.25 and 0.75 microg/ml. Resistance to other antibiotics ranked: cotrimoxazole (51.6%), tetracycline (26.6%), erythromycin (20.6%), lincomycin (18.7%), chloramphenicol (12.5%) and ampicillin (1.6%). None of the isolates was resistant to cephalothin. The significant risk factors for PRSP infection were previous antibiotic use within 3 months (Adjusted OR 40.83, 95% CI 3.71 to 449.41) and alcoholism (Adjusted OR 8.82, 95% 1.25 to 62.46). Bacteremia and empyema thoracis were found more commonly in PRSP than PSSP infection, but not statistically significant. Pneumonia-related mortality was nearly the same, PRSP 9.1% vs PSSP 9.5% (p = 0.96). The reason why the clinical outcomes of these two groups were not different may be the patients were infected with mildly resistant organisms. Thus, pneumonia caused by intermediate-level penicillin resistant S. pneumoniae appears to be adequately treated with beta-lactams or aminopenicillin antibiotics. The MIC levels of penicillin resistance should be monitored further. The need for antibiotics active against drug-resistant S. pneumoniae was required if high-level penicillin resistance was detected.

Most patients with community-acquired pneumonia are treated as out-patients with empirical therapy, since initially the etiologic agent is unknown. We prospectively assessed the etiologies and treatment outcomes of pneumonia from February 2003 to 2004 at ambulatory clinics. Forty-four patients were included with a mean age of 49.2 (SD 18.2) years. The male to female ratio was 1:1.4. The incubation period was 6.9 (SD 4.4) days. Half of the patients were healthy. Asthma and COPD were common in patients with underlying diseases. The etiologic diagnosis was determined by a sputum culture and a serology test of paired serum samples. Hemo-culture produced no growth in any patients. Atypical pathogens and H. influenzae were the most common finding, each occurring in 31.8% of the patients followed by S. pneumoniae and H. parainfluenzae (27.3% each). Twenty-two patients were infected with multiple pathogens. C. pneumoniae was the most common co-infecting pathogen. Two of 12 S. pneumoniae isolates were penicillin resistant. Nine of 14 H. influenzae isolates were cotrimoxazole resistant and 8 of 14 were not sensitive to erythromycin. For H. parainfluenzae, 11 of 12 isolates were not sensitive to erythromycin, and 7 of 12 were not sensitive to cotrimoxazole. Oral antibiotics were prescribed as out-patient treatment. Forty patients (90.9%) improved, with symptoms-score improvement averaging 6.4 days. Four patients got worse and needed a change of antibiotics, the symptoms usually worsen within 3-5 days. We conclude that, antibiotics for CAP out-patients should cover atypical pathogens, H. influenzae, S. pneumoniae and H. parainfluenzae. If the clinical symptoms do not respond after 3-5 days of out-patient treatment, resistance or an unusual organism (eg B. pseudomallei) should be considered.

We present a rare case of pulmonary actinomycosis complicated with massive hemoptysis. The patient was a 41-year-old male farmer, who had experienced prolonged fever and off-and-on blood streaked sputum for 2 years. He was admitted to our hospital because of 3 days of massive hemoptysis. He had no underlying medical illnesses, but was a heavy smoker and an alcoholic. The chest radiograph revealed patchy alveolar infiltration of the right upper lobe, mimicing tuberculosis. Massive hemoptysis was not controlled using conservative treatment and anti-tuberculous drugs. Emergency right upper lobe lobectomy was needed to stop the bleeding. Histopathologic examination demonstrated aggregates of filamentous gram-positive organisms in characteristic "sulfur granules", indicating actinomycosis. The fever subsided after intravenous augmentin was given, followed by 6 months of oral amoxicillin. The patient is doing well and has had no recurrent hemoptysis.

Massive hemoptysis is a life-threatening condition and can lead to asphyxiation. This is a retrospective review of 101 patients hospitalized with massive hemoptysis at Srinagarind Hospital, Khon Kaen, Thailand, between January 1993 and December 2002. The male to female ratio was 2.1:1. The average age was 47.1 (SD 16.8) years. Half the subjects were farmers and three-fourths had an underlying disease; most notably old pulmonary tuberculosis (41.6%). The mean duration of massive hemoptysis was 3.2 (SD 3.7) days. An initial hematocrit < or = 30% was found in 34.6% of patients, and a prolonged prothrombin time in 4.0%, and thrombocytopenia in 2.0%. Chest radiographs revealed unilateral, bilateral lesions and normal lungs in 57.4, 40.6, and 2.0%, respectively. A chest CT was done in 14.8% of patients. Bronchoscopy localized the bleeding and diagnosed the etiology in 19.8%. The most common causes of massive hemoptysis were bronchiectasis (33.7%), active pulmonary tuberculosis (20.8%) and malignancy (10.9%). Patients were grouped by treatment: 1) conservative (88); 2) emergency bronchial artery embolization (7); and, 3) emergency surgery (6). Of the 88 patients in group 1, the bleeding was stopped in 71 (80.7%) and recurred in 4. Of the 7 patients undergoing emergency bronchial artery embolization, the bleeding was stopped in 6 (86%) and recurred in 1. In the 6 patients who underwent emergency surgery, the bleeding was stopped in all and recurred in 1. Recurrent hemoptysis usually arose within 7 days of the first episode and was well controlled with bronchial arterial embolization. The mortality rate was 17.8%. Of the discharged patients, 36.1% had recurrent hemoptysis. Most of them occurred within one month after discharge. We conclude that, the most common cause of massive hemoptysis is benign rahter than malignant disease. Intensive care with conservative treatment should be applied vigorously. Bronchial artery embolization is an excellent, non-surgical alternative to control bleeding, and should be done before specific surgical intervention.