THE OSTIA VENAE HEPATICAE AND THE RETHROHEPATIC ...

THE OSTIA VENAE HEPATICAE AND THE RETHROHEPATIC 

SEGMENTS OF THE IVC IN THAIS 

Sompit Imjai, Rosarin Ratnalekha 

Department of Anatomy, Faculty of Medicine Siriraj Hospital, Mahaiol University, Bangkok, 

Thailand. 

Key words : liver, IVC, hepatic vein 

Anatomic studied of 144 normal adult livers, the length of the retrohepatic segment of the 

inferior vena cava was 6.6 centimeters was totally enclosed by liver substance in 12.5% of cases. Altogether 

1,581 ostia venae hepaticae were found, average 11 per liver and classified as large, medium, small and 

minimum. The localisation of these openings were studied according to the division of interior wall of the 

retrohepatic segment of IVC into 16 areas. 

RECOVERY AFTER TOTAL INTRAVENOUS ANESTHESIA (TIVA) 

USING PROPOFOL AND INHALATION ANESTHESIA (IA) USING 

HALOTHANE IN DAY CASE SURGERY 

Ubolrat Santawat, Jariya Lertakyamanee, Oranee Svasdi-xuto 

Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University. 

Key words : anesthetic technique, propofol, outpatient 

The aims of this study were to compare recovery by clinical tests, the Perceptual Speed 

Test (PST) and the Ball Bearing Test (BBT), home recovery, side effects and satisfaction of anesthesia 

between total intravenous anesthesia using propofol and inhalation anesthesia using halothane in day case 

surgery and to determine average cost per case of each technique from the provider’s the perspective. 

Forty patients were randomly allocated into TIVA and IA groups. The anesthetic times 

were 42.1 + 26.47 minutes and 37.6 + 14.75 minutes respectively. 

Recovery was assessed by the time to orientation, sitting up, standing up and to success 

in obtaining baseline values of the PST & BBT. The observer was blinded to the anesthetic technique that 

the patient received. Recovery tests showed no difference between the two groups. The recovery times 

of TIVA and IA as assessed by the PST and BBT were 1.2 + 0.41 and 1.1 + 0.31 hour respectively. 

From a home questionnaire, both groups showed no difference in the first 2-3 hours of 

home recovery, incidence of side effects and satisfaction of anesthesia. When asked about the difficulty 

in getting home, no TIVA patients complained of sleepiness whereas 6/16 IA patients did (p = 0.018). 

The average cost per case of TIVA and IA was 642.15 and 363.15 bahts respectively. 

(J Med Assoc Thai 1999; 82: 770-7) 

165 

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166 Faculty of Medicine Siriraj Hospital 

WHEN SHOULD WE ORDER PREOPERATIVE BLOOD GLUCOSE, BUN, 

CREATININE, OR ELECTROLYTES? : A SYSTEMATIC REVIEW AND 

CLINICAL PRACTICE GUIDELINES 

Santawat U 1 , Lertakyamanee J 1 , Neti T 2 , Somprakit P 1 , Chulajata D 2 , Tritrakan T 2 , Soontranan 

P 2 , Piti-manaaree S 2 , Vasuvattakul S 3 , Yamwong P 4 

1 2 Department of Anesthesiology and Clinical Epidemiology Unit, Department of Anesthesiology, 

3 4 Department of Medicine, Department of Preventive and Social Medicine, Faculty of Medicine 

Siriraj Hospital, Mahidol University. 

Key words : preoperative investigation, systematic review, blood chemistry 

Objectives of the study were to apply a systematic review to answer the question whether 

routine preoperative investigation affected health outcomes; and to construct clinical practice guidelines 

for preoperative checking of blood glucose, BUN, creatinine and electrolytes. The guidelines were prepared 

for elective, non-cardiothoracic surgery in adult patients. Methods of the study were Medline 

search (1980-1998) and a search of studies published in Thailand. Criteria for high validity and reliability 

were applied to paper selection. The results of the systematic review were discussed among 

anesthesiologists and other specialists and the guidelines were drawn by consensus. Results from the 

systematic review suggested there were no randomized controlled trials to answer the question and no 

studies reported health outcomes. From this review and the consensus, we proposed guidelines which 

consisted of history questionnaire, physical examination and indications for investigation. For the 

preoperative checking of blood glucose, the indications were: age ³ 60 years, obesity, diabetes, 

hypoglycemia, liver disease, alcoholism, severe infection, alteration of consciousness, hypothalamic, 

pituitary, pancreatic and adrenal disease, and steroid therapy. The common indications for both BUN/ 

creatinine and electrolytes checking were: age ³ 60 years, undergoing TURP, TUR-BT and major KUB 

surgery, obesity, diabetes, hypertension, chronic renal failure, renal disease, liver disease, alcoholism, 

severe infection, severe vomiting or diarrhea, history of fluid, acid base or electrolyte disturbance, alteration 

of consciousness, hypothalamic, pituitary, pancreatic and adrenal disease, ADH abnormality and 

diuretic or digoxin therapy. The additional indications for electrolyte checking were: convulsion or 

muscle weakness, CNS disease with increased ICP and steroid therapy. 

(Siraj Hosp Gaz 1999; 51: 779-90) 

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WHEN SHOULD WE ORDER PREOPERATIVE COMPLETE BLOOD 

COUNT AND URINALYSIS?: A SYSTEMATIC REVIEW AND CLINICAL 

PRACTICE GUIDELINES 

Lertakyamanee J 1 , Somprakit P 1 , Santawat U1, Tritrakan T 2 , Chulajata D 2 , Neti T 2 , Soontranan 

P 2 , Piti-manaaree S 2 , Bhuripanyo K 3 , Lertakyamanee N 4 

1 2 Department of Anesthesiology and Clinical Epidemiology Unit, Department of Anesthesiology, 

3 4 Her Mahesty Cardiac Center, Department of Surgery, Faculty of Medicine Siriraj Hospital, 

Mahidol University. 

Key words : preoperative investigation, systematic review, CBC and urinalysis 

Routine preoperative investigation is expensive especially at this time when Thailand is 

suffering a severe financial crisis. Objectives of the study were to apply a systematic review to answer 

the question whether routine preoperative investigation affected health outcomes; and to construct clinical 

practice guidelines for preoperative complete blood count (CBC) and urinalysis (UA). The guidelines 

were prepared for elective, non-cardiothoracic surgery in adult patients. Methods of the study were 

Medline search (1980-1998) and a search of studies published in Thailand. Criteria for high validity and 

reliability were applied to paper selection. The results of the systematic review were discussed among 

anesthesiologists and other specialists and the guidelines were drawn by consensus. Results from the 

systematic review found that there were no randomized controlled trials to answer the question and no 

studies reported health outcomes. Routine preoperative CBC and urinalysis yielded few clinically significant 

positive results and was not very useful for patient care.. from this review and the consensus, we 

proposed a guideline which consisted of a history questionnaire, physical examination and indication for 

investigation. For the preoperative CBC the indications were: age ³ 60 years, would have an operation 

that needed blood transfusion, had acute or chronic blood loss, malnutrition, pregnancy, heart disease, 

cancer, chronic renal failure, liver disease, severe infection, SLE, connective tissue disease, radiotherapy 

or chemotherapy. The guidelines for preoperative UA were: pregnancy, diabetes, abnormal urination, 

chronic renal failure, SLE or connective tissue disease. Preoperative CBC and UA requests according to 

these guidelines should be more cost-effective and routine preoperative investigation should be abandoned. 

(Siriraj Hosp Gaz 1999; 51: 492-505) 

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167


PREEMPTIVE INTRAPERITONEAL BUPIVACAINE DOES NOT PROVIDE 

ANALGESIA AFTER TRANSABDOMINAL HYSTERECTOMY 

(227) 

Visalyaputra S 1 , Sanansilp V 1 , Parakkamodom S 1 , Vudhikamraksa S 1 , Ngamsanga C 1 , Pitiwan 

A 2 , Tantipusanont S 1 , Prungsri S 1 , Pinthurak J 1 , Phadermwongsa P 1 

1 2 Department of Anesthesiology, Department of Obstetric and Gynecology, Faculty of Medicine 


Key words : preemptive analgesia, bupivacaine, hysterectomy 

A controversy exists over the effectiveness and clinical value of preemptive analgesia. 

To investigate the preemptive effects of intraperitoneal bupivacaine, a randomized double blinded placebo 

controlled study was done in 62 patients undergoing transabdominal hysterectomy under general anesthesia. 

Patients in group A (placebo) received 80 ml of intraperitoneal instillation of normal saline with epinephrine 

0.2 mg after the abdominal cavity had been opened but before the surgical manipulation of the uterus. 

Patients in group B (bupivacaine) received 80 ml of 0.125% bupivacaine with epinephrine 0.2 mg instead 

of normal saline in the same manner as group A. Pain which was assessed by patients using visual 

analogue scale at 2, 6, 18, 24 h after surgery and the analgesic requirements were not different between 

the two groups. Metabolic endocrine responses (cortisol levels) were not different either. Plasma 

bupivacaine levels were investigated. We concluded that intraperitoneal instillation of bupivacaine cannot 

preempt postoperative pain indicated by cortisol levels, visual analogue scores and postoperative morphine 

requirement. 

(Thai J Anesth 1999; 25: 242-6. Supported by grant from Siriraj China Medical Board Foundation) 

INTRAPERITONEAL LIDOCAINE DECREASES INTRAOPERATIVE PAIN 

DURING POSTPARTUM TUBAL LIGATION 

Shusee Visalyaputra, Jariya Lertakyamanee, Nuchsaroch Pethpaisit, Pradit Somprakit, Sudta 

Parakkamodom, Plida Suwanapeum 

Department of Anesthesiolgy, Faculty of Medicine Siriraj Hospital, Mahidol University. 

Key words : pain, intraperitoneal lidocaine, tubal ligation 

(228) 

We conducted a randomized, double-blinded, placebo-controlled trial to evaluate the effectiveness 

of intraperitoneal lidocaine, IM morphine, or both drugs together for pain relief in postpartum 

tubal ligation. Eighty postpartum patients scheduled to have tubal sterilization were randomly divided into 

four groups to receive IM isotonic sodium chloride solution (1mL) and intraperitoneal instillation of 80 mL 

of isotonic sodium chloride solution (Group P); IM morphine (10mg in 1 mL) and intraperitoneal instillation 

of 80 ml of isotonic sodium chloride solution (Group M); IM injection of isotonic sodium chloride solution 

and intraperitoneal instillation of 0.5% lidocaine in 80 mL (Group L); and both IM morphine and intraperi-

toneal lidocaine instillation (Group ML). The minilaparotomy was performed after local infiltration with 

15 mL of 1% lidocaine. A numerical rating score was used to rate pain on a 0-10 scale during the surgical 

procedures. The mean pain scores were 1.2 in Group L and 0.8 in Group ML. These pain scores were 

significantly lower than those in Groups P and M, which were 5.5 and 6.0, respectively (P < 0.001). 

Implications: Pain relief was inadequate in patients undergoing postpartum tubal ligation under local 

anesthesia, even after the administration of IM morphine. Instilling lidocaine into the abdominal cavity, 

however, effectively decreased intraoperative pain in these patients. 

(Anesth Analg 1999; 88: 1077-80. Funded by the Siriraj-China Medical Board Foundation) 

NITRIC OXIDE PRODUCTION BY HUMAN PERIPHERAL BLOOD 

MONONUCLEAR LEUCOCYTES IN SEPSIS. 

Toomtong P 1 , Young JD 2 

1 Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Nuffield 

Department of Anaesthetics, University of Oxford, UK. 

Key words : nitric oxide production, sepsis, leukocytes 

(229) 

Introduction . Increased nitric oxide (NO) production rate has been reported in human 

sepsis1 - 

. The reports are mainly based on measurements of the stable end metabolites of nitric oxide NO2 - /NO . The direct measurement of NO from intact human peripheral blood mononuclear cells (PBMs) 

3 

from septic patients has not been reported. 

Methods. We investigated NO production rate from PBMs in both control and septic 

patients. PBM were collected by a density centrifugation technique from both groups. An NO sensitive 

electrode (ISO-NO) was used to measure NO production by PBMs. NO production rate was measured 

as both endogenous NO production without extracellular L-arginine and the production after the addition 

of extracellular L-arginine 20mM. 

Results. Data (NO production rate) are shown in mean + SD for both groups. 

Group Endogenous After L-arginine 

(n) (ρM/ 10 6 cells/min) (ρM/ 10 6 cells/min) 

Control (9) 1.37 + 1.38 1.53 + 0.78 

Septic (23) 2.83 + 3.33 3.91 + 2.63* 

Endogenous NO production could not be detected in 5 septic patients, while 4 septic and 1 control patients 

had endogenous production rate above 4rM/ 10 6 cells/min. The higher NO production rate in the septic 

group was statistically significant (p

170 

WHEN SHOULD WE ORDER PREOPERATIVE CHEST RADIOGRAPHY : 

A SYSTEMATIC REVIEW AND CLINICAL PRACTICE GUIDELINES 

Pitimana-aree S, 1 

Lertakayamanee J, 2 

Somprakit P, 2 

Santawat U, 2 

Neti T, Soontranan P, 1 

Chulachata D, 1 

Tritrakarn T, 1 

Charoenratanakul S, 3 

Kongpattnakul S, 4 

1 

Department of Anesthesiology, 2 

Department of Anesthesiology and Clinical Epidemiology Unit, 

3 

Department of Medicine, 4 

Department of Pharmacology, Faculty of Medicine Siriraj Hospital, 

Mahidol University 

Routine preoperative investigation consumes much resource while Thailand suffers severe 

financial crisis. Objectives of the study were to apply a systematic review to answer the question 

whether routine preoperative investigation affected health outcomes; and to construct clinical practice 

guidelines for preoperative chest radiography (CXR). The guidelines were prepared for elective, noncardiothoracic 

surgery in adult patients. Methods of the study were Medline search (1980-1998) and 

search from studies published in Thailand. Criteria for high validity and reliability were applied to paper 

selection. The results of the systematic review were discussed among anesthesiologists and other specialists 

and the guidelines were drawn by consensus. Results from the systematic review, there were no 

randomized controlled trials to answer the question and no studies reported health outcomes. Routine 

preoperative investigations yielded few positive results and were not very useful for patient care. From 

this review and the consensus, we proposed the guidelines, which consisted of a history questionnaire, 

physical examination and indication for investigation. For the preoperative CXR the indications were: 

age > 45 years, history of cardiovascular and respiratory diseases, autoimmune deficiency syndrome 

(AIDS), heavy smoking, chronic cough or fever, malignancy and findings of abnormal breath sounds on 

examination. This study recommends and prefers preoperative CXR as indicated by history and physical 

examination to routine. 

(Siriraj Hosp Gaz 1999;51: 669-681.) 

HEMODYNAMIC RESPONSES TO CAPTOPRIL DURING SPLENECTOMY 

IN THALASSEMIC CHILDREN 

Vorapa Suwanchinda 1 

, Voravarn Tanphaichitr 2 

, Sangsom Pirayavaraporn 1 

, Pradit Somprakit 1 

, 

Mongkol Laophpensang 3 

1 


Department of Pediatrics, 3 

Department of Surgery, Faculty of 

Medicine Siriraj Hospital, Mahidol University. 

Key words : thalassemia, splenectomy, hypertension 

Faculty of Medicine Siriraj Hospital 

Splenectomy in β-thalassemic children is frequently accompanied by perioperative hypertension 

which occasionally is followed by convulsion. The efficacy of captopril in attenuating the 

hypertensive response to splenectomy was investigated in 82 thalassemic children. The control group, 

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consisting of 40 patients, received intravenous furosemide (1 mg/kg) preoperatively; whereas, 42 children 

were randomly allocated into 2 groups to receive oral captopril (0.7 mg/kg) or a combination of captopril 

(0.7 mg/kg) and furosemide (1 mg/kg) before the operation. 

Before anesthetic induction, both systolic and diastolic arterial pressures in the captopril 

and the combined groups were significantly lower than the furosemide group (P

172 

WHEN SHOULD WE ORDER PREOPERATIVE ELECTROCAR- DIOGRAPHY : 

A SYSTEMATIC REVIEW AND CLINICAL PRACTICE GUIDELINES (233) 

Somprakit P 1 

, Lertakayamanee J 1 

, Soontranan P 2 

, Bhuripanyo K 3 

, Santawat U 1 

, Pitimana-aree 

, Neti T, Chulachata D 1 

, Tritrakarn T 1 

, Kachintorn U 4 

S 1 

1 

Department of Anesthesiology and Clinical Epidemiology Unit, 2 

Department of Anesthesiology, 

3 

Her Majesty Cardiac Center, 4 

Department of Medicine, Faculty of Medicine Siriraj Hospital, 


Key words : preoperative investigation, electrocardiography, systematic review 

Routine preoperative investigation consumes much resource while Thailand suffers severe 

financial crisis. Objectives of the study were to apply a systematic review to answer the question 

whether routine preoperative investigation affected health outcomes; and to construct clinical practice 

guidelines for preoperative electrocardiography (ECG). The guidelines were prepared for elective, noncardiothoracic 

surgery in adult patients. Methods of the study were a Medline search (1980-1998) and a 

search from studies published in Thailand. Criteria for high validity and reliability were applied to paper 

selection. The results of the systematic review were discussed among anesthesiologists and other specialists 

and the guidelines were drawn by consensus. Results from the systematic review found that there 

were no randomized controlled trials to answer the question and no studies reported health outcomes. 

Routine preoperative investigations yielded few positive results and were not very useful for patient care. 

From this review and consensus, we proposed the following guidelines: a history questionnaire, physical 

examination and indication for investigation. For the preoperative ECG the indications are: age > 45 

years, history of hypertension, heart disease, palpitation or frequent syncope, diabetes, chronic cough for 

> 3 weeks or pulmonary disease, heavy smoking (> 10 pack/days for > 10 years), radiotherapy or chemotherapy. 

Preoperative ECG carried out according to these guidelines would be more cost-effective and 

routine preoperative investigation should be abandoned. 

(Siriraj Hosp Gaz 1999;51: 586-96.) 

FACTORS AFFECTING DISTRESS AT INDUCTION OF ANESTHESIA IN 

CHILDREN 

Kongsayreepong S, Suraseranivongse S, Gunreka P, Montapaneewat T, Manon J 


Key words : children, anesthesia, distress behavior 


(234) 

This prospective study was designed to determine factors that could affect the distress 

behavior during induction of anesthesia in children. Two hundred and two abmulatory children, age 1-8 

years old, ASA class I-II, without premedication were randomly allocated to a parent present and parent

absent group. A modified behavioral scoring system using five markers of anxiety score was used to 

assess the child’s behavior before induction and response during inhalation induction. Score 1 and 2 

were determined as success and score 3 to 5 were determined as failure. Children’s factors were recorded; 

age, sex, sequence of birth, behavioral before induction, knowing about surgery, previous history 

of anesthesia and/or surgery. Parents’ factors were recorded as education, marrital status, income 

and anxiety. The behavior of children during induction were analysed by multivariate analysis with 

Backward Logistic Regression. It was found that factors influencing distress behavior included age 

under 4 years old (p.0006) parent absence (p.0497), poor preoperative behavior (p.0065) and previous 

experience of surgery and anesthesia (p < 0.0001). The most important factors were preoperative mood 

or behavior and previous experience of surgery and anesthesia with odd ratio (95% CI): 10.99 (2.78 to 

43.46) and 4.07 (1.38 to 12.33) respectively. More care or plan such as parental accompanying to the 

theatre or play room to distract anxiety should be considered when these children come for anesthesia. 

(Thai J Anesth 1999; 25: 1-9.) 

TECNOLOGY ASSESSMENT OF ANESTHESIA DELIVERY SYSTEM : I. 

MANPOWER, KNOWLEDGE, AND CARE 

Lertakyamanee J, Santawat U, Soontranant P, Somprakit P, Waisayarat N 


Key words : technology assessment, anesthesia, manpower 

Introduction : The assessment of a technology comprises of its use, personnel who use 

it and their knowledge, the problems of the use and acquisition. Anesthesia system is a mandatory equipment 

for anesthesia. We reported part I of the technology assessment of anesthesia system in 342 hospitals 

around Thailand. Methods: The questionnaire were sent to personnel who were responsible for anesthetic 

service of the hospitals and asked about manpower, knowledge and care of the equipment. We also 

organized site visits to 18 hospitals in 5 parts of Thailand during 1996-1997. Results: Nurse anesthetists 

were the most common personnel and there were lack of anesthesiologists, nurse aids and technicians. 

The personnel that the hospitals wanted most were anesthesiologists. Only 26.5% of nurse anesthetists 

felt that they had enough knowledge to work and solve problems should problems occurred during the use 

of anesthesia system. All nurses wanted to gain more knowledge. The warning of safety in using an 

anesthesia system were few and far between. These occurred in only 27.7% of all hospitals. Preuse 

check up of anesthesia machine still waited for guidelines which was being drawn. Conclusion: All parties 

involved, including high-level administrators and policy planners should pay more interest and cooperate 

on post-training knowledge distribution, safety warning, guidelines and standards for the whole country. 

There should also be follow up and evaluation after distribution of guidelines and allocation of budget. 

Only with these effort would anesthesia system be utilized safely and cost-effectively. 

(Thai J Anesth 1999; 25:10-20.) 

173 

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TECNOLOGY ASSESSMENT OF ANESTHESIA DELIVERY SYSTEM : II. 

PROBLEMS OF EQUIPMENT AND ACQUISITION 

Lertakyamanee J, Soontranant P, Somprakit P, Santawat U, Waisayarat N 


Key words : anesthesia, equipment, and technology assessment 

Introduction : The assessment of a technology comprises of its use, personnel who use 

it and their knowledge, the problems of the use and acquisition. Anesthesia system is a mandatory equipment 

for anesthesia. We reported part I of the technology assessment of anesthesia system in 342 hospitals 

around Thailand. Methods: The questionnaire were sent to personnel who were responsible for anesthetic 

service of the hospitals and asked about utility, encountered problems and acquisition. We also 

organized site visits to 18 hospitals in 5 parts of Thailand during 1996-97. Results: We reported the problems 

of gas sources, safety components, vaporizers, breathing systems, scavenging systems and ventilators. 

In the acquisition of machines, the users did not have the opportunity to specify what they needed. 

There were lack of budget and standard of specification. When problems of the equipment occurred, 

repair was very slow and there was no satisfactory aftersale service. Conclusion: The technology of 

anesthesia delivery system has not been used properly in Thailand. All parties involved, including highlevel 

administrators and policy planners, academic and professional organizations, should play more roles 

and cooperate on post-training knowledge distribution, enforcement of safety practice, establishment of 

national guidelines and standards, follow up and evaluation after distribution of guidelines and allocation of 

budget. Only with these efforts would anesthesia system be utilized safely, properly and cost-effectively. 

(Thai J Anesth 1999: 25; 21-34) 

LIFE-THREATENING HAZARDS OF ANESTHESIA EQUIPMENT 

Soontranant P, Koompong P, Pitimana-aree S, Raksakietisak M, Svastdi-Xuto O 

Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol Uinversity. 

Key words : anesthesia equipment, hazard, safety 

Life-threatening hazard of anesthesia equipment is defined as any incident occurred 

from defective equipment or related technique that severely effects patients’ vitality if is not properly 

corrected in time. This prospective study was done by collecting hazards which were reported to The 

Equipment Committee of Department of Anesthesiology. Five incidents had been reported consecutively 

during 3-year period which involved 13 patients and resulted in 1 death. These incidents were 1) Intentionally 

shut off zone valve of O 2 pipeline without previous notification which deprived O 2 supply of 2 

intensive care units. The pressure regulator of O 2 reserved manifold was also out of order. Three criti- 

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cally-ill patients suffered cyanosis. 2) Three out of 6 N 2 O cylinders installed to the manifold were incorrectly 

filled with CO 2 , resulted in clinical manifestations of severe hypercarbia. At least 5 patients undergone 

general anesthesia were insulted. 3) The O 2 and N 2 O connectors were cross-linked. Neither postinstallation 

nor preuse check up was done. One patient developed severely cyanosis after induction of 

general anesthesia. 4) Defective part inside halothane vaporizer caused the output concentration much 

higher than the dial setting. One patient got marked hypotension during anesthesia. 5) Liquid halothane 

remained outside the vaporizing chamber of the vaporizers which caused very high concentration of a 

vapor. Three patients undergone general anesthesia developed dysrhythmia and severe hypotension. 

Comparing to our previous report with minor effects on the patients in 1995, the contributing factors 

were the same, e.g. lack of knowledge, ignorance and no maintenance. The only difference was detection 

after insulting the patients. We conclude that close monitoring, early detection and properly decision 

making can prevent and alleviate outcome severity of the hazard of equipment. We encourage all personnel 

to practice with good quality of care whenever dealing with anesthesia equipment. 

(Thai J Anesth 1999; 25: 115-20.) 

THE COMPARISON BETWEEN INTRATHECAL HYPERBARIC AND 

ISOBARIC BUPIVACAINE IN COMBINED SPINAL-EPIDURAL TECHNIQUE 

FOR CESAREAN SECTION 

(238) 

Amornyotin S, Thepchatri C, Visalyaputra S, Sakulpachareon N 


Key words : anesthetic technique, combine spinal-epidural, cesarean section 

The combined spinal-epidural (CSE) technique for cesarean section was investigated by 

comparing between intrathecal hyperbaric and isobaric bupicacaine. Sixty patients, ASA I-II, undergeoing 

for Cesarean section were randomly assigned to receive 0.5% hyperbaric bupivacaine (group I) and 

0.5% isobaric bupivacaine (group II). Both groups received 2% lidocaine with adrenaline 1: 400000 via 

epidural space in the same dose. Level and efficacy of blockage, satisfaction of patients, muscle relaxation 

and side effects were observed. The result showed both hyperbaric and isobaric bupicacaine were 

good for CSE for cesarean section and there was no statistically significant difference between the two 

groups. 

(Thai J Anesth 1999; 25: 121-6.) 

175

176 

COMBINED SPINAL EPIDURAL ANESTHESIA VERSUS SPINAL 

ANESTHESIA FOR CESAREAN SECTION ; EFFECT ON MATERNAL 

HYPOTENSION, A RANDOMIZED, DOUBLE BLIND CONTROLLED 

TRIAL 

Neti T, Visalyaputra S, Pechpaisit N, Upatinkat K, Nakkuntod A, Chamadol S, Sakulpachareon 

N 


Key words: anesthetic technique, combined spinal epidural, cesarean section 

This study was designed to compare the effect of combined spinal epidural anesthesia 

(CSEA) and spinal anesthesia on the incidence and severity of hypotension of patients undergone cesarean 

section. Sixty term parturients, ASA class I-II were randomly divided into two groups. Regional 

anesthesia was performed in right lateral, horizontal plane position. In Group I, spinal group, 2.0- 2.5 ml of 

0.5% hyperbaric bupivacaine was given intrathecally. In group II, CSE group, 1.5- 2.0 ml of 0.5% 

bupivacaine was given intrathecally and epidural lidocaine would be added if analgesic level was lower 

than T 4 at 15 minutes after intrathecal injection or inadequate analgesia occurred during surgery. There 

were no significant differences in the incidence and severity of maternal hypotension, ephedrine requirement, 

maximal cephalad level of analgesia and analgesic level at 15 minutes after intrathecal injection 

between the two groups. CSEA in right lateral, horizontal plane position has no advantages in term of 

maternal hypotension during cesarean section as compared to spinal anesthesia. 

(Thai J Anesth 1999; 25:192-200.) 

IS I NTRA MUSCULAR PROMETHAZINE A PROPHYLACTIC 

TREATMENT FOR EPIDURAL MORPINE- INDUCED PRURITUS IN 

CESAREAN SECTION? 

Vichitvejpaisal P, Ae-mornkun R, Mahaphan P, Napachoti T, Suksopee P 


Key words : epidural morphine, pruritus, promethazine 


Objectives. Our objective was to study the clinical effectiveness of promethazine in the 

prevention of epidural morphine-induced pruritus in cesarean section. Methods. A prospective randomized 

double-blind placebo-controlled study, 60 ASA I-II patients undergoing cesarean section under epidural 

anesthesia with 15-25 ml of 2% lidocaine with 1: 200000 adrenaline. After the delivery of a newborn, 

each patient were randomly devided into 2 groups to receive intramuscular injection of 1 ml normal 

saline in placebo group and 25 mg of promethazine in promethazine group respectively. In the postoperative 

period, the pruritus and nausea/vomiting were assessed every 2 hours for 48 hours. Twenty five mg 

of oral diphenhydramine was also administered as required for the treatment of pruritus during the study. 

Results. There was no statistically significant differences in the demographic data, the incidence and 

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severity of pruritus. The incidence of pruritus was 76.7% in placebo group and 60% in promethazine 

group. The intensity of pruritus was 3.7 ³ 2.6 and 2.6 ³ 2.4 in placebo group and promethazine group 

respectively. The diphenhydramine requirement for treatment of pruritus showed to increase significantly 

in placebo group (17.4 ³ 29.6 mg/ patient) as compare to promethazine group (8.3 ³ 19.2 mg/patient). 

Additionally the nausea/vomiting in placebo group (30%) had a higher incidence than that in promethazine 

group (3.3%). Conclusion. Intramuscular promethazine could not prevent the epidural morphine-induced 

pruritus in this study. However it appeared to reduce the diphenhydramine requirement for the treatment 

of pruritus and incidence of nausea/vomiting in patients undergoing cesarean section with epidural morphine 

anesthesia. 

(Thai J Anesth 1999;25: 254-8.) 

CLINICAL EVALUATION OF ALFENTANIL ADDED TOPICAL ANALGESIA 

FOR ESOPHAGOGASTROSCOPIC PROCEDURE 

Pirayavaraporn S 1 

, Chevawattana S 1 

, Tongdeelers P 1 

, Kijlertphairoj S 1 

, Chalayonnawin V 1 

, 

Udompanthurak S 2 

1 


Clinical Epidemiology Unit, Faculty of Medicine Siriraj Hospital, 


Key words : topical anesthesia, esophagogastroscope, alfentanil 

Using only topical anesthesia in esophagogastroscopy was found uncomfortable in either 

patients or surgeons due to unavoidable side effects occurred while passing the instrument. The most 

common side effects found are nausea, vomiting and cough. Additional intravenous alfentanil, short acting 

synthetic opioid, prior to esophagoscopic procedure was studied with a view to minimize the afore-mentioned 

undesirable side effects and thereby acceptable by both of the surgeons and patients. 

This double blind clinical evaluation was studied among 80 Thai patients (ASA I-II) who 

were undergone elective esophagogastroscopy with or without esophageal dilatation under topical anesthesia. 

Half of the patients who received only topical anesthesia were used as control group where as the 

other forty patients (50%) that received additional intravenous alfentanil prior to topical were study group. 

The study revealed that more frequent nausea was found in control group (75%) than in 

study group (45%). No significant difference of cough and vomiting in both groups. More satisfaction was 

found in study group (8 patients or 20%) than in control group (one patient or 2.5%). Patients’ and 

surgeons’ satisfaction were also assessed by using scoring as excellent, good, fair and poor respectively. 

Results of the satisfaction assessment showed no significant difference. The author suggested that intravenous 

alfentanil 10 microgram/kg might be considered as another alternative method in minimizing side 

effects. Definite and clearer conclusion could be obtained by increasing number of patients in both study 

and control group. 

(Thai J Anesth 1999;25: 259-65.) 

177 

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INTRA-TRACHEAL LIDOCAINE FOR COUGH SUPPRESSI ON DURING 

EXTUBATION 

(242) 

Vorakitpokatorn P, Chintanapramote B, Raksamani A, Raksamani A 


Key words : extubation, lidocaine, cough 

Extubation as well as intubation is associated with cough that give many deteriorated 

effects to the patient as increase intracranial, intraocular, intragastric pressure. And for cardiovascular 

system, cough can produce dysrhythmia, tachycardia, hypertension. Cardiovascular changes before and 

after extubation and also severity of coughing were observed in 90 urological patients (35 females and 55 

males) ASA I-II, age 41.65 ³ 13.83 (20-65) years and weight 55.05 ³ 8.67 (40-76) kg, who had to be 

operated with kidney position. Among these patients, we devided to 3 groups by randomization to give 

intratracheally 0.9% NSS or 1% or 2% lidocaine 0.1 ml/kg with LITA tracheal tube (for more effective 

application than ordinary endotracheal tube). We found that severe cough could be significant suppressed 

with 1% or 2% lidocaine but not by 0.9% NSS (p= 0.00015). Efficiency for cough dsuppression 

by 2% lidocaine is better than 1% but not significant. And also changing in systolic, diastolic blood 

pressure, heart rate were less when adding lidocaine and when lidocaine increase from 1 to 2% it seemed 

more cardiovascular stability any how not significant. We conclude that 1 and 2% lidocaine 0.1 ml/kg 

intratracheally can reduce adverse effect of extubation as severe cough significantly and can also reduce 

CVS change. 

(Thai J Anesth 1999;25: 266-70.) 

EFFICACY OF EMLA AND PLACEBO CREAM IN REDUCING PAIN 

DURING EXTRA-COPROREAL PIEZOELECTRIC SHOCK WAVE 

LITHOTRIPSY 

Koompong P 1 

, Tritrakarn T 1 

, Soontarapa S 2 

, Somprakit S 1 

1 


Department of Surgery, Faculty of Medicine Siriraj Hospital, 


Key words : pain, EMLA cream, EPSWL 

(243) 

Background : The objectives were to study whether EMLA or placebo cream could 

reduce pain during extracorporeal piezoelectric shock wave lithotripsy (EPSWL) using the Piezolith 2300 

and to determine which of the components of the application i.e. the occlusive dressing, the cream or the 

local anesthetics reduce pain. 

Methods : Two hundred and two ambulatory patients, 125 males and 77 females, ASA 

I and II subjected to EPSWL were randomly allocated into 5 groups to receive (A) nothing on the skin 

(control), (B) plastic occlusive dressing, (C) placebo cream and plastic occlusive dressing, (D) EMLA

cream and plastic occlusive dressing which were left immersed under water throughout the procedure, 

(E) EMLA cream and plastic occlusive dressing for 60 min to achieve cutaneous anesthesia and removed 

before EPSWL. 

Results : Patients in the group that had either placebo (group C) or EMLA cream 

(group D) under occlusive dressing had less pain than patients in the control groupwhile those who had 

only plastic occlusive dressing or cutaneous anesthesia (EMLA cream dressing removed before EPSWL) 

had no difference in pain score from the control group. 

Discussion : EMLA or placebo cream under an occlusive dressing on the skin at the 

area of the entry of the shock wave and left immersed in water throughout the procedure behaved as a 

coupling medium facilitating transmission of the shock wave through skin, reducing energy reflection and 

absorption and hence reducing skin trauma and pain. This procedure provides a simple, safe and economical 

method of pain relief for patients subjected to EPSWL without causing any side effect. 

(Thai J Anesth 1999;25: 271-7.) 

TIME REQUIRED FOR ARTIFICIAL CSF TO FLOW THROUGH COMMONLY 

USED SPINAL NEEDLES IN THAILAND IN VARIOUS PRESSURES 

(244) 

Duangrat T 1 

, Somprakit P 2 

, Ratanathaworn S 1 

, Sanansil V 1 

1 


Department of Anesthesiology and Clinical Epidemiology Unit, 

Faculty of Medicine Siriraj Hospital, Mahidol University. 

Key words : spinal needle, CSF, pressure 

The standard size of spinal needle is determined by the external diameter, but the important 

quality, the flow through it, is related to the internal diameter. Twelve needles for each 6 types of 25G 

spinal needles available in Thailand, namely Pencan (B. Braun), Pencil point (Portex), Whitacre (B-D), 

Spinocan (B. Braun), Quinke (B-D) and Terumo, were studied using randomized crossover design at 4 

different pressure levels. Times required for appearance and drop of artificial CSF were compared among 

them. We found that the time required for appearance and to drop of CSF were significant different 

among different levels of pressure and also among different types of spinal needle. The times required for 

appearance and to drop of CSF may markedly vary especially at the low CSF pressure (from 1.86 to 4.46 

seconds and from 50.86 to 162.14 seconds repectively). This means that we should wait for a proper time 

for different types of spinal needle to judge that the spinal needle is not in a proper position. 

(Thai J Anesth 1999;25: 278-84.) 

179

180 

RENAL FUNCTION IN ADULT Hb-H DISEASE 

Leena Ong-ajyooth 1 , Sompong Ong-ajyooth 2 , Pensri Pootrakul 1 , Duangporn Chuawattana 1 , 

Sompong Liammongkolkul 2 , Surin Khanyok 2 

1 2 Department of Medicine, Department of Biochemistry, Faculty of Medicine Siriraj Hospital, 

Mahidol University, Bangkok 

Key words: Renal function, Oxidative stress, Hb-H disease 

disease 

Objective: To investigate the renal function and oxidative stress in patients with Hb-H 

Patients & Methods: Forty eight patients, 12 males and 36 females, age 33³13 yr 

were studied comparing with 26 age-matched (32³9 yr) healthy controls. 

Results: Creatinine clearance was elevated in patients with Hb-H disease (118³36 vs 

94³20 ml/min/1.73 m2 - , p

IMPROVED DETECTION OF RADIOFREQUENCY CURRENT-INDUCED 

MINOR MYOCARDIAL INJURY BY CARDIAC ROPONIN T 

MEASUREMENT 

Kosit Sribhen 1 , Kiertijai Bhuripanyo 2 , Ongarn Raungratanaamporn 2 , Sudcharee Kiartivich 1 , 

Wattana Leowattana 1 , Suphachai Chaithiraphan 2 

1 Department of Clinical Pathology, 2 Her Majesty’s Cardiac Centre, Faculty of Medicine, Siriraj 

Hospital, Mahidol University, Bangkok 10700. Thailand. 

Key words : Radiofrequency ablation, Minor Myocardial Injury, Cardiac Troponin T 

Transcatheter radiofrequency current application in patients with cardiac arrhythmias 

was reported to be associated with a low rate of an increase in the activity of enzyme creatine kinase 

(CK) and CK-MB isoenzyme. As the novel heart-specific protein troponin T (cTnT) was shown to be 

superior to CK and CK-MB in detecting small damage to myocardial tissue in various clinical situations 

including unstable angina, a comparison of the diagnostic efficiency of these marker proteins to detect 

myocardial damage was made in 34 patients (mean age 38.3 ³ 15.6 years) undergoing radiofrequency 

(RF) catheter ablation of accessory pathways (n = 17) and atrioventricular nodal reentrant tachycardia (n 

= 17). Serial measurements of total CK and CK-MB activity before and every 8 hours for 24 hours after 

ablative procedure were performed with enzymatic and immunoinhibition method, respectively, using 

automated chemical analyzer Hitachi 717. Serum concentration of cTnT was determined by one-step 

sandwich ELISA performed on ES 300 analyzer (Boehringer Mannheim). 

With a median of 7.0 (range 1-39) RF current pulses only 12 (35%) and 10 (29%) of 34 

patients showed an increase above the upper limit of normal CK and CK-MB activity, respectively. The 

peak activity of CK (mean peak = 285.8 ³ 517.7 IU/L) occurred at a variable time that infrequently 

coincided with those of peak CK-MB activity (23.1 ³ 8.0 IU/L). By contrast, all except 4 (88 %) of 34 

patients exhibited a distinct elevation of cTnT concentration (mean peak = 0.56 ³ 0.63 ng/ml), with almost 

all (33) of these 34 patients showed an early peak value at 8 hours postprocedural. There was, on the 

average, a small but distinct higher relative increase (5.6 times) in cTnT concentration from the upper 

limit of reference range compared with those of CK (1.5 times) and CK-MB peak activity (0.9 time). 

In conclusion, cTnT exhibited a minor but distinct elevation in its concentration and demonstrated 

a higher rate and magnitude of increase following radiofrequency current application than the 

conventional CK and CK-MB isoenzyme. Measurements of cTnT serum concentration may thus provide 

a useful test method for assessing the effect of the new transcatheter ablation procedures on myocardial 

tissue. 

(J Med Assoc Thai 1999 ; 82 : 256-62.) 

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181

182 

COMPARATIVE STUDY OF CARDIAC TROPONIN T CONCENTRATION 

DETERMINED BY ELISA AND ELECTROCHEMILUMINESCENCE 

IMMUNOASSAY 

Kosit Sribhen 1 , Sudcharee Kiartivich 1 , Wattana Leowattana 1 , Kiertijai Bhuripanyo 2 , Suphachai 

Chaithiraphan 2 

1 Department of Clinical Pathology, 2 Her Majesty’s Cardiac Centre, Faculty of Medicine, Siriraj 

Hospital, Mahidol University, Bangkok 10700. Thailand. 

Key words: Cardiac troponin T, ELISA, ECL immunoassay 

Assay of cardiac troponin T (cTnT) has assumed a significant role in the biochemical 

diagnosis of myocardial cell necrosis. The objective of the present study was to evaluate the analytical 

performance of the newly developed electrochemiluminescence (ECL) immunoassay compared with the 

conventional ELISA method. Measurements of cTnT concentration were performed on 40 patients with 

a variety of clinical conditions associated with myocardial injury. The results showed that, with the 

concentrations ranging from 0.01 to approximately 10.0 ng/ml, there was a strong correlation between 

ELISA-TnT and ECL-TnT (n = 109, r = 0.982, y = 0.017 + 1.068x). A lower but significant association 

between cTnT levels determined by both methods was also observed in a subset of patients with creatinine 

levels > 2.0 mg/dl (n = 25, r = 0.941, y = 0.047 + 0.725x, p < 0.0001). Neither ELISA-TnT nor ECL- 

TnT concentrations exhibited significant correlation with creatinine levels. As the new test can be performed 

in random access mode with “stat” capabilities and because of its short turnaround time and low sample 

volume required, ECL immunoassay performed on the Elecsys autoanalyzer (Boehringer Mannheim) is 

more suitable for use in clinical laboratory practice than the conventional ELISA method. 

(Thai Heart J 1999 ; 12 : 9-14) 


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THE PREVALENCE OF CHLAMYDIA PNEUMONIAE ANTIBODIES IN 

THAI PATIENTS WITH CORONARY ARTERY DISEASE 

Wattana Leowattana 1 , Nithi Mahanonda 2 , Kiertijai Bhuripanyo 2 , Amorn Leelarasamee 3 , 

Bootsaba Suwimol 1 , Sasikan Pokum 1 

1 Department of Clinical Pathology, 2 Her Majesty’s Cardiac Center, 3 Department of Medicine, 

Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand. 

Key words : Prevalence, C. Pneumoniae, CAD 

Blood samples were obtained from 243 consecutive coronary artery disease (CAD) 

patients (177 male, 66 female) aged 35 – 78 years (mean, 61 years) admitted for coronary angiography 

because of suspected coronary heart disease, and from 115 blood donors (91 male, 24 female) aged 25 – 

60 years (mean, 47 years). Of the 243 CAD patients, 179 (74%) were positive by an ELISA method for 

Chlamydia pneumoniae antibodies IgG and 132 (54%) were positive for C. pneumoniae IgA. Among 

the 115 blood donors, 80 (70%) were positive for C. pneumoniae IgG and 49 (43%) were positive for C. 

pneumoniae IgA. When IgG antibodies were considered, there was no significant difference between 

CAD patients and healthy controls (OR = 1.29, 95% CI = 0.79 – 2.10, p > 0.05). In cases of positive IgA 

antibodies alone, there was a significant difference between CAD patients and healthy controls (OR = 

1.58, 95% CI = 1.01 – 2.4, p = 0.029). If both IgG and IgA antibodies were positive, OR was increased 

from 1.58 to 1.80 (95% CI = 0.97 – 3.36, p = 0.044). In conclusion, C. pneumoniae infection is common 

in Thai people but chronic C. pneumoniae infection is more common in CAD patients than in middleaged 

blood donors. 

(J Med Assoc Thai August 1999) 

183 

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Mahidol University Annual Research Abstracts 2000 




















blood donors. 


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183




















blood donors. 


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186 

TREATMENT OF SEVERE ALOPECIA AREATA WITH TOPICAL 

DIPHENYLCYCLOPROPENONE : A PILOT STUDY AT SIRIRAJ 

HOSPITAL 

Sukamas Suwanwalaikorn, Apichati Sivayathorn, Rungsima Vanadurongwan 

Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University 

Key words : Alopecia areata, Diphenylcyclopropenone, Immunotherapy 

Background : The psychosocial problem of patient with extensive alopecia areata (AA) 

is enormous. Topical immunotherapy with diphenylcyclopropenone (DPCP) was first reported by Happle 

et al in 1983. Subsequent reports confirmed that this method was effective for the treatment of severe 

AA. However, the response rate varied greatly among these studies. DPCP is a potent contact sensitizer 

which has proved to be non-mutagenic, non-teratogenic and non-organ toxicity. Many cytokines and 

growth factors have been proposed to involved in the mechanism of induction of hair growth. 

AA 


(251) 

Objective : To evaluate the efficacy of DPCP in Thai patients who suffer from severe 

Material and Method : 4 patients with alopecia universalis and 5 with extensive multiple 

AA (hair loss more than 30% of total hair) were recruited (5 females, 4 males). All subjects were first 

sensitized with 2% DPCP solution, followed by weekly application of a concentration sufficient to elicit a 

mild allergic contact dermatitis on one side, whereas the other side was served as untreated control. The 

concentration ranged from 1.0, 0.5, 0.1, 0.01 to 0.001%. When hair growth was established, the other side 

would then be treated. The dosage adjustment was made according to the patient’s reactivity. 

Result : Topical DPCP was capable of inducing an allergic contact sensitivity in all 

subjects. 5 patients achieved cosmetically regrowth of normally pigmented terminal hair, 2 patients achieved 

partial hair growth within 4 months and 2 showed no response to the treatment. Hair regrowth first 

appeared between 4 to 9 weeks of treatment. Common side effects found in this study were pruritus, mild 

to moderate dermatitis, hyperpigmentation at treated sites. No abnormal laboratory tests were observed. 

Conclusion : Topical DPCP is an effective stimulator of hair growth in Thai patients 

with extensive AA. Further study is being conducted to identify criteria, prognostic factors which allow 

selection of patients who are likely to benefit from this treatment. 

(Presented at the Annual Meeting of the Dermatological Society of Thailand, Bangkok, Thailand, 

4-5 March 1999)

COMPARATIVE TREATMENT OF ORAL CANDIDIASIS IN AIDS 

PATIENTS WITH CLOTRIMAZOLE TROCHES AND ITRACONAZOLE 

ORAL SOLUTION 

Rumpa Linpiyawan 1 , Kitti Jittreprasert 2 , Apichati Sivayathorn 1 

1 Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University and 

2 Bumrajnaradura Hospital. 

Key words : Candidiasis, Clotrimazole, Itraconazole, AIDS 

Objective : To compare the efficacy and safety of itraconazole versus clotrimazole 

troche in the treatment of oropharyngeal candidiasis in AIDS patients. 

Methods and Patients : All HIV-infected patients who visit our clinic with confirmed 

oropharyngeal candidiasis were randomly, observer-blind treated with clotrimazole troches (10 mg, 5 

times daily) or Itraconazole oral solution (10 mg/15 ml twice daily), each for 1 week. Clinical follow up 

and mycological assessment were carried out on 4 consecutive days, 1, 2 and 4 weeks after the start of 

treatment was done. Clinical cure was defined as resolution of all signs and symptoms. Mycological cure 

was defined as negative result in both KOH preparation and fungal culture. Combined clinical and mycological 

efficacy were used for global evaluation. Relapses were defined as renewed signs and symptoms with 

either a positive KOH examination or culture. 

Results : Of the 29 patients, 15 were treated with clotrimazole troches (group I) and 14 

with itraconazole oral solution (group II). Both groups were comparable in age, sex, episodes of occurrence, 

mean clinical severity scores before treatment and the mean CD4 cell counts. We observed global evaluation 

as cure in 73.33% (group I) vs 66.7% 9group II) (p=0.806) of patients by the end of 1 week 

treatment. The relapse rate at 2 wk was 38.5% vs 16.7% (p=0.301) and the relapse rate at 4 wk was 

62.5% vs 33.3% (p=0.347) for group I and II, respectively. The clinical efficacy & mycological cure were 

not significantly different between both groups throughout the study. No any adverse effects were reported 

in both groups. 

Conclusion : Both drugs were effective and safe agents in the treatment of oral candidiasis 

in AIDS. The relapse rates were also not statistically different. 


4-5 March 1999) 

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188 

MYCOBACTERIAL SKIN INFECTIONS : 4-YEAR EXPERIENCE FROM 

GRANULOMA CLINIC, SIRIRAJ HOSPITAL, THAILAND 

(253) 

Pankae Mahaisavariya 1 , Apichati Sivayathorn 1 , Angkana Chaiprasert 2 , Puan Suthipinittharm 1 , 

Preeyawis Na Ubol 2 , Somboon Srimuang 2 , Nipa Gengvinij 2 

1 2 Department of Dermatology, Department of Microbiology, Faculty of Medicine Siriraj Hospital, 


Key words : Mycobacterium, Tuberculosis, Skin infection 


Design and method : We proposed to search for etiologic agents by special staining of 

histologic section, culture method and PCR technique. The sequences of specific primers used for DNA 

amplification of M.tuberculosis complex, M.marinum and M.fortuitum complex were designed according 

to 16s rRNA gene sequence of mycobacteria contained in Entrez nucleotide sequence database. The 

skin biopsy specimens were obtained from dermatologic patients who attended Granuloma Clinic from 

June 1994 to 1998. Tuberculous (TB) cases were treated by standard anti-TB drugs, 3-month course of 

doxycycline 100 mg bid for M.marinum, and clarithromycin 250 mg bid plus ciprofloxacin 250 mg bid for 

rapid growers, or surgical excision in operable cases. 

Results : Thirty-one cases, 7 cutaneous tuberculosis, 23 non-tuberculous cases and 1 

mixed TB and non TB (M.avium) case were found. In non-tuberculous group, we found 8 M.marinum, 

10 M.chelonae-fortuitum, 1 mixed infection of M.sulzgai and M.terrae and 4 unknown species cases. 

Cutaneous tuberculosis and non-tuberculous cases caused by M.marium and the unknown species responded 

well to medical treatment while the rest did not. 

Conclusion : In our series, non-tuberculous mycobacterial infections were about 3 times 

more common than tuberculous infections. Cutaneous TB should be treated with short course anti-TB 

drugs. Our recommended regimen for M.marium was doxycycline 100 mg bid for 3 months and combined 

medical and surgical treatment for rapid grower mycobacteria. 


4-5 March 1999)

DEEP FUNGAL AND HIGHER BACTERIAL SKIN INFECTIONS : 

CLINICAL MANIFESTATIONS AND TREATMENT REGIMENS 

Punkae Mahaisavariya 1 , Angkana Chaiprasert 2 , Apichati Sivayathorn 1 , Puan Suthipinittharm 1 , 

Pornpan Hauhan 2 , Nipa Gengvinij 1 

1 2 Department of Dermatology, Department of Microbiology, Faculty of Medicine Siriraj Hospital, 


Key words : Deep fungal infection, Granuloma 

Design and method : Cases were prospectively collected with provisional diagnosis of 

deep fungal and higher bacterial infections from 1994-1997 in Granuloma Clinic, Department of Dermatology, 

Faculty of Medicine Siriraj Hospital, to study for demographic data, clinic manifestations, causative 

organisms, histologic features, treatments and outcomes. 

Results : Total cases in the 4-year period were twenty seven with nearly equal numbers 

of males and females. Mycetoma was found to be the most common and chromoblastomycosis ranked 

the second. Actinomycetoma was found in an equal number as eumycetoma. The only causative organism 

that could be identified among mycetoma cases was C.carrionii which caused mycetoma on the buttock 

of an aplastic anemia patient at the site of bone marrow aspiration. Surgical treatment was recommended 

for eumycetoma. Chromoblastomycoses were caused by C.carrionii and F.compactum which responded 

well to itrconazole orally. Mycotic abscesses were found in 4 cases, basidiobolomycosis in 2 cases and 

cutaneous nocardiosis in 1 case. Cotrimoxazole was recommended for the treatment of actinomycetoma, 

cutaneous nocardiosis and basidiobolomycosis. 

Conclusion : Localized, chronic, slow progressive and usually asymptomatic skin lesion 

was the main cutaneous manifestation of deep fungal and higher bacterial skin infections. Skin biopsy 

should be done in every suspected cases for histologic study and culture identification. The causative 

organisms were found in histologic sections of every cases but only about one-third were found by culture 

method. 


4-5 March 1999) 

189 

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190 

ACQUIRED PROGRESSIVE KINKLING OF THE HAIR (APKH) 

Sukamas Suwanwalaikorn, Apichati Sivayathorn, Kleophant Thakerngpol 

Department of Dermatology and Pathology, Faculty of Medicine Siriraj Hospital, Mahidol University 

Key words : Alopecia 


(255) 

Background : APKH is a rare disorder of scalp hair characterized by rapid onset of 

tightly curl hair shaft in association with an increasingly coarse texture resembling pubic hair. These may 

follow by progressive hair loss, which lead to common baldness soon after the event. The main affected 

areas are in the frontal-parietal and vertex regions which correspond to those usually involve in androgenetic 

alopecia (AGA). It occurs primarily at or soon after puberty and is more common in males. Hormonal 

changes may play an important role in pathophysiological events. 

Methods and patients : We report 2 cases, which demonstrated the changes in hair 

abnormality believed to be characteristic of APKH. 

Case I. M.S., 28 year-old woman, complained of progressively hair loss over period of 2 

years. She noticed all these abnormalities after childbirth. 

Case II C.C., 21 year-old man presented with one year history of hair loss. 

Results : Clinical examination revealed a slight increase in telogen count in the affected 

area. Light microscope and scanning electron microscope confirmed the presence of alteration in hair 

shaft diameter with partial twists. Canalicular grooves were seen on its longitudinal axis, together with 

some broadened and flattened sections. Cross section of the hair showed elliptical or heart-shaped appearances. 

Blood tests result including sex hormones and copper level were normal. 

Conclusion : The differential diagnosis of APKH includes all the syndromes of woolly 

hair, whisker hair, uncombable hair syndrome and all woolly hair occurring as a result of external trauma 

and drug. This entity may be more common than previously recognized and is probably a prognostic sign 

heralding severe AGA. 


4-5 March 1999)

CLINICAL AND MICROBIOLOGIC FINDINGS IN CELLULITIS IN THAI 

PATIENTS 

Kanokvalai Kulthanan 1 , Yong Rongrungruang 2 , Aimon Siriporn 1 , Waranya Boonchai 1 , Puan 

Suthipinittharm 1 , Apichati Sivayathorn 1 , Patcharee Sunthonpalin 1 . 

1 Department of Dermatology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 

10700, Thailand. 2 Infectious Division, Department of Internal Medicine, Faculty of Medicine, 

Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand. 

Key words: Cellulitis, Clinical Features, Microbiologic Study 

Background: Cellulitis is an inflammation of subcutaneous tissue in which infective, 

generally bacterial cause is proven or assumed. However, attempts to culture bacteria from 

lesions are often unsuccessful. 

Method: One hundred and fifty cases diagnosed as cutaneous cellulitis at Siriraj Hospital 

between 1992 and 1995 were retrospectively studied. 

Results: Our study in 150 adult Thai patients with cellulitis showed that the most common 

site of infection was the lower extremity. Forty two per cent of the patients had history of preceding local 

trauma. Fever and regional lymphadenopathy were detected in 77.3 per cent and 22.6 per cent respectively. 

Sixty nine per cent of patients had leukocytosis with a mean neutrophil ratio of 79.7 per cent of 

patients with underlying diseases predisposed to the infection, 61.6 per cent had positive lesional culture 

results in contrast to 31.6 per cent in patients without. Needle aspiration and blood gave low positive 

culture yields. The common organisms detected were S.aureus and Streptococcus group A (83%) in 

immunocompetent patients. Of immunocompromised patients, in one half of the cases gram negative 

bacteria were found. 

Conclusions: This study showed that in immunocompetent patients, the major bacterial 

isolated in cellulitis were S.aureus and Streptococcus group A. In immunocompromised patients, gram 

negative bacteria were found in one half. These findings may help in the selection of antimicrobials before 

the results of bacterial cultures are available or in culture negative cases. 

(J Med Assoc Thai 1999; 82: 587-92.) 

191 

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192 

COMBINED LASER RESURFACING WITH THE 950-mSEC PULSED 

CO 2 + ER: YAG LASERS 

Mitchel P. Goldman, Woraphong Manuskiatti. 

Dermatology Associates of San Diego County, Inc., 850 Prospect Street, La Jolla, CA 92037 

Introduction: Laser resurfacing with the 950 mmsec pulsed CO laser has been proven 

2 

to be efficacious in improving photodamaged skin and acne scarring. Unfortunately, prolonged erythema 

and delayed wound healing are common adverse sequelae, which require intensive patient education and 

intervention. These adverse effects may be due to the degree of nonspecific thermal damage present 

after resurfacing with the CO laser. Since erbium: YAG (Er: YAG) laser vaporization leaves far less 

2 

thermal damage, it is hypothesized that its use after CO laser resurfacing will decrease the extent of 

2 

nonspecific damage and result in improved wound healing. 

Methods: Ten patients were randomized to receive laser resurfacing of one-half of the 

face with the 950 mmsec pulsed CO 2 laser with 3 passes at 300 mJ, utilizing the computer pattern 

generator (CPG) at settings of 596, 595, 584, and the other half of the face (randomly chosen) resurfaced 

with the 950 mmsec pulsed CO 2 laser 2 passes with the CPG at 300 mJ at settings of 596 and 595, 

followed by 2 passes with the Er: YAG laser (Derma-20 or Derma-K, ESC Medical Systems, Inc., 

Needham, MA) with a 4 mm diameter spot size at 1.7 J (approximately 14 J/cm 2 ). Patients were evaluated 

in a “blinded” manner clinically and histologically before resurfacing, immediately after resurfacing, 2 to 3 

days postoperatively, 1 week postoperatively, and 4 to 8 weeks postoperatively. 

Results: There was slightly less inflammation with the CO 2 /Er: YAG-treated patients. 

The epidermis re-formed 1 to 2 days faster with combination (UPCO 2 )/Er: YAG treatment than with 

UPCO 2 laser treatment alone. In 7 of 10 patients, Er: YAG erythema resolved within 2-3 weeks with CO 2 

x 3 erythema persisting at the 8-week follow-up period in all patients. Three of 10 patients had no difference 

in the degree of erythema between the 2 treatment areas. Clinical findings correlated with histologic 

findings of vascularity. There was no difference in the extent or time of edema between techniques. The 

usual demarcation line between cheek and neck at the mandibular angle was less apparent when the 

UPCO 2 /Er: YAG combination was used. Two of 10 patients noted quicker healing with the combination 

laser technique. 

Conclusion: Treating a patient with the Er: YAG laser after treatment with the UPCO 2 

laser results in a decreased incidence of adverse sequelae without a noticeable difference in the degree of 

wrinkle improvement. 

(Dermatol Surg 1999;25:160-163.) 


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LASER HAIR REMOVAL AFFECTS SEBACEOUS GLANDS AND SEBUM 

EXCRETION: A PILOT STUDY 

Woraphong Manuskiatti, 1* Christine C. Dierickx, 1 Salvador González, 1 Tai-Yuan David Lin, 1 

Valeria B. Campos, 1 Ernesto González, 2 R. Rox Anderson. 1 

1 

The Wellman Laboratories of Photomedicine and 2 

the MGH Dermatology Laser Center, Department 

of Dermatology, Harvard Medical School, Massachusetts General Hospital, 

*Dr.Manuskiatti is currently affiliated with the Department of Dermatology, Siriraj Hospital, 

Mahidol University, Bangkok, Thailand. 

Background: During laser-assisted hair removal, sebaceous glands closely associated 

with hair follicles might also be affected. 

Objective: We investigated the effect of the long-pulsed ruby laser on sebaceous glands. 

Methods: Sebum excretion rates (SERs) of 16 subjects were measured quantitative by 

means of sebum-absorbent tape and analyzed by means of image analysis techniques on laser-treated 

sites, compared with adjacent untreated areas. Evaluation was done at an average of 9 months (range, 

4.5 to 12 months) after the last treatment. Histologic examinations were performed on 3 representative 

subjects before treatment, immediately after treatment, and 9 months after the last treatment. 

Results: Significant increases in SERs were observed in 11 of 16 subjects (68.75%). 

Three subjects (18.75%) showed lower SERs, whereas 2 subjects (12.5%) demonstrated no difference 

in SERs between treated and untreated areas. Biopsy specimens showed an apparent reduction in sebaceous 

gland size. Specimens taken immediately after laser irradiation revealed sporadic damage to sebaceous 

glands. 

Conclusion: In some patients a variable but statistically significant increase in sebum 

excretion occurs 4 to 12 months after ruby-laser hair removal treatment at high fluences. A reduction in 

sebaceous gland sizes on laser-treated areas was observed. We hypothesize that decreased resistance to 

sebum outflow may explain this result, following miniaturization or absence of hair shaft after ruby laser 

treatment. Further study is needed to assess mechanisms for this interesting response. 

(J Am Acad Dermatol 1999;41:176-80.) 

LASER RESURFACING OF THE NECK WITH THE ERBIUM: YAG LASER (259) 

Mitchel P. Goldman, Richard E. Fitzpatrick, and Woraphong Manuskiatti. 

Cosmetic Laser Surgery Center, 9850 Genesee Ave., Suite 480, La Jolla, CA92037 

Background: Laser resurfacing of the face is widely used to correct the effects of 

photoaging. The neck also develops a similar degree of photoaging, but is not usually treated because a 

higher incidence of adverse effects can occur with laser treatment. 

Objective: To present a new method for treating photoaged skin of the neck with an 

erbium: yttrium aluminum garnet (Er: YAG) laser. 

193 

(258)

194 

Methods: Twenty patients underwent Er: YAG laser resurfacing of the neck with one 

of two methods. Methol 1 consisted of using the Er: YAG with a 5-mm diameter collimated beam at a 

fluence of 8.7 I/cm 2 followed by a second pass using a 0.2 mm diameter non-collimated spot at 1.7 J in a 

defocused mode with spot sizes ranging from about 5 to 10 mm in diameter (fluences from 2-9 J/cm 2 ). 

Method 2 consisted of treating the entire neck with a single pass of the Er: YAG laser with a 4 mm 

diameter non-collimated spot at 1.7 J (fluence of 13.5 J/cm 2 ). A second pass at identical settings was 

made on the upper half of the neck with a more defocused pass using a 6-10 mm diameter spot (fluence 

of 2-6 J/cm 2 ) on the lower half of the neck. Patients were evaluated by two nontreating physicians as to 

overall satisfaction and improvement in skin texture and color. 

Results: Overall, 51% of patients were satisfied with their results. Skin texture improved 

an average of 39%. Method 1 produced a 28% improvement, Method 2 a 48% improvement. Skin color 

improved an average of 37%l Method 1 produced a 28% improvement, Method 2 a 45% improvement. 

Conclusion: Photoaged skin of the neck can be effectively treated with the Er: Yag 

laser with minimal adverse effects. 

(Previously presented at the 1998 Annual Meeting of the American Society of Laser Medicine and 

Surgery, San Diego, CA, April, 1998, and the 1998 Annual Meeting of the American Society for 

Dermatologic Surgery, Portland, OR, May, 1998.) 

(Dermatol Surg 1999;25:164-168.) 

LINEAR IgA BULLOUS DERMATOSIS OF CHILDHOOD: A LONG TERM 

STUDY 

Kanokvalai Kulthanan 1 , Rutsanee Akaraphanth 2 , Thada Piamphongsant 2 , Preya Kullavanijaya 2 

1 Department of Dermatology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 

10700, Thailand., 2 Institute of Dermatology, Department of Medical Services, Ministry & 

Public Health, Bangkok 10400, Thailand. 

Key word: Linear IgA, Bullous Dermatosis, Childhood 


(260) 

Background: Linear IgA bullous dermatosis (LAD) of childhood is a rare acquired 

subepidermal blistering disease of young children. Most of the studies were reported from the USA and 

European countries. 

Method: Twelve cases of Thai patients diagnosed as LAD of childhood were analyzed 

concerning clinical, histopathological, immunopathological findings including treatment responses and 

courses compared with those of Caucasians.

Result: The mean age of onset was 5.1 years. The areas of common involvement were 

the perioral region, lower abdomen, perineum, buttock, inner thighs and extremities. Histopathology in half 

of the cases showed features of dermatitis herpetiformis or bullous pemphigoid. All patients had positive 

linear IgA band at the basement membrane zone (BMZ) by direct immunofluorescence. Only one patient 

had positive circulating anti BMZ antibody at the titer of 1:10. Most patients responded well to dapsone. 

The mean duration before remission was 1.9 years. 

Conclusion: Our study in Thai patients with LAD of childhood produced data similar to 

previous studies carried out in the Caucasian nations. 

( J Med Assoc Thai 1999; 82: 707-12.) 

LONG-TERM EFFECTIVENESS AND SIDE EFFECTS OF CARBON DIOXIDE 

LASER RESURFACING FOR PHOTOAGED FACIAL SKIN 

(261) 

Woraphong Manuskiatti,* Richard E. Fitzpatrick, Mitchel P Goldman. 

Dermatology Associates and Cosmetic Laser Associates of San Diego County, Inc. *Current 

address: Department of Dermatology, Siriraj Hospital, Mahidol University, Bangkok, Thailand. 

Background : Laser resurfacing has been used for treatment of photoaged facial skin 

since late 1993. Very few long-term follow-up studies regarding the effectiveness and side effects of this 

procedure have been reported. 

Method : Patients who received carbon dioxide laser resurfacing for facial photoaging 

and wrinkling from Dec 17, 1993, to Nov 30, 1996, were followed up with clinical evaluation and patient 

questionnaires. Histologic study was also performed in 10 representative patients who had had preoperative 

biopsies. All treatments were performed by 2 experienced laser surgeons (R.E.F. and M.P.G.). 

Results : One hundred four patients were examined and interviewed with an average 

24-month postoperative follow-up (range 12 to 44 months). We observed high patient satisfaction ratings 

and significant persistence of wrinkle score improvement. Long-term histologic features confirmed the 

long-lasting nature of the clinical improvement and demonstrated continuing, progressive improvement in 

solar elastosis deep in the dermis for an average follow-up period of 2 years. Prolonged use of topical 

tretinoin (retinoic acid) postoperatively may contribute to continued improvement. The incidence of longterm 

side effects, including pigmentary changes and scarring was generally very low and these side 

effects were usually not noticed by the patients. 

Conclusion : Improvement from cutaneous laser resurfacing has persisted for an average 

24-month postoperative period with a low incidence of side effects. Hypopigmentation is the most common 

long-term side effect and appears to be related to the degree of pre-existing photodamage as it 

contrasts with the newly healed undamaged skin. 

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(J Am Acad Dermatol 1999;40:401-11) 

PROPHYLACTIC ANTIBIOTICS IN PATIENTS UNDERGOING LASER 

RESURFACING OF THE SKIN 

Woraphong Manuskiatti, Richard E Fitzpatrick, Mitchel P Goldman, Niels Krejci-Papa. 

The Dermatology Associates and Cosmetic Laser Associates of San Diego County, Inc.*Dr. 

Manuskiatti is currently with the Department of Dermatology, Siriraj Hospital, Mahidol University, 

Bangkok, Thailand. 

Background: Carbon dioxide (CO 2 ) laser resurfacing produces a superficial second 

degree burn that needs to be protected from bacterial and fungal infections. 

Objective: We investigated the effects of various systemic and topical antimicrobial 

regimens. 

Methods: Four different regimens using oral ciprofloxacin, topical antibiotics (intranasal 

mupirocin ointment and otic solution), oral ketoconazole, and oral fluconazole were tested in four time 

periods. The frequency and types of the infections with various regimens was compared. 

Results: The study included 356 sequential patients who underwent facial CO 2 laser 

resurfacing. Infections occurred in 27 patients (7.6%). Without antibiotic prophylaxis, 8.2% of patients 

had bacterial infections from days 3 to 12 after the procedure (average, day 5). With prophylactic 

ciprofloxacin only, 4.3% of patients had bacterial infections; these occurred almost exclusively after 

ciprofloxacin was discontinued. For 7 months, patients were randomly assigned to either receive or not 

receive mupirocin intranasally. All Staphylococcus aureus infections that occurred were seen in patients 

who had used intranasal mupirocin. Yeast infections were seen in 6 patients (1.7%), but mostly occurred 

more than 10 days after the procedure. Yeast infections were if approximately equal occurrence in the 

ciprofloxacin group (2.2%) and in the non-ciprofloxacin group (1.8%). No yeast infections occurred in 

patients who had undergone antifungal prophylaxis. 

Conclusion: Post-CO 2 resurfacing infections are not rare but can appear subtly and 

might only be noticeable in the second postoperative week. Prophylactic intranasal mupirocin is ineffective, 

but ciprofloxacin is effective in preventing infection with both gram-positive and gram-negative 

bacteria. Oral ketoconazole and fluconazole are effective in preventing yeast infections. 

(J Am Acad Dermatol 1999;40:77-84.) 


(262)

DEEP FUNGAL AND HIGHER BACTERIAL SKIN INFECTIONS IN 

THAILAND : CLINICAL MANIFESTATIONS AND TREATMENT 

REGIMENS 

Punkae Mahaisavariya 1 , Angkana Chaiprasert 2 , Apichati Sivayathorn1, Supakan Khemngern1 

1 2 Department of Dermatology and Microbiology, Faculty of Medicine, Siriraj Hospital, Mahidol 

University, Bangkok, Thailand 

Supported by Siriraj-China Medical Board, Faculty Research Grant, Faculty of Medicine, Siriraj 

Hospital, Mahidol University, Bangkok, Thailand 

Key words: deep fungal infection, higher bacterial skin infection 

Background: Deep fungal and higher bacterial skin infections occur fairly frequently in 

Thailand. 

Method: Cases with a provisional diagnosis of deep fungal and higher bacterial infections 

were prospectively collected from 1994 to 1997 in the Granuloma Clinic, Department of Dermatology, 

Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand. Demographic data, clinical 

manifestations, causative organisms, histologic features, treatment, and outcome were investigated. 

Results: The total cases in a 4-year period numbered 27. The male to female ratio was 

approximately 1:1. Mycetoma was most common, followed by chromoblastomycosis. Actinomycetoma 

was similar in incidence to eumycetoma. The only causative organism that could be identified among the 

mycetoma cases was Cladosporium carrionii, which caused mycetoma of the buttock of an aplastic 

anemia patient at he site of bone marrow aspiration. Surgical treatment was recommended for eumycetoma. 

Chromoblastomycosis was caused by C. carrionii and F.compactum and responded well with itraconazole 

orally. Mycotic abscesses were found in four cases, basidiobolomycosis in two cases, and cutaneous 

nocardiosis in one case. Cotrimoxazole was recommended in the treatment of actinomycetoma, cutaneous 

nocardiosis, and basidiobolomycosis. 

Conclusions: Localized, chronic, slow, progressive, and usually asymptomatic were the 

main cutaneous manifestations of deep fungal and higher bacterial skin infections. A skin biopsy for 

histologic study and culture identification should be performed in every suspected cases. The causative 

organisms were found in the histologic sections of every case, but only about one-third were found by 

culture. 

(Supported by Siriraj-China Medical Board, Faculty Research Grant, Faculty of Medicine, Siriraj 

Hospital, Mahidol University, Bangkok, Thailand) (International Journal of Dermatology 

1999;38:279-84.) 

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LESIONAL T-CELL SUBSET IN LEPROSY AND LEPROSY REACTION 

Punkae Mahaisavariya, Kanokvalai Kulthanan, Supakan Khemngern, Sumruay Pinkaew. 

Department of Dermatology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, 

Thailand. 

Key words : T cell subset leprosy, leprosy reaction 

Background : The T-cell-mediated immune response plays an important role in leprosy. 

The in situ proportion and pattern of distribution of T-cell subsets in leprosy skin lesions have been 

studied, but no conclusion could be drawn. 

Methods : We used monoclonal antibodies for T-helper and T-suppressor surface antigen 

to define the nature of dermal infiltration in 17 cases of nonreactional leprosy and 20 cases of reactional 

leprosy. 

Results : We found T helper admixed with T suppressor in an aggregated pattern in the 

granulomas of most cases of nonreactional leprosy and in type I reactional leprosy, but a diffuse infiltrate 

throughout the dermis of type II reactional leprosy. The T-helper/suppressor ratio was 1.68 in tuberculoid 

and 1.5 in lepromatous cases. The T-helper/suppressor ratios of borderline tuberculoid (3.11) and type I 

reactional leprosy (2.54) were not statistically different. The T-helper/suppressor ratio of type II reactional 

leprosy (5.83) was statistically higher than nonreactional lepromatous cases. 

Conclusions : The alteration of the T-helper/suppressor ratio in our study is mainly due 

to the reduction of T-suppressor cells in the dermal infiltrates, especially in type II reactional leprosy. 

Further studies of T-suppressor functions may be important in the pathogenesis of leprosy. 

(Supported by Chalerm Prakiat Fund Faculty Research Grant, Faculty of Medicine, Siriraj Hospital, 

Mahidol University, Bangkok, Thailand.) (International Journal of Dermatology 1999;38:345- 

347.) 

MAST CELLS IN LEPROSY AND LEPROSY REACTION 

Punkae Mahaisavariya 1 , Sukhum Jiamton 1 , Jane Manonukul 2 , Supakan Khemngern 1 . 

1 Department of Dermatology, 2 Department of Pathology, Faculty of Medicine, Siriraj Hospital, 

Mahidol University, Thailand. *Supported by Chalerm Prakiat Fund, Faculty Research Grant, 

Faculty of Medicine, Siriraj Hospita Mahidol University, Bangkok, Thailand. 

Key words : Mast cell, leprosy, leprosy reaction 


(264) 

(265) 

Background: Mast cells can be visualized in routine acid-fast staining paraffin-tissue

section as metachromatic staining cell and can be activated to release inflammatory mediators 

which play roles in cell-mediated immune response. 

Method: The skin biopsy tissues were taken from the most active skin lesion of each 

leprosy patient at the time of diagnosis (non-reactional group) and at the time of reaction (reactional 

group) during the years 1994-1997 in leprosy clinic, Department of Dermatology, Faculty of Medicine, 

Siriraj Hospital, Mahidol University, Thailand. Mast cells were identified by metachromatic staining purple 

in Fite’s stain sections and reported as average number of cell per high power field in 3 compartments, at 

the center and at the periphery of the granuloma and in the interstitium. The data was analysed into 3 

groups: non-reactional group, type I and type II leprosy reactions. The mast cell count of each group and 

each compartment of the section, expressed in mean ³ standard error were compared. 

Result: A total of 95 persons were included in the study, but 108 tissue sections were 

obtained due to 9 cases having more than one section. . Among these patients, 63 cases (66.32%) had no 

reaction, 19 cases (20%) had type I reaction and 13 cases had type II reaction. No difference in age and 

sex among these groups. Mast cell count in the interstitium was higher than within the graunloma, both at 

the center and at the periphery, in every type and the count in this area reduced significantly in leprosy 

reactions, both type I and type II, compared with the non-reactional group. 

Conclusion: The change of average mast cell number in non-reaction leprosy and leprosy 

reactions may indicated the important roles of mast cell in dynamic change of cell-mediated immune 

response in leprosy and leprosy reaction. 

(Supported by Chalerm Prakiat Fund, Faculty Research Grant, Faculty of Medicine, Siriraj Hospita 

Mahidol University, Bangkok, Thailand.) International Journal of Dermatology . (Inpress) 

BASAL CELL CARCINOMAS IN CHRONIC ARSENICISM OCCURRING IN 

QUEENSLAND AFTER INGESTION OF AN ASTHMA MEDICATION 

Waranya Boonchai 1* , Adele Green 2 , Jack Ng 3 , Anthony Dicker 4 , Georgia Chenevix- 

Trench 5 (266) 

. 

1 Cancer Unit, Queensland Institute of Medical Research, Brisbane, Australia, 2 Epidemiology 

Unit, Queensland Institute of Medical Research, Brisbane, Australia, 3 National Research Center 

for Environmental Toxicology, Brisbane, Australia, 4 Epithelial Pathobiology Group, Centre for 

Immunology and Cancer Research, Department of Medicine, University of Queensland, 

Princess Alexandra Hospital, Brisbane, Australia, 5 Joint Experimental Oncology Program, The 

Queensland Institute of Medical Research and University of Queensland, Brisbane, Australia. 

* Current address is Department of Dermatology, Siriraj Hospital, Mahidol University, Thailand. 

Key words : arsenic, basal cell carcinoma 

Background : Ingestion of trivalent inorganic arsenic has long been recognized as a 

cause of basal cell carcinomas (BCCs), and has been reported most often in Taiwan and Singapore. 

Objective : To study the clinical and histological characteristics of BCCs occurring in 

199

Caucasian cases with 92 arsenic-related BCCs. 

Main Outcome Measures: The expression and the intensity of p53 were scored semiquantitatively. 

Statistical analysis was performed with the Chi-squared test. 

Results: Arsenic-related BCCs express p53 less often and at a lower intensity than 

sporadic BCCs (p = 0.001; two-sided test). BBCs from sun-exposed sites, whether arsenic-related or 

sporadic, more frequently show overexpression of p53 than those from less sun-exposed areas (p = 

0.004; two-sided test). The more aggressive subtypes of BCC show a higher level of expression of p53 

than the less aggressive forms (p = 0.04, cc 2 two-sided). 

Conclusions: These results are consistent with the hypothesis that the TP53 gene is 

down-regulated by methylation in arsenic-related BCC, particularly those from less sun-exposed sites. 

However, an alternative possibility is that mutations in TP53 that stabilize the protein are less common in 

arsenic-related BCCs. Further analysis will be necessary to distinguish between these two hypotheses. 

PATCHED MUTATIONS IN SPORADIC AND ARSENIC-RELATED BASAL 

CELL CARCINOMAS 

Timothy Evans 1 , Waranya Boonchai 2 , Susan Shanley 2 , Ian Smyth 1,3 , Susan Gillies 1 , Kylie 

Georgas 1 , Brandon Wainwright 1,3 , Georgia Chenevix-Trench 2,4 , Carol Wicking 1 *. 

1 The Centre for Molecular and Cellular Biology, University of Queensland, QLD 4072, 2 The 

Queensland Institute of Medical Research, RBH Post Office, Herston, QLD 4029, 3 The Biochemistry 

Department, University of Queensland, QLD 4072, 4 Joint Oncology Programme, 

The Queensland Institute of Medical Research and the University of Queensland, RBH Post 

Office, Herston, QLD 4029. 

Key words: patched, mutation, basal cell cacinoma 

(268) 

Inactivating mutations in the human patched (PTCH) gene have been identified in both 

familial and sporadic basal cell carcinomas (BCCs). In some tumours mutations have been detected in 

both alleles thereby supporting the role of PTCH as a tumour suppressor gene. The sporadic BCCs 

examined to date are likely to have arisen largely as a consequence of sun exposure, and the mutation 

profile observed reflects this with a high incidence of C -> T-substitutions at dipyrimidine sites. We have 

examined 93 sporadic BCCs, as well as 105 BCCs that appear to have developed as a result of arsenic 

exposure, for loss of heterozygosity (LOH) around the PTCH gene. The frequency of LOH was 31.5% 

and 29.7% in the microdissected sporadic and arsenic-related BCCs respectively, implying that the PTCH 

gene is also involved in the genesis of arsenic-related BCC. We analysed 22/23 coding exons of PTCH 

for mutations in 20 sporadic and 24 arsenic-related BCCs. Ten mutations were found, with no significant 

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difference between the frequency or type of mutations in the two types of BCCs. Most of the 

mutations found are C -> T substitutions at dipyrimidine sites, indicating a role for ultraviolet B in the 

genesis of both the sporadic and arsenic-related tumours. 

PRURITIC PAPULAR ERUPTION IN HIV SEROPOSITIVE PATIENTS : 

A CUTANEOUS MARKER FOR IMMUNOSUPPRESSION. 

Waranya Boonchai 1 , Rungroj Laohasrisakul 1 , Jane Manonukul 2 , Kanokvalai Kulthanan 1 

1 Department of Dermatology, Faculty of Medicine, Siriraj Hospital, Mahidol University. 2 Department 

of Pathology, Faculty of Medicine, Siriraj Hospital, Mahidol University. 

Key words: pruritic papular eruption, human immunodeficientcy virus infection, CD4. 

(269) 

Background: Previous reports show the correlation between certain skin disorders and 

immune status in HIV infected patients. Pruritic papular eruption (PPE) is the most common cutaneous 

manifestation in HIV infected patients. The purpose of the study is to define the relationship between 

presentation of PPE and the stage of immune in HIV infection, as measured by T-cell subset and to 

establish usefulness of the common eruption as a predictor of CD4 count. 

Method: In this cross-sectional study, twenty HIV-positive patients with characteristic 

of pruritic papular eruption were studied in their clinical data, skin biopsy and evaluated immune status by 

measuring CD4, CD8 and CD4 / CD8, 

Results: 75% of patients already had antecedent skin disorders so PPE is not leading 

symptom in HIV infected patients 81.25% of PPE patients had advanced degree of immunosuppression 

with CD4 count below 100/ cu.mm. and 75% below 50/cu.mm. 

Conclusion: PPE can be regarded as a cutaneous marker of advanced HIV infection.

ROLE OF b-CATENIN, A KEY MEDIATOR OF THE Wnt SIGNALING 

PATHWAY, IN BCC 

Waranya Boonchai, 1* Michael Walsh, 2 Margaret Cummings, 2 Georgia Chenevix-Trench. 3 

(270) 

1 The Queensland Institute of Medical Research, Brisbane, Australia, 2 Department of Pathology, 

University of Queensland, Australia, 3 Joint Experimental Oncology Program, The Queensland 

Institute of Medical Research and University of Queensland, Brisbane, Australia. *Current 

address is Department of Dermatology, Siriraj Hospital, Mahidol University, Thailand. 

Key words : b-CATENIN, Basal cell carcinoma 

Background: Patched gene, which has been found to be responsible for the genesis of 

familial and sporadic BCCs, is a major component of HH signaling pathway. PTCH has been implicted in 

the transcriptional repression of genes, encoding members of TGFb, BMP and WNT proteins families. 

Recent studies have revealed the striking role for ³-catenin in signal transduction in the Wnt signaling 

pathway. The aim of this study is to examine the association of the two pathways and the role of b-catenin 

in BCCs, which so far no previous report in this aspect. 

Observations: None of tested BCCs showed nuclear translocation or an increase in 

the cytoplasmic accumulation of ³-catenin. BCCs showed a heterogeneous pattern of b-catenin membrane 

and cytoplasmic staining within individual tumor masses. The staining in the tumors was always less 

intense than in normal epidermis. b-catenin positivity was prominent at the periphery of some tumor 

masses, especially in the solid subtype of BCCs. The expression of ³-catenin was similar with respect to 

either histology or sun-exposure of the tumors. 

Conclusions: The findings did not support the hypothesis that activation of smoothened 

signaling as a consequence of PTCH (or SMO) mutations may ultimately result in translocation of b- 

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PHOTOTESTING IN ORIENTAL PATIENTS WITH LUPUS 

ERYTHEMATOSUS 

Vichit Leenutaphong, Waranya Boonchai 

Department of Dermatology, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand. 

Key words : phototest; lupus erythematosus; Oriental 


(271) 

Light sensitivity is an important clinical characteristic of several forms of lupus erythematosus 

(LE). Recently, investigations have been able to induce LE-like lesions in LE patients with 

UVA as well as UVB, although most of these studies were conducted in Caucasians. Thus, there is 

insufficient data on phototesting in Oriental patients with LE. The aim of this study was to evaluate light 

sensitivity in Oriental patients with LE. Fifteen patients with various forms of LE were tested. Patients 

were evaluated by provocative phototesting, and threshold doses of UVA and UVB radiation that produced 

erythema and pigmentation were determined. The minimal erythema doses (MED) of UVB, 

immediated pigment darkening (IPD), and minimal tanning doses (MTD) were within the normal range in 

LE patients compared to a control group. Skin lesions clinically and histologically compatible with LE 

were induced in two of six patients with SLE, and four of nine patients with DLE. These lesions developed 

in about 2 weeks (range 5 to 23 days) after irradiation and lasted approximately 1 to 3 months (47+24 

days), The action spectrum of the induced lesions was within the UVB and UVA ranges in four patients, 

in the UVA range in one patient, and in the UVB and UVA ranges in one patient. We found no correlation 

between a positive history for UV sensitivity and phototest reactions. Inconclusion, the incidence of 

positive phototest reactions in Oriental patients with LE seems to be similar to or a little lower than in 

Caucasians. There was no correlation between a positive history for UV sensitivity and phototest reactions. 

(Phototesting in Oriental patients with lupus erythematosus. Photodermatol Photoimmunol Photomed 

1999: 15: 7-12. ©Munksgaard, 1999.)

ANALYSIS OF REG I b GENES IN THAI DIABETIC PATIENTS 

Napatawn Banchuin1 , Pa-thai Yenchitsomanus2 , Sathit Vannasaeng3 , Pinya Pulsawat1 , Watip 

Boonyasrisawat1 , Sirirat Ploybutr3 , Sutin Sriussadaporn3 (272) 

1 Department of Immunology, 2 Medical Molecular Biology and Molecular Genetic Units, Office 

for Research and Development, 3 Department of Medicine, Faculty of Medicine Siriraj Hospital, 

Mahidol University, Thailand. 

Several lines of evidences have suggested the possible role of reg gene in islet regeneration 

and its likely involvement during autoimmune diabetogenesis. However, such a role of reg gene is 

still controversial. In this study, we have analysed reg I b gene in 31 Thai diabetic patients (12 insulin 

dependent diabetes mellitus, 7 non-insulin dependent diabetes mellitus, and 12 fibrocalculous pancreatic 

diabetes) and 13 normal controls, by polymerase chain reaction-single strand conformation polymorphism 

(PCR-SSCP) technique. It was found that, reg I b gene in almost all diabetic patients showed 

normal SSCP patterns for all 6 exons. Only one that had a mobility shift in exon 4 was that from a patient 

with fibrocalculous pancreatic diabetes, which was due to a nucleotide substitution at codon 84 (GTG ³ 

CGC), leading to a change of valine to alanine (V84A). However, the importance of this amino acid 

change is still unknown. Thus, by PCR-SSCP technique, we did not find the association between reg I b 

gene abnormality and diabetes mellitus in Thai patients. 

RAPID IDENTIFICATION OF BURKHOLDERIA PSEUDOMALLEI IN 

BLOOD CULTURES BY A MONOCLONAL ANTIBODY ASSAY 

Supinya Pongsunk1 , Nittaya Thirawattanasuk2 , Nuanchan Piyasangthong3 , and Pattama Ekpo4 (273) 

1 Department of Microbiology, Faculty of Medicine, Srinakharinwirot University, Bangkok, 

2Department of Bacteriology, Sappasitprasong Hospital, Ubonratchathani, 3 Department of 

Clinical Pathology, Khonkaen Regional Hospital, Khonkaen, 4 Department of Immunology, 

Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand. 

Burkholderia pseudomallei is the causative agent of melioidosis. In northease Thailand, 

this gram-negative bacterial is a major cause of mortality from septicemia. The definitive diagnosis 

of this disease is made by bacterial culture. In this study, we produced a monoclonal antibody (MAb) 

specific to the 30-kDa protein of B. pseudomallei by in vivo and in vitro immunization of BALB/c mice 

with a crude culture filtrate antigen. The MAb could directly agglutinate with all 243 clinical isolates of 

B. pseudomallei but not with other gram-negative bacteria except for one strain of B. mallei. However, 

the MAb cross- reacted with the gram-positive bacteria, Bacillus sp. and S. pyogenes. B. pseudomallei 

in brain heart infusion broth (BHIB) subcultured from a BacT/Alert@ automated blood culture system 

could be identified by simple agglutination with this Mab assay. The sensitivity and specificity of direct 

agglutination compared to the ‘gold standard’, the culture method, were 94.12% and 98.25%, respectively. 

However, the MAb adsorbed to polystyrene beads or latex particles directly identified the bacterium in 

blood culture specimens and in BHIB subcultured from a BacT/Alert@ automated blood culture system. 

The sensitivity of the latex agglutination test was 100% for both blood culture and BHIB specimens. The 

205

206 

specimens, respectively. The specificity could be increased if the nonspecific materials in the blood 

culture broths were eradicated by centrifugation at low speeds. Thus, a combination of blood culture and 

the agglutination method could be used for rapid diagnosis of melioidosis in the routine bacteriological 

laboratory. This method could speed up the detection of the bacterium in blood culture at least 2 days 

compared to the conventional bacterial culture method. In addition, the Mab is stable at room temperature 

for 2 weeks and at 4, -20 and –70 degrees C for at least 1 year. The latex reagent was stable for at least 

6 months at 4 degrees C. 

EVALUATION OF CRUDE CULTURE FILTRATE ANTIGEN FROM 

BURKHOLDERIA PSEUDOMALLEI FOR DIAGNOSIS OF MELIOIDOSIS 

Supinya Pongsunk1 and Pattama Ekpo2 

1Department of Microbiology, Faculty of Medicine Srinakharinwirot University, 2Department 

of Immunology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok Thailand. 

Melioidosis is an infection caused by Burkholderia pseudomallei. The disease is an 

important cause of morbidity and mortality in Thailand, Southeast Asia and northern Australia. Current 

method for the diagnosis of melioidosis is based on bacteriological culture. However, the method is 

time-consuming. In this present study, we evaluated the usage of indirect enzyme linked immunosorbent 

assay (indirect ELISA) using crude culture filtrate antigen for detecting specific IgG. The indirect 

ELISA was studied in 219 sera. Of 219 sera, 89 are sera from melioidosis patients, 72 are sera from 

patients with other bacterial infections, and 58 are normal sera from healthy populations living in endemic 

area. The sensitivity, specificity, positive predictive value, and negative predictive value are 82.02%, 

86.92%, 81.11%, and 87.60%, respectively. 

THE BURKHOLDERIA PSEUDOMALLEI 30-KILODALTONS OUTER 

MEMBRANE PROTEIN ANTIGEN : MOLECULAR CLONING AND 

EXPRESSION 

Pattama Ekpo1, Supinya Pongsunk 2 and Takayuki Ezaki3 


1Department of Immunology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2Department 

of Microbiology, Faculty of Medicine, Srinakharinwirot University, Bangkok, Thailand 

and 3Department of Microbiology, Gifu University School of Medicine, Gifu, Japan. 

Monoclonal antibody directed against the major component of Burkholderia 

pseudomallei crude culture filtrate and outer membrane protein antigens, the 30-kDa protein, was used 

to monitor cloning and expression of the gene from B. pseudomallei genomic DNA libraries. The gene 

was analyzed and recombinant protein was produced in Escherichia coli JM 105. A DNA sequence 

analysis of the 30-kDa gene revealed the presence of an open reading frame that encoded a protein 

having 290 amino acid residues and a calculated molecular weight of 31-kDa. Our result of the 30-kDa 

protein provides a basis for further biochemical analysis, immunostimulatory study, investigation of the 

role of this protein in host-pathogen interactions and development of rapid and specific diagnosis system 

for melioidosis. 

(274) 

(275)

NEUTRALIZING MONOCLONAL ANTIBODY TO BURKHOLDERIA 

PSEUDOMALLEI CYTOLETHAL TOXIN 

Pattama Ekpo1, Supinya Pongsunk2 and Takayuki Ezaki3 

1Department of Immunology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2Department 

of Microbiology, Faculty of Medicine, Srinakharinwirot University, Bangkok, Thailand 

and 3Department of Microbiology, Gifu University School of Medicine, Gifu, Japan. 

Little is known about the virulence factors associated with infection by Burkholderia 

pseudomallei, the causative organism of melioidosis. The toxins are ones of the virulence factors that 

might be responsible for the rapid onset of the melioidosis and dramatic course of septicemic melioidosis. 

In this study, a cytolethal toxic activity of the crude culture filtrate (CCF) of B. pseudomallei to cell 

culture, THP-1 cell; human monocyte cell line, was studied. The highest activity of the cytolethal toxin 

was in the CCF fraction with MW ranging from >30,000-100,000. The evidence from a laser scanning 

confocal microscope that used for examining the THP-1 cells at time intervals after adding the toxin 

showed that there were many pores on the cells’ surface before lysis. Therefore, the mechanism of the 

toxin might generate holes on the cells’ membrane. We produced a monoclonal antibody (MAb) by using 

the CCF as immunogen. The MAb was specific to the 30-kDa protein of B. pseudomallei. The MAb 

can neutralize the cytolethal toxin in the CCF and the CCF fraction (MW>30,000-100,000). 

The purified cytolethal toxin will be further studied for its role in pathogenesis. It might 

be a candidate for one of the factors involved in the rapid onset and dramatic course of septicemic 

melioidosis. 

CLONING AND CHARACTERIZATION OF A NONHEMOLYTIC 

PHOSPHOLIPASE C GENE FROM BURKHOLDERIA PSEUDOMALLEI 

Sunee Korbsrisate, 2* Nuttiga Suwanasai, 1 Amornurt Leelaporn, 2 

Takayuki Ezaki, 3 Yoshiaki Kawamura, 3 and Suttipant Sarasombath 3 

1 

Department of Immunology and 2 

Microbiology, Faculty of Medicine Siriraj Hospital, Mahidol 

University Bangkok 10700, Thailand, and 3 

Department of Microbiology, Gifu University School 

of Medicine, Gifu 500, Japan3 

We cloned and characterized a phosphatidylcholine hydrolyzing phospholipase C (PC- 

PLC) gene from Burkholderia pseudomallei. DNA sequence analysis of the gene indicated an open 

reading frame coding for 700 amino acids with a 34-amino-acid signal peptide. When cleaved, this yields 

a secreted 73-kDa mature protein. The deduced amino acid sequence exhibited 48% similarity to that of 

a nonhemolytic PLC from Pseudomonas aeruginosa. The expressed PC-PLC was heat stable, nonhemolytic 

for sheep erythrocytes, and active between pH2 and 8. Western blot analysis with sera from 

melioidosis patients indicated that they produced immunoglobulin M antibodies against this PC-PLC 

protein. 

(276) 

207 

(277)


CHARACTERIZATION OF A PHASE 1-D EPITOPE ON SALMONELLA 

TYPHI FLAGELLIN AND ITS ROLE IN THE SERODIAGNOSIS OF 

TYPHOID FEVER 

Sunee Korbsrisate 1 , Ariya Thanomsakyuth 1 , Napatawn Banchuin 1 , Stan McKay 2 , Moazzem 

Hossain 3 and Suttipant Sarasombath 1 

1 Department of Immunology, Faculty of Medicine Siriraj Hospital,Mahidol University, 2 World 

Vision International cambodia, Phnom-Penh, Kingdom of Cambodia, 3 Sir Salimullah Medical 

College, Dhaka, Bangladesh. 

A monoclonal antibody (Mab) directed against Samonella typhi 52 kDa flagellin protein 

has been previously produced by our group. In this study, we have demonstrated that the epitope specific 

to the Mab is unique to phase 1-d. To map the epitope, plasmids encoding different regions of S. typhi 

flagellin gene were constructed. Analysis of protein produced from each recombinant plasmid indicated 

that the epitope specific to the Mab resided within amino acids 171-303 (region IV) of S. typhi flagellin 

protein. The recombinant region IV flagellin was used to develop an ELISA for the detection of IgM 

antibody to S. typhi in serum. In the hemoculture-positive typhoid group, the developed ELISA was 

positive in 77 of 92 cases. In patients with non-typhoidal Salmonella, gram-positive and gram-negative 

bacteria or dengue virus, the ELISA was negative in all 78 cases. Two from 116 healthy control subjects 

had positive reactions with the assay. The calculated sensitivity, specificity, positive and negative predictive 

values of the test were 83.7%, 99.0%, 97.5% and 92.8%, respectively. With such high validity 

together with the requirement of only a single serum specimen and one day for performing the test, the 

developed ELISA should become a valuable diagnostic test for typhoid fever. 

DETECTION OF IgM ANTIBODY AGAINST REGION IV FLAGELLIN OF 

SALMONELLA PARATYPHI A 

Sunee Korbsrisate 1 , Suttipant Sarasombath 1 , Nuttaya Praaporn 1 , Pattara Iamkamala 2 , 

Moazzem Hossain 3 and Stan Mckay 4 

1 Department of Immunology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Department 

of Medicine, Lardprao General Hospital, Bangkok, Thailand, 3 Sir Salimullah Medical 

College, Dhaka, Bangladesh, 4 World Vision International Cambodia, Phnom-Penh, Kingdom 

of Cambodia. 

Salmonella paratyphi A is a pathogenic bacterium that causes paratyphoid fever. The 

current laboratory diagnostic techniques are unsatisfactory. To improve diagnosis, a plasmid (pSK-8E) 

encoding phase 1 flagellin gene nucleotide position 452-890 from S. paratyphi A has been constructed. 

The recombinant protein expressed from the plasmid has been used to develop an indirect ELISA for 

IgM antibody detection. Sera from patients with hemoculture positive for S. paratyphi A, S. typhi, other 

gram-positive and gram-negative bacteria, and dengue hemorrhagic fever as well as from healthy control 

subjects were tested. Sensitivity, specificity, positive and negative predictive values of the test were 

56.9%, 98.8% 90.6% and 92.1%, respectively. Since the sensitivity was low, the explanation for this 

result was investigated. It was found that the sensitivity of the test could be increased to 83.3% if the 

sera were obtained 9-12 days after onset of fever. The sera obtained earlier or later gave only 33.3% 

and 66.6% sensitivity, respectively. This result suggests that the IgM antibody detection assay which we 

have developed is a valuable tool for diagnosis of S. paratyphi A infection when the serum samples are 

taken at the appropriate time. 

(278) 

(279)

THE EFFECT OF THALASSEMIC SERUM ON PLASMODIUM 

FALCIPARUM GROWTH IN VITRO 

Phantip Vattanaviboon 1 , Chaluay Sriklup 1 , Chutaporn Polkaew 1 , Pranit Pravatmuang 2 , and 

Wanida Ittarat 1 . 

1 Department of Clinical Microscopy, Faculty of Medical Technology and 2 Division of Hematology, 

Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 

10700, Thailand. 

Thalassemia and malaria are present at high frequency in tropic and subtropic regions. 

Impaired growth of Plasmodium falciparum has been demonstrated in vitro in both α- and β- thalassemic 

erythrocytes. In this study, we investigated the effects of thalassemic sera on Plasmodium 

falciparum development including 5 α-thalassemia1/α-thalassemia2 (HbH) sera, 4 α-thalassemia1/ 

hemoglobin Constant Spring (HbH/HbCS) sera and 7 β-thalassemia/HbE sera compared to 7 normal 

sera. Study on malarial growth in medium containing 10% various sera for 4 days revealed that HbH and 

β-thalassemia/HbE sera was significantly inhibited (p


BASIC TECHNIC UP TO MOLECULAR STUDIES IN AN ALPHA 

THALASSEMIA : A FAMILY REPORT 

Pranit Pravatmuang 

(281) 

Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Bangkok 


To explore an important of basic technic up to molecular studies in an alpha thalassemia as in 

a family report. A couple of high risk for HbBart’s hydrops fetalis was referred to Siriraj Hospital for 

prenatal diagnosis (PND) with the DNA studies confirmed that a couple are carriers of alpha thalassemia 

1. The routine investigation of CBC, reticulocyte count and inclusion bodies were performed to 

assure that the patients are carriers of alpha thalassemia 1 and 28% of inclusion bodies were found in 

blood sample of husband and Hb type were performed. The chorionic villi sampling (CVS) at 14 

weeks of gestation were separated for two laboratories. The DNA characterization was performed by 

polymerase chain reaction (PCR) with primers set of A4 ( 5’-GGG GCG CCT TGG GGA GGT TC-3’ 

), A1B ( 5’-GTT CCC TGA GCC CCG ACA CG-3’ ), A9 ( 5’- ATA TAT GGG TCT GGA AGT 

GTA TC-3’) to see whether the alpha thalassemia 1 gene homozygote of HbBart’s hydrops fetalis 

was present or not. Either carrier of alpha thalassemia 2 or HbCS trait was first reported by one 

laboratory. The other laboratory result showed that the deletion band of alpha thalassemia 1 gene was 

present as 570 bp band in 1.5% agarose gel electrophoresis. The cooperation was well organized and 

the two laboratories started to explore the PCR again and the final results showed that both of the 

normal band of 194 bp and deletion band of 570 bp are present. The ultrasound was suggested to 

follow up the fetus for HbBart’s hydrops fetalis and it is going on at 24, 28 and 32 weeks of gestation 

and cord blood studies also advise at the time of delivery. 

This family report is an example in emphasizing an important of laboratory inorder to explore 

the diagnostic technology in thalassemias and hemoglobinopathies from the basic technic up to molecular 

level as well. 

(Supported Grant by Siriraj Foundation D1837. Presented at The Seminar in the 23 rd Annual 

Meeting of Medical Technologists Association of Thailand, April 28-30, 1999, Khon Kaen, Thailand 

: P160)

THALASSEMIA MUTATION STUDIES BY RDB VS ASO OF BIO-RAD 

Egarit Noulsri and Pranit Pravatmuang 

Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol 

University, Bangkok 10700, Thailand. 

The universal studies of b thalassemia mutation are reverse dot blot hybridization (RDB) 

and allele specific oligonucleotide hybridization (ASO) except long deletion as 619 bp. The commercial 

avaiable of ASO 3 kits (30 tests) of The Bio-Rad mDx Tm BeTha Gene 2 were comparable studies to 

RDB of manually performed. The BeTha Gene 2 can detect the most common b o thalassemia mutation 

of codons 17(A-T), 41-42(-CTTT), 71-72(+A), IVS 2:654(C-T) and b + thalassemia mutation of –28(A- 

G), codons 19(A-G), 26 (HbE), IVS 1:5 (G-C). The RDB using the primer set of Neo1-4 in PCR 

performance and hybridized with 17 mutant probes which have been found in Thailand. The results 

showed 21 good correlated outcome within the 8 common mutations of BeTha Gene 2 which included 

(#1) IVS 2:654 heterozygote with unidentified a variant, 3 cases missing because out of probes and HbC, 

2 cases loosing because of processing error and 1 controversial case resulted from normal by 3 times 

repeated ASO from 3 kits to b19 by RDB. The total number of cases ( ) as following : 

Heterozygote Double b thal/HbE Out of probes Other 

heterozygote 

and homozygote 

-28 (1) -28/17 -28/26 (1) 41 (-C)/26 (1) Normal (1) 

17 (1) 41-42/17 (1) 17/26(2) IVS 1:1(G-T)/26 (1) Processing 

19 (1) -28/-28 (1) 41-42/26 (2) IVS 1:1(G-T)/HbC error (2) 

26 (1) 26/26 (1) IVS 1:5/26 (1) (1) Cotroversial 

41-42 (2) IVS 2 : 654/2 (2) (1) 

71-72 (1) 

IVS 2:654 (1) 

IVS 2:654 (#1) 

The advantage of commercial available of BeTha Gene 2 is easy to perform at room 

temperature and 37 o c but the control should have the same number of the tests. The disadvatage is still 

high cost and does not cover the known mutations in Thailand. The patients with uncommon mutations 

out of 8 probes still come for PND. The reverse dot blot hybridization can overcome these problems by 

extended the probes cover the range up to 17 mutations which have been reported in Thailand so far. 

(Supported Grant by Siriraj Foundation and 3 FOC BeTha Gene 2 kits of Bio-Rad. Presented at 

The 7 th International Conference on Thalassaemia and The Haemoglobinopathies and The 9 th 

Thalassaemia Parent and Thalassaemics International Conference Program and Abstract 31 May- 

4 June, 1999, Bangkok, Thailand : P 292) 

211 

(282)

212 

HEMOGLOBINOPATHIES : A COMPARATIVE STUDIES OF HbA1C 

LEVEL BETWEEN TWO TECHNIQUES OF IMMUNOTURBIDIMETRY 

AND IONICEXCHANGE HPLC 

(283) 

Pravatmuang P 1 , Sae-Ngow B 1 , Whanpuch T 2 , Leowattana W 2 . 


1 Division of Hematology, Department of Medicine and 2 Department of Clinical Pathology, Faculty 

of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand. 

HbA1C is the glycated hemoglobin b chain at N-terminal amino acid valine. It is popular 

used as a marker to follow up diabetes mellitus patients. The comparative studies of HbA1C by two 

quantitative techniques of immunoturbidimetry (BM/Hitachi 912) and ionic exchange HPLC (Bio-Rad) 

had been performed in hemoglobinopathies groups, since it is high prevalence in Thailand. The disease 

forms around 1%, majority are b thalassemia/HbE and HbH diseases. The carriers around 50%, majority 

are HbE 10-50%, HbCS at least 4%, a thalassemia 20-30% and b thalassemia 3-9%. The basal studies 

of HbA1C (%) levels in each group are as the following : 

HbType No %A2(E) %F Hitachi Bio-Rad p r 

A2A 34 2.37+0.36 0.98+1.95 5.55+1.11 5.01+1.13 0.050 0.710 

A2^A 17 6.37+1.67 2.06+1.82 5.28+0.89 4.81+1.25 0.335 0.525 

EA 36 27.66+5.60 1.46+2.29 6.01+1.79 5.76+1.71 0.857 0.510 

EE 37 89.49+3.74 3.63+2.00 4.96+0.69 8.23+1.42 0.001 -0.093 

EF/EFA 36 55.23+17.83 26.08+18.44 4.34+1.16 5.88+2.58 0.004 0.234 

EABart’s 11 15.49+1.06 3.00+1.90 5.41+1.09 4.14+2.13 0.028 -0.464 

A2/CSAH 34 1.80+2.26 0.48+0.56 4.96+1.12 2.79+1.15 0.0001 0.093 

FA 13 (15.3+11.59) 85.12+11.47 3.45+0.54 0.49+0.40 0.0001 0.139 

(A) 

This studies evaluate that the effect of HbType to HbA1C levels by immunoturbidimetry 

are less than ionic exchange HPLC especially in HbE homozygote (EE), b thalassemia/HbE (EF/EFA), 

EABart’ss diseases (EABart’ss), Hb H diseases (A2/CSAH) and cord blood (FA) showing significant 

differene of p values and r of non correlation. Therefore, in the cases of using HbA1C by ionic-exchange 

HPLC to follow up the patients in those cases the established values should be used as a guide base line. 

(Supported Grant by Siriraj Foundation. Published in Asian Pacific Journal of Allergy and Immunology 

1999 ; 17 (suppl.1) : 42. Abstract of the IX Congress of the International Society of 

Hematology, Asian-Pacific Division, October 24-28, 1999, Bangkok, Thailand.)

COMPARISON IN LEUKOCYTE ALKALINE PHOSPHATASE ACTIVITY 

IN PATIENTS WITH MYELOPROLIFERATIVE DISORDERS BEFORE AND 

DURING DISEASE TRANSFORMATION 

(284) 

Sriprapa Chinprasertsuk, Sanan Visuthisakchai, Maneenop Yimyam, Wanna Muangsup, Tipawan 

Boonyapanichskul and Prayoon Tanamsuk 

Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahodol 


Chronic myeloid leukemia (CML), polycythemia vera (PV), myelofibrosis (MF) and 

essential thrombocythemia (ET) are chronic myeloproliferative disorders (MPD) with clonal disorder of 

multipotent hemopoietic stem cells. There is often considerable overlap between the myeloproliferative 

disorders and in progression of the diseases, some of them may end up with acute leukemia. Leukocyte 

alkaline phosphatase (LAP) is helpful in diagnosis and assessment of the stage of MPD. In our studies, 

LAP score was 49.9+27.4 in normal control. In CML, CML with myelofibrosis, CML with blastic transformation 

and ex CML after bone marrow transplantation, their LAP score were 0.9+2.0, 8.6+20.3, 

6.3+19.1 and 77.8+67.5 respectively. LAP score in CML patients increased when the disease transformed 

and returned to normal level when the patients entered recovery by bone marrow transplantation. 

LAP score in patients with polycythemia vera, myelofibrosis and essential thrombocythemia were 176+45, 

77+73 and 80+40 respectively. There were little to marked changes in LAP score when the diseases in 

this group were transformed. LAP score in a patient with polycythemia vera which had transformed 

from essential thrombocythemia was as high as LAP score in polycythemia vera patients. 

(Published in Thai J Hematol Transf Med 1999;9:21-7) 

QUANTITATIVE ANALYSIS OF CD34+ CELLS AND HEMATOPOIETIC 

PROGENITOR CELLS IN PATIENTS WITH β-THALASSEMIA/ HEMO- 

GLOBIN E DISEASE. 

(285) 

U-pratya Y 1 , Yimyam M 1 , Pattanapanyasat K 2 , Pakdeesuwan K 1 , Moungsab W 1 , Issaragrisil S 1 . 

1 Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj Hospital, 2 Faculty 

of Graduate Studies, Mahidol University, Bangkok 10700, Thailand. 

The hematopoietic progenitor cells of the thalassemia patients were studied by flow 

cytometry and methylcellulose culture system. Sixty-one patients with b-thalassemia/Hemoglobin E 

disease were studies. Thirty-one patients were non-splenectomized and 30 were splenectomized. The 

percentage of CD34+ cells in patients were significantly higher than normal controls (splenectomy and 

non-splenectomy vs normal controls were 0.41³0.06 and 0.22³0.03 vs 0.08³0.02 (P

214 

tomized cases were 137.99³29.54 x 10 4 /L and 29.83³9.63 x 10 4 /L and non-splenectomized were 

76.99³14.03 x 10 4 /L and 16.92³2.83 x 10 4 /L, respectively whereas they were 12.17³2.93 x 10 4 /L and 

6.19³1.35 x 10 4 /L, respectively in normal individuals. The number of BFU-E after splenectomy were 

higher than non-splenectomy significantly (P

At present, Faculty of Medicine Siriraj Hospital supports Division of Hematology in doing the Hb Typing 

for routine analysis by automatic machine with very high consumable cost per case, 160 Baht. The 

automatic machine is supported gratis by other group of Mahidol University. 

The new alternative method is developed by hoping that this new method can reduce the 

expense of the Faculty. By using HPLC technique, the column type: Shim-pack WCX-1, buffers: Buffer 

A, 0.02 mol/L Phosphate buffer/0.0015 mol/L Potassium Cyanide pH 6.3, Buffer B, 0.1 mol/L Sodium 

Sulphate in Buffer A pH 6.3, and buffer condition: 2 minutes of Buffer A, followed by 3 minutes of linear 

gradient from 0-25% of Buffer B and 5 minutes of 25% Buffer B and 5 minutes of linear gradient of 

Buffer B from 25-100% and 4 minutes of 100% Buffer B which are suitable for Hb Typing are searched 

and found which can reduce the cost to the amount of less than 50 Baht per case. 

Although the general purpose HPLC machine which is used in this development has a 

very high price. But Faculty is not necessary to pay for this expense if the existing machine which 

belongs to other Divisions or Departments is supported. That is Faculty can save the expense of consumable 

part about 110 Baht per case. 

In the year 1999, about 5515 cases of blood sample are requested for Hb Typing. So if 

this new method is used, Faculty can save 606,650 Baht. 

(This research received financial support from the Division of Hematology, Department of Medicine, 

Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, THAILAND.) 

RISK FACTORS FOR MELIOIDOSIS AND BACTEREMIC MELIOIDOSIS 

(288) 

Yupin Suputtamongkol, Wipada Chaowagul, Ploenchan Chetchotisakd, Nimit Lertpatanasuwun, 

Sunanta Intaranongpai, Theera Ruchutrakool, Duangkao Budhsarawong, Piroon Mootsikapun, 

Vanaporn Wuthiekanun, Nitaya Teerawatasook, and Aroonlug Lulitanond 

Department of Medicine, Faculty of Medicine, Siriraj Hospital, and the Wellcome Unit, Faculty 

of Tropical Medicine, Mahidol University, Bangkok; Department of Medicine, 

Sappasitprasong Hospital, Ubon Ratchatani; Department of Medicine, Faculty of Medicine 

and Department of Clinical Microbiology, Faculty of Associated Medical Sciences, Khon Kaen 

University, Khon Kaen; Department of Medicine, Srisaket Hospital, Srisaket; and Department 

of Medicine, Surin Hospital, Surin, Thailand. 

Key words : Melioidosis, Risk Factors, Bacteremic 

A case-control study was conducted in four hospitals in northeastern Thailand to identify 

risk factors for melioidosis and bacteremic melioidosis. Cases were patients with culture-proven melioidosis, 

and there were two types of controls (those with infections, i.e., with community-acquired septicemia 

caused by other bacteria, and those without infection, i.e., randomly selected patients admitted with 

noninfectious diseases to the same hospitals). Demographic data, clinical presentations, and suspected 

risk factors were analyzed. Diabetes mellitus, preexisting renal diseases, thalassemia, and occupational 

exposure, classified by the soil and water risk assessment, were confirmed to be significant risk factors 

for melioidosis and bacteremic melioidosis. Only diabetes mellitus was a significant factor associated 

with bacteremic melioidosis, ad compared with nonbacteremia. A significant interaction was found 

between diabetes mellitus and occupational exposure. Thus, diabetic rice farmers would be the most 

appropriate population group for targeted control measures such as vaccination in the future. 

(Financial support: Thailand Research Fund. Clinical Infectious Diseases 1999;29:108-13) 

215


ANTILIPOPOLYSACCHARIDE II : AN ANTIBODY PROTECTIVE 

AGAINST FATAL MELIOIDOSIS 

Chadarat Charuchaimontri, Yupin Suputtamongkol, Churairat Nilakul, Wipada Chaowagul, 

Ploenchan Chetchotisakd, Nimit Lertpatanasuwun, Sunanta Intaranongpai, Paul J. Brett, and 

Donald E. woods 

Department of Clinical Microbiology, Faculty of Medical Technology and Department of Medicine( 

Faculty of Medicine Siriraj Hospital). Mahidol University, Bangkok, Thailand; Department 

of Medicine, Sappasitprasong Hospital, Ubon Ratchatani, Thailand; Department of Medicine, 

Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand; Department of Medicine, 

Srisaket Hospital, Srisaket, Thailand; Department of Medicine, Surin Hospital, Surin 

Thailand; and Department of Microbiology and Infectious Diseases, Faculty of Medicine, University 

of Calgary Health Sciences centre, Calgary, Alberta, Canada. 

Key words : Melioidosis, Antilipopolysaccharide, Fatal 

This was a study of IgG antiboby responses to two S-type lipopolysaccharides (LPS I 

and LPS II) and flagellin of Burkholderia pseudomallei in patients with melioidosis. The specificity of 

these antibodies was 91.7%, 90.3%, and 93.8%, reapectively, when compared to responses in a population 

where the organism is not endemic. Only the level of antibody to LPS II (anti-LPS II) was significantly 

higher in patients who survived than in those who died, as well as in patients with nonsepticemic 

vs. septicemic melioidosis. Results of logistic regression analysis, controlled for confounding factors 

such as duration of illiness before treatment and bacteremic status, confirmed that a high level of anti- 

LPS II was a significant factor protective against fatal melioidosis. Thus, LPS II of B. Pseudomallei 

would be a potentially useful component of a vaccine developed against fatal melioidosis. Further studies 

are in progress to determine the level of this antibody among those with asymptomatic infection in areas 

where melioidosis is endemic. 

(Financial support: Thailand Research Fund. Clinical Infectious Diseases 1999;29:813-8) 

SIRIRAJ ACUTE STROKE UNIT : THE STROKE PARADIGM OF 

THAILAND 

Niphon Poungvarin, Varapun Senanarong, Naraporn Prayoonwiwat, Arkhom Arayawichanont 

Division of Neurology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Bangkok 


Background : It is well established that the management of stroke in the stroke unit has 

been an excellent results. Siriraj Acute Stroke Unit has been established in Thailand since May 1997, and 

it is the only unit in the country. It composes of 11 beds with fully trained stroke team including nurses, 

physiotherapist, radiologists and neurologists. 

(289) 

(290)

Methods : We analysed 363 patients from the total of 363 admitted cases during the 

last 18 months, using SPSS 7.0. 

Results : Three hundred and sixty three stroke patients were admitted at Siriraj acute 

stroke unit. 180 patients (49.59 per cent) were female, maen age was 63.11 + 13.84 years old (range 19- 

94 yrs). 89.26 per cent of them had CT/MRI brain scan either before or on the arrival at the stroke unit. 

Seventy six point five eight per cent of the patients had cerebral infarction, 17.36 per cent had cerebral 

haemorrhage and 3.96 per cent had transient ischaemic attack. Risk factors of stroke were as the 

following : 57.58 per cent had hypertension, 30.58 per cents had diabetes mellitus 22.33 per cent had 

underlying heart disease, valvular heart disease, or cardiac arrhythmia. 13.22 per cent had history of 

current alcoholic drinkers, 33.88 percents had hyperlipidaemia. Mortality rate in this stroke unit was only 

2.2 per cent (8 from 363). 

Conclusion : Mortality rate of acute stroke patients being managed at general medical 

ward at our hospital was about twenty five percents. Thus Siriraj Acute Stroke Unit has given patients 

a better chance of survival. 

STROKE AND DEMENTIA IN THE ELDERLY : PERSPECTIVE FROM 

THAILAND. 

Niphon Poungvarin, Vorapun Senanarong, Naraporn Prayoonwiwat, Rungsan Chaisevikul, 

Rungnirund Praditsuwan, Adulya Viriyavejakul 

Department of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand. 

Background : The epidemiology of stroke and dementia in the elderly are important for 

strategic planning in health management. Dementia and stroke can occur in the same individual and both 

conditions are major public health problems. In Thailand, there is no such data available, thus it is essential 

to conduct cross-sectional survey countrywide. 

Method : All the 3,177 Thai elderly from 4 selected regions (Central 774, Northern 840, 

North-Eastern 706, and Southern 857) were examined by neurologists in the community setting study 

during August 1994 to October 1996. Blood sample of 3,036 individuals were taken to analyse haematological 

and biochemical profiles. 

Result : The mean age of the studied population was 69.03+6.86 years and 61 per cent 

were female. Thirty four stroke patients were identified from 3,036 elderly (prevalence rate of 10.1 per 

cent). Dementia (using the criteria of the Thai mental state examination = TMSE below 24) was diagnosed 

in 1,165 from 3,177 people (prevalence rate of 52.4 per cent). If we applied DSM IV criteria 

(TMSE and impaired activity of daily living below 25 percentile), the prevalence rate of dementia would 

be 9.8 per cent (311 from 3,177). Stroke risk factors were also identified in the Thai elderly as the 

following : hypertension (BP over 140/90 Torr in 34.2 per cent, BP over 160/90 Torr in 16.3 per cent), 

diabetes mellitus (FBS over 126 mg/dl in 12.1 per cent), smoking (51.9 per cent), hypercholesterolemia 

(over 200 mg/dl in 97 per cent, over 240 mg/dl in 44.3 per cent), hypertriglyceridemia (over 200 mg/dl in 

58 per cent), and underlying heart diseases (6.3 per cent). Cardiac murmur, carotid bruit and cardiac 

arrhythmia were recorded in 5.2, 1.6 , and 1.2 per cent of the elderly respectively. 

217 

(291)


Conclusion : Dementia due to stroke (vascular dementia) is prevalent in the Thai 

elderly and this condition is preventable. Dementia and stroke prevention should be aimed at the elderly 

who is the most high risk group. This is best achieved by identifying risk factors and then managing 

properly. 

(This study was supported by Mahidol University.) 

VARIATION IN IN-PATIENT STROKE MANAGEMENT IN TEN CENTRES 

IN DIFFERENT COUNTRIES : THE INCLEN MULTICENTRE STROKE 

COLLABORATION 

(292) 

Niphon Poungvarin 

Department of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand. 

Key words: International, Variation, Stroke Management 

Background and purpose : Large within-country variations have been described in 

stroke management and there have been a few studies of between-country variaion (in the USA and the 

UK). We designed a study to examine stroke management across a wide range of countries representing 

different stages of economic development. Large variations would suggest the need to explore 

methods of increasing the uptake of evidence-based stroke practice. 

Methods : Members of the International Clinical Epidemiology Network (INCLEN) 

from 14 centres in ten countries agreed to review the records of the last 50 patients admitted to hospital 

with a clinical diagnosis of stroke. Information on demographic variables, the clinical diagnosis of stroke 

type, investigations performed and treatments given and the discharge destination of the patient were 

recorded and sent to the coordinating centre in Australia for analysis. 

Results : There were statistically significant between-centre differences in the proportions 

of patients cared for by a neurologist, staying in hospital for at least ten days and having CT or MRI 

scans. Significant between-centre differences were also seen for treatment, for example, the use of 

aspirin in non-haemorrhagic stroke varied from 11 to 79%. The variation (for all interventions studied) 

was no longer statistically significant when examined within strata according to availability of facilities. 

Conclusions : The large variation between centres in the management of stroke is 

largely ‘explained’ by teh availability of resources, even for interventions that do not depend on resource 

availability. It well be important to develop management guidelines that reflect evidence-based practice 

of relevance across a range of econnomic settings. 

©1999 Elsevier Science B.V. Management

SUCCESSFUL MEDICAL TREATMENT OF MULTIPLE CRYPTOCOC- 

COMAS : REPORT OF A CASE AND LITERATURE REVIEW 

Arkhom Arayawichanont1 , Naraporn Prayoonwiwat1 , Anchalee Churojana2 , Tumtip Sangrunchi3 , 

Niphon Poungvarin1 (293) 

1 Division of Neurology, Department of Medicine, 2 Department of Radiology, 3 Department of 

Pathology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand. 

Key words : Cerebral Cryptococcosis, Cryptococcoma, CNS Cryptococcosis 

We report a 35 year old man diagnosed as having CNS cryptococcosis with multiple 

cryptococcomas, presenting with headache, papilloedema and impaired metal function in a previously 

healthy man. Cerebrospinal fluid (CSF) examination revealed lymphocytic pleocytosis with low glucose 

level. Gram’s stain, acid fast bacilli stain and Indian ink examination were all negative. CSF cryptococcal 

antigen was positive, however, several fungal cultures were negative. Early cranial CT scan showed 

focal cerebritis over the right temporal lobe while subsequent imaging studies showed multiple contrastenhancing 

masses with severe surrounding brain oedema over bilateral frontoparietal areas. Brain biopsy 

showed cryptococcal granulomatous lesions. Treatment was successful with antifungal agents and 

steroids without surgical removal. 

AUTOSOMAL RECESSIVE DISTAL RENAL TUBULAR ACIDOSIS 

ASSOCIATED WITH SOUTHEAST ASIAN OVALOCYTOSIS 

Somkiat Vasuvattakul, Pathai Yenchitsomanus, Prayong Vachuanichsanong, Peti Thuwajit, 

Charoen Kaitwatcharachai, Vichai Laosombat, Prida Malasit, Prapon Wilairat and Sumalee 

Nimmannit 

Renal Division and Medical Molecular Biology Unit, Siriraj Hospital, Mahidol University; 

Songklanakarin Hospital, Prince of Songkla University,Songkla; and Department of Biochemistry, 

Faculty of Science, Mahidol University, Bangkok, Thailand. 

Key words : band 3 protein, anion exchanger 1, AE1 gene, DNA sequencing, renal acidification 

(294) 

Background : A defect in the anion exchanger 1 (AE1) of the basolateral membrane 

of type A intercalated cells in the renal collecting duct may result in a failure to maintain a cell-to-lumen 

H + gradient, leading to distal renal tubular acidosis (dRTA). Thus, dRTA may occur in Southeast Asian 

ovalocytosis (SAO), a common AE1 gene abnormality observed in Southeast Asia and Melanesia. Our 

study investigated whether or not this renal acidification defect exists in individuals with SAO. 

Methods : Short and three-day NH 4 Cl loading tests were performed in 20 individuals 

with SAO and in two subjects, including their families, with both SAO and dRTA. Mutations of AE1 

gene in individuals with SAO and members of the two families were also studied. 

219


Results : Renal acidification in the 20 individuals with SAO and in the parents of the 

two families was normal. However, the two clinically affected individuals with SAO and dRTA had 

compound heterozygosity of 27 bp deletion in exon 11 and missense mutation G701D resulting from a 

CGG→CAG substitution in exon 17 of the AE1 gene. Red cells of the two subjects with dRTA and SAO 

and the family members with SAO showed an approximate 40% reduction in sulfate influx with normal 

4,4’ -di-isothiocyanato-stilbene-2,2’ -disulfonic acid sensitivity and pH dependence. 

Conclusion: These findings suggest that compound heterozygosity of abnormal AE1 

genes causes autosomal recessive dRTA in SAO. 

(©1999 by the International Society of Nephrology) 

DISTAL RENAL TUBULAR ACIDOSIS AND HIGH URINE CARBON 

DIOXIDE TENSION IN A PATIENT WITH SOUTHEAST ASIAN 

OVALOCYTOSIS 

Charoen Kaitwatcharachai, Somkiat Vasuvattakul, Pa-thai Yenchitsomanus, Peti Thuwajit, Prida 

Malasit, Dungporn Chuawatana, Sumitra Mingkum, Michell L. Halperin, Prapon Wialirat, 

Sumalee Nimmannit 

Renal Unit, Songklanakarin Hospital, Prince of Songkla University; Renal and Medical Molecular 

Biology, Siriraj Hospital; Faculty of Medicine, Department of Biochemistry, Faculty of 

Science, Mahidol University, Bangkok, Thailand; and the Renal Division. St. Michael’s Hospital, 

University of Toronto, Canada. 

+ + Key words : band 3 protein, anionic exchanger, NH excretion, NH4 production, 

4 

U-B Pco , H 2 + -ATPase 

Southeast Asian ovalocytosis (SAO) is the best-documented disease in which mutation 

in the anion exchanger-1 (AE1) causes decreased anion (chloride. [Cl-]/bicarbonate [HCO -] transport. 

3 

Because AE1 is also found in the basolateral membrane of type A intercalated cells of the kidney, distal 

renal tubular acidosis (dRTA) might develop if the function of AE1 is critical for the net excretion of acid. 

Studies were performed in a 33-year-old woman with SAO who presented with proximal muscle weakness, 

hypokalemia (potassium, 2.7 mmol/L), a normal anion gap type of metabolic acidosis (venous 

+ plasma pH, 7.32; bicarbonate, 17 mmol/L; anion gap, 11 mEq/L), and a low rate of ammonium (NH ) 4 

+ excretion in the face of metabolic acidosis (26µmoL/min). However, the capacity to produce NH did 4 

+ not appear to be low because during a furosemide-induced diruesis, NH excretion increased almost 

4 

threefold to a near-normal value (75µmol/L/min). Nevertheless, her minimum urine pH (6.3) did not 

decrease appreciably with alkalinized type A intercalated cell in the distal nephron. Unexpectedly, when 

her urine pH increased to 7.7 after sodium bicarbonate administration, her urine minus blood carbon 

dioxide tension difference (U-B Pco ) was 27 mm Hg. We speculate that the increase in U-B Pco might 

2 2 

arise form a misdirection of AE1 to the apical membrane of type A intercalated cells. 

(American Journal of Kidney Diseases, Vol 33, No 6 (June), 1999: pp 1147-1152) 

(295)

THE RENIN - ANGIOTENSIN SYSTEM GENE POLYMORPHISMS AND 

CLINICOPATHOLOGICAL CORRELATIONS IN IgA NEPHROPATHY 

Sompong Ong-Ajyooth 1 , Apinan Limmongkon 1 , Leena Ong-Ajyooth 2 , Anchalee Tiensingh 2 , 

Sanga Nilwarangkur 2 , Paisal Parichatikanon 3 

1 Department of Biochemistry, 2 Department of Medicine, 3 Department of Pathology, Faculty of 

Pathology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand. 

Key words : RAS Gene Polymorphism, IgA Nephropathy, Clinicopathology 

Genetic variability in the renin-angiotensin system (RAS) may modify renal responses 

injury and disease progression. We examined whether RAS alleles affect severity of IgA nephropathy. 

These genetic variants include angiotensin I converting enzyme deletion polymorphism in intron 16 (ACE 

I/D), a point mutation in the angiotensinogen (AGT) gene resulting in a methionine to threonine substitution 

at residue 235 (M235T) and an angiotensin receptor type I (ATR) A to C transition at bp 1166 (A 

1166 C). A total of 53 patients with biopsy-proven IgA nephropathy and 80 normal control subjects were 

recruited for study. These patients were classified into two groups according to serum creatinine at renal 

biopsy. Group l patients (n = 40) had normal renal function, serum creatinine < 1.5 mg/dl and group 2 

patients (n = 13) had renal insufficiency with serum creatinine > 1.5 mg/dl. The blood pressure and 

urinary protein of group 2 patients were higher than group 1 (p < 0.01). The mean scores of histological 

parameters including mesangial proliferation, glomerular sclerosis (global and segmental), the interstitial 

fibrosis and crescent formation in group 2 patients were significantly higher than in group l patients (p < 

0.05). The most frequent genotype in IgA patients was ID (47%) genotype, followed by II (45%) and 

DD (8%) genotype of ACE gene. The mean serum ACE activity in the DD group was significantly 

higher than in the II group (P < 0.05) but was not significantly different from that of the ID group. No 

statistically significant differences were found with respect to allele frequencies between IgA group 1, 

group 2, or between controls and all IgA patients. Furthermore, no significant difference in AGT alleles, 

ATR alleles frequencies was detected between groups of IgA patients, although a trend for a higher 

frequency of DD genotype and AGT-TT genotype were noted in IGA group 2. The combined analysis 

of the ACE-DD and AGT-TT genotypes did not show any genetic influence on the risk of the disease 

susceptibility. To resolve the true role of ACE genotype and any dependent effect on progression, larger 

collaborative studies are required. 

LONG RT-PCR AMPLIFICATION OF THE ENTIRE CODING SEQUENCE 

OF THE POLYCYSTIC KIDNEY DISEASE 1 (PKD1) GENE 

Wanna Thongnoppakhun 1,2 , Propon Wilairat 2 , Kriengsak Vareesangthip 1 and Pa-thai 

Yenchitsomanus 1 

1 2 Faculty of Medicine Siriraj Hospital, Faculty of Science, Mahidol University, Bangkok, 

Thailand. 

(296) 

221 

(297)

222 

Characterization of mutations of the PKD1 gene has been limited by the fact that three - fourths of this 

gene at its 5’ end is homologous to sequences of at least three other genes on the same chromosome. We 

have therefore developed a method of long reverse transcription PCR for selective amplification of the 

entire coding sequence of the PKD1 gene from its mRNA. A PCR primer specific to the sequence in the 

3’ unique region of the PKD1 gene was synthesized for use coupled with a primer binding to sequence in 

the homologous region at a distance of about 13.6 kb apart. The commercial availability of RNase Hfree 

reverse transcriptase for long cDNA synthesis and of an enzyme mixture containing Taq and Pfu 

DNA polymerases for long-range PCR have made this development possible. The long PCR product 

was proven to be derived from PKD1-mRNA. The results clearly indicated that the long PCR product 

contained the coding sequence derived from PKD1-mRNA. To our knowledge, this is the first report of 

a pricedure that can reproducibly isolate full-length PKD1 coding sequence from its mRNA transcript, 

which will prove useful for screening and characterization of mutations in the PKD1 gene. 

(BioTechniques 26:126-132 (January 1999) ) 


MONITORING AREA UNDER THE CURVE OF CYCLOSPORINE BY 

LIMITED SAMPLING STRATEGY 

(298) 

Dejvorakul S., Vasuvattakul S., Mareesangthip K., Leowattana W., Sritippayawan S., Ong-ajjooth 

L., Nimmannit S. 

Renal Unit, Department of Medicine, Department of Clincal Pathology, Siriraj Hospital, 


Backgroud : Cyclosporine A is considered as the principal immunosuppressive drug in 

organ transplantation. Careful drug monitoring is necessary due to its narrow therapeutic range. Area 

under the time-concentration curve (AUC) has been shown to represent drug exposure more accurately 

than trough level. However, it is impractical because multiple blood samples are required. Currently 

Neoral a new form of cyclosporine is wildly used in clinical practice. Since its microemulsion composition 

give a highly reproducible pharmacokinetic profiles, we expected that fewer blood samples could be 

required in monitoring the blood level. This study was carried out to investigate the accuracy of limited 

sampling strategy in monitoring the cyclosporine level. 

Methods : Blood for cyclosporine assay (cloned enzyme donor immunoassay) was 

obtained at 0, 0.5,1,1,5,2,3,4,6,8,10 and 12 hr after neoral administration in 40 renal transplant patients. 

Multiple stepwise regression analysis was used to identify timepoints of blood samples. which showed 

good correlation with AUC. Prediction errors of the blood sampling strategies were compared to select 

the best one. 

Results : The study showed that at least three time-points of blood collection were 

required to predict AUC accurately. [more than 90% of the estimated AUC were within the acceptable 

range of actual AUC (10% error)]. The best three time-points that predict AUC of cyclosporine were at 

1-3-10 hr after drug administration (r=0.99, p

Conclusions : Our study suggests that limited sampling strategy with three time-points 

of blood collection at 0-1-3 hr or 1-3-4 hr can be used to predict AUC of cyclosporine accurately. This 

methods would be more practical and convenient. 

ABNORMAL KINETICS OF ERYTHROCYTE Na/Li COUNTER- 

TRANSPORT IN RENAL TRANSPLANT PATIENTS TREATED WITH 

CYCLOSPORINE A 

Vareesangthip K., Nimmannit S., Pidetcha P., Suwannaton L., Ong-Aj-Yooth L. 

(299) 

Renal Unit., Department of Medicine, Faculty of Medicine Siriraj Hospital, Department of 

Clinical Chemistry. Faculty of Medical Technology, Mahidol University, Bangkok, Thailand. 

Cyclosporine A (CyA) has become an integral part of the standard immunosuppressive 

therapy after organ transplantation. An increase in systemic blood pressure is the most frequently 

observed adverse event. The pathophysiological mechanisms of CyA -associated hypertension are still 

unclear. There is evidence showing that renal transplant patients developed insulin resistance and hypertension 

during therapy with CyA. Both insulin resistance and hypertension are associated with the 

kinetics of erythrocyte sodium-lithium countertransport (Na/Li CT.) 

Na/Li CT is a sensitive indicator of membrane function and has a pathological link to 

essential hypertension. Recently, it has been shown that the kinetics of Na/Li CT are modulated by at 

least two types of thiol proteins. The current model suggests that the type 1 thiol protein can be blocked 

by N-ethylmaleimide (NEM) in choline medium (Chol) and this reduces Km for external sodium and 

increases the Vmax/Km ratio suggesting an increase in the ion association reaction. The type 2 thiol 

protein can be blocked by NEM in sodium medium (Na) causing a decreased in Vmax probably due to 

reduced turnover of Na/Li CT. We have studied the kinetics of erythrocyte Na/Li CT with and without 

NEM in 8 normal controls (NC) and 9 renal transplant patients who were on CyA (CyA). All had plasma 

cratinine less than 1.3 mg/dl. The results (mean + SEM) are shown in the Table 1. 

Vmax Km Vmax/Km 

UT Chol Na UT Chol Na UT Chol Na 

NC .40+.04 .36+.03 .19+.01 a 74+11 43+7 a 38+5 a 6.1+9 11.2+3.2 6.2+1.2 

CyA .35+.05 .35+.05 .26+.03 a 37+3 b 40+4 37+4 10.2+1.7 b 9.3+1.3 7.8+1.4 

P


URETERITIS DUE TO CYTOMEGALOVIRUS INFECTION IN RENAL 

TRANSPLANT RECIPIENT - A CASE REPORT AND REVIEW OF THE 

LITERATURE 

(300) 

A. Vongwiwatana, K. Vareesangthip, S. Vasuvattakul, C. Nualyong 1 , P. Parichatikanond 2 , L. 

Ong-Aj-Yooth, S. Nimmannit 

Renal Unit, Department of Medicine, 1 Department of Surgery and 2 Department of Pathology, 

Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand. 

Even though newer and powerful immunosuppressive agents have been developed with 

the main aim to treat rejection and, in turn, prolong graft survival in renal transplantation, the incidence of 

infectious complication with unusual clinical manifestations after transplantation may increase. Cytomegalovirus 

(CMV) is the important organism that causes an infection in renal transplantion recipients, 

particularly within 4 months post transplantation. Additionally, the incidence of CMV infection is significantly 

increased in patients who received anti-rejection agents such as high dose methylprednisolone, 

polyclonal and monoclonal antilymphocyte globulin. We report here a 31-year-old lady underwent a 

cadaveric unusual manifestation. She developed rejection which was treated with pulse methylprednisolone. 

Other immunosuppressive drugs are cyclosporine A and mycophenolate mofetil (MMF). Three 

weeks after pulse methylprednisolone treatment, allograft dysfunction due to ureteric stenosis secondary 

from fibrosis was noted. No systemic symptoms were observed. The patient underwent pyelocystostomy 

with resection of the fibrosed ureter. The pathological study of the ureter revealed CMV-infected 

mucosal cell with intracellular inclusion bodies. This patient represent an unusual case of CMV infection 

manifested as ureteritis without other systemic symptoms. 

MAGNESIUM STATUS IN CRITICALLY Ill PATIENTS 

Sritippayawan S., Chaikuna J., Vasuvattakul S., Ongajyooth L., Nimmannit S. 

(301) 

Renal Division, Respiratory Division, Department of Internal Medicine, Siriraj Hospital, 


Hypomagnesemia is a common finding which may contribute to the high mortality observed 

in critically ill patients, hence Mg status should be assessed. However, serum Mg does not 

accurately reflect Mg status, therefore a Mg loading test (MLT) as described by Gullestad was done in 

23 critically ill patients after baseline 24 hour urine (24hU) collection. All were hemodynamically stable. 

The creatinine clearance was > 20 ml/min and serum Mg was < 4.8 mg/dl. None had bradyarrhythmia. 

The mean age was 49 years (19-82). Male to female ratio was 12:11. 52,22 and 17% of them had 

respiratory failure, sepsis and heart failure respectively. Hypomagnesemia, normomagnesemia and 

hypermagnesemia were found in 48, 48 and 4% respectively. After MLT, all except one had a Mg 

retention > 30% which indicated the presence of Mg depletion. 83% had clinical signs and symptoms of 

Mg depletion (tachyarrhythmia 48%, convulsion 9%) and 65% had biochemical changes (hypokalemia, 

hypophosphatemia and hypocalcemia). There was no correlation between Mg retention and serum Mg

even in those with hypomagnesemia. In the patients with Mg depletion, 87% had renal Mg loss (base line 

24hU Mg>24mg). In the patients with Mg depletion without renal Mg loss, the fractional excretion of Mg 

was >7%. There was no correlation between APACHEII score, Mg retention and serum Mg. The two 

patients who died from their illness had higher Mg retention than those who survived while their serum 

Mg were higher but both were not statistically significant. No complications were observed during the 

test. This study demonstrated that Mg depletion is prevalent in critically ill patients and MLT is a useful 

tool, even in those with renal Mg loss, for the assessment of Mg status. 

A LONG-TERM COMPARISON OF THE EFFECTS ON RENAL FUNCTION 

OF BP CONTROL WITH EITHER ATENOLOL (A) OR ENALAPRIL(E) IN 

POLYCYSTIC KIDNEY DISEASE (PKD) 

(302) 

Michael L. Watson 1 , Anne M. Macnicol 1 , J. Borg-Costenzi 2 , K. Vareesanghip 3 , Dominique 

Chauveau 4 , Geoff Cohen 1 , M. Elasad 3 

1 Medicine, Royal Infirmary, Edinburgh, United Kingdom; 2 Medicine, Royal Infirmary, Manchester, 

United Kingdom; 3 Medicine, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom; 

4 Nephrology, Necker Hospital, Paris, France. 

54 patients with PKD, mild renal impairement and hypertension were randomised to the 

two treatment groups (A or E) and followed for 3 years. 

BP and renal function (inulin clearance) were similar in each group at randomisation: 

(A:147.9/99.0 mmHg, 115.6ml/min/1.73sqm; E 150.7/100.8 mmHg, 113.1ml/min/1.73sqm. Treatment in 

each group was titrated to achieve the BP target (sitting diastolic BP

226 


USE OF A CA REPEAT POLYMORPHISM PHYSICALLY LINKED TO 

THE HUMAN AE1 (BAND 3) ANION EXCHANGER GENE TO DIAGNOSE 

AUTOSOMAL DOMINANT DISTAL RENAL TUBULAR ACIDOSIS 

ASSOCIATED WITH THE AE1 MUTATION R589H AND IMMUNO- 

CYTOCHEMICAL STUDY OF KIDNEY FROM ONE PATIENT 

(303) 

C. Shayakul 1,2 , P. Jarolim 3,4 , H. Ideguchi 5 , D. Prabakaran 1 , D. Cortez 7 , D. Zakova 4 , M. 

Zachlederova 3,4 , A.K. Stuart-Tilley 1 , C. Haller 6 , S.L. Alper 

1 Molecular Medicine and Renal Units, Beth Israel Deaconess Med. Ctr. and Harvard Medical 

School, Boston, MA; 2 Dept. of Medicine Siriraj Hospital, Mahidol University, Bangkok, 

Thailand; 3 Dept. of Pathology Brigham and Women’s Hospital and Harvard Medical School, 

Boston, MA; 4 Inst. of Hematology and Blood Transfusion, Charles Univ. School of Medicine, 

Prague, Czech Republic; 5 Dept. of Clin. Chem. and Laboratory Medicine, Fukuoka Univ., 

Fukuoka, Japan; 6 Dept. of Medicine, Univ. of Heidelberg, Heidelberg, Germany; 7 Sinsheim, 

Germany. 

We have found and characterized a polymorphic CA repeat located −90kb upsteam of 

the 5’ end of the human AE1 (band 3) gene of chromosome 17q21-q22, and separated from the AE1 

gene by the Rap2-inteacting protein 8 gene, a Flt4-related gene, and the epithelin gene. The CA repeat 

(at least 12 alleles) exhibits heterozygosity of > 50% among 160 normal individuals from Czech, Thai, and 

Japanese populations, and does not cosegregate across cohorts either with the AE1 gene in a German 

family in which heterozygosity for the AE1 R589H mutation was found to cosegreagate with disease. 

Immunostaining of kidney resected at surgery from one affected individual was remarkable for the 

presence of intercalated cells lacking AE1, and for substantially increased vH-ATPase staining in proximal 

tubular brush border. However, the presence in the dRTA specimen of extensive interstital scarring 

due to chronic pyelonephritis, nephrolithiasis, renal adenoma, and squamous cell bladder carcinoma in the 

setting of congenital bilateral ureteropelvic duplication complicated interpretation of the immunohistochemical 

findings.

TRANSPLANT PATIENTS 

K. Vareesangthip, S. Nimmannit, S. Vanichakarn, P. Pidetcha, L. Ong-Aj-Yooth 

Faculty of Medicine Siriraj Hospital, Faculty of Medical Technology, Mahidol University, 


The major cause of death following renal transplantation is cardiovascular disease. Among 

the several processes involved in hypertension, atherogenesis, oxidative stress and insulin resistance. 

There is evidence showing that renal transplant patients developed insulin resistance and hypertension 

during therapy with cyclosporine A (CyA). Both insulin resistance and hypertension are associated with 

the kinetics of erythrocyte Na/Li countertransport (Na/Li CT). Na/Li CT is a sensitive indicator of 

membrane function and might be used as marker to identify patients who are at risk for cardiovascular 

disease. It has been shown that the kinetics of Na/Li CT are modulated by two types of thiol proteins. 

The current model suggests that the type 1 thiol protein can be blocked by N-ethylmaleimide (NEM) in 

choline medium (Chol) and this reduces Km for external sodium and increases the Vmax/Km ratio 

suggesting an increase in the ion association reaction. The type 2 thiol protein can be blocked by NEM 

in 15 normal controls (NC) and 15 CyA treated renal transplant patients who had normal renal function. 

The results are shown in the Table. 

Vmax Km Vmax/Km 

UT Chol Na UT Chol Na UT Chol 

Na 

Na .46+.04 .40+.03 .20+.01a 70+7 39+4a 37+4a 7.0+0.7 12.4+1.8a 6.2 + 0.7 

CyA .38+.04 .40+.04 .24+.02a 39+2b 38+3 33+3 10.2+1.1b 9.9 + 0.8 8.0 + 0.9 

mean+SEM. P


PREVALENCE OF TYPE SPECIFIC EPSTEIN-BARR VIRUS IN THE GENITAL 

TRACT OF GENITAL HERPES SUSPECTED PATIENTS 

(305) 

Wannee Kantakamalakul, Preechaya Naksawat, Raweewan Kanyok, Pilaipan Puthavathana 

Department of Microbilogy, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 


Key words : Epstein-Barr Virus, Genital Tract, Genital Herpes 

A total of 62 clinical specimens from the genital tract of patients who were suspected of 

contracting genital herpes were investigated for HSV infection by the virus isolation method, and also 

investigated for the co-infection with EBV infection by detection EBV DNA using nested PCR. HSV 

infection was diagnosed in 30 (48.4%) of the study cases, and so was EBV. EBV DNA was present in 

17 (56.7%) of these two viruses together. EBV DNA was detected in genital specimens of cervical, 

vaginal, urethral, and anal swabs. Ninety per cent of EBV belonged to type 1, and the remainder belonged 

to type 2 and mixed types. The role of EBV in genital tract infection needs to be further investigated. 

VANCOMYCIN SUSCEPTIBILITY OF METHICILLIN-RESISTANT 

STAPHYLOCOCCUS AUREUS IN SIRIRAJ HOSPITAL : 1997-1998 

Kulkanya Chokephaibulkit 1 , Somporn Srifuengfung 2 , Kanokporn Tosasuk 1 , Chertsak 

Dhiraputra 2 

1 Department of Pediatrics, 2 Department of Microbiology, Faculty of Medicine Siriraj Hospital, 

Mahidol University, Bangkok, Thailand. 

Vancomycin susceptibility status of methicillin-resistant Staphylococcus aureus (MRSA) 

isolates in Siriraj Hospital during 1997-1998 was determined by E-test. Of 95 strains isolated, all had 

minimal inhibitory concentration (MIC) of < 2 µg/mL. The MIC 50 was 1.5 µg/mL. and MIC 90 was 2µg/ 

mL. Seventy-five percent of all the isolates of MRSA had the MIC of 1.5-2 µg/mL. The findings in this 

study indicated the possibility of heterogeneous resistant strains whose MICs may appear between 1 and 

2 µg/mL. Ongoing surveillance for emerging vancomycin-resistant MRSA is warranted. 

(J Infect Dis Antimicrob Agents 1999; 16:149-50) 

(306)

PULMONARY RHODOCOCCOSIS : AN UNRECOGNIZED PULMONARY 

INFECTION IN AIDS PATIENTS 

Athavudh Deesomchok 1 , Kittipong Maneechotsuwan 1 , Somporn Srifuengfung 2 , Surapol 

Suwanagool 3 

1 Department of Medicine, 2 Department of Microbiology, 3 Department of Preventive and Social 

Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand. 

Pulmonary rhodococcosis is an uncommon pulmonary infection in human beings, but the 

case reports have been increasing in HIV-infected patients. We report a female AIDS patient presenting 

with fever, productive cough and weight loss over 6 weeks. Chest x-ray showed a cavitary lesion with air 

fluid level in the right upper lobe infiltration. Sputa for AFB stain were negative for 3 consecutive days. 

Fiberoptic bronchoscopy was performed and bronchoalveolar lavage fluid was examined. It showed a 

gram-positive, weakly acid-fast coccobacilli. The culture grew only Rhodococcus equi. She was treated 

with erythromycin and rifampin and responded well. 

(Siriraj Hosp Gaz 1999; 51: 284-8) 

ROLE OF MATERNAL HUMORAL IMMUNITY IN VERTICAL TRANSMISSION 

OF HIV-1 SUBTYPE E IN THAILAND 

(308) 

S. Louisirirotchanakul 1 , S. Beddows 1 , R. Cheingsong 1 , N. Shaffer 2 , T.D. Mastro 2 , S. 

Likanonsakul 3 , C. Wasi 4 , G.P. Taylor 1 , and J. Weber 1 

1 Imperial College School of Medicine at St. Mary’s London, UK; 2 The HIV/AIDS Collaboration, 

Nonthaburi, Thailand, and Centers for Diseases Control and Prevention, Atlanta, 

USA; 3 Bamrasnaradura Infectious Diseases Hospital, Nonthaburi, Thailand; and 4 Faculty of 

Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand. 

Key words : HIV-1 Antibody Vertical transmission Binding and neutralizing Subtypes B 

and E Hemodilution. 

The significance of the meternal humoral immune response in relation to vertical transmission 

of HIV-1 was investigated in 123 mothers infected with subtype E from Thailand. Antibody 

binding titers to HIV-1 env domains (monomeric gp120, the CD4/gp120 binding site [BS]. V3 loop, and 

gp41) and antibody-mediated neutralization of primary and T-cell line-adapted (TCLA) subtypes B and E 

HIV-1 antibodies at delivery and vertical transmission of HIV-1 subtype E was found. However, a trend 

to higher titer antibody-mediated cross-neutralization of a heterologous subtype B TCLA isolate, HIV- 

1 MN , was observed in nontransmitting mothers postpartum. The HIV-1-specific antibody titers in these 

infected mothers increased significantly from delivery to 6 months postpartum (p


IN VITRO ANTI-STAPHYLOCOCCAL ACTIVITY OF CEFDINIR 

Amorn Leelasamee 1 , Suwanna Trakulsomboon 1 , Podjanee Komolpis 2 

1 Division of Infectious Diseases and Tropical Medicine, Department of Medicine, 2 Department 

of Microbiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, 

Thailand. 

Key words : Cefdinir, S.aureus 

Ninety strains of S.aureus isolated from blood in 1997 and ten other strains isolated in 

1995 were used to determine the susceptibility to cefdinir, cefixime, ceftibuten, cefpodoxime and cephalothin 

by the E-test method. The MIC50 and MIC90 of cefdinir were comparable or slightly superior to 

cephalothin i.e. MIC 50 of cefdinir : cephalothin = 0.75: 1.6 mg/L and MIC 90 = 1:3.1 mg/L respectively. 

These values were slightly less than our results from previous study. The MICs for S. aureus isolated 

from blood in 1995 fell in similar range. By contrast, the MIC ranges, MIC 50 and MIC 90 values of 

cefpodoxime for S. aureus were 2-12, 4, 6; cefixime 6-64, 16, 24 and ceftibuten 128- >256, >256, >256, 

mg/L respectively. Our finding confirms that cefdinir is currently, the only oral third-generation cephalosporin 

that retains adequate anti-staphylococcal activity of the first-generation cephem. 

(JInfect Dis Antimicrob Agents 1999; 16 (1):17-20) 

SALMONELLA BACTEREMIA : SEROTYPE DISTRIBUTION AND 

ANTIMICROBIAL SUSCEPTIBILITY DURING 1991-1995 

Podjanee Komolpis, Somporn Srifuengfung, Chertsak Dhiraputra, Busabawart Pingwang 

Department of Microbiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok. 

Key words : Salmonella bacteremia 

Seven hundred and forty-one strains of Salmonella were isolated from blood of patients 

admitted to Siriraj Hospital, during a 5-year period, 1991-1995. There were 30 serotypes of salmonella. 

Among the 6 most common serotypes. S. enteritidis ranked first (36.0%) followed by S. choleraesuis 

(19.7%), S. paratyphi A (15.7%), Salmonella I 1, 4, 5, 12:i -(8.2%), S. typhimurium (7.4%) and S. typhi 

(2.6%). Their susceptibities to 24 antimicrobial agents were assessed. For ampicillin, the percentages of 

sunsitivity were 97, 24, 94, 32, 78 and 88 persent respectively. For chloramphenicol, the percentages of 

sensitivity were 98, 90, 98, 26, 71 and 88 persent respectively. The strains which were resistant to 

ampicillin, chloramphenicol and/or co-trimoxazole were sensitive to ofloxacin pefloxacin and ciprofloxacin 

(92-100%). Most serotypes were sensitive to 3 rd generation cephalosporins. 

(J Infect Dis Antimicrob Agents 1999: 16; 49-52.) 

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MICROBIOLOGY OF CLINICALLY IMPORTANT ENVIRONMENTAL 

MYCOBACTERIA 

Angkana Chaiprasert 1 , Amorn Leelarasamee 2 

1 Division of Mycology and Mycobacteriology, Department of Microbiology, and 2 Department 

of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand. 

Key words : environmental mycobacteria, non-tuberculous mycobacteria, mycobacteriosis 

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Mycobacteria are aerobic or microaerophilic, non-motile bacteria that are characteristically 

aicd-fast, free-living saprophytes and minority of obligate pathogens. Thus the term ‘environmental mycobacteria’ 

(EM) is used to describe their ubiquity while the pathogenic Mycobacterium tuberculosis 

and M. leprae as typical tubercle and ‘MOTT’ (mycobacteria other than typical tubercle) are used to 

represent all other cultivable species associated with human disease. The method of Runyon based on 

colony pigmentation and growth rate has been used to classify EM into four groups. Several newer 

classification schemes have been proposed recently by the International Working Group on Mycobacterial 

Taxonomy to provide a scientific background for the logical separation and identification of species 

within the genus. There are currently more the 60 described species and at least 9 new pathogenic 

species were discovered by new culture method and molecular diagnostic technique. Some of EM are 

potential pathogens especially for AIDS patients. The list of newly recognized EM is expanding and 

hopefully new antimicrobials will be available soon for treatment of current difficult-to-treat EM infection 

in humans. 

(J Infect Dis Antimicrob Agents 1999 ; 16:29-40.) Thailand Tropical Research Programm (T-2) 

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DEEP FUNGAL AND HIGHER BACTERIAL SKIN INFECTIONS IN 

THAILAND : CLINICAL MANIFESTATIONS AND TREATMENT 

REGIMENS 

Punkae Mahaisavariya 2 , Angkana Chaiprasert 1 , Apichati Sivayathorn 2 , Supakan Khemngern 2 

1 Division of Mycology and Mycobacteriology, Department of Microbiology, and 2 Department 

of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkoknoi, Bangkok 


Key words : deep fungal infections, Thailand, treatment regimens 

Thailand. 

Background : Deep fungal and higher bacterial skin infections occur fairly frequently in 

Methods : Cases with a provisional diagnosis of deep fungal and higher bacterial infections 

were prospectively collected from 1994 to 1997 in the Granuloma Clinic, Department of Dermatology, 

Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand. Demographic data, 

clinical manifestations, causative organisms, histologic features, treatment, and outcome were investigated. 

Results : The total cases in a 4-year period numbered 27. The male to female ratio was 

approximately 1:1. Mycetoma was most common, followed by chromoblastomycosis. Actinomycetoma 

was similar in incidence to eumycetoma. The only causative organism that could be identified among the 

mycetoma cases was Cladosporium carrionii, which caused mycetoma of the buttock of an aplastic 

anemia patient at the site of bone marrow aspiration. Surgical treatment was recommended for eumycetoma. 

Chromoblastomycosis was caused by C. carrionii and F. compactum and responded well with itraconazole 

orallyy. Mycotic abscesses were found in four cases, basidiobolomycosis in two cases, and cutaneous 

nocardiosis in one case. Cotrimoxazole was recommended in the treatment of actinomycetome, cutaneous 

nocardiosis, and basidiobolomycosis. 

Conclusions: Localized, chronic, slow, progressive, and usually asymptomatic were the 

main cutaneous manifestations of deep fungal and higher bacterial skin infections. A skin biopsy for 

histologic study and culture identification should be performed in every suspected case. The causative 

organisms were found in the histologic sections of every cases, but only about one-third were found by 

culture. 

(Siriraj China Medical Board Fund.) 

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COMPARISON OF PRONUCLEAR STAGE EMBRYO TRANSFER AND 

IN VITRO FERTILIZATION - EMBRYO TRANSFER FOLLOWING 

INTRACYTOPLASMIC SPERM INJECTION 

Somboon Kunathikom, Roengsin Choavaratana, Supakdee Julavijitpong, Suwit Suppinyopong, 

Singpetch Suksompong, Phakphum Phophong 

Depatment of Obstetrics and Gynecology, Faculty of Medicine, Siriraj Hospital, Mahidol 

Universtiy, Bangkok 10700, Thailand. 

Key word : - Pronuclear Stage Embryo Transfer - In Vitro Fertilization-Embryo 

Transer - Intracytoplasmic Sperm Injection 

To detrmine whether the mode of embryo transfer (PROST vs IVF) affected the outcome 

in intracytoplasmic sperm injection (ICSI) cycles, 237 ICSI cycles (106 PROST and 131 IVF) were 

analyzed. Several parameters, including patient age, duration of infertility, amounts of hMG used, number 

of mature aggs retrieved and injected, fertilization rate, number of embryos transferred, and clinical 

pregnancy rate, were compared. Most of the variable factors were not significantly different, except 

the mean numbers of transferred embryos which were significantly higher in the PROST group. The 

clinical pregnancy rate showed no statistical difference between PROST and IVF cycles (25.5 and 

16.8% ; p = 0.139). This study suggests that even the pregnancy rate in PROST cycles was slightly 

higher than IVF cycles, but there was no statistically singificant difference between the two groups. 

(J Med Assoc Thai January 1999 Vol.82 No. 1) 

NUCLEAR DNA NORMALITY OF SPERMATOZOA SELECTED BY 

SWIM-UP AND TWO-LAYER PERCOLL GRADIENT TECHNIQUES 

Somboon Kunathikom, Orawan Makemaharn, Tasanee Suteewan, Singpetch Sukompong, 

Suphakde Julavijitphong 

Depatement of Obstetrics and Gynecology, Faculty of Medicine, Siriraj Hosptial Mahidol 

University, Bangkok, Thailand. 

Key words : nuclear DNA normality, acridine orange test, swin-up. 

Objective : To use acridine orange (AO) test to compare sperm DNA normality 

between washing and swim-up, and two-layer Percoll gradient techniques for both normal and abnormal 

semen samples. 

Design : Experimental study. 

Setting : Division of Infertility, Department of Obstetrics and Gynaecology, Faculty 

of Medicine, Siriraj Hospital, Mahidol University. 

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Subjects and methods : Semen samples from 112 male partners of infertilie couples 

were divided into two aliquots, which were separated by washing and swim-up, and two-layer Percoll 

gradient techniques. AO test was performed on the sperm before and after sperm separation. 

Results: The percentage of green-fluorescing sperm is improved after the two methods 

of sperm preparation but is more improved after two-layer Percoll gradient than washing and swim-up, 

both in normal and abnormal semen samples (89.0 + 7.9 versus 81.9 + 10.2 and 85.2 + 10.2 versus 74.6 

+ 14.8 ; p > 0.001 respectively). 

Conclusion : Two-layer Percoll gradient selected more sperm with nuclear DNA normality 

than washing and swim-up separation that may influence the outcome of assisted reproductive 

techniques. 

(Thai Journal of Obstetrics and Gynaecology, March 1999, Vol. 11, pp. 43-47.) 

HIGHER PREGNANCY RATE WITH INTRAFALLOPIAN TUBAL 

GAMETE OR ZYGOTE TRANSFER (GIFT OR ZIFT) THAN 

INTRAUTERINE EMBRYO TRANSFER (IVF-ET) 

Suphakde Julavijitphong, Orawan Makemahan, Tasanee Sutewan, Piengchai Vichaidith 

Infertility Unit, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, 

Bangkok 10700, Thailand. 

Key word : Pregnancy rate intrafallopian tubal gamete or zygote transfer, intrauterine embryo transfer 

From November 1996 to September 1998, we had trated infertile couples who required 

assisted reproductive conception by allocating to either one of the three treatment methods : IVF-ET for 

those with bilateral tubal obstruction; ZIFT for those with at least one tubal patency but poor sperm; and 

GIFT for those with at least one tubal patency and normal sperm (unexplained infertility), The ovarian 

stimulation protocol was all the same by using GnRH analogue (Suprefact³) injection for ovarian 

stimulation. The oocyte pick up was due when the leading follicle reach 18 mm. For IVF-ET and ZIFT, 

the fertilization was obtained by conventional in vitro fertilization or by ICSI depending on the sperm 

quality. Laparoscopic intrafallopian tubal gamete or zygote transfer was preformed on day 0 (ovum pick 

up day) for the GIFT or on day 1 for the ZIFT group. Intrauterine embryo transfer was performed on 

day 2-3 for the IVF-ET group. Every treatment cycle was conducted by the investigator group to 

minimize the variation of technical bias. Of all the 213 treatment cycles, 82 were IVF-ET< 92 were 

ZIFT, and 39 were GIFT. The average female patient age in each groups was not different. The pregnancy 

rate achieved in the GIFT and ZIFT groups were significantly higher than the IVF-ET group (46.2%, 

40.2% and 23.2% respectively, p < 0.05). For the pregnancy outcome, the abortion rate seemend to be 

highest in the IVF-ET group (36.8%) whereas the multiple pregnancy rate seemed to be higher in the 

fallopian tubal transfer group (27% for ZIFT and 38.9% for GIFT), although there were no statistical 

significance. The benefit of the higher pregnancy rate for the intrafallopian tubal transfer treatment 

group could be due to the more suitable environment for the early stage embryo and the more synchronize 

of the endometrial receptivity and the embryo arrival timing provided by the fallopian tube. In 

conclusion, until the optimal in vitro embryo culture system can be developed, gaete and zygote intrafallopian 

tubal transfer should yield higher pregnancy rate than intrauterine embryo transfer. 

(Siriraj Hosp Gaz Vol. 51, No. 6, June 1999.) 


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COMPARATIVE STUDY OF EMBRYO CULTURE MEDIA CONTAINING 

AND WITHOUT CONTRAINING GLUCOSE ENERGY SUBSTRATE 

Suphakde Julavijitphong, Orawan Makemahan, Charunee Karavakul 

Infertility Unit, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, 

Bangkok 10700 , Thailand. 

Key word : embryo culture media, glucose energy substrate 

The aim to increase pregnancy rate by in vitro fertilization (IVF-ET) is to improve the 

embryo culture system, especailly the culture media. Most of the conventional IVF media has been 

developed from somatic cell culture which contrains glucose as the energy substrate, Many recent 

studies in mammals, including human, reported that glucose was not the preferred nutrient for the zygote 

and early cleaving embryo, and may stimulate premature glycolysis, which induce the Crabtree effect; 

thus depressing respiratory rate and energy production. This study was conducted to evaluate the embryo 

culture outcome that grows in conventional IVF media containing 5 mM of glucose (Medicult media) as 

compared to the home-made media withou glucose (SJ-media), Ten infertile couples were enrolled in the 

study for eleven treatment cycles. Seventy eight oocytes were retrieved, of which sixty three were 

fertilized as 2 PN embryo, that were randomly allocated into two culture groups: 32 embryos in group I 

(Medicult media), and 31 embryos in group II (SJ-media). Twenty eight hours after the cultrue, the 

embryos in both groups were compared. There was no statistical difference between the embryos of the 

two culture groups (p > 0.05), but there was a trend in whcih embryos in group I had more 3-4 blastomere 

than group II (68.8% vs 51.5%); embryos in group II; however; ahd less fragmentation (67.7% 

vs 50% for fragmentation < 5%) and were of better quality than group I (51.6% vs 40.6% for embryo 

grade A, and 32.2% vs 25% for grade B). In conclusion, this study has confirmed that human embryos 

can grow in media devoid of glucose; at least; as well as glucose containing media. A larger sample size 

study; however; need to be carried out. 

(Siriraj Hosp Gaz Vol. 51, No. 9, September 1999.) 

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RISK OF OMENTAL METASTASIS IN ENDOMETRIAL CARCINOMA 

Suwanit Therasakvichya, Chairatana Leelaphatanadit, Prakob Wongwai, Surintip 

Piam-somboon, Dittakarn Boriboonhirunsarn, Weerasak Wongtiraporn, Puchung Padungsutt, 

Chaiyod Thirapakawong, Perapong Inthasorn, Somchaya Neungton, Monkol Benjapibal, 

Sumrit Senapad, Surin Tosukowong 

Department of Obstetrics and Gynaecology, Siriraj Hosptial, Faculty of Medicine, Mahidol 

University, Bangkok, Thailand. 

Key word : omental metastasis, endometrial carcinoma 

A retrospective histologyc assessment of the omentum obtained during prmary surgery 

for 100 cases of endometrial carcinoma between January 1994 and December 1998 was studied. The 

purpose of this study was to determine relative frequency and risk factors of omental involverment in 

endometrial carcinoma. Omental metastases were found in 14 (14%) of 100 patients with all stages and 

9% in FIGO stage I tumor. These metastases were microscopic and macroscopic in 10% and 4% 

respectively. Hogh tumor grading (p = 0.031), deep myometrial invasion (p = 0.05), adnexal involvement 

(p = 0.001(, and positive peritoneal cytology (p = 0.042) were significant risk factors associated with 

omental spreading. Only high tumor grading was the most important pre-operative risk (OR - 5.86; 95% 

CI = 1.27 - 27.11). The study indicated that silent omental metastases are neglected in endometrial 

carcinoma patients during primary surgical staging. Whether omental assessment should be done or 

whether omentectomy has therapeutic value in “high risk” patients warrants further study. 

(Thai Journal O Obstetrics and Gynaecology, August 1999, Vol. 11, Suppl. 1, pp. 83-87.) 

EMBRYONIC TESTICULAR REGRESSION SYNDROME : A CASE 

REPORT 

Manee Rattanachaiyanont 1 , Pahakphum Phophong 1 , Kitira Techatraisak 1 , Pichai 

Charoenpanich 2 , Phaibul Jitpraphai 3 

1 Division of Reproductive Endocrinology, 2 Division of Pathology, Department of Obstetrics 

and Gynecology, 3 Division of Urology, Department of Surgery, Faculty of Medicine, Siriraj 

Hospital, Mahidol University, Bangkok, Thailand. 

Key word : embryonic testicular regression syndrome 


A case of testicular regression syndrome was reported. The patient was an 18 year old 

girl presenting with primary amenorrhoea. Physical examination revealed normal female external genitalia 

and underdeveloped secondary sexual characteristics. Hormonal profile indicated gonadal failure. Chromosome 

analysis revealed 46, XY karyotype. Diagnostic laparoscopy demonstrated undeveloped internal 

genital organs. Remnants of epididymis, vas deferens and seminiferous tubule were uncovered during 

exploratory laparotomy. Ontogeny of sexual differentiation and phthogenesis of testicular regression 

syndrome were reviewed and discussed. 

(J Med Assoc Thai 1999 May; 82 (5): 506-10. Fertil Steril 1999, May; 71(5): 937-40. ) 

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LACK OF CORRELATION BETWEEN OOCYTE-CORONA-CUMULUS 

COMPLES MORPHOLOGY AND NUCLEAR MATURITY OF OOCYTES 

COLLECTED IN STIMULATED CYCLES FOR INTRACYTOPLASMIC 

SPERM INJECTION 

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Manee Rattanachiyanont, Arthur Leader, Marie-Claude Leveille 

Fertility Center, Ottawa Hospital, Ontario, Canada. 

Key word : oocyte-corona-cumulus complex, nuclear maturity, intracytoplasmic sperm injection 

Objective : Toevaluate the usefulness of morphology grading of the oocyte-coronacumulus 

complex (OCCC) as a marker of oocyte nuclear maturity, fertilizability, embryo cleavage, and 

likelihood of pregnancy. 

Design : Prospective cohort study 

Setting : Academic fertility center. 

Patient(s) : Eighty-three infertile couples undergoing IVF-ET/intracytoplasmic 

sperm injection treatment. 

Intervention(s) : All patients underwent a long stimulation protocol of GnRH 

agonist therapy followed by hMG administration and transvaginal oocyte recover. 

Main outcome measure(s) : All OCCCs, oocytes, and embryos were assessed. The 

relation among OCCC morphology and the nuclear maturity of denuded oocytes, the fertilization rate, 

and embryo development to the cleavage stage were analyzed. 

Result(s) : Of 909 OCCCs collected from 92 cycles, 2.5%, 4.2%, 79.9% and 

13.4% were prophase I, metaphase I, metaphase II, and degenerating, respectively. No statistically 

significant differences were found in the percentage of intact metaphase II oocytes, the fertilization rate, 

or the cleavage rate among complexes with different morphologic grades. The morphologic grade of the 

OCCCs of transferred embryos in the pregnant group was not different from that in the nonpregnant 

group. 

Conclusion(s) :Most oocytes were in metaphase II at the time of retrieval after ovarian 

stimulation. However, no relaation was observed between the OCCC morphologic grade and oocyte 

nuclear maturity, the fertilization rate, or embryo cleavage. These observations suggest that OCCC. 

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TREATMENT OF ACATHAMOEBA KERATITIS WITH CHLORHEXIDINE (320) 

Kosrirukvongs P, Wanachiwanawin D, Visvesvara GS 

Department of Ophthalmology, Faculty of Medicine, Siriraj Hospital, Mahidol University 

Objective : To evaluate the efficacy of chlorhexidine solution in the treatment of patients 

with Acanthamoeba kerati tis. 

Design : Prospective nonrandomized study. 

Participants : Five patients infected with culture proven Acanthamoeba keratitis. 

Intervention : Chlorhexidine solution was used hourly on six eyes and gradually reduced 

to four times a day after 1 month. Follow-up ranged from 1 to 10 months (mean, 4 months). 

Main Outcome Measures : Severity of symptoms and signs, time for healing, andfinal 

visual acuity. 

Results : Clinical results in four patients showed improved visual acuity, with a rapid 

recovery within 1 week. No adverse drug reaction was encountered, but one patient with a perforated 

ulcer developed glaucoma. Eighty-three percent of 6 eyes were medically cured with chlorhexidine and 

recovered visual acuity 6/18 or better. Four of five patients improved within 3 weeks, with resolution of 

infiltration and healing of epithelial defects. By 2 to 3 weeks, visual acuity 6/18 or better had improved in 

four (66.7%) of six eyes and recovered 6/6 in two eyes (33.3%). Bacterial coinfection occurred in one 

eye. 

Conclusion : Chlorhexidine dramatically hastened clinical improvement in all eyes and 

is a successful medical therapy that has excellent results in patients who are diagnosed early. 

(Ophthalmology 106:798-802, 1999) 

MIXTURE OF 2.5% PHENYLEPHRINE AND 0.75%TROPICAMIDE FOR 

PUPIL DILATATION 

Trinavarat A, Pituksung A, Udompunturak S 

Department of Ophthalmology, Faculty of Medicine, Siriraj Hospital, Mahidol University. 

Key words : pupil dilatation (mydriasis), phenylephrine, mydriatics 

Objective: To evaluate an efficacy and adverse effects of the eyedrop made from 10% 

phenylephrine and 1% tropicamide in the ratio of 1:3 for pupil dilatation. Methods: The mixture was 

instilled every 15 minutes, no more than 4 times to get the pupils dilated to 8 mm in diameter. The study 

was conducted in 76 eyes of 39 patients with the pupil diameters of 2.18 + 0.56 (1-3) mm. Results: Fiftynine 

eyes (77.6%) were dilated to 8 mm by 2.8 + 0.7 (2-4) instillations. In the remaining eyes, pupil 

diameters were 6.56 + 0.73 (5-7) mm after 4 times of application. The pupils were dilated to 7 mm in 70 

eyes (92.1%). No significant changes in blood pressure and pulse rate were found in all patients. Conclusions: 

Mixture of 2.5% phenylephrine and 0.75% tropicamide can be used effectively and safely as a 

mydriatic drug. 

(Thai J Ophthalmol 13:11-5, 1999) 

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FREQUENCY–DOUBLED ND : YAG LASER FOR RETINOPATHY OF 

PREMATURITY 

Trinavarat A, Tanterdtham J, Namatra C, Singalavanija A, Rodanant N 


Key words : Retinopathy of Prematurity Frequency - doubled Nd : YAG laser. 

Objective : To evaluate the outcome of treatment for stage III plus ROP using frequency 

- doubled Nd : YAG laser photocoagulation ( 532 nm. wavelength ). 

Method : A retrospective study of ROP cases treated with this laser via indirect ophthalmoscope 

who were followed up for at lest 3 months between December, 1996 and May, 1998 was 

conducted. Patient : Twenty four eyes of 12 infants with gestational age of 26 - 35 ( 29.2 + 2.57 weeks 

and birth weight of 720 – 1,650 (1,050 + 305) grams were evaluated. 

Results : All eyes were treated within one week after detection of stage III plus. The 

follow – up period ranged from 4 to 17 months ( 11.5 + 4.07 months ). Regression of the retinopathy was 

found in 22 eyes after single treatment while two eyes required another session of treatment. Mean of 

the regression time was 3.916 + 1.64 (2-8) weeks. Nineteen eyes showed normal posterior poles. Two 

had abnormal angulation of temporal vessels. Other two had macular heterotropia and one eye was found 

to have peripheral vitreous hemorrhage. No evidence of any visually significant complication from laser 

treatment was found. 

Conclusion : The results suggest that frequency - doubled Nd : YAG laser can be an 

alternative for the treatment of ROP. 


A UNIQUE 3.5-KB DELETION OF THE MITOCHONDRIAL GENOME 

IN THAI PATIENTS WITH KEARNS-SAYRE SYNDROME 

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Lertrit P, Imsumran A, Karnkirawattana P, Devahasdin V, Sangruchi T, Atchaneeyasakul L, 

Mungkornkarn C, Neungton N 

Department of Biochemistry, Faculty of Medicine Siriraj Hospital, Mahidol University 

Kearns-Sayre syndrome is one of the neurological diseases caused by a defect in the 

energy-producing system of mitochondria. Keams-Sayre is known to be associated with a deletion in the 

mitochondrial genome and is usually detected in muscle biopsies of the patients. In this study, we report 

the molecular lesion of mitochondrial DNA (mtDNA) in four Thai patients admitted to hospital with 

encephalomyopathies. The 3.5-kb deletion of mtDNA was detected by Southern analysis, mapped by 

amplification with five primer pairs covering almost the total mitochondrial genome, and confirmed by 

PCR primer shift analysis. The deleted position was localized to nt 10208/13765 or nt 10204/13761 spanning 

the coding area of subunits 3 (ND3), 4L (ND4L), 4 (ND4), and 5 (ND5) of respiratory chain 

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enzyme complex I and the tRNA genes for histidine, serine, leucine, and arginine. The sequence flanking 

the deletion was a 4-bp repeat of TCCC. All four patients have exactly the same 3558-bp mtDNA 

deletion; this is the only deleted position in their mtDNA but is different from those reported in the literature. 

The deletion seems to be found only in Thai patients, although they present with different clinical 

manifestations and none of them is not related. 

(Hum Genet 105:127-31, 1999) 

SURGICAL OUTCOMES OF RETINAL DETACHMENTS WITHOUT 

BREAKS 

Bamroongsuk P, Singalavanija A, Tantaterdtum J, Namatra C, Trinavarat A, Rodanant N 


Forty-five patients with retinal detachment without breaks were analyzed. All cases 

were treated by encircling scleral buckling combined with pars plana vitrectomy and gas injection. Eighteen 

cases were phakic detachment, eleven cases were aphakic detachment and sixteen cases were 

pseudophakic detachment. Statistic analyses showed that there was statisticall significant difference in 

anatomical reattachment and reoperated requirement between phakic and aphakic or pseudophakic group. 

The surgical outcomes o these three groups showed that the phakic group had the best result. The 

limitation in visualization and surgical approach made the unsatisfactory results in aphakic or pseudophakic 

group. 


SURGICAL MANAGEMENT OF NONDIABETIC VITREOUS 

HEMORRHAGE 

Singalavanija A, Tanterdtham J, Namatra C, Trinavarat A 

Department of Ophthalmology, Faculty of Medicine, Siriraj Hospital, Mahidol University 

Sixty-one patients (62 eyes) with vitreous hemorrhage not associated with diabetic retinopathy 

or perforating injuries who required surgical treatment were studied. The patients had dense 

vitreous hemorrhage with preoperative visual acuity of counting finger or worse in 55 eyes (88.7%) . 

After the operation, the final visual acuity of 6/60 or better was found in 33 eyes (53%). The common 

causes of vitreous hemorrhage were subretinal neovascularization, blunt trauma, branch retinal vein 

occlusion, post-cataract extraction, retinal detachment with tears and retinal vasculitis. There was no 

association between the postoperative visual outcome and the preoperative visual acuity or the duration of 

vitreous hemorrhage. The pathological change at the macular area was the main factor that influenced 

the visual outcome. 

(J Med Assoc Thai 82:460-5, 1999) 


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ACCURACY OF ORBSCAN TOTAL OPTICAL POWER MAPS IN 

DETECTING REFRACTIVE CHANGE AFTER MYOPIC LASER IN SITU 

KERATOMILEUSIS 

Srivannaboon S, Reinstein DZ, Sutton HF, Holland SP 

Department of Ophthalmology, University of British Columbia, Vancouver, Canada. 

Purpose : To determine whether the refractive change obtained using the Orbscanderived 

total optical power (TOP) map is in concordance with the manifest refractive change produced 

by laser in situ keratomileusis (LASIK). 

Setting : LASIK Vision Canada, Vancouver, BC, Canada (an ambulatory surgical center 

for refractive surgery). 

Methods : Twenty eyes of 10 consecutive bilateral LASIK patients were included in 

the study. Orbscan topographical analysis and manifest refraction were performed preoperatively and at 

least 1 month postoperatively. The change in manifest refraction (corrected to the corneal plane) before 

and after LASIK was correlated with the corneal power change averaged within the 2.0, 3.0, 4.0, and 5.0 

mm diameter zones of TOP and axial power maps. 

Results : The central 4.0 mm zone TOP map gave the best correlation between manifest 

refractive change and Orbscan-measured corneal power change (r2 = 0.835, P < .004). The correlation 

was higher with TOP maps than with anterior axial power maps. 

Conclusion : The corneal power change measured by the Orbscan TOP maps correlated 

highly with the changes in manifest refraction after LASIK. 

(J Cataract Refract Surg 25:1596-9, 1999) 

CORNEAL TOPOGRAPHY OF SMALL-BEAM TRACKING EXCIMER 

LASER PHOTOREFRACTIVE KERATECTOMY 

Coorpender SJ, Klyce SD, McDonald MB, Doubrava MW, Kim CK, Tan AL, Srivannaboon 

LSU Eye Center, New Orleans 70112, USA 

Purpose : To evaluate the topographic characteristic of photorefractive keratectomy 

(PRK) for low myopia performed with a small beam (0.9 mm) tracking excimer laser. 

Setting : Department of Ophthalmology, LSU Eye Center, Louisiana State University 

Medical Center School of Medicine in New Orleans, and the Refractive Surgery Center of the South at 

the Eye, Ear, Nose, & Throat Hospital, New Orleans, Louisiana, USA. 

Methods : Sixty-seven eyes of 47 patients had PRK with a small-beam tracking laser. 

Of these, 49 eyes had data permitting evaluation of ablation centration; usable data for topographic analysis 

were available for 59 eyes preoperatively, 54 eyes at 1 month, 42 eyes at 3 months, and 25 eyes at 6 

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242 

months, permitting measurement of various topographic parameters, including the cylinder (CYL), average 

corneal power (ACP), surface regularity index (SRI), surface asymmetry index (SAI), corneal eccentricity 

index (CEI), and coefficient of variation of corneal power (CVP). 

Results : Preoperatively, all eyes were topographically normal. Postoperatively, no eye 

exhibited a “central island” by even the least-restrictive definition, and all eyes had best spectacle corrected 

visual acuities (BSCVAs) of 20/20 or better at all follow-ups. Mean decentration of the ablations 

from the pupil centers was 0.42 mm +/- 0.28 (SD) (n = 49). There was no correlation between measured 

decentration and BSCV (P = .46). The central cornea was flattened (decreased ACP; P < .001) and 

made oblate (decreased CEI; P < .001) as expected. There was no increase in SRI or SAI (irregular 

astigmatism) at 6 months compared with preoperative values (P = .91); however, CYL and CVP (varifocality) 

increased slightly (P = .04 and .02, respectively). 

Conclusion : The absence of significant regular or irregular astigmatism 6 months after 

PRK with the small-beam laser is an improvement over published results achieved with wide-beam lasers 

and is consistent with th excellent visual acuity results in this cohort. 

(J Cataract Refract Surg 25:674-84, 1999) 

LEBER’S HEREDITARY OPTIC NEUROPATHY (LHON) WITH 

MITOCHONDRIAL ND4 GENE MUTATION (11778) IN A THAI PATIENT 

Lertrit P, Ruangvaravate N, Trongpanich Y, Imsumran A, Mungkornkarn C, Neungton N 

Department of Biochemistry, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, 

Thailand. 

Leber’s hereditary optic neuropathy (LHON) is a maternally transmitted disease, characterized 

by bilateral optic atrophy predominantly in healthy young males. This disorder has shown to be 

associated with DNA mutation in mitochondrial genome of the patients. We report here a young man who 

came to the hospital with subacute visual loss in one eye, followed by the other eye within two months. 

His echocardiogram was normal. A G—>A base substitution at nucleotide position 11,778 which changes 

a conserved arginine to histidine at amino acid position 340 of ND4, a protein subunit of respiratory chain 

enzyme complex I in oxidative phosphorylation system, was detected in his leucocyte mitochondrial genome. 

(J Med Assoc Thai 82:59-64, 1999) 


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ENDOPROSTHETIC RECONSTRUCTION FOR MALIGNANT UPPER 

EXTREMITY TUMORS 

Apichat Asavamongkolkul, Jeffery J. Eckardt, Frederick R. Eilber, Frederick J. Dorey, William 

G. Ward, Cynthia M. Kelly, Philip Z. Wirganowicz, and J. Michael Kabo 

Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University. 

Key words: Endoprosthetic reconstruction, Malignant tumor, Upper extremity 

Between December 1980 and December 1992, 59 patients underwent 60 reconstruction 

with endoprostheses after resection of malignant tumors in the upper extremity. There were 32 male 

patients and 27 female patients, with a mean age of 33 years (range, 3-83 years). The type of reconstruction 

was based on the location of the primary tumor site. The histologic diagnoses included osteosarcoma, 

chondrosarcoma, Ewing’s sarcoma, malignant fibrous histiocytoma, soft tissue sarcoma, and fibrosarcoma 

of bone. Most of the patients had Stage IIB disease (N=38), as established by the Musculoskeletal 

Tumor Society classification. An additional six patients had metastatic tumors to the upper extremity. 

Twenty-seven of 59 patients died of disease progression. Two patients died of other causes (chronic 

leukemia, human immunodeficiency virus infection). The 30 survivors had a mean follow-up of 90 months 

(range, 60-170 months) The Musculoskeletal Tumor Society functional analysis for the patients with a 

minimum 2-year follow-up (N=41) averaged 74%. Sixteen of the 59 (27%) patients had local complications. 

Problems related to mechanical failure and infection were managed successfully with second operation. 

Amputation was rare, occurring in three of 60 (5%) patients and was related only to local recurrent. 

Endoprosthetic reconstructions of the upper extremity after tumor resections have proven to be successful. 

(From Clinical Orthopaedics and Related Research 1999; 360: 207-220) 

MODULAR ENDOPROSTHETIC RECONSTRUCTION FOR LIMB SALVAGE 

IN TUMOR AND NON-TUMORAL CONDITIONS: N=90 

(330) 

Apichat Asavamongkolkul, Jeffrey J. Eckardt, Frederick J. Dorey, Michael J. Kabo, Frederick 

R. Eilber 

Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University. 

Key words: Modular endoprosthesis, Reconstruction, Limb salvage 

The purpose of this study was to review the initial experience of 90 modular endoprostheses 

with a minimum of 2-year follow up following tumor resectionand other new indications. A retrospective 

review of the first 90 modular endoprostheses in 85 patients have been implanted and were followed up 

for a minimum of 2 years since November 1985. Seventy-seven were primary modular endoprostheses 

and 13 were revision endoprostheses. The mean age was 40 years (range 9-91) and 47% was males. 

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244 

The reconstruction was in 44 distal femur, 17 proximal humerus, 12 proximal femur, 6 total femur, 6 

intercalary, 3 proximal tibia and 1 distal humerus and total humerus. The indication were for reconstruction 

following primary malignant tumor resection in 48, failed endoprosthesis revision in 13, acute fracture or 

failed ORIF/or total joint replacement in 12, metastatic disease in 10, soft-tissue sarcoma in 4 and giant 

cell tumor in 3. In this series, 85 patients (69%) were without any complications. There were 9 amputations 

and 10 patients required a revision of the endoprosthesis. For the patients receiving primary endoprosthesis 

the 3-year failure rate was 22% versus 43% for a prior surgery for failed internal fixation or total joint 

replacement group, while the 3-year amputation rate was 8% versus 37%. The mean MSTS function 

analysis in primary endoprosthesis group was 84% versus 61% for a prior surgery group. In conclusion, 

modularity has extened the indication for endoprosthetic reconstruction. Although the complications were 

higher when compare with endoprosthesis for tumor resection alone, the function analysis for most of the 

patients equally good. 

(From Proceedings of the Sixty-Sixth Annual Meeting of the American Academy of Orthopaedic 

Surgeons, Anaheim, USA, 1999, P. 160-161) 

EXPANDABLE ENDOPROSTHETIC RECONSTRUCTION FOR LIMB 

SALVAGE AS A LIMB EQUALIZATION TECHNIQUE IN THE SKELETALLY 

IMMATURE TUMOR PATIENT 

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A. Asavamongkolkul, J J. Eckardt, R. Yang, FR..Eilber 

Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 

Bangkok 10700 

Key words : Expandable endoprosthesis, Limb salvage, Skeletally immature patient 


Purpose: To evaluate the initial UCLA experience (N - 32) of expandable endoprosthesis 

as a mean of limb salvage and extremity equalization in skeletally immature malignant tumor patients. 

Methods: Between September 1984 to January 1996, 32 expandable endoprostheses 

were used for limb reconstruction following resection of malignant bone tumors in skeletally immature 

patients, giving a minimum of a 2 year follow-up for survivors. The 20 males and 12 females ranged in 

age from 3-15 years (mean 9.7 years) and had the MSTS stage of IIA-1, IIB-22, III-7, and parosteal 

osteosarcoma in 2. The histologic diagnosis was osteosarcoma in 23 and Ewing’s sarcoma in 9. All 

patients but parosteal osteosarcomas received standard neoadjuvant therapy. Utilized were 22 Lewis 

Expandable Adjustable Prosthesis, 4 modular Wright Medical, 4 modular Howmedica, and 2 Techmedica 

expandable endoprosthesis. 

Results: Thirteen of 32 died, 2 are NED and 17 are CDF. Sixteen of 32 (51%) have not 

been expanded, because of early death in 1, the attainment of skeletally immaturity in 1, with an additional 

3 waiting expansion. Sixteen of 32 (50%) have undergone 32 expansions, to a maximum of 8 cm, without 

any infection. The average time to the first expansion was 19 months (range 8-46 months). Seven 

patients had 1 expansion, 4 patients had 2, 3 patients had 3 and 2 patients had 4. The median expansion

was 2 cm (range 1-2.5 cm). Nine patients are waiting further expansion. Nine patients have reached 

skeletal maturity, 6 with equal extremity length and 3 with residual discrepancies. Fourteen of the 32 

patients had 27 complications: aseptic loosening in 5, mechanical failure of L.E.A.P. in 2, fatigue fracture 

in 2, local recurrence in 2, flexion contracture in 3, temporary nerve palsy in 4, collapse of L.E.A.P. in 4 

and single instances of wound dehiscence, shoulder subluxation, failure of a modular endoprosthesis to 

disengage, fat embolism, and a fatal postoperative pulmonary embolism. One instance of local recurrence 

and 2 of mechanical failure resulted in amputation. All L.E.A.P. endoprosthesis were associated 

with large amount of titanium debris. Functional results are similar to the adult series with an average of 

good and excellent at the knee, fair to good at the hip and fair about the shoulder. Rehabilitation in the 

very young (5-8 years) remains problematic and careful selection of patient and family is necessary. The 

L.E.A.P. prosthesis should probably for this very young age group (5-8 years). 

Conclusion: Expandable endoprosthesis can be an effective means of limb salvage and 

extremity equalization in carefully selected skeletally immature malignant tumor patients. 

(From Proceedings of the Siriraj Scientific Congress, Bangkok, Thailand, 1999, P. 281) 

IMAGING OF EXTRAOSSEOUS OSTEOSARCOMA 

Kullanuch Prompitaksa, Anchalee Churojana, Pipat Chiewvit, Apichat Asavamongkolkul 

Department of Othopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol university, 

Bangkok 10700. 

Key words: Imaging, Extraosseous osteosarcoma 

Extrosseous osteosarcoma is rare neoplasm with very few cases having been found. 

The radiologist and clinician particularly evaluated it as soft tissue tumor. 

We studied two cases imaging features and diagnosis as extraosseous malignant bone 

tumor with pathologic confirm. The diagnosis in these cases was difficult to be definitive, mainly because 

the distinction from osseous form was often unclear. This distinction had some importance because these 

two conditions were usually treated in different ways. Although there was a limited role initially for 

staging the disease of extraosseous osteosarcoma. The imaging features were useful. 

This article focused on major imaging characteristic that had practical interest in diagnosis 

of extraosseous osteosarcoma. 

(From Proceedings of the Thirty-Sixth Annual Scientific Meeting of the Radiological Society of 

Thailand and the Royal College of Radiologists of Thailand, Bangkok, Thailand, 1999, P. 56) 

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THE MANAGEMENT OF SACROCOCCYGEAL CHORDOMA 

A. Asavamongkolkul, S. Waikakul, K. Prompitaksa, N., Suntornpong, S. Benjarassamerote, S. 

Kuntisomboon 

Department of Orthopaedic Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, 

Bangkok, Thailand 

Key words : Chordoma, Sacrococcyx, Management 


Purpose : Chordoma is a potentially life-threatening disease which needs a good 

multidisciplinary care team. Surgery is the main treatment and challenging, either subtotal or total sacrectomy. 

The surgical technique is controversial, depends on tumor extent and surgeon preference. The 

purpose of this study was to review the results of treatment in patients who had a sacrococcygeal chordoma. 

Materials and Methods : A retrospective study of 8 sacrococcygeal chordoma with 

complete clinical data, radiographic imagings and histological report were reviewed since 1990. The mean 

age was 50 years (range 41-62) and 75% were males. The common problems that patients presented 

with were leg pain, mass, bowel and bladder dysfunction, buttock pain and weight loss respectively. The 

time from initial symptom until having the diagnosis was 19.5 months. Two patients were treated before 

referred to our hospital. One patient had an L4-5 discectomy and the other one had an intralesional 

curettage following with local irradiation. Four patients had a wide excision surgery (1 total sacrectomy 

and 3 subtotal sacrectomy) and the other fours had an intralesional curettage. All surgical procedures 

were done by posterior approach. Adjuvant postoperative irradiation was given to all 1 subtotal sacrectomy 

and 2 intralesional curettages but one patient with intralesional curettage was administered 

preoperatively. 

Results : All patients were followed with a mean follow-up time of 28 months (range 3- 

60). Seven patients are continuous disease free and one is alive with disease. There were 5 complications; 

2 local recurrences, 2 infections and 1 wound dehiscence. All local recurrences were occurred following 

intralesional curettage. One was treated by wide excision and the other had local irradiation. Two infections 

were managed successfully by multiple debridements. One wound dehiscence was healed by using 

of myocutaneous flap and skin graft. 

Conclusion : The management of sacrococcygeal chordoma is difficult and complicated. 

Surgery of this disease is challenging and technically demands. The result of the treatment depends on 

extent of the tumor and staging of the disease. Although wide excision has more wound complications but 

gives more promising result for local disease control. 

(From Proceedings of The Fourth Combined Meeting of Spinal and Paediatric Sections in WPOA 

and The Twenty-First Annual Meeting of the Royal College of Orthopaedic Surgeons of Thailand 

and The Thai Orthopaedic Association, Pattaya, Thailand, 1999, P. 218) 

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TREATMENT OF CONGENITAL DISLOCATED HIP BY ARTHROPLASTY 

WITH FEMORAL SHORTENING 

Keerati Chareancholvanich, Douglas A. Becker, and Ramon B. Gustilo, MD 



Key words: Hip, Arthroplasty 

This was a retrospective study of 15 hips in 11 patients with complete congenital dislocation 

of the hip treated by total hip arthroplasty and femoral shortening with a subtrochanteric double 

chevron derotation osteotomy. The mean age at the time of surgery was 51 years (range, 21-74 years), 

and the mean followup was 5.5 years (range, 2-8.5 years). Functional evaluation using the modified 

Harris hip rating system showed an excellent result in five hips and a good result in seven hips (80 % 

success rate). The location of the hip center was lowered by a mean of 8.3 cm (range, 5.7-10.4 cm). Leg 

length discrepancy in seven patients with unilateral involvement was reduced from a mean of 3.9 cm 

(range, 1.7-8.2 cm) before surgery to a mean of 1.4 cm at the latest followup (range, 0-4 cm). The 

Trendelenbury sign was assessed in 10 of 15 hips and was corrected from a positive preoperative status 

to a negative postoperative status in eight of these 10 hips. There were no cases of nonunion, dislocation, 

nerve palsy, or radiographic loosening. The only complications were a supracondylar fracture below the 

femoral component in a patient with severe osteoporosis 6 months after surgery and loosening of the 

cemented titanium metal backed acetabular component in the same patient 1.5 years after surgery. The 

current series showed that total hip arthroplasty in combination with a subtrochanteric double chevron 

derotation osteotomy has promising short to midterm results in the treatment of complete congenital 

dislocation of the hip in adults. 

(From Clinical Orthopaedics and Related Research 1999; 360: 127.) 

CEMENTLESS ACETABULAR REVISION FOR ASEPTIC FAILURE OF 

CEMENTED HIP ARTHROPLASTY 

Keerati Chareancholvanich, Antonio Tanchuling, Takahiro Seki, And Ramon B. Gustilo. 



Key words: Hip, Arthroplasty 

This study is a 5-10 to 11-year retrospective followup of 40 hips in 33 patients with 

cementless acetabular revision for aseptic failure of a cemented total hip arthroplasty. A porous coated, 

Harris-Galante acetabular component was used in all revision. Thirty-eight of the 40 hips received acetabular 

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248 


bone grafting at revision. The mean Harris Hip Score improved from 51 points just before the index 

cementless revision to 87 points at the most recent followup. Twenty-nine of 40 (73 %) hips were classified 

as having a good or excellent result. Radiolucencies were observed in seven of the 40 (18%) hips at 

the most recent followup, but none of these radiolucencies were complete or progressive. Five of the 40 

(13%) hips were rated as failures and required repeat revision. Two (5%) of these failures were caused 

by aseptic loosening, with both hips having severe acetabular bone damage at the time of the index 

revision. This failure rate for aseptic loosening was less than that reported for cemented acetabular 

revision, thereby confirming the efficacy of cementless acetabular components in revision hip surgery in 

the intermediate term. 

(From Clinical Orthopaedics and Related Research 1999; 361: 140-149) 

KNEE PAIN AFTER FEMORAL SHAFT FRACTURE AND 

OSTEOSYNTHESIS 

Waikakul S. and Waikakul W. 

Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 


Key words : Pain, Fracture femur, Arthritis 

Ispilateral knee synovitis and pain after femoral shaft fracture and osteosynthesis was 

studied in 73 patients, 11 females and 62 males. All had isolated closed fracture of the femoral shaft 

without direct injury to the knee. Synovitis was found in 12 patients (16.4%) and 9 patients (12.3%) had 

significant knee pain which retarded rehabilitation of knee function. The synovitis and pain related to the 

severity of injury and surgical approach. Prevention of this condition should be studied to promote recovery 

of the patients. 

(From : J Hand Surg (Br) 1999;243Z3X:325-7) 

ROLE OF ALLOPURINOL IN DIGITAL REPLANTATION 

S. Waikakul, A. Unnanantana and V. Vanadurongwan 



Key words : Replantation, Allopurinol 

The clinical effect of allopurinol on the attenuation of reperfusion injury in thumb replantation 

after prolonged inschaemic time were studied in a randomized control trial with a 2 year follow-up. 

There were 60 patients, in the trial group, and 38 patients in the control group. All were young and healthy 

labourers who had sharp or locally crushed amputations of the thumb at the proximal phalanx with a total 

ischaemic time of more than 10 hours. The standard management for thumb replantation was used in 

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(337)

these patients, except that 300 mg for another 5 days. After operation, the trial group had a lower infection 

rate, and less postoperative pain and chronic swelling than the control group. Recovery of sensation was 

also better in the trial group. 

(From : Pain Clin 1999;11(4):339-43) 

CHRONIC UPPER EXTREMITY PAIN IN RUBBER TREE PLANTATION 

WORKERS 

Saranatra Waikakul and Waraporn Waikakul 

Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 


Key words: Pain, Replantation 

Problems: To assess the prevalence, severity, and characteristics of cumulative trauma 

disorders involving the upper extremity in rubber tree plantation workers. 

Method: A cross-sectional study was carried out in the four southernmost provinces of 

Thailand between 1989 and 1994. There were 2609 workers, 1006 females and 1603 males. Their ages 

ranged from 28 top 69 years. Each worker was interviewed and a physical examination was carried out. 

Results: Significant chronic pain and disability in the upper extremity were found in 560 

workers (21.5%). One hundred and seventy-one (6.5%) needed regular medical treatment. The most 

common condition was carpal tunnel syndrome, followed by ulnar wrist pain, de Quervain disease and 

trigger finger. About 34% of the patients who had chronic upper extremity pain had bilateral involvement. 

Conclusion: Chronic upper extremity pain is a significant problem in these workers. 

Ways of preventing this, such as redesigning the workers’ tools and exercise, are now on trial. 

(From: Pain Clin 1999;11Z3:217-21) 

249 

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V. Rojvanit 

TOTAL KNEE ARTHROPLASTY - PS TYPE IB-II VS NEXGEN 

Department of Orthopaedic Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University 


Key words : Knee, TKA, Arthroplasty 


Purpose: A group of patients performed and followed up by a single surgeon was reviewed 

retrospectively. There were some significant clinical improvement in the latest group that using 

newer model prosthesis. The clinical outcome was measured and reported. 

Material and Methods: Between Sept. 1990 – July 1997 there were 178 cases 

underwent TKA using mostly IB-II-PS type of prosthesis. There were 158 females and 20 males. The 

age ranged from 46 to 81 years (Av. 63.4). The latest group (Aug 1997 – June 1998) underwent TKA 

using NEXGEN – LPS prosthesis. There were 37 females and 5 males in this later group. The age 

ranged from 55 to 81 years old. (Av. 65.8) The surgical approach were mostly anteromedial. 

Results: The follow up period of the first group averaged 4.8 years. The latest group 

was followed from 4 – 14 months. As far as the instrumentation was concerned, the newer system gave 

better femoral component alignment (3 degree external rotation). Clinically, the group that NEXGEN- 

LPS were used showed better range of motion (110³ - 130³ of flexion) The patellar tracking was smoother. 

Only a few case in the later group that need lateral release. This in turn reduced postoperative bleeding 

and enhance rapid postoperative rehabilitation. There were 3 superficial wound infection and 5 deep 

wound infection. Three deep wound infection were salvaged after multiple joint debridement including 

gentamycin – beads placement. Two cases required knee arthrodesis. There were 2 patellar components 

loosening which were left without replacing a new one. Three patellar clunk syndrome were encountered 

in the IB-II group. These were cleared easily under arthroscopic control. There were 3 DVT and 1 

suspected pulmonary embolism. 

Conclusion: When a well design total knee prosthesis was chosen, with good surgical 

technique and thorough postoperative rehabilitation program, the satisfactory outcome can be expected 

and obtained. We elected to resurface most of the patella. The most often used size was “button” ³ 29 

mm. The original thickness of the patella were measured and restored. 

(339)

V. Rojvanit 

RECONSTRUCTION OF ACL COMPARATIVE STUDY OF THE MIDDLE 1/3 

VS THE LATERAL 1/3 OF PLATELLAR TENDOM GRAFT (B-T-B) 

(340) 



Key words: Knee, ACL reconstruction, Patellar tendon graft (B-T-B) 

Purpose : The most commonly used autograft for ACL reconstruction is considered to 

be either patellar tendon (B-T-B) or hamstring. Middle 1/3 of patellar tendon graft with interference 

screw fixation was considered to be one of the most popular method. The author started to use lateral 1/ 

3 of the patellar tendon (B-T-B) with good preliminary result since March 1997. Review of cases in 2 

groups were carried out. The outcome in two groups were compared and reported. 

Materials and Methods : Between April 1996-Aug. 1997 there were 20 cases of ACL 

deficiency knees underwent reconstruction using patellar tendon graft (B-T-B). In group 1 (10 cases: 

eight males and two females) middle 1/3 of patellar (B-T-B) tendon was used. In group 2 (10 cases: nine 

males and one female) lateral 1/3 of patellar tendon (B-T-B) was used. In group 1 fixation was accomplished 

by using interference screws. In group 2 Mitek anchoring device was used. The average age in 

each group was almost equal: 29.6 and 31.8 years respectively. The immediate fixation was tested 

intraoperatively by manual testing and appeared to be equally stable by both techniques. Postoperatively, 

all patients were immobilized with the regular hinged-knee support. CPM was instituted postoperatively 

from day one whenever available. 

Results : Average follow-up period in this small series is 16 months (range 13-28 

months). Most of the patients were placed on crutch-walk for 4 weeks. R.O.M. were in the 

range of 120-140 degrees at 6 weeks. There was no laxity postoperatively. Depend on the 

strength of the thigh muscles in each individual, some felt much stronger than preop and required 

knee support and crutch-walk for less than 3 weeks. Practically vigorous rehabilitation programs 

were allowed. Both objective and subjective short-term results in both groups appeared to be 

satisfactory. As far as the timing for going back to sports participation is concerned, a period of 

9 months span was advised. 

Conclusion: The advantage of using lateral one third of patellar tendon as a graft is that 

there is no need to add extra suture at the gap of the harvested site. The bony defect in the patella was 

filled with cancellous graft obtained from tibial side. Clinically, good short term results in both groups 

seem to be comparable. 

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V. Rojvanit 

AVOIDNESS AND TREATMENT OF COMPLICATION IN PRIMARY TOTAL 

KNEE ARTHROPLASTY 



Key words : Knee, Arthroplasty, Complication 


Purpose: Although total joint arthroplasty in osteoarthritic and rheumatoid arthritis patients 

is a common procedure. There were failures in the knee that leading to revision total knee replacements 

up ten or more percents in some centers. This study evaluated the outcomes of our first 210 

primary total knee arthroplasty. 85% of the cases were observed through a period that extended beyond 

5 years. 

Material and Methods: Beginning in Sept. 1990, data from 210 patients were reviewed 

and analysed. There were 195 females and 25 males. The age ranged from 46-81 (Av. 64.6). The most 

often used prosthesis in this small series were mostly IB-II-PS type. About 15% of the cases were 

replaced with the newer model NEXGEN-LPS. The approach were anterior midline and paramedial 

patellar approach. 

Results : There were 9 wound complications 3 superficial and 6 deep wound infections. 

Three deep wound infection were salvaged after multiple joint debridement. Three cases required knee 

arthrodesis. There were 5 patellar complications mostly aseptic loosening, 2 were re-resurfaced, 3 were 

left without putting in a new prosthesis. Periprosthetic fracture were encountered in 3, open reduction 

and internal fixation were attempted. Three patellar clunk syndrome were seen exclusively in the group 

that using IB-II prosthesis. Arthroscopic removal of the fibrotic tissue helped relieving the symptom. 

Three deep vein thrombosis and one suspected pulmonary embolism were also encountered. 

Discussion : Primary wound healing is critical for the success of any total knee arthroplasty 

(TKA). Proper selection of skin incision and an understanding of vascular anatomy are mandatory. 

Infection remain the nightmare that every one try to avoid. Although multiple debridement may sometimes 

salvage the prosthesis, majority of cases still had to undergo revision or arthrodesis. Patello-femoral 

resurfacing resulted a high rate of complications in the past (5-55%). We tried to use smaller diameter 

“button” like ³³ 29 and avoid metal-backed. Patellar clunk syndrome can be avoided by intraoperative 

removal of synovium and plicae at the posterior aspect of quadriceps closed to the proximal pole of the 

patella. Supracondylar fracture is a challenging problem , although lateral plating had been widely practiced, 

however a locked intramedullary rod is also worthy of consideration. 

Conclusion : One of the most fundamental consideration for the prevention of TKA 

complications in general is the selection of an implant and instrumentation system that yield the best 

flexibility and minimize the chances for technical error. Alignment and stability are the two most important 

points when durability issue is concerned. We felt that the PCL-substituting designs offer a wider margin 

of safety. Cemented designs possess more inherent stability and will better tolerate the aggressive ligament 

release required to correct severe deformities. 

(341)

PRIMARY TOTAL KNEE ARTHROPLASTY OUR RECENT ATTITUDE 

Vatanachai Rojvanit 

Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University 

Key words : Knee, Arthroplasty 

Purpose : We reviewed our past experiences of performing primary total knee 

arthroplasty since 1990 in order to pick up surgical pitfalls and avoid complications. 

Materials & Methods : Two hundred and ten cases were reviewed. There were 195 

females and 25 males in this small series. We emphasized on preoperative planning with full-length AP 

radiographs of both legs. Intraoperatively, careful soft tissue balance along with precise bone cut will 

enable one to obtain nice extension and flexion gap. Appropriate size of prosthesis should be selected. 

Positioning of the femoral component was of utmost important. Three degrees of external rotation was 

usually added. We preferred to install a smaller diameter of patellar “button” : ³ 29 or ³ 26 mm. 

Restoration of the patellar thickness (height) were attempted and measured. Postoperative care : bulky 

Jones compression dressing with two vacuum drains were left for 2 days. From the 3 rd postop. day 

mobilization was allowed with walking aid and CPM machines were used whenever available. 

Results: More than half of this group had a 5-years follow up. Those who have gained 

good ROM (>120³) usually obtained such range within 4 weeks. Only a few number of patient needed 

manual manipulation under anesthesia. Wound infection remain one of the greatest drawback in this type 

of surgery. The incidence was 2.5% which was considered to be high when comparing this data to other 

series. The rest of the complications were patellar clunck which can be avoided by excision of the 

suprapatellar plicae and synovium. 

Discussion : We felt that patient selection should be strictly follow according to the 

criteria. The surgeon should be acquainted with the instrumentation that being used. The correct alignment 

of the leg and soft tissue balancing were two key factors that govern both the longevity of the prosthesis 

and also R.O.M. of the knee. All medical personnels and surgical team who were involved and surgical 

theatres should be under strict sterile technique control. 

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PNEUMOCYSTIS CARINII SEVERE PNEUMONIA AMONG HUMAN 

IMMUNODEFICIENCY VIRUS-INFECTED CHILDREN IN THAILAND : 

THE EFFECT OF A PRIMARY PROPHYLAXIS STRATEGY. 

(343) 

Chokephaibulkit K. Wanachiwanawin D. Chearskul S. Wanprapa N. Unganont K. Tantinikorn 

W. Udompunthurak S. 

Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol 

University, Bangkok, Thailand. Sikch@mahidol.ac.th 

Background : A knowledge of the epidemiology of Pneumocystis carinii pneumonia 

(PCP) is important for the development of a strategy of primary PCP prophylaxis and empiric treatment 

for severe pneumonia in HIV-infected children. However, little is known about the epidemiology of PCP 

in developing countries. Objective. To measure the relative rate of PCP among hospitalized HIV-infected 

children with severe pneumonia in Bangkok and evaluate the effect of a strategy of primary PCP prophylaxis 

in HIV-exposed infants. 

Methods : All HIV-infected children hospitalized from January, 1996, to December, 

1997, for severe pneumonia were investigated for PCP with the use of specimens obtained from 

bronchoalveolar lavage, endotracheal aspiration of lung tissue necropsy. Characteristics associated with 

severe pneumonia were described, and the differences between PCP and non-PCP in these severely ill 

children were analyzed. In June, 1996, a strategy of primary PCP prophylaxis using trimethoprimsulfamethoxazole 

in all HIV-exposed infants from 1 to 6 month of age was initiated in our institution. The 

effect of this strategy was evaluated. 

Results : of 279 hospitalized HIV-infected children 128(46%) were diagnosed with 

pneumonia and 26 (20%) of these had severe pneumonia. P. Carinii was identified in 9 (35%) children 

with severe pneumonia. After June, 1996, the rate of severe pneumonia among all hospitalized children 

decreased from 16% from January through June, 1996, to 7% from July, 1996, through December, 1997 

(P=0.02). Cases of PCP decreased from 9 in 1996 to zero in 1997. The percentage of HIV-infected 

children receiving PCP prophylaxis at the time of admission increased from 53% before June, 1996, to 

72% in late 1997 (P=0.04). The overall percentage of patients with severe pneumonia receiving PCP 

prophylaxis at the time of admission was 34%. Breakthrough PCP occurred in 2 children with poor 

compliance. Patients with PCP were significantly younger than those without PCP (mean age, 10.6+/- 

10.6 vs. 29.8+/-28.3 months, P=0.02). 

Conclusion : PCP occurred in one-third of cases of severe pneumonia in HIV-infected 

children in Bangkok. The data suggest that PCP prophylaxis can prevent both PCP and non-PCP. 

(Pediatric Infectious Disease Journal. 18(2): 147-52, 1999 Feb)

PRIMARY CRYTOCOCCAL INFECTION OF THE LARYNX IN A PATIENT 

WITH AIDS : A CASE REPORT 

Cheerasook Chongkolwatana1 , Parvinee suwanagool2 , Surapol 

suwanagool3 , Kanthong Thongyai1 , Samut Chongvisal1 (344) 

, Choakchai Metheetrirut 

1 Department of Otolaryngology, 

2 Department of Pathology, 3 Department of Preventive Medicine, Faculty of Medicine, Siriraj 

Hospital, Mahidol University, Bangkok 10700, Thailand. 

Primary larygeal cryptococcosis was reported in a 42-year-old man with AIDS. The patient also 

had pulmonary tuberculosis and hydropneumothorax as a complication. Serological tests and/or cultures 

from blood, CSF, urine and pleural fluid were all negative for crypremained clear in the follow-up period 

9 months after treatment. 

(Journal of the Medical Association of Thailand. 81(6):452-7, 1998 Jun.) 

THE FIRST NASO-SINUS LABORATORY FOR CADAVER PREPARATION 

IN THAILAND 

(345) 

Bunnag C. Dachpunpour P. Jareoncharsri P. Vitavasiri A. 

Department of Otolaryngology, School of 

Medicine, Siriraj Hospital, Mahidol University,Bankok. 

The first naso-sinus laboratory has been set up in Siriraj Hospital for better training of 

rhinosurgeons. The specimens used for practice operation are the entire nasal cavities with all paranasal 

sinuses, taken from cadavers and preserved in 95% ethanol. The “Siriraj” sinus holder is specially designed 

and constructed to hold various sizes of specimens. It is made of plastic board and stainless steel 

screws; it is an inexpensive and simple device which can be afforded by every centre. With this nasosinus 

laboratory, ENT residents and rhinosurgeons can achieve their skills in performing nasal endoscopy, 

endoscopic or microscopical sinus surgery and all kinds of sinus operations at their convenience. 

(Rhinology. 34(2):125-7 , 1996 Jun.) 

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256 

NASOPHARYNGEAL TUBERCULOSIS 

Cheerasook Chongkolwatana 1 , Samut Chongvisal 1 , Choakchai Metheetrairut 1 , Amornwan 

Nilsuwan 2 , Phawin Keskool 2 

1 Department of Otolaryngology, Faculty of Medicine, Siriraj Hospital, Mahidol University, 

Bangkok 10700. 2 Department of Otolaryngology, Faculty of Medicine, Thammasart 

University, Pathumthani 12120, Thailand. 

Nasopharyngeal tuberculosis used to be a common disease in the upper aerodigestive 

system. Before 1920, 1.4 and 6.5 per cent of all adenoids and tonsils removed from asymptomatic 

patients were infected by tuberculosis. After the introduction of antituberculous chemotherapy and 

BCG vaccination, this disease was considered uncommon and sporadic cases were reported in the 

medical literature. Recently, tuberculosis has begun to increase again due to the high global HIVinfected 

rate and antituberculous drug resistance among these people. To describe and highlight the 

clinical features of this condition, fifteen Thai patients (7 males and 8 females) from the Department of 

Otolaryngology, Sirirah Hospital, Bangkok, Thailand were reviewed. Cervical lymphadenopathy was 

the most common presenting symptom in our series (93.34%). 11 of them were classified as primary 

nasopharyngeal tuberculosis and most had abnormal nasopharyngeal findings by mirror examination 

except 2 cases. Although all had histopathological confirination of nasopharyngeal tuberculosis, 

sometimes problems occur in the diagnosis between this disease and nasopharyngeal carcinoma, which 

are also common among Oriental people in many of their clinical similarities. Therefore routine 

nasopharyngeal biopsy is considered justified and diagnostic. 

(Journal of the Medical Association of Thailand. 81(5):329-33, 1998 May.) 

TRANSPOSITION OF THE LINGUAL THYROID : A NEW ALTERNATIVE 

TECHNIQUE 

Rojananin S. Ungkanont K. 


Division of Head, Neck, and Breast Surgery, Department of Surgery, Faculty of Medicine, 


Background : In symptomatic lingual thyroid, surgical transposition of the gland with 

its vascular supply infact seems to have superior results to those obtained by surgical ablation and 

autotransplantati. However, the procedure should be simple, reproducible, reliable, and cause less 

morbidity as well as providing simple access to and evaluation of the gland postoperatively. 

Methods : We present the case of a 33-year-old female with lingual thyroid who was 

treated by transposing the whole gland to the lateral pharyngeal wall through a lateral pharyngotomy 

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incision. The transposed lingual thyroid was nourished by a random tongue muscle pedicle flap. 

Result : At the 5-month postoperative stage, iodine scanning reviewed the radioactivity 

uptake of the transposed gland. Even though the patient was not on postoperative thyroid hormone supplement, 

her thyroid function gradually returned to normal after initially showing hypothyroid postoperatively. 

Conclusion : This new technique for transposition of lingual thyroid is simple and reliable 

and should be considered as an alternative method in the management of symptomatic patients. 

Copyright 1999 John Wiley & Sons, Inc. Head Neck 21: 480-483, 1999. 

(Head & Neck. 21(5):480-3, 1999 Aug.) 

CHARACTERISTICS OF ATROPHIC RHINITIS IN THAI PATIENTS AT 

THE SIRIRAJ HOSPITAL 

C. Bunnag 1 , P. Jareoncharsri 1 , P. Tansuriyawong 1 , W. Bhothisuwan 2 , N. Chantarakul 3 

1 Department of Otolaryngology, 2 Department of Radiology, 3 Department of Pathology, Faculty 

of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand. 

The common characteristics of primary atrophic rhinitis were studied in 46 Thai patients. 

From history and demographic data the female to male ratio was found to be 5.6 to 1. The significance of 

environmental factors was supported by the findings that 69.6% were people from rural areas and 43.5% 

were industrial workers but a hereditary factor has not been confirmed. The results of the blood tests did 

not elucidate iron deficiency anemia or nutritional deficiency as the cause of primary atrophic rhinitis. 

However, all nasal swab cultures yielded pathogenic organisms where Klebsiella species especially, K. 

Ozaena, were the most common bacteria isolated which were 100% susceptible to cephalosporins. This 

finding together with the evidence of sinusitis seen in 58.7% of either plain x-rays or CT scans, was 

suggestive of the important role of infection in atrophic rhinitis. Atrophic change of the mucosa and bone 

with widening of the nasal cavity were constant findings in the CT scans but the developmental anomaly 

of the maxillary antrum was found in only 15.2%. The histological study showed characteristic changes 

especially squamous metaplasia and 80% of the cases were compatible with the Type II histopathological 

classification, i.e vasodilatation of the capillaries. The mucociliary function was proven to be impaired in 

accordance with the loss of cilia. The evidence of Type I allergy demonstrated by skin testing, which was 

obvious in 85%, is highly suggestive of allergic/immunologic disorders. Although many factors have been 

cited previously as the possible cause of primary atrophic rhinitis, the common characteristics found in our 

patients indicate that only bacterial infection, environmental factors and allergic/immunologic disorders 

could be one or more of its multifactorial etiology and should be further investigated. 

(Rhinology. 37: 125-130,1999) 

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NASAL ENDOSCOPIC FINDINGS IN PATIENTS WITH PERENNIAL 

ALLERGIC RHINITIS 

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Perapun Jareoncharsri, Vathana Thitadilok, Chaweewan Bunnag, Kitirat Ungkanont, Siriporn 

Voraprayoon and Prayuth Tansuriyawong 

Department of Otolaryngology, Faculty of Medicine Siriraj Hospital, Mahidol University. 

Nasal endoscopy was carried out in 83 patients with perennial allergic rhinitis to evaluate 

endonasal anatomic variation and to find the correlation between the symptoms of patients and the endoscopic 

findings. All of the patients had nasal symptoms, 7.2% of the patients were runner, 7.2% were 

blocker and 85.6% were both. 86.75% of the patients had allergyrelated symptoms, ie. Throat symptoms 

(73.5%), sinus headache (50.6%), and smell disturbance (10.8%). 95.2% of patients had abnormal 

endoscopic findings, ie. Deviated: nasal septum (72.3%), abnormal middle turbinate (49.4%), narrowing 

of the entrance into the frontal recess (30.1%), septal spur (25.3%), obstruction of the entrance into the 

frontal recess (30.1%), septal spur (25.3%), obstruction of the entrance into the frontal recess (19.3%), 

nasal polyps (15.7%), mucopurulent discharge (14.5%), inferior turbinate hypertrophy (10.8%), abnormal 

uncinate process (9.6%), abnormal ethmoid bullae (7.2%), and enlargement of aggar nasi cells (2.4%). 

There was no significant correlation between each symptom and each endoscopic finding. However, 

there was a significant correlation between sinus headache and all of the combined abnormal endoscopic 

findings (P

WARMING OF FEET ELEVATES NASAL MUCOSAL SURFACE 

TEMPERATURE AND REDUCES THE EARLY RESPONSE TO NASAL 

CHALLENGE WITH ALLERGEN 

Assanasen P. Baroody FM. Naureckas E. Naclerio RM. 

Section of Otolaryngology-Head and Neck Surgery, The Prizker School of Medicine, The University 

of Chicago, 60637, USA. 

Background : We have previously shown that hot, humid air partially reduces the early 

allergic response. Mechanisms for this effect have been suggested, but none has gained universal acceptance. 

The most likely explanations are a modification of mucosal temperature or a reduction in nasal 

secretion osmolality. 

Objective : We sought to investigate whether increasing the nasal mucosal surface 

temperature by immersing feet in warm water (WW) could decrease the immediate nasal response to 

challenge with allergen. METHODS: We performed a randomized, 2-way crossover study on 14 subjects 

with seasonal allergic rhinitis outside of their allergy season. They immersed their feet in either WW (42 

degrees C) or room temperature water (RW; 30 degrees C) for 5 minutes before and during nasal challenge 

with diluent for the allergen extract, followed by 2 increasing doses of allergen. 

Results : There was a statistically significant increase in nasal mucosal temperature 

from baseline after warming of feet (WW, 1.9 +/- 0.1 degrees C, vs RW, 0.2 +/- 0.1 degrees C; P=.001), 

but there were no significant differences in body temperature (WW , 0.1+/- 0.1 degrees C, vs RW, 0.4+/ 

- 0.1 degrees C; P=1). Net changes from diluent challenge for all parameters were compared between 

immersion of feet in WW and RW. Immersion of feet in WW significantly inhibited allergen-induced 

sneezes (WW, 5.7 +/- 1.1 , vs RW, 11.6 +/- 3.2; P, .01), human serum aibumin levels (WW, 941.7 +/- 172.2 

microg/mL Vs RW, 1524.8 +/- 220.6 microg/mL; P< .01), and secretion weights (WW, 30.5 +/- 7.2 mg , 

vs RW, 41.8 +/- 6.8 mg; P< .01). 

Conclusion : Our data show that warming of feet decreases the early response to 

nasal challenge with antigen. This inhibitory effect is probably related to the increase in the nasal mucosal 

temperature. 

(Journal of Allergy & Clinical Immunology. 104(2 Pt 1):285-93, 1999 Aug.) 

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INTESTINAL PARASITIC INFECTIONS IN HIV AND NON-HIV 

INFECTED PATIENTS WITH CHRONIC DIARRHEA IN THAILAND 

Darawan Wanachiwanawin 1 , Sathaporn Manatsathit 2 , Punpob Lertlaituan 1 , Kleophant 

Thakerngpol 3 , Parvinee Suwanagool 3 

Departments of 1 Parasitology, 2 Medicine, 3 Pathology, Faculty of Medicine Siriraj Hospital, 

Mahidol University, Bangkok 10700, Thailand. 

Key words : intestinal parasitic infections, HIV and non-HIV, chronic diarrhea 

Chronic diarrhea is a common problem in AIDS patients, and enteric parasites are recognized 

as important causes. This study determined the prevalence of parasitic infections in HIV infected 

patients with chronic diarrhea. Ninety-one patients with AIDS who presented with chronic diarrhea and 

103 patients who were HIV negative were enrolled in the study. Detection of stool parasites was made 

by microscopy of simple smear, formalin-ether concentration method, modified acid-fast and modified 

trichrome staining techniques. Species identification of microsporidia spores was made by transmission 

electron microscopy (TEM). Cases in which serial fecal examinations were negative were subjected to 

gastroduodenoscopy and/or colonoscopy. Parasitic infections were found in 51 (56%) AIDS patients 

with chronic diarrhea and in 18 (17%) non-HIV cases (p < 0.001). Microsporidia and Cryptosporidium 

parvum were the most common parasites found in HIV infected patients and were also significantly more 

prevalent than in non-HIV infected cases [29% vs 0% for microsporidia, (p < 0.001), and 25% vs 1% for 

C.parvum,(p

parasites found in stool were Blastocystis hominis, hookworms, Giardia lamblia, Strongyloides 

stercoralis and Opisthorchis viverrini. Such findings were similar to previous reports, but in 

lower percentages. Thus, continuity of public health education and sanitation improvement should be 

concerned for prevention and control of parasitic infections. 

(Siriraj Hosp Gaz 1999; 51: 225-231.) 

TREATMENT OF ACANTHAMOEBA KERATITIS WITH 

CHLORHEXIDINE 

Panida Kosrirukvongs 1 , Darawan Wanachiwanawin 2 , Govinda S. Visvesvara 3 

Departments of 1 Ophthalmology, 2 Parasitology, Faculty of Medicine Siriraj Hospital, Mahidol 

University, Bangkok 10700, Thailand. 3 Division of Parasitic Diseases, Center for Disease Control, 

Atlanta, Georgia, U.S.A. 

Key words : Acanthamoeba keratitis, treatment, chlorhexidine 

Objective: To evaluate the efficacy of chlorhexidine solution in the treatment of patients 

with Acanthamoeba keratitis. 

Design: Prospective nonrandomized study. 

Participants: Five patients infected with culture-proven Acanthamoeba keratitis. 

Intervention: Chlorhexidine solution was used hourly on six eyes and gradually reduced 

to four times a day after 1 month. Follow-up ranged from 1 to 10 months (mean, 4 months). 

Main Outcome Measures: Severity of symptoms and signs, time for healing and final 

visual acuity. 

Results: Clinical results in four patients showed improved visual acuity, with a rapid 

recovery within one week. No adverse drug reaction was encountered, but one patient with a perforated 

ulcer developed glaucoma. Eighty-three percent of 6 eyes were medically cured with chlorhexidine and 

recovered visual acuity 6/18 or better. Four of five patients improved within three weeks with resolution 

of infiltration, and healing of epithelial defects. By two to three weeks visual acuity 6/18 or better had 

improvedin 4 (66.7%) of 6 eyes and recovered 6/6 in 2 eyes (33.3%). Bacterial coinfection occurred in 

one eye. 

Conclusion: Chlorhexidine dramatically hastened clinical improvement in all eyes and is 

a successful medical therapy that has excellent results in patients who are diagnosed early. 

(Ophthalmology 1999; 106: 798-802.) 

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IMMUNODEFICIENCY VIRUS-INFECTED CHILDREN IN THAILAND: 

THE EFFECT OF A PRIMARY PROPHYLAXIS STRATEGY 

Kulkanya Chokephaibulkit 1 , Darawan Wanachiwanawin 2 , Sanay Cherskul 1 , Nirun Wanprapa 1 , 

Kitirat Unganont 3 , Weerachai Tantinikorn 3 , Suthipol Udompunthurak 4 

Departments of 1 Pediatrics, 2 Parasitology, 3 Otolaryngology and 4 Epidemidogy, Faculty of Medicine 


Key words : Pneumocystis carinii pneumonia, HIV-infected children, prophylaxis 

Objective: To measure the relative rate of PCP among hospitalized HIV-infected children 

with severe pneumonia in Bangkok and evaluate the effect of a strategy of primary PCP prophylaxis 


Methods: All HIV-infected children hospitalized from January, 1996 to December, 1997, 

for severe pneumonia were investigated for PCP In June, 1996, a strategy of primary PCP prophylaxis 

using trimethoprim-sulfamethoxazole in all HIV-exposed infants from 1 to 6 month of age was initiated in 

our institution. 

Results: Of 279 hospitalized HIV-infected children 128 (46%) were diagnosed with 

pneumonia and 26 (20%) of these had severe pneumonia. P. carinii was identified in 9 (35%) children 

with severe pneumonia. After June, 1996, the rate of severe pneumonia among all hospitalized children 

decreased from 16% from January through June, 1996, to 7% from July, 1996, through December, 1997 

(P = 0.02). Cases of PCP decreased from 9 in 1996 to zero in 1997. The percentage of HIV-infected 

children receiving PCP prophylaxis at the time of admission increased from 53% before June, 1996, to 

72% in late 1997 (P = 0.04). The overall percentage of patients with severe pneumonia receiving PCP 

prophylaxis at the time of admission was 34%. 

Conclusion: PCP occurred in one-third of cases of severe pneumonia in HIV-infected 

children in Bangkok. The data suggest that PCP prophylaxis can prevent both PCP and non-PCP. 

(Pediatr Infect Dis J 1999; 18: 147-52.) 

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DETECTION OF TOXOPLASMA GONDII IGG ANTIBODIES IN 

THAI PATIENTS BY ENZYME-LINKED IMMUNOSORBENT AND 

IMMUNOBLOT ASSAYS 

Vanna Mahakittikun 1 , Sirichit Wongkamchai 1 , Nimit Morakote 2 , Virach Junnu 1 , Darawan 

Wanachiwanawin 1 , Joon Wah Mak 3 

1 Department of Parasitology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 

10700, Thailand, 2 Department of Parasitology, Faculty of Medicine, Chiang Mai University, 

Chiang Mai, Thailand, 3 Institute for Medical Research, Kuala Lumpur, Malaysia. 

Key words : Toxoplasma gondii; immunoblot; ELISA; IgG anti-Toxoplasma antibodies 

An in-house ELISA was developed for detection of IgG Toxoplasma antibody using 

either pellets and/or supernatant from sonicated Toxoplasma tachyzoites as crude antigen. This method 

was compared with a commercial p-30 ELISA which uses the membrane protein p-30 protein as the 

predominant antigen. A total of 259 sera from 3 groups of patients were tested. The in-house ELISA 

using either parasite pellets or supernatant antigen showed equal sensitivity (87.0%) in detection of IgG 

antibodies to Toxoplasma. The specificities of pellet and supernatant-based assays were 97.9% and 

95.3% respectively. By Kappa analysis, highly significant correlation coefficient was obtained between 

the in-house ELISA and the commercial test kit (Kappa correlation between the in-house ELISA using 

pellet as antigen and Platelia = 0.869, p < 0.001; that using the supernatant as antigen and Platelia = 0.822, 

p < 0.001). There was a good concordance between in-house ELISA and p-30 ELISA results. In 

addition, the usefulness of the immunoblot assay for the detection of IgG antibodies to Toxoplasma was 

evaluated. Both antigens show generally similar polypeptide bands. The protein component with a molecular 

weight of 31 kDa reacted strongly with IgG antibodies in the majority of Toxoplasma seropositive 

sera (75.3%). It may represent a specific marker for diagnosis of Toxoplasma infection in Thai patients. 

(International Medical Research Journal 1999; 3(1): 51-55.) 

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UTILITY OF GELATIN PARTICLE INDIRECT AGGLUTINATION TEST 

FOR SERODIAGNOSIS OF TOXOPLASMA GONDII IGG ANTIBODIES 

DETECTION OF TOXOPLASMA GONDII IGG ANTIBODIES 

Vanna Mahakittikun 1 , Sirichit Wongkamchai 1 , Sumalee Pogprasart 2 , Virach Junnu 1 , Dorn 

Watthanakulpanich 3 

1 Department of Parasitology, 2 Department of Clinical Pathology, Faculty of Medicine Siriraj 

Hospital, 3 Department of helminthology, Faculty of Tropical Medicine, Mahidol University, 

Bangkok 10700, Thailand. 

Key words : gelatin particle indirect agglutination test, GPAT, toxoplasmosis 

The antibody response against Toxoplasma gondii was evaluated by gelatin particle 

indirect agglutination test (GPAT) in 296 sera. The test was compared with p-30 ELISA for the ability to 

detect Toxoplasma specific IgG antibodies. Gelatin particle, an antigen carrier was sensitized with soluble 

antigen from sonicated Toxoplasma tachyzoites. The cutoff value of > 1:16 was considered positive. In 

296 sera studied, 286 sera (96.62%) gave the same qualitative result in both tests while the remaining 10 

sera (3.37%) show discrepancies results. Thirty-three of 37 (89.18%) sera from patients with symptoms 

suggestive of toxoplasmosis tested positive by GPAT and ELISA. By Kappa analysis, the correlation 

between antibody titer obtained with GPAT and ELISA was statistically significant (k = 0.849, p < 0.001 

and r 2 = 0.7068). The GPAT can be easily and rapidly performed without specialized equipment and 

likewise seems to be useful for the test of small number of specimens as well as mass screening or where 

laboratory facilities are limited. 

J Protozool Res 1999; 9(3) (in press) 

IMMUNOBLOTTING AND ENZYME LINKED-IMMUNOSORBENT 

ASSAY FOR DIAGNOSIS OF TOXOPLASMA INFECTION IN HIV 

THAI PATIENTS 

Sirichit Wongkamchai 1 , Vanna Mahakittikun 1 , Paron Dekumyoy 2 , Jerawan Onrotchanakun 1 . 

1 Department of Parasitology, Faculty of Medicine Siriraj Hospital, 2 Department of Parasitology, 

Faculty of Tropical Medicine, Mahidol University. 

Key words : immunoblot, enzyme-linked immunosorbent assay, Toxoplasmosis and HIV 

Toxoplasma gondii has been recognized as an important cause of morbidity and mortality 

among immunocompromised persons. The diagnosis of T. gondi infection is most often based on serological 

tests results. Serological diagnosis can be limited in AIDS patients because of depressed antibody 

responses. Fifty serum samples were used in this study to investigate serological evidence of toxoplasmosis 

in HIV positive Thai patients by Platelia kit, the commercial enzyme-linked immunosorbent assay 

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(ELISA) in which the membrane protein p-30 is the predominant antigen and immunoblot technique (IB). 

Sera of HIV positive Thai patients with Toxoplasma infection recognized the same antigenic component, 

the 32 kDa antigenic band, as is recognized by Toxoplasma positive sera from immunocompetent patients 

and it may represent a specific marker for diagnosis of Toxoplasma infection in HIV positive Thai patients. 

Both ELISA and IB are comparable for the detection of Toxoplasma infection in HIV infected 

patients. 

Southeast Asian J Trop Med & Public Health 1999; 30 (3) (in press) 

FACTORS AFFECTING THE VIABILITY OF PATHOGENIC 

NAEGLERIA SPECIES ISOLATED FROM THAI PATIENTS 

Tiewchaloren S, Junnu V. 

Department of Parasitology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Prannok 

Road, Bangkoknoi, Bangkok 10700, Thailand. 

Key words : viability, pathogenic Naegleria sp. 

Three pathogenic Naegleria species were compared to a reference strain for their ability 

to withstand extremes of temperature, pH, salinity, chlorine, ultraviolet light and formalin. There was 

no marked difference between the strains. Trophozoites degenerated in hours at temperatures below 

–40 oC. After being frozen, trophozoites in both groups did not survive in culture in axenic Nelson 

medium. Pathogenic Naegleria sp. were killed at temperatures greater than 50 oC for 24 hours. Amoebae 

could not survive in a pH of less than 5 or more than 12. Trophozoites were destroyed in saline 

concentrations higher than 2% and chlorine concentrations greater than 0.75 ppm. In addition, all Naegleria 

were sensitive to formalin at concentrations greater than 0.05%. However, they were resistant to ultraviolet 

light. 

(J Trop Med Parasit 1999; 22: 15-21.) Supported in part by Research Grant No 75-348-270 from 

the China Medical Board Fund 1997. 

IN VITRO EFFECT OF AMPHOTERICIN B AND GENTAMICIN 

ON PATHOGENIC NAEGLERIA SPECIES ISOLATED FROM 

TWO CASES OF PRIMARY AMOEBIC MENINGOENCEPHALITIS 

Tiewchaloren S, Lertlaituan P. 

Department of Parasitology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 


Key words : amphotericin B, gentamicin, pathogenic Naegleria sp. 

An amoeba of the genus Naegleria causing fatal meningoencephalitis in human subjects 

was investigated for its sensitivity to amphotericin B and gentamicin. The efficiancy of both drugs for 

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pathogenic Naegleria sp. (PNS) was investigated in two strains isolated from dead patients 

with primary amoebic meningoencephalitis infection from Siriraj Hospital (1986) and Ramathibodi Hospital 

(1987). The results showed that the minimum inhibitory concentration (MIC) of amphotericin B to the 

two PNS specimen from Siriraj and Ramathibodi Hospital were 0.5 and 0.25 mg/ml in 6 hours, respectively 

(p

ULTRASTRUCTURE OF PATHOGENIC NAEGLERIA SP. ISOLATED FROM 

THREE CASES OF PRIMARY AMOEBIC MENINGOENCEPHALITIS 

INFECTION FROM THAI PATIENTS 

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Mangkalanond K, Tiewchaloren S, Junnu V, Pattavum A. 

Department of Pathology, Faculty of Medicine Siriraj Hospital, 1 Department of Parasitology, 

Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Department of Nursing, Faculty of 


Key words : ultrastructure pathogenic Naegleria sp. strain 

The proliferative form of Naegleria sp. isolated from three fetal Thai patients were 

studied. The showed no differentiation from the pathogenic Naegleria fowleria reference strain. In 

light microscope, the amoebae were active, progressive and had directional movement. They were 

variable in sized and shape, the round amoebae were measuring about 8 to 30 mm. in diameter. The blunt 

psuedopadia were protruded on the surface of the cell. In iron hematexyline stain, the cytoplasm appears 

finely granular nucleolus giving it the appearance of a halo. Contractile and food vacuoles were demonstrated. 

The ultrastructure of the pathogenic Neagleria sp. were not distinguished from that of the 

control. Scanning electron microscope showed irregular outer surface was and points of contact between 

them were conspicuous. Sucker-like structure on amoebostomes were found in either group. 

Transmission electron microscope demonstrated that the surrounding unit membrane was composed of 

two electron-dense layers. Rough endoplasmic reticulum appear as elongated tubular vesicle covered 

with ribosomes. Dumb-bell-shape mitochondria was bound by two membranes separated by a clear 

space. Both, cup-shaped and oval-mitochondria were also found. The vacuoles were bound by unit 

membrane and contained electron-dense materials surrounded by whorl-like formations. The nuclear 

membrane was bounded by two clearly visible electron dense layers that were seperated by a clear 

space. A few pores could be seen within the nuclear envelope. Nucleolus at the central portion of the 

nucleus appears dens. In conclusion, the results showed remarkable similarities between the pathogenic 

Naegleria sp. and the control. Therefore, these pathogenic Naeglerias isolated from fatal cases of 

amoebic meningoencephalites were considered as Naegleria fowleri. 

(Mahidol J 1999; 6: 85-88.) 

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ANGIOCENTRIC LYMPHOMA OF THE PANCREAS PRESENTING 

AS LATE ONSET DIABETES MELLITUS WITH OPTIC NEUROPATHY : 

A CASE REPORT 

S. Sukpanichnant 1 , T. Sangruchi 1 , P. Prasopchoke 1 , S. Vatanavicharn 2 , S. Charoenratanakul 2 , 

V. Leenutaphong 3 , K. Kulthanan 3 , W. Cheunkongkaew 4 

Departments of 1 Pathology, 2 Medicine, 3 Dermatology, and 4 Ophthalmology, Faculty of Medicine 

Siriraj Hospital, Mahidol University, Bangkok, Thailand. 

Malignant lymphoma of the pancreas presenting with clinical diabetes mellitus (DM) is 

rare. We report angiocentric lymphoma of the pancreas in a 65-year-old Thai female who presented with 

progressive deterioration of visual acuity of both eyes, only 20 months after the diagnosis of DM at the 

age of 63. She had received 5 mg of glibenclamide daily but the level of blood sugar was poorly controlled 

(approximately 200 mg/dL). She did not have hypertension. She was previously healthy and was a 

mother of 9 healthy children. She had developed bilateral arteritic optic neuropathy, which was uncontrolled 

despite systemic corticosteroid therapy for 4 months prior to the referral to Siriraj Hospital. The 

visual acuity of both eyes was at the distance of hand movement. On admission, she suffered from 

diarrhea, fever, and adrenal insufficiency. She recovered after treatment for adrenal insufficiency and 

other supportive cares. No lymphadenopathy or organomegaly was noted. On the follow-up fundoscopy, 

only changes consistent with diabetic retinopathy were noted; no arteritis was detected. On the 12 th 

admission day, she developed erythematous rashes on her face and trunk. She later had fever, deterioration 

of consciousness, and eventually died from shock. A skin biopsy and bone marrow examination 

revealed angiocentric T-cell lymphoma, confirmed by paraffin-section immunoperoxidase shortly after 

the patient’s death. At autopsy, in contrast to other typical cases of long standing DM, only mild atherosclerosis 

was noted and no diabetic retinopathy was found. The pancreas was extensively infiltrated by 

lymphoma cells, responsible for clinical DM. Moreover, lymphoma heavily infiltrated choroid of both 

eyes. It also had a widespread involvement of nearly all organs but no superficial lymphadenopathy was 

detected. To the best of our knowledge, this is the first case of lymphoma involving the pancreas and both 

eyes producing clinical DM and optic neuropathy. 

CENTRAL NERVOUS SYSTEM IN VOLVEMENT IN ROSAI-DORFMAN 

DISEASE :REPORT OF A CASE WITH A REVIEW OF THE LITERATURE 

Shanop Shuangshoti Jr, 1 Yot Navalitloha, 2 Sanya Sukpanichnant, 3 Churaiorn Unhasuta 1 and Samruay 

Shuangshoti 1 

Departments of 1 Pathology and 2 Surgery, Faculty of Medicine, Chulalongkorn University and 3 Department 

of Pathology, Faculty of Medicine, Siriraj Hospital, Mahidol University. 

Key words : Central nervous system; massive lymphadenopathy, Rosai-Dorfman disease. 

A 55-year-old woman had Rosai-Dorfman disease (RDD) forming multiple masses of 

abnormal histiocytes, three in the cranial cavity and one in the left orbit that was proptotic. The masses 

were removed and found to consist of abnormal histiocytes that were immunoreactive to cluster designa 

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tion 68 (CD68) (KP-1), alpha-1-antitrypsin and S-100 protein and showed emperipolesis. A review of 28 

cases of RDD, including this instance, revealed a ratio of 5:2 between males and females and a mean age 

of 32 years. Intracranial involvement was much more frequent than that of the spinal cord. Histologically, 

central nervous system (CNS) RDD must be distinguished from meningioma, Langerhans cell histiocytosis, 

and plasma cell granuloma. Surgical extirpation appears to be the treat ment of choice for this 

idiopathic histiocytic proliferative disorder of the CNS in comparison with radiotherapy and steroid treatment, 

which have also been tried. 

(Published in Neuropathology 1999;19:341-6) 

CLOFAZIMINE-INDUCED CRYSTAL STORING HISTIOCYTOSIS 

PRODUCING CHRONIC ABDOMINAL PAIN IN A LEPROSY PATIENT 

Sanya Sukpanichnant, 1 Narumol Srisuthapan Hargrove, 2 Udom Kachintorn, 3 Sathaporn 

Manatsathit, 3 Thawee Chanchairujira, 3 Noppadol Siritanaratkul, 3 Thawatchai Akaraviputh, 4 

Kleophant Thakerngpol 1 

Departments of Pathology, 1 Radiology, 2 Medicine, 3 and Surgery, 4 Faculty of Medicine Siriraj 

Hospital, Mahidol University, Bangkok10700 

Background: Clofazimine (Lamprene; B663), a riminophenazine compound, is used in 

treatment of leprosy, HIV patients with disseminated Mycobacterium avium complex infection, and a 

number of dermatological disorders. Besides the common reddish discoloration of the skin, clofazimine 

produces a variety of gastrointestinal disturbance - sometimes leading to severe abdominal pain resulting 

in exploratory laparotomy if the pathologic changes caused by this drug are not recognized. 

Design: A case of clofazimine-induced crystal storing histiocytosis producing chronic 

abdominal pain in a leprosy patient is reported. 

Results: A 32-year-old Thai man was a known case of leprosy treated by multidrug 

therapy including dapsone, rifampicin, prednisolone, and clofazimine. He had received clofazimine 200 

mg/day for 5 months and then 300 mg/day for 10 months. After discontinuation of the drug for 1 month, 

he had developed chronic intermittent abdominal pain for 1 year. One month prior to this admission, the 

pain became aggravating and he lost 4 kg. of his weight. No fever or other systemic symptoms were 

observed. Radiological abnormalities of the small intestine and mesenteric lymphadenopathy led to a 

suspicion of malignant lymphoma. At exploratory laparotomy, the black discoloration of the small intestine, 

omental fat, and mesenteric lymph nodes was observed. Purplish red clofazimine crystals loaded in 

histiocytes were identified in the frozen section histologic preparation of the mesenteric lymph node 

biopsy but they were dissolved away and left clear in the routinely processed histologic sections. Most 

crystals were also clear in the electron microscopic (EM) study of the paraffin embedded tissue. But 

some osmiophilic bodies and crystals were identified in some histiocytes, in addition to the clear crystals, 

when fixed tissue was used directly for the EM study. Clofazimine-induced crystal storing histiocytosis in 

the jejunal biopsy produced infiltrative lesions mimicking malignant lymphoma or other infiltrative disorders 

in radiological studies of the small intestine. Associated plasmacytosis in the histologic sections could 

simulate lymphoplasmacytoid lymphoma or multiple myeloma with crystal storing histiocytosis, but these 

plasma cells were proven to be polyclonal, indicating reactive plasmacytosis. At follow-up, the patient still 

had episodic abdominal pain which could be relieved by analgesic and anxiolytic drugs. 

Conclusion: With the knowledge of this rare condition caused by clofazimine, an appropriate 

management to avoid an unnecessary exploratory laparotomy is possible. 

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MALIGNANT LYMPHOMA IN THAILAND : A HISTOLOGIC AND 

IMMUNOPHENOTYPIC ANALYSIS OF 1,149 CASES AT SIRIRAJ 

HOSPITAL 

Sanya Sukpanichnant, 

Department of Pathology, Faculty of Medicine Siriraj Hospital, Mahidol University. 

Key words: Malignant lymphoma; phenotype; Thailand 

A retrospective pathologic analysis of 1,149 lymphoma cases at Siriraj Hospital was 

conducted during the 69 month period from August 1993 to April 1999. Conventional histologic 

diagnostic criteria for Hodgkin’s disease (HD) and non-Hodgkin’s lymphoma (NHL) were used. 

Classification followed the Rye classification for HD and the Working Formulation for NHL due to the 

incomplete data on the immunophenotypes only available from paraffin-section immunoperoxidase 

(PSIP) studies. One hundred and one cases of HD (8.8%) and 1,048 cases of NHL (91.2%) were 

diagnosed. Nodular sclerosis (NS, 44 cases), mixed cellularity (MC, 41 cases), lymphocyte depletion 

(LD, 12 cases), and lymphocyte predominance (LP, 4 cases) were classified. Among the 60 cases 

(59.4%) available for PSIP, B-cell phenotype was established in 2 cases of LP (1 nodular and 1 

diffuse variants). Focal expression of CD20 was observed in 8 cases (2NS, 3 MC, 3 LD) and that 

of CD3 in 2 cases (1 NS, 1 LD). Low, intermediate, and high grades constituted 12.5%, 64.9%, and 

18.2% of NHL, respectively. The frequency of B-cell (B, 69.4%), T-cell (T, 27.4%), and 

undetermined (U, 3.2%) phenotypes was observed in 865 cases (82.5%) available for PSIP. The 

frequency of such phenotypes in various subtypes of NHL was demonstrated. 

Subtype of NHL (cases) B T U 

Small lymphocytic (87) 75.4% 17.4% 7.2% 

Follicular, small cleaved cell (23) 100% - - 

Follicular, mixed (21) 100% - - 

Follicular, large cell (52) 100% - - 

Diffuse, small cleaved cell (15) 100% - - 

Diffuse, mixed (247) 58.1% 40.1% 1.8% 

Diffuse, large cell (366) 82.0% 16.3% 1.7% 

Immunoblastic (59) 87.8% 10.2% 2.0% 

Small noncleaved cell (33) 96.3% - 3.7% 

Lymphoblastic (50) 12.5% 85.0% 2.5% 

Mycosis fungoides (15) - 91.7% 8.3% 

Anaplastic large cell (49) 32.7% 49.0% 18.3% 

Unclassifiable (31) 46.4% 50.0% 3.6% 

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This study concurs with the previous study at Siriraj (Cancer 1998;83:1197-1204). 

(Presented at the IX Congress of the International Society of Hematology, Asianfacific Division, 

Ban kok, 1999) [Asian Pacific J Allerg Immunol 1999;17(Suppl1): 28(Abstr)] Partly supported 

by Siriraj-CMB Fund Grant No.75-348-213.

HODGKIN’S LYMPHOMA INVOLVING THE BREAST A CASE REPORT 

AND LITERATURE REVIEW 

Kanita Kayasut, 1 Tuenjai Chuangsuwanich, 1 Chirayu Auewarakul, 2 Adune Ratanawichitrasin, 3 

Sanya Sukpanichnant 1 

1 2 3 Department of Pathology, Department of Medicine, Department of Surgery, Faculty of Medicine 

Siriraj Hospital, Mahidol University 

Key words: Hodgkin’s lymphoma, Hodgkin’s disease, breast 

We report a case of Hodgkin’s lymphoma (HL) involving the breast as a recurrence of 

the disease, a rare presentation, in a 39-year-old female patient. She was first diagnosed as nodular 

sclerosis HL, stage IIA, presenting with left cervical lymph node enlargement at the age of 33 and was 

treated by combination chemotherapy and radiation. However, she developed a right breast mass 8 

months after complete remission. The excisional biopsy of the breast mass was proven to be recurrent 

HL. The disease was evaluated to be in stage IE. A literature review of HL involving the breast confirms 

this rarity. 

PLACENTAL PATHOLOGY IN A CASE OF BECKWITH–WIEDEMANN 

SYNDROME 

Chetana Ruangpratheep, Mongkol Uiprasertkul, Suchart Benjarassameeroj, and Tuenjai 

Chuangsuwanij 

Department of Pathology, Faculty of Medicine Siriraj Hospital, Mahidol University 

Key words: placental pathology; Beckwith – Wiedemann syndrome; adrenal hemorrhagic cysts 

Background: Beckwith – Wiedemann syndrome (BWS) is a sporadic genetically complex 

congenital disorder with main features of exomphalos, macroglossia, visceromegaly, ear creases, neonatal 

hypoglycemia and cytomegaly of the adrenal cortex. Only few reports on placental pathology have been 

described. 

Clinical history: We report a 1,690 gm. Male baby vaginally delivered with poor Apgar 

scores to a 21-year-old, G2P0010 Thai mother at 29 weeks’ gestation with a history of prolonged premature 

rupture of membranes. He died at the age of 4 hours. At autopsy, the baby was large for gestational 

age, the crown – heel length was 39 cm. and the brain weight was 138 gm. The latter lead to the 

gestational age of 28-29 weeks. He had macroglossia (without craniofacial anomaly), mild abdominal 

distention, cryptorchidism, hepatomegaly, bilateral adrenal hemorrhagic cysts of definitive cortex and 

cytomegaly of fetal cortex, nephromegaly with medullary dysplasia, islet cell hyperplasia, Leydig cell 

hyperplasia and cytomegaly of ectopic adrenal tissue in one testis. All findings are consistent with BWS. 

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The 1,020 gm., 19.5 x 18.5 x 5.5 cm. placenta were boggy and pale with focal small dark 

brown areas. Microscopically, it consisted of immature intermediate villi, some edematous villi and stem 

villi with peripheral reticular stroma admixed with mature intermediate villi as well as some areas which 

were composed mainly of intermediate villi with voluminous cellular stroma. There were neither trophoblastic 

proliferation nor erythroblastosis. A few areas of chorangiosis and one 1.5 cm. chorangioma were 

found. Cavitated stem villi were not present. 

Flow cytometric analysis of formalin – fixed paraffin embedded tissue yielded diploid 

DNA content. 

This was the first reported case of placental pathology of BWS in Thailand. Presented 

in the IAP Interhospital slide seminar at the Department of Pathology, Faculty of 

Medicine Siriraj Hospital, Mahidol University on July 30 th, 1999. 

SURGICAL PATHOLOGY AND CLINICOPATHOLOGICAL CORRELATION 

OF 110 CONSECUTIVELY REMOVED AORTIC VALVES IN SIRIRAJ 

HOSPITAL 

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Tuenjai Chuangsuwanich, 1 Malee Warnnissorn, 1 Piyavadee Leksrisakul, 1 Pansak 

Luksanabunsong, 2 Punnarerk Thongcharoen, 2 Yongyuth Sahasakul 3 

1 Department of Pathology, 2 Department of Surgery, 3 Department of Medicine, Faculty of Medicine 


Key words: Aortic valve; postinflammatory disease; degenerative calcific change. 


Objectives: To study the pathology, determine the prevalence and the clinicopathological 

correlation of various diseases of surgically removed aortic valves (AV). 

Materials and Methods: All the native surgically excised AV from June 1997 to March 

1999 (20 months period) were studied macroscopically, photographed, entirely microscopically examined 

and classified into 3 functional disorders of pure aortic stenosis (AS), aortic stenosis with regurgitation (AS- 

AR) and pure aortic regurgitation (AR). The patients’ charts were reviewed and the etiology was determined 

according to the macroscopic, microscopic and clinical findings. 

Results: Of 110 AV (76 isolated AV and 34 with coexisting mitral valve specimens, age 

range 15-96 years, mean age 47.54 years, male:female = 1.39:1), 24 (21.81%) were AS, 33 (30%) were 

AS-AR, and 53 (48.19%) were AR. Eighty four (76.36%) were tricuspid, 16 (14.54%) were bicuspid 

and 10 were undetermined. All AS specimens were related to moderate or sever calcification and causes 

included postinflammatory disease (14 cases, 58.33%, age range 38-67 years, mean age 53.28 years, 

male:female = 1:1.8), degenerative calcific change (10 cases, 41.67%, male:female = 1.5:1, mean age 

67.25 years of 4 tricuspid AV and 60.83 years of 6 bicuspid AV). In AS-AR, 29 cases (87.88%, mean age 

47.10 years, male:female = 1:0.81) were postinflammatory disease and 4 cases (mean age 71.25 years) 

were degenerative calcific change. In pure AR, there were 21 cases (age range 15-65 years, mean age 

29.76 years) of postinflammatory disease, 14 cases of infective endocarditis (IE) and post IE

(age range 20-63 years, mean age 42.21 years, all 10 IE cases contained gram positive cocci), 4 cases 

(mean age 65.67 years) of degenerative calcific change, 8 cases of AV with dilated valve ring, 5 cases 

of miscellaneous causes and 2 cases of indeterminate etiology. Aschoff’s like bodies were found in 3 

AR cases. Four of 18 postinflammatory AS-AR and 4 of 14 postinflammatory AR cases had past 

history of rheumatic fever. Severe degenerative calcific change had a higher incidence of underlying 

diabetes (3 of 16 cases, 18.75%), hypertension (9 of 12 cases, 75%) and dyslipoproteinemia (10 of 14 

cases, 71.42%) in comparison with 3.37% for diabetes, 9.09% for hypertension and 30.98% for 

dyslipoproteinemia in other AV diseases. 

Conclusion: The three common causes of severe AV functional disorders were 

postinflammatory disease (58.18%), degenerative calcific change (15.45%) and IE-post IE (12.72%). 

Underlying diseases of severe degenerative calcific change included hypertension, dyslipoproteinemia 

and diabetes. 

(To be presented in Siriraj Scientific Congress, March 2000 . Supported by Chalermprakiat 

Fund) 

SURGICAL PATHOLOGY AND CLINICOPATHOLOGICAL 

CORRELATION OF 154 CONSECUTIVELY REMOVED MITRAL 

VALVES IN SIRIRAJ HOSPITAL 

Tuenjai Chuangsuwanich, 1 Malee Warnnissorn, 1 Piyavadee Leksrisakul, 1 Pansak 

Luksanabunsong, 2 Punnarerk Thongcharoen, 2 Yongyuth Sahasakul 3 

1 Department of Pathology, 2 Department of Surgery, 3 Department of Medicine, Faculty of 

Medicine siriraj Hospital, Mahidol University 

Key words : Mitral valve; postinflammatory disease; chordal rupture. 

Objectives : To study the pathology, determine the prevalence and the clinicopathological 

correlation of various types of mitral valvular disease from surgical specimens. 

Materials and Methods : All the native surgically excised mitral valves (MV) from 

June 1997 to March 1999 (20 months) were studied macroscopically, photographed and entirely examined 

microscopically. They were classified into functional disorders of pure mitral stenosis (MS), mitral 

stenosis with regurgitation (MS-MR) and pure mitral regurgitation (MR). The etiology was determined 

according to the macroscopic, microscopic and clinical findings. The patients’ charts were reviewed 

and the clinical information was recorded. 

Results : Among 154 MV (120 isolated MV and 34 with concomittant aortic valves; 

age range 7-79 years, mean age 43.98 years), there were 68 MS (44.15%), 30 MS-MR (19.48%) and 

56 MR (36.36%) cases. All MS cases (age range 10-65 years, mean age 45.37 years, male:female = 

1:1.51), all MS-MR cases (age range 20-66 years, mean age 40.03 years; male:female = 1:1.31) and 20 

of 56 MR cases (35.71% of MR cases, 12.98% of total cases, age range 8-63 years, mean age 31.21 

years, male:female = 1.22:1) were attributable to postinflammatory disease. Prominent calcification 

occurred in 76.47% of MS, 70% of MS-MR and 25% of postinflammatory disease MR cases. 

Moderate 

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neovascularization was found in 34.32% of MS, 56.66% of MS-MR and 65% of MR cases. Aschoff’s 

like bodies were found in 1 MS and 4 MR cases. Eight of 39 MS (20.51%), 4 of 16 MS-MR (25%) 

and 6 of 13 (46.15%) postinflammatory disease MR cases had past history of rheumatic fever. Other 

causes of pure MR included floppy valves (18 cases, 32.14% of MR cases, age range 40-79 years, 

mean age 61.72 years, male:female = 3.5:1, 15 cases with chordal rupture), infective endocarditis (IE) 

(7 cases including one with postinflammatory disease MS and one post IE {age range 20-50 years, 

mean age 34.12 years, male:female = 6:1} with gram positive cocci in all IE), papillary muscle necrosis 

(1 case), ruptured necrotic papillary muscle (1 case), miscellaneous (associated with ASD and prior 

MV repair 5 cases) and indeterminate cause (4 cases). Among MS and MS-MR postinflammatory 

valves, 90.81% were completely excised whereas partial specimens were received in 40% of MR, 

61% of floppy valves and 53.8% of miscellaneous cases. 

Conclusion : Postinflammatory (presumably rheumatic) disease of MV is still a 

problem in Thais as it accounted for 75.97% of all MV specimens. In pure MR the most three 

common causes were postinflammatory disease, floppy valve and infective endocarditis. Macroscopic 

and microscopic examinations together with clinical information, echocardiographic findings and 

operative details are important in evaluation of the etiology of valvular diseases especially in partial 

specimens. 

(To be presented in Siriraj Scientific Congress, March 2000. Supported by Chalermprakiat 

Fund)

PNEUMONIA IN HOSPITALIZED HUMAN IMMUNODEFICIENCY 

VIRUS-INFECTED CHILDREN 

Kulkanya Chokephaibulkit, Narong Lertpreanthum, Sanay Chearskul, Nirun Vanprapar, Sumalee 

Pakaworawuth 

Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 


Key words : Pneumonia, HIV-Infected Children, Pneumocystis carinii Pneumonia. 

Pneumonia has been a major cause of hospitalization among human immunodeficiency 

virus (HIV)-infected children. Of 222 hospitalization of HIV-infected children at Siriraj hospital from 

January 1996 to June 1997, 98 (44%) cases had pneumonia. Forty percent of cases with pneumonia were 

severely symptomatic for HIV infection and 57% had CD4 level of severely immunosuppression. Seventy-three 

(74%) had the evidence of second or third degree malnutrition. Fifty-one (52%) of pneumonia 

cases were younger than 1 year of age and 95 (97%) were younger than 5 year of age. Only 55 (56%) 

cases were on PCP prophylaxis and 31 (32%) were on antiretroviral therapy at the time of admission. 

Etiologic agents were identified in 34 (35%) cases and 20 (20%) cases were bacteremic. S.pneumoniae 

and Salmonella were the most common pathogens found (16%). P.carinii was identified in 9 cases. 

Compare with the cases with pneumonia from other causes, cases with PCP were younger, more frequently 

present with cyanosis, less frequently to be on PCP prophylaxis, hospitalized longer and had a 

higher mortality rate. Overall mortality rate of patients hospitalized with pneumonia was 16%. The 

strategy of universal primary PCP prophylaxis in HIV-exposed infants remarkably prevent PCP in HIVinfected 

children. 

(J Infect Dis Antimicrob Agents 1999;16:53-7.) 


IMMUNODEFICIENCY VIRUS-INFECTED CHILDREN IN THAILAND: 

THE EFFECT OF A PRIMARY PROPHYLAXIS STRATEGY 

Kulkanya Chokephaibulkit 1 , Darawan Wanachiwanawin 2 , Sanay Chearskul 1 , Nirun Vanprapar 1 , 

Kitirat Unganont 3 , Weerachai Tantinikorn 3 , Suthipol Udompunthurak 

1 Department of Pediatrics, 2 Department of Parasitology, 3 Department of Otolaryngology, Faculty 

of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand. 

Key words: Severe pneumonia, Pneumocystis carinii pneumonia, prophylaxis, 

HIV-infected children, Tahiland. 

Background : A knowledge of the epidemiology of Pneumocystis carinii pneumonia 

(PCP) is important for the development of a strategy for primary PCP prophylaxis and empirical treatment 

for severe pneumonia in human immunodeficiency virus (HIV)-infected children. However, little is 

known about the epidemiology of PCP in developing countries. 

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Objective : To measure the relative rate of PCP among hospitalized HIV-infected children 

with severe pneumonia in Bangkok and evaluate the effect of a strategy of primary PCP prophylaxis 


Methods : All HIV-infected children hospitalized from January 1996 to December 1997 

for severe pneumonia were investigated for PCP using specimens obtained from bronchoalveolar lavage, 

endotracheal aspiration or lung tissue necropsy. Characteristics associated with severe pneumonia were 

described and the differences between PCP and non-PCP in these severely ill children were analyzed. In 

June 1996, a strategy of primary PCP prophylaxis using trimethoprim-sulfamethoxazole (TMP-SMX) in 

all HIV-exposed infants from 1 to 6 month of age was initiated in our institution. The effect of this strategy 

was evaluated. 

Results : Of 279 hospitalized HIV-infected children, 128 (46%) were diagnosed with 

pneumonia and 26 (20%) of these were severe pneumonia. P.carinii was identified in 9 (35%) children 

with severe pneumonia. After June 1996, the rate of severe pneumonia among all hospitalized children 

decreased from 16% during January-June 1996 to 7% during July 1996-December 1997 (p=0.02). Cases 

of PCP decreased from 9 in 1996 to zero in 1997. The percentage of HIV-infected children receiving 

PCP prophylaxis at the time of admission increased from 53% before June 1996 to 72% in late 1997 

(p=0.04). The overall percentage of patients with severe pneumonia receiving PCP prophylaxis at the 

time of admission was 34%. Breakthrough PCP occurred in 2 children with poor compliance. Patients 

with PCP were significantly younger than those without PCP (mean age 10.6+10.6 vs 29.8+28.3 months, 

p=0.02). 

Conclusion : PCP occurred in one third of cases of severe pneumonia in HIV-infected 

children in Bangkok. The data suggests that PCP prophylaxis can prevent both PCP and non-PCP. 

(Pediatr Infect Dis J, 1999;18:147-52.) 

COMPARISON OF BACTEC AUTOMATED BLOOD CULTURE SYSTEM 

AND CONVENTIONAL SYSTEM IN HOSPITALIZED PEDIATRIC PATIENTS (373) 

Kulkanya Chokephaibulkit 1 , Piyawan Sitthitrai 1 , Nirun Vanprapar 1 , Sanay Chearskul 1 , Somporn 

Srifuengfung 2 , Busabawart Pingwang 2 , Chertsak Dhiraputra 2 



Key word : Blood Culture, Automated System, Bacteremia 


A prospective study in pediatric patients compared the BACTEC system, an automated 

blood culture system using Bactec Ped Plus/F broth media, with the conventional system using Brain 

Heart Infusion broth media. Each single blood drawn for culture from hospitalized children was evaluated 

by both systems simultaneously. Of 244 pairs of blood samples, 44 (18%) were positive for microorganisms. 

Of these isolates, 24(55%) were detected by both systems, 10(23%) were detected by the BACTEC 

system only, and 10 (23%) were detected by the conventional system only. The mean turn around time of 

the BACTEC system (0.56+0.34, range 0.08-1.55 days) was significantly shorter than that of the conventional 

system (3.36+2.72, range 1-7 days, p

taminants grew out after 5 days of incubation and were detected by the conventional system only. In this 

study the BACTEC system and the conventional system were equally effective in detecting microorganisms 

in the patients’ blood samples even if antibiotic therapy had been previously administered. However, 

the results from the BACTEC system were available much sooner and less likely to be contaminants. 

(J Med Assoc Thai 1999;82:1011-6.) 

VANCOMYCIN SUSCEPTIBILITY OF METHICILLIN-RESISTANT 

STAPHYLOCOCCUS AUREUS IN SIRIRAJ HOSPITAL:1997-1998 

Kulkanya Chokephaibulkit1 , Somporn Srifuengfung2 , Kanokporn Tosasuk1 , Chertsak 

Dhiraputra2 (374) 



Key words : MRSA, VRSA, VISA, Staphylococcus aureus, Vancomycin resistance. 

Vancomycin susceptibility status of methicillin-resistant Staphylococcus aureus (MRSA) 

isolates in Siriraj Hospital during 1997-1998 was determined by E-test. Of 95 strains isolated, all had 

minimal inhibitory concentration (MIC) of < 2 mg/mL. The MIC 50 was 1.5 mg/mL and MIC 90 was 2 mg/ 

mL. Seventy-five percent of all the isolates of MRSA had the MIC of 1.5-2 mg/mL. The findings in this 

study indicated the possibility of heterogeneous resistant strains whose MICs may appear between 1 and 

2 mg/mL. Ongoing surveillance for emerging vancomycin-resistant MRSA is warranted. 

(J Infect Dis Antimicrob Agents 1999;16:149-50.) 

EFFECTS OF GENERAL AND REGIONAL ANESTHESIA ON THE 

NEONATE (A PROSPECTIVE, RANDOMIZED TRIAL) 

Thrathip Kolatat, 1 Achra Somboonnanonda, 1 Jariya Lertakyamanee, 2 Titima Nutrakul, 2 

Thara Tritrakarn, 2 Jarinya Muangkasem 2 

1 2 Department of Pediatrics , Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, 


Key words : Neonate, Effect, Anesthesia 

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Anesthetic methods used during Cesarean section have advantages and disadvantages 

to both mothers and infants and may result in short and long term neonatal effects. 

Objective : To determine the effects of general and regional anesthesia on the infants, 

a prospective, randomized trial was performed in Siriraj Hospital, Mahidol University. 

Material and method : 341 uncomplicated pregnant women who were to be delivered 

at term by Cesarean section were recruited and randomized to receive general anesthesia, GA (103); 

epidural anesthesia, EA (120) and spinal anesthesia, SA (118). The immediate fetal and neonatal effects 

were assessed by cord blood gas analysis and an infant’s Apgar scores. The Neurologic and Adaptive 

277


Capacity Scores (NACS) was performed within 4 hours after birth by two Pediatricians who were 

blinded to the anesthetic method. 

Result : Maternal age, weight, height, duration of the operation and infants’ birth weight 

were not different among the study groups. In EA and SA group, maternal systolic blood pressure decreased 

more than 20% from baseline in more than half. The infants’ Apgar scores at 1 and 5 minute 

were 8.3+1.9; 8.2+1.6; 6.7+2.8, and 9.7+0.9; 9.8+0.7; 9.2+1.6 in EA, SA and GA group respectively. The 

adaptive capacity, active tone, passive tone, general assessment and primary reflexes of the NACS were 

not statistically different. 

Conclusion: Apgar scores of the infants whose mothers received general anesthesia 

were lower than infants whose mothers received regional anesthesia but the NACS were not statistically 

different among the three study groups. 

COMPARISON OF GENERAL AND REGIONAL ANESTHESIA FOR 

CESAREAN SECTION : SUCCESS RATE, BLOOD LOSS AND 

SATISFACTION FROM A RANDOMIZED TRIAL. 

Jariya Lertakyamanee1 , Thitima Chinachoti1 , Thara Tritrakarn1 , Jarinya Muangkasem1 , Achra 

Somboonnanonda2 , Thrathip Kolatat2 1 2 Department of Anesthesiology, Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, 

Mahidol University, Bangkok. 

Key word : Anesthesia, General, Regional 

Objective : A prospective randomized trial was organized to compare the effectiveness 

of general and regional anesthesia for cesarean section (C/S). 

Method : Three hundred and forty-one patients were randomized into the general 

anesthesia group (GA), epidural anesthesia group (EA) and spinal anesthesia group (SA). The effectiveness 

of interest was success rate, blood loss and patient satisfaction. 

Result: We found that the success rates of EA and SA were lower than GA. Success in 

EA should be improved by using an epidural catheter to add more local anesthetic drug instead of a single 

shot; and the surgeon should allow more time for the block to work adequately. Success in SA should be 

improved by using bupivacaine instead of lidocaine. GA resulted in significantly more blood loss, lower 

postoperative hematocrit, and higher proportion of patients who had postoperative hematocrit < 30 per 

cent than EA and SA. The patients’ satisfaction scores were not different among the 3 techniques. This 

meant that, given adequate explanation and perioperative care, Thai women were satisfied with regional 

anesthesia. 

Conclusion : Regional anesthesia is a better choice of anesthesia for C/S than general 

anesthesia. However, the availability of different techniques and ability to change the technique when 

needed were very useful and important. If GA is chosen, all safety procedures must be followed. Oxygen 

supplement and endotracheal intubation facilities must be available in all techniques. Guidelines of anesthesia 

for C/S at a national level should be agreed upon, including the type of personnel, monitoring equipment 

and postoperative care. 

(Published in : J Med Assoc Thai 1999 Jul;82(7):672-80) 

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DENGUE INFECTION PRESENTED WITH CENTRAL NERVOUS SYSTEM 

MANIFESTATION 

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Pongkiat Kankirawatana 1 , Kulkanya Chokephaibulkit 1 , Pilaipan Puthavathana2, Sutee Yoksan 3 , 

Somchai Apintanapong1, Viroj Pongthapisit2 Department of Pediatrics1, Department of Microbiology2, 

Faculty of Medicine Siriraj Hospital, And Center for vaccine development, Institute of sciences 

and technology for development3, Mahidol University, Bangkok, Thailand. 

Key words: Dengue infection, Encephalitis, Encephalopathy 

Dengue hemorrhagic fever and Dengue fever are among the most common infectious 

diseases in Southeast Asia. Due to the abundant of its vectors, Aedes aegypti in all Southeast Asia 

countries, Dengue fever and Dengue hemorrhagic fever impose a substantial cost to the health care in 

this region. There have been very few reports on the Dengue manifestation of the central nervous system. 

Between 1996-1998, we prospectively studied all pediatric patients with encephalitis who were admitted 

to the Department of Pediatrics, Siriraj Hospital. 8 of 44 encephalitic patients were diagnosed as Dengue 

infection, 6 by serological diagnosis and 2 by viral isolation. Five of these patients had clinical courses and 

laboratory findings compatible with typical Dengue infection. All had obvious encephalitic clinical 

manifestations with normal cerebrospinal fluid findings. All of these patients were recovered completely 

and had benign clinical course except only one patient developed leakage symptoms. We conclude that 

Dengue virus can cause encephalitis and its clinical course and prognosis are usually favorable. 

Supported by: Partially supported by China Medical Board Presented at: the Asean Society Neurological 

Association Congress, Febuary 1999, Chiangmai, Thailand (Published in : submitted to Journal 

of Child Neurology.) 

KETOGENIC DIET : AN ALTERNATIVE TREATMENT FOR 

REFRACTORY EPILEPSY IN A DEVELOPING COUNTRY 

Pongkiat Kankirawatana, Pipop Jirapinyo, Renu Wongarn, Nuchnoi Thamanasiri, Suthida 

Kankirawatana. 

Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 

Thailand. 

Key words: Ketogenic diet, Refractory Epilepsy, Developing country 

Rationale: The aim of this study was to establish the ketogenic diet program in Thailand 

and to assess its feasibility as well as its efficacy. 

Methods: 30 children with refractory epilepsy were enrolled in the study. All patients 

were admitted during the starvation period and the initiation of the ketogenic diet. The classic “4:1” 

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formula ketogenic diet was used with some modification. MCT oil was not used in the protocol due to its 

high price. The patients’ parents were allowed to improvise and use any fatty diets that were available in 

the market such as coconut milk. Parents were closely supervised and instructed on how to prepare 

patient own diet while in the hospital and continued to attend our neurology and nutrition clinics. The 

seizure outcome and side effects were monitored and a daily test for urine ketones was carried out. 

Results: 15 patients had improved seizure outcome and continued on the diet. 13 patients 

failed to respond and 2 patients were lost to follow up. One patient was able to withdraw all 

antiepileptic drugs with good control of seizures. 

Conclusion: Ketogenic diet can be tried as another option of management of refractory 

epilepsy. It is not too difficult to implement even in a developing country, like Thailand where resources 

are limited. It may help reduce the cost of treatment especially from the high price of new antiepileptic 

drugs. 

Supported by: Partially supported by Chalermprakiat Fund of Siriraj Foundation Presented at: the 23rd 

International League Against Epilepsy Congress at Czech Republic on September 15th, 1999 

(Published in: Epilepsia 1999 volume 40 supplement 2 page 171.) 

VIGABATRIN THERAPY IN SYMPTOMATIC INFANTILE SPASM 

Pongkiat Kankirawatana, Suthida Kankirawatana. 


Thailand. 

Key words : Vigabatrin, Infantile spasm 


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Rationale: To determine the clinical outcome and side effects of vigabatrin (VGB) in 

the treatment of symptomatic infantile spasm (IS). 

Methods: This study was an open trial study. All children with symtomatic IS were 

treated with vigabatrin. Clinical data regarding age of onset, duration of IS before therapy started, recurrence 

of IS, types of seizures that relapse, clinical outcome and side effects were monitored. 

Results: 15 children with IS participated the study. Mean age of onset of IS was 124 ? 

98 day-old. The etiologies of symptomatic IS in this study were tuberous sclerosis (4), hypoxic ischemic 

encephalopathy (3), porencephaly (1), periventricular leukomalacia (1), partial agenesis of corpus callosum 

(1), hemimegalencephaly (1), cortical dysplasia(1), and microcephaly (2). 12 of 15 patients responded 

to VGB within a mean 2.83 ? 5.44 days. Recurrence rate was 50% (6 of 12 patients), with IS recurrent 

in 2 patients (within a mean of 58 ? 8.4days), and relapse into different types of seizures in 4 patients 

(within a mean of 195.5?111.7 days). The duration of IS before VGB treatment in the non-recurrent 

group (mean 52 ? 70 days) were significantly shorter than the recurrent group (mean 191.5?167 days). 

Three patients weaned off VGB successfully after 1-2 years of treatment (mean 708 ? 28.5 days) and 

remained seizures free. Transient drowsiness was reported in 1 patient. Visual fields abnormalities were 

not found but difficult to fully assess in this study. 

Conclusion: Even though the recurrent rate is high, VGB should be tried in symptomatic 

IS, especially in tuberous sclerosis. Delayed treatment of IS is associated with high recurrent rate of 

seizures. 

Supported by: Partially supported by Chalermprakiat Fund of Siriraj Foundation Presented at: the 23rd 

International League Against Epilepsy Congress at Czech Republic on September 15th, 1999 

(Published in: Epilepsia 1999 volume 40 supplement 2 page 174)

TRANSCATHETER CLOSURE OF LARGE PATENT DUCTUS BY 

AMPLATZER TM DUCT OCCLUDER ? DELIVERY SYSTEM 

Kritvikrom Durongpisitkul, Jarupim Soongswang, Duangmanee Laohaprasitiporn, Apichart 

Nana 


Thailand. 

Key words : PDA = Transcatheter closure of patent ductus arteriosus 

(380) 

Although the technique of coil embolization rapidly gained popularity for transcatheter 

closure of patent ductus arteriosus (PDA) this, however, was known to be effectively only in small PDA. 

Reports of transcatheter ductal occlusion device for large PDA, Rashkind PDA occluder and Sideris 

“button” device, were published in the past. The relatively large sheath (8-11 French) required for placement 

of such devices, however, was a major disadvantage. A new self-expandable, repositionable, 

Amplatzer TM duct occluder ? (ADO) was used to close a large PDA in our patient. The procedure was 

conducted under FDA investigation protocol and approval by the ethic committee with inform consent 

obtained from the parents. 

A ten years old boy who is in functional class I had grade 4/6 continuous murmur on 

examnination. The chest radiography revealed a CT ratio of 0.6 with increased pulmonary vascularity. 

The ECG showed evidence of left ventricular hepertrophy. Echocardiogram revealed PDA measured 5 

mm. During the cardiac catheterization the initial hemodynamic revealed a normal pulmonary artery 

pressure (27/15 nmmHg) with calculated Qp:Qs = 4.6:1. The angiogram revealed type A-1 PDA with 

smallest diameter measured 6.8 mm and largest (ampulla) diameter measured 8.8 mm. A multipurpose 

catheter was placed through PDA antergradely with wire exchanged for 6 F delivery sheath. 

A 10/8 mm ADO was selected and delivered retrogradely with dise open in aorta and pull back to PDA 

respectively. Residual left to right shunt was noted initially. Brief epsode of hematuria (6 hours) was noted 

during the first 24 hours. Follow-up at two weeks, 3 and 6 months revealed tiny residual left to right shunt. 

Conclusion: We demonstrated the capability of the Amplatzer TM duct occluder ? that 

could be effectively and safely deployed to close a large PDA. Futher studies with long term follow-up 

are required to establish its value in a large number of patients. 

281

282 

INTERMEDIATE TERM FOLLOW-UP ON TRANSCATHETER CLOSURE 

OF ATRIAL SEPTAL DEFECTS BY AMPLATZER TM SEPTAL OCCLUDER 

Kritvikrom Durongpisitkul, Jarupim Soongswang, Duangmanee Laohaprasitiporn, Apichart 

Nana. 

Division of Pediatric Cardiology, Department of Pediatrics. Faculty of Medicine, Siriraj Hospital, 


Key words : ASD = Transcatheter closure of atrial septal defects 


(381) 

Background: Surgical repair of secundum atrial septal defects (ASD) is a safe procedure, 

however, it is associated with morbidity and thoracotomy scar. The Amplatzer TM Septal Occluder 

(ASO) is a new device designed for closure of ASD. 

Objective: We report our clinical experience with closure of ASD by using the ASO 

with intermediate term follow-up. 

Patients & Methods: Patients having ASD met established criteria for transcatheter 

closure were selected. Procedures were performed under general anesthesia. ASD was measured by 

transesophageal echocardiogram (TEE) and balloon occlusion method (stretched diameter). The ASO 

was chosen to be equal to ±1 mm of the stretched diameter. Device was advanced transvenously into a 

guiding sheath and deployed under fluroscopic and TEE guidance. 

Results : There were 26 patients with mean age of 17.2±15.9 years old (2 to 60) and 

mean weight of 22±37.5 kg (10.7 to 62.5). The mean ASD diameter measured by TEE was 18.3±5.2 mm. 

with stretched diameter of 22±7.5mm. Four patients who had ASD stretched diameter over 32 mm were 

excluded because of the larger size devices were not available. Device were deployed in 22 patients with 

size from 9 to 30 mm (median=22mm). Immediate after closure tiny residual shunt was observed at the 

core of the device in each case. At 24 hours only two patients had small (

UTILITY OF INTRAOPERATIVE TRANSESOPHAGEAL ECHOCARDIO- 

GRAM IN PATIENTS WIHT CONGENITAL HEART DISEASE 

Kritvikrom Durongpisitkul1 , Jarupim Soongswang1 , Duangmanee Laohaprasitiporn1 , Unkarb 

Prakarnrat2 , Sumpun Pornwirawan 3 

, Thaworn Subtaweesin 3 

, Somchai Sriyoschati 3 

, Apichart 

Nana1 

1 

Department of Pediatrics, 2 


Department of Surgery, Faculty of 

Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand. 

Key words : TEE = Intraoperative transesophageal echocardiogram in congenital heart disease 

Background Transesophageal echocardiogram (TEE) became the technique of choice 

for intraoperative study in congenital heart patients. We conducted a study to determine the impact of 

intraoperative TEE findings on the decision of the surgical planning. 

Methods Patients who had intraoperative TEE performed during their operation from 

March 1998 to September 1998 were enrolled. Biplane or multiplane TEE were used. Both pre- and 

postbypass studies were performed. 

Results Thirty three patients had TEE during study period without any complication. 

The patients age ranged from 4 mo. to 40 years old (mean = 7.9 yr.) with their weight ranged from 4.1 kg 

to 88 kg (mean = 20 kg). Their congenital heart disease were : Tetrallogy of Fallot (TOF) = 7, Ventricular 

septal defect (VSD) = 3, Complete transposition of great arteries (D-TGA) with/without VSD = 6, Atrioventricular 

canal = 2, Ebstein’s anomaly = 2, Complex congenital heart = 4 and others = 9. 

Prebypass studies: new finding were obtained in 14/33 patients. Out of these, six had 

significant impact on the surgical planning as follow: Arterial switch operation was performed instead of 

Mustard in one patient, revision of Fontan anastomosis in two patients, extension of VSD was added 

during Rastelli operation, two ventricular repair was done in one patient with D-TGA and right modified 

B-T shunt was done instead of bi-directional cavopulmonary anastomosis (BDCPA). 

Postbypass studies: new findings were found in 19/33 patients. Out of these, TEE findings 

have significant impact in seven patients as shown in the table. 

Patients Surgery performed Postbypass findings Impact on surgery 

TOF Complete repair residual VSD Rebypass 

Complex modified Fontan anastomosis obstruction Rebypass-revision 

Ebstein’s Tricuspid valve replace Prosthesis obstruction Rebypass-Fontan 

Complex modified Fontan occlusion pulmonary vein Rebypass-revision 

PA/IVSvalvulotomy aortic cannula obstruction Off pump successfully 

Complex BDCPA aortic cannula obstruction Off pump successfully 

TOF Complete repair 2:1 AV block Off pump successfully 

Conclusions TEE findings prompted a change in surgical procedure or a return to 

bypass to repair residual defects or helping decision in came off bypass in 13/33 patients (39.4%) in our 

patients. Many of these residual lesions would have gone undetected. TEE was useful in decision making 

during the perioperative period in complex congenital heart patients. 

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PRIMARY INFECTION OF HUMAN HERPRESVIRUS 6 IN 

CHILDREN WITH VERTICAL INFECTION OF HUMAN IMMUNO- 

DEFICIENCY VIRUS TYPE 1 

Uraiwan Kositanont 1 

, Chantapong Wasi 1 

, Nirun Wanprapar 2 

, Piyaporn Bowonkiratikachorn 3 

, 

Kulkunya Chokephaibulkit 2 

, Sanay Chearskul 2 

, Kanittha Chimabutra 3 

, Ruenpung Sutthent 1 

, 

Suporn Foongladda 1 

, Reiko Inagi 4 

, Takeshi Kurata 5 

, and Koichi Yamanishi 4 

1 

Department of Microbiology, and 2 

Department of Pediatrics, Faculty of Medicine Siriraj Hospital, 

Mahidol University, Bangkok, Thailand; 3 

Charoenkrung-Pracharak Hospital, Bangkok 

Metropolitan Administration, Bangkok, Thailand; 4 

Department of Microbiology, Osaka University, 

Medical School, Osaka, Japan; 5 

Department of Pathology, National Insitute of Infectious 

Diseases, Tokyo, Japan. 

Key words : HHV-6, vertical transmission of HIV-1, progression of HIV diseases 

The role of human herpesvirus 6 (HHV-6) infection in 227 children born to human immunodeficiency 

virus (HIV)-seropositive mothers was investigated. Of 41 HIV-uninfected infants. 3(7%) 

were positive for HHV-6 DNA in the first month of life, suggesting possible intrauterine infection. The 

cumulative infection rates of HHV-6 at 6 and 12 months of age were significantly lower in HIV-infected 

children (11% and 33%, respectively) than in uninfected children (28% and 78%, respectively); (P < .001) 

. There was an association between high CD4 + 

cell numbers (>15%) before HHV -6 infection and high 

HHV-6 infection rate. Twenty-two infants with HIV classed as Centers for Disease Control and Prevention 

stages N1 or N2 were studied for an association of HHV-6 infection with progression of HIV 

disease. Ten of the infants had HHV-6, and 12 didt not. In 5 of the infants without HHV-6 (42%), HIV 

disease had not progressed by 1 year of age; however, HIV disease had progressed in all 10 children with 

HHV-6 infection and progression of HIV disease in the study children with vertical HIV-1 infection 

(P

Maple syrup urine disease (MSUD) is a rare autosomal recessive inborn error of amino acid 

metabolism in which the primary defect is that of oxidative decarboxylation of branched - chain a keto 

acids (BCKAs) derived from three branched-chain amino acids (BCAAs) : leucine , isoleucine and 

valine. There are 4 different phenotypes : classical , intermittent , intermediate and thiamine-responsive 

types. 

We report 4 cases of classical MSUD : Case 1 Three years and 6 mths old male infant 

referred from Cholburi provincial hospital , diagnosed having MSUD at age 30 days with history of 

lethargy , poor appetite , weak cry and coma with positive urine DNPH and typical urine musty odor 

prompted quantitative amino acid analysis leading to diagnosis and treatment with restricted protein intake 

and placed on MSUD diet. Subsequently developed moderately severe mental retardation. Case 2- 

Three-months-old male , product of consanguineous marriage of Indian Sikh couple from Bangkok ; fed 

poorly at day 3 , hypotonia , inactive and apneic , quantitative amino acid analysis demonstrated markedly 

elevated leucine (>2000) , isoleucine and valine typical of MSUD. Diagnosis was made on day 14 , he 

was placed on MSUD diet and rigorous treatment to correct severe metabolic acidosis. He survived 

several episodes of metabolic acidosis and intercurrent infections , only to succumb at age 11 months to 

overwhelming sepsis/DIC , hepatic and cardiorespiratory failure inspite of aggressive treatment ; skin 

fibroblast culture for decarboxylation assay confirmed biochemical diagnosis of MSUD. Case 3- Twomonth-old 

male infant from Nakornsawan province referred to Department of Pediatrics , Ramathibodi 

Hospital with chief complaint of macrocephaly and persistent metabolic acidosis. Initially diagnosed and 

treated as acute encephalitis with cortical brain and optic atrophy. Case 4- Four-month-old male referred 

from Rayong province to Department of Pediatrics, King Mongkut Hospital with chief complaint of 

convulsion and persistent metabolic acidosis. Tachypnea and poor feeding were noted since first week of 

life. Consanguinity was denied. Spasticity , weak cry were observed prompted quantitative plasma amino 

acid analysis which demonstrated marked elevation of leucine , isoleucine and valine. Patient subsequently 

expired. 

MEDIUM - CHAIN ACYL CoA DEHYDROGENASE DEFICIENCY 

IN A THAI INFANT 

Pornswan Wasant 1 , Isamu Matsumoto 2 , Somporn Liammongkolkul 1 

1 Medical Genetics Unit, Department of Pediatrics, Siriraj Hospital Faculty of Medicine, Mahidol 

University, Bangkok,Thailand; 2 MILS Matsumoto Institute of Life Sciences, Kanazawa Medical 

University, Kanazawa , Japan. 

Medium chain acyl CoA dehydrogenase deficiency or MCAD deficiency is the most 

common defect in the mitochondrial fatty acid oxidation disorders. Most frequent presentation is 

episodic hypoketotic hypoglycemia provoked by fasting and usually.presents in first 2 years of life. We 

report a 6 weeks old male infant who developed sudden cardiorespiratory arrest , who was resuscitated 

successfully in the first episode. Urine organic acid profile by gas liquid chromatography mass spectrometry 

demonstrated increased excretion of lactic acid , 2-hydroxybutyric acid , 3-hydroxybutyric acid. In addition 

, the index compounds of medium - chain acyl -CoA dehydrogenase deficiency (MCAD) - adipic acid , 

malic acid , suberic acid and sebacic acid were detected in large amounts. Treatment consist of intravenous 

glucose infusion and supportive measures. 

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The patient recovered completely only to succumb during the second episode of sudden 

cardiac arrest precipitated by viral illness. This is most likely first reported case of MCAD deficiency in 

Thailand. 

METHYLMALONIC ACIDEMIA IN THAI INFANT 

P. Wasant1 , E.W. Naylor 2 , I. Matsumoto3 , S. Liammongkolkul 1 

, C.Srisomsap + , J.Svasti + 

(386) 

1 

Genetics Unit , Department of Pediatrics, Siriraj Hospital Faculty of Medicine ,Mahidol 

University , Bangkok , Thailand; + 

Laboratory of Biochemistry , Chulabhorn Research , Institute 

Bangkok , Thailand; 2 

MaGee’s Women and Children Hospital of Pittsburgh, NeoGen Screen, 

Inc. Pittsburgh , Pennsylvania , U.S.A.; 3 

Matsumoto Institute of Life Science , Kanazawa Medical 

University , Kanazawa , Japan. 

Methylmalonic acidemia (MMA) is a rare inborn error of metabolism of organic acid 

disorder. There are 4 forms - complete methylmalonyl CoA mutase deficiency (mut?) , partial deficiency 

(mut - ) , deficiency of a mitochondrial Cbl reductase (cblA) and mitochondrial Cob (I) alamin 

adenosyltranferase (cblB) deficiency. Most common clinical presentation are lethargy ,failure to thrive , 

recurrent vomiting , dehydration , respiratory distress and muscular hypotonia. 

We reported an 18-month-old infant who presented with neonatal onset of severe metabolic 

acidosis (bicarbonate 6) , pancytopenia , increased anion gap , ketonuria , hyperammonemia and coma on 

day 18. The diagnosis of MMA was made via tandem mass spectrometry and urine GC/MS respectively. 

Treatment consisted of correction of metabolic acidosis , hydration , removal of toxic metabolites via 

exchange transfusions ,vit B12 and L-carnitine. She subsequently developed multiple episodes of severe 

metabolic acidosis responsive to aforementioned therapy. Inspite of aggressive treatment , chronic metabolic 

acidosis , growth failure , microcephaly and developmental retardation developed. Methylmalonyl CoA 

mutase deficiency (mut?) is suspected , and DNA analysis is being done. 

MULTIPLE CARBOXYLASE DEFICIENCY IN A THAI INFANT 

Pornswan Wasant 1 , Isamu Matsumoto 2 , Somporn Liammongkolkul 1 

(387) 

1 Medical Genetics Unit, Department of Pediatrics, Siriraj Hospital Faculty of Medicine, Mahidol 

University , Bangkok , Thailand; 2 MILS Matsumoto Institute of Life Sciences, Kanazawa 

Medical University, Kanazawa , Japan. 

Multiple Carboxylase Deficiency (MCD) is a disorder of biotin metabolism resulting in 

deficiencies of at least 3 biotin-dependent mitochondrial carboxylases : propionyl - CoA carboxylase , 3 

methyl crotonyl - CoA carboxylases and pyruvate carboxylase. There are 2 forms : a neonatal form and 

a juvenile form. We report an 8 months old male infant who presented with severe metabolic acidosis 

, an erythematous periorificial dermatitis and alopecia since 5 months of age. Quantitative plasma amino 

acids analysis was within normal limits : however urine organic acids analysis by gas liquid chromatography 

and mass spectrometry demonstrated a series of abnormal compounds characteristic of multiple 

carboxylase deficiency. Therapy consist of 60 - 80 mg of biotin per day with dramatic response. This is 

the first reported case of Multiple Carboxylase Deficiency in Thailand.

PLASMA AMINO ACID AND URINE ORGANIC ACID ANALYSES 

OF METHYLMALONIC ACIDEMIA IN THAI INFANT 

C. Srisomsap 1 , P. Wasant 2 , J. Svasti 1,3 , D. Chokchaichamnankit 1 , and S. Liammongkolkul 2 

1 Laboratory of Biochemistry, Chulabhorn Research Institute, Bangkok 10210 ; 2 Medical 

Genetics Unit, Department of Pediatrics, Siriraj Hospital, Faculty of Medicine, Mahidol 

University, Bangkok 10700; and 3 Department of Biochemistry, Faculty of Science, Mahidol 


Methylmalonic acidemia (MMA) is an inborn error of organic acid metabolism resulting 

from functional defects in methylmalonyl CoA mutase (MCM) which requires a vitamin B12 coenzyme, 

adenosyl-cobalamin. It is an autosomal recessive inherited disorder , usually presenting as life threatening 

or lethal metabolic ketoacidosis in neonatal or infantile forms. 

We describe a 15-month-old Thai infant with neonatal onset who demonstrated typical 

biochemical abnormalities : methylmalonic aciduria , ketonuria and intermittent hyperglycemia : not 

responsive to administration of vitamin B12. Quantitative plasma amino acid analysis using the Waters 

PicotagTM system for biological fluids showed marked elevation of glycine (876.52 and 386.34 nmole/ml) 

in episodic metabolic acidosis. Urine organic acid analysis via high pressure liquid chromatography (HPLC) 

demonstrated methylmalonic acid (8.126 gm/L). Supported by a grant from the Chulabhorn Research 

Institute. 

PLASMA AMINO ACID ANALYSES IN TWO CASES OF MAPLE SYRUP 

URINE DISEASE 

R. Surarit 1,2 , C. Srisomsap 1 , P. Wasant 3 , J. Svasti 1,4 , U. Suthatvoravut 5 , D. 

Chokchaichamnankit 1 , and S. Liammongkolkul 3 

1 Laboratory of Biochemistry, Chulabhorn Research Institute; 2 Dept. of Physiology & 

Biochemistry, Faculty of Dentistry, Mahidol University; 3 Medical Genetics Unit, Dept. of 

Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University; 4 Dept of Biochemistry, 

Faculty of Science, Mahidol; 5 Dept. of Pediatrics, Faculty of Medicine Ramathibodi Hospital, 

Mahidol University; Bangkok , Thailand. 

Maple Syrup Urine Disease (MSUD) is a rare inborn error of metabolism caused by 

imparired branched-chain a-keto acid dehydrogenase (BCKAD) complex, an enzyme common to the 

degradative pathways of three branched-chain amino acids (BCAA) : leucine, isoleucine and valine. The 

corresponding branched-chain keto acids (BCKA), 2-oxo-3-methylpentanoic, 2-oxo-3-methylbutanoic and 

2-oxo-4-methylpentanoic and the hydroxy acid 2-hydroxy-4-methylpentanoic are susally excreted in the 

urine. It is an autosomal recessive metabolic disorder with panethnic distribution. We report 2 cases of 

MSUD in Thai infants. Case 1 was a two-year and 8 months-old male, referred to the Faculty of 

287 

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(388)


Medicine Siriraj Hoshital from Cholburi provincial hospital on day 28, subsequently diagnosed on day 30. 

He later developed a few episodes of severe metabolic acidosis in first year of life. In spite of rigorous 

treatment with MSUD formula , restricted protein diet, and vitamin B1, severe developmental retardation 

and spasticity were noted and his DQ was 38. Quantitative plasma amino acid analysis demonstrated 

marked elevation of leucine (808.17 nmole/ml), valine (143.79 nmole/ml) and isoleucine (73.24 nmole/ml). 

Case 2 was a two-months-old male, referred from Nakornsawan provincial hospital to the Faculty of 

Medicine Ramathibodi Hospital with macrocephaly. The infant became lethargic and refused feedings on 

day 5 and subsequently developed severe metabolic acidosis (CO2=10). IBEM was suspected at 2 months 

of age when plasma amino acid analysis showed marked elevation of leucine, isoleucine and valine. 

Supported by the Chulabhorn Research Institute. 

UREA CYCLE DISORDER ORNITHINE TRANSCARBAMYLASE 

DEFICIENCY (OTC) IN A THAI INFANT - A CASE REPORT 

Pornswan Wasant 1 , Saul Brusilow 3 , Pipop Jirapinyo 2 , Maureen Tay*, Somporn 

Liammongkolkul 1 

1 

Genetics Unit1, 2 

Nutrition Unit, Department of Pediatrics, Faculty of Medicine Siriraj Hospital; 

*Central Instrument Facility, Faculty of Science , Mahidol University ; Bangkok , Thailand ; 

3 

Division of Metabolism, Johns Hopkins Medical Institutions , Baltimore , Maryland , USA. 

Urea cycle defect is an inborn error of urea synthesis which ammonium and other 

nitrogenous precursors of urea accumulate leading to episodic coma and high mortality rate. Therapy 

with peritoneal dialysis , essential amino acids or their nitrogen-free analogues has increased survival. 

Although life has been prolonged by these measures , long-term results have been discouraging with 

death usually occurring in the first year of life during an episode of hyperammonemic coma. 

We report an eleven-month-old male infant product of non-consanguineous marriage, 

who developed neonatal onset of hyperammonemia (plasma ammonia of 1486) on day 5 after birth. Poor 

feeding, lethargy , hypothermia , seizure , apnea and coma were noted. He responded to exchange transfusion 

(x2), developed spontaneous respiration and was rescued from neonatal hyperammonemic coma on day 

9 after aggressive treatment given. Due to inability to perform peritoneal dialysis / hemodialysis , we did 

exchange transfusion (x3 more) , followed by administration of sodium benzoate , sodium phenylacetate 

and L-arginine with successful outcome. He was subsequently placed on product 80056 (Mead-Johnson) 

+ regular formula in calculated amount to provide protein 1-1.5 gm/kg/d. He continued to gain weight and 

doing well (DQ=95) developmentally at age 6 months ; he had recurrent episodes of hyperammonemia 

(x2) until he acquired viral infection and developed hyperammonemia (plasma ammonia 1500), hypothermia 

(390) 

ensued and expired at age eleven months. Unable to do urine orotic acid we are unable to differentiate 

between OTC/CPS. Various sources of DNA were obtained (blood , skin fibroblast and liver tissue) and 

genetic counseling was given. 

(389)

UREA CYCLE DISORDER ARGININOSUCCINATE LYASE DEFICIENCY 

IN A THAI INFANT - A CASE REPORT 

Pornswan Wasant 1 , George H. Thomas 4 , Pipop Jirapinyo 3 , Sompin Leelahabooneim 2 

1 Genetics and 3 Nutrition Units , Department of Pediatrics, Siriraj Hospital Medical School , 

Mahidol University, 2 Department of Pediatrics, Bangkok Christian Hospital , Bangkok , 

Thailand; 4 Genetics Laboratory, The Kennedy Krieger Institute in affiliation of the Johns 

Hopkins Hospital , Baltimore , Maryland , U.S.A. 

Inborn errors of metabolism (IBEM) is a group of biochemical genetic disorders which 

causes by autosomal recessive genes resulting in the manifestation of defective enzymes. Approaching 

200-300 disorders are known and are often present in the neonatal period or early infancy. The clinical 

approach to diagnosis of IBEM relies heavily on a large fund of knowledge, on the part of the experienced 

clinician because of the large number of disorders , a high index of suspicion and access to expert laboratory 

services. 

This report describes a 2 months old male infant , product of consanguineous marriage , 

with poor feeding , lethargy , convulsion, hepatomegaly , respiratory alkalosis leading to respiratory failure 

and coma , hyperammonemia , elevation of glutamic acid and argininosuccinic acid and its anhydrides , 

confirming the diagnosis of Urea Cycle Disorder , specifically argininosuccinate lyase deficiency (ALD). 

Treatment of urea cycle disorders is considered emergency procedure and consists of immediate and 

long-term plan. The short term or immediate treatment emphasizes elimination of hyperammonemia which 

causes cerebral edema, seizures , coma , mental retardation and neurological deficits. The long term 

treatment consists of limited protein intake , L-arginine free base and a mixture of essential amino acid to 

supply adequate caloric intake. 

DETECTION OF INBORN ERRORS OF METABOLISM IN THAI INFANTS 

VIA GAS CHROMATOGRAPHY AND MASS SPECTROMETRY 

P. Wasant 1 , I. Matsumoto 2 , S. Liammongkolkul 1 

1 Division of Medical Genetics, Department of Pediatrics , Siriraj Hospital Faculty of Medicine, 

Mahidol University , Bangkok , Thailand; 2 Matsumoto Institute of Life Science, Kanazawa 

Medical University , Kanazawa , Japan. 

We had studied inherited metabolic disorders at Department of Pediatrics , Siriraj Hospital 

Faculty of Medicine , Mahidol University since 1987 using limited resources available and collaboration 

with other laboratories , both in Thailand and United States. Since April 1998 , we started collaboration 

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(392)


with MILS and Kanazawa Medical University , Japan studying inborn errors of metabolism in Asian 

Countries using urine filter paper and a new GC/MS method. We have since successfully discovered 

several patients with metabolic disorders. 

Out of 33 high-risk cases we sent for biochemical diagnosis during April-July 1998 , 13 

abnormal results were found which is approximately 39.4%. Inherited metabolic disorders identified 

were as follow: medium-chain acyl CoA dehydrogenase deficiency (MCAD) , multiple carboxylase 

deficiency (MCD) , methylmalonic acidemia (MMA) , Fanconi syndrome , galactosemia and neuroblastoma 

DETECTION OF INHERITED METABOLIC DISORDER VIA TANDEM 

MASS SPECTROMETRY IN THAI INFANTS 

P.Wasant 1 , E.W. Naylor 2 , S.Liammongkolkul 1 

(393) 

1 Division of Medical Genetics, Department of Pediatrics, Siriraj Hospital Faculty of Medicine 

Mahidol University, Bangkok, Thailand; 2 MaGee’s Women and Children Hospital of Pittsburgh 

NeoGen Screen, Inc., Pittsburgh, Pennsylvania, U.S.A. 

From a retrospective study in Medical Genetics Unit, Department of Pediatrics, Siriraj 

Hospital Faculty of Medicine, Mahidol University in Bangkok (1983-1988) ; the estimated pediatrics 

patients with clinically suspected IEM are approximately 2-4 per cent of total annual pediatrics admission 

of 5,000 or more. This is, of course, a low estimation since survey from all teaching hospitals in the 

country including the largest Children’s Hospital in Bangkok indicated presence of numerous IEM. 

However, most IEM were clinically diagnosed with limited laboratory facilities. 

We started a collaboration with MaGee’s Women and Children’s Hospital of Pittsburgh 

and NeoGen Screen, USA ; using tandem mass spectrometry to diagnose high risk infants and children 

for IEM from July 1993 to March 1998. Of total 146 samples sent, we had detected numerous metabolic 

disorders (11.2%) e.g. phenylketonuria, organic acidemia, maple syrup urine disease, isovaleric acidemia, 

methylmalonic acidemia, albinism, translocase/ carnitine palmitoyltransferase type II, G6PD deficiency 

and lysinuric protein intolerance.

INHERITED METABOLIC DISORDERS - IN THAILAND SIRIRAJ 

EXPERIENCE 

Pornswan Wasant 1 , Somporn Liammongkolkul 1 , Sukruethai Wongsubin 2 ,Maureen Tay 2 ,Edwin 

H Kolodny 3 ,Edwin W Naylor 4 , George H Thomas 5 ,Hugo W Moser 5 

1 Medical Genetics Unit, Department of Pediatrics, Siriraj Faculty of Medicine ; 2 Central 

Instrument Facility, Faculty of Science, Mahidol University Bangkok 10700 , Thailand ; 

3 Neurology Department, New York University Medical Center, New York , New York , USA ; 

4 Magee’s Women and Children Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; 5 Kennedy 

Krieger Institute, The Johns Hopkins Hospital, Baltimore, Maryland, USA. 

The incidence of IBEM in Thailand is yet unknown, however, by estimation it is generally 

accepted to be 1 in 5000. From a survey in 7 medical schools from different parts of the country and a 

largest pediatric hospital in Bangkok, we found numerous cases of IBEM nationwide. These are amino 

acids disorders, carbohydrate disorders, urea cycle defects, peroxisomal, lysosomal storage disorders and 

many others. Since Thais are quite homogeneous in their genetic make-up; it is, therefore, very likely that 

IBEM is much more prevalent than we realized. With the exception of thalassemias, IBEM is probably 

very common in Thailand and other countries in the Asia-Pacific region. 

IBEM identified are phenylketonuria , maple syrup urine disease,urea cycle disorders 

e.g. ornithine transcarbamylase deficiency (OTC), argininosuccinic lyase deficiency (ALD); glycogen 

storage disorders e.g. Pompe’s disease; organic acid disorders e.g. isovaleric acidemia , propionic acidemia 

and Lesch-Nyhan syndrome. Lysosomal storage disorders identified are GM1 gangliosidosis, mucolipidosis 

II,Hurler, Hunter, Maroteaux-Lamy, Sialidosis (Neuraminidase deficiency), Sly ,Scheie ,Gaucher, Niemann- 

Pick, Sandhoff and many other neurodegenerative disorders e.g. Neuronal ceroid lipofuscinosis (NCL), 

leucodystrophies etc. Peroxisomal disorders identified are rhizomelic chondrodysplasia punctata (RCDP) 

and primary hyperoxaluria Type I. Recently fatty acid oxidation disorder (VLCAD) or translocase deficiency 

is also identified. 

(1. 7th Asean Pediatric Federation Conference , Bangkok , Thailand , November 23-25 , 1994. 2. 

3rd Joint Clinical Genetics Meeting of 27th Annual March of Dimes Clinical Genetics Conference 

and American College of Medical Genetics 3rd Annual Meeting , San Antonio , Texas , USA , 

March 11-14 , 1996. 3. Siriraj 37 th Annual Scientific Congress , Siriraj Hospital Faculty of Medicine, 

Bangkok, Thailand , March 3-7 , 1997. 4. 7 th International Congress of Inborn Errors of 

Metabolism, , Vienna , Austria , May 21-25 , 1997. 5. 20th Anniversary of Neonatal Screen in 

Japan , Tokyo , Japan , September 18-20 , 1997.6. 3rd Asia-Pacific Regional Meeting of the 

International Society of Neonatal Screen , Chiengmai ,Thailand , November 15-18 , 1998.) 

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292 

NEONATAL SCREENING FOR CONGENITAL HYPOTHYROIDISM AND 

PHENYLKETONURIA AT SIRIRAJ HOSPITAL, MAHIDOL UNIVERSITY, 

BANGKOK, THAILAND - A PILOT STUDY 

(395) 

Pornswan Wasant 1 , Somporn Liammongkolkul 1 , Chachawan Srisawat 2 


1 Medical Genetics Unit, Department of Pediatrics, 2 Department of Biochemistry, Siriraj Hospital, 

Faculty of Medicine , Mahidol University, Bangkok , Thailand. 

Newborn screening program for congenital hypothyroidism (CH) and phenylketonuria 

(PKU), a pilot study , was initiated at Medical Genetics Unit , Department of Pediatrics , Siriraj Hospital 

Faculty of Medicine , Mahidol University in Bangkok , Thailand from January 1994 to December 1998 , 

using dried blood spots (DBS). Total of 18,739 infants (out of 85,150 livebirths) were screened (22 % 

coverage). Three cases of congenital hypothyroidism (CH) were identified (incidence of 1 : 6,246 , livebirths) 

, by enzyme linked immunosorbent (ELISA) and fluoroimmunoassays using cut-off level of TSH >20 

mmIU/ml ; the recall rate of 0.24%. The screening for PKU was done by fluorometric (Guthrie) and 

enzyme linked immunosorbent (ELISA) method ; using cut-off level of phenylalanine > 4 mg/dl and > 3.6 

mg/dl respectively ; the recall rate of 0.13%. There was no PKU found. 

Our study , a voluntary program , emphasizes the importance of parental education and 

consent ; specimen collection and handling ; appropriate follow-up and referral to specialists for treatment 

and counseling. Routine newborn screening for CH and PKU is being established to ascertain the maximum 

coverage , using recommendations and guidelines from this pilot study.

THREE-MARKER MATERNAL SERUM SCREENIN FOR DOWN 

SYNDROME AND NTD IN THAI PREGNANT WOMEN 

Pornswan Wasant , Somporn Liammngkolkul 

Genetics Unit , Department of Pediatrics, Siriraj Hospital Faculty of Medicine Siriraj Hospital, 

Mahidol University , Bangkok 10700 , Thailand. 

Maternal serum screening has gained widespread acceptance as a major prenatal 

screening tool for chromosomal abnormalities in US and Europe since Merkatz et al described association 

between low maternal serum alpha - fetoprotein (AFP) levels and increased risk for trisomy 21 in 1984. 

In 1988 Wald et al proposed using a screening program based on maternal age in combination with three 

biochemical markers : AFP , hCG and unconjugated estriol. Our study from January 1996- August 1999 

included 838 pregnant women. (between 15-22 week gestation) which were divided into 2 groups ; those 

> 35 years , 573 cases (68.38%) and < 35 years , 265 cases (31.62%). A second trimester risk for trisomy 

21 > 1 : 270 was considered screen positive and genetic counseling to discuss risks and benefit of 

amniocentesis offered. 

We found 679 cases (81.0%) with negative screening (not increased risk of DS and 

NTD) ; 94 cases (11.2%) with increased risk of DS ; 2 cases (0.2%) with increased risk of DS and 

raised AFP ; 11 cases (1.3%) with raised AFP ; 22 cases (2.6%) with previous DS only ; 4 cases (0.5%) 

with previous NTD only ; 10 cases (1.2%) with test done too early and 16 cases(1.9%) with test done too 

late. 

Our data support the observation by Haddow et al that triple-marker screening offers 

another option for older women , who traditionally have all been considered candidates for amniocentesis. 

(1. Presented at the 38 th Annual Meeting , Siriraj Scientific Congress , March 2-6 , 1998 , Siriraj 

Hospital Faculty of Medicine , Mahidol University. 2. Presented at the 3rd Asia-Pacific Regional 

meeting on Neonatal Screen ,November 15-18 , 1998 , Chiengmai , Thailand. 3. Presented at the 

Annual Meeting , The Perinatal Society of Thailand , October 6-8 , 1999 , Pattaya , Thailand.) 

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294 

SENSITIVE AND SIMPLE HPLC ASSAY FOR BIOEQUIVALENCE STUDIES 

OF AMOXICILLIN. 

(397) 

Piyapat Pongnarin, Suwat Wimolwattanapun, and Suporn Klyprayong. 

Department of Pharmacology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 

10700,Thailand. 

Key words : Amoxicillin, HPLC assay. 

Amoxicillin is presently the most commonly used antibiotic.To understand the 

pharmacokinetic behaviors of amoxicillin in human, a sensitive and reliable quantitative method of the 

drug is needed. Several high performance liquid chromatography(HPLC) methods for the determination 

of amoxicillin in body fluids have been developed. Most of the methods use direct UV detection at low 

wavelengths (225-330 nm).There are many kinds of solvent used as the mobile phases. Ion-paired reagents 

and special techniques such as postcolumn derivatization or column switching have been used to 

enhance sensitivity and selectivity. Different methods of sample preparation have been applied prior to 

the chromatographic analysis, mostly based on protein precipitation by acids, organic solvents or more 

complicated extractions such as solid-phase extraction. After evaluation of the various conditions of 

HPLC assay, a suitable and sensitive assay for the measurement of amoxicillin in human serum have 

been developed by us using reversed-phase HPLC. Amoxicillin and an internal standard, hydrochlorothiazide 

were extracted from serum with 10% perchloric acid. The supernatant solution was neutralized 

with 0.8M Na 2 HPO 4 . The extract was separated on C 18 column and detected with UV detection at 227 

nm. The mobile phase was 3% acetronitrile in 0.067M phosphate buffer. The minimal level of quantitation 

was 0.3 mg/ml. This method was developed for bioequivalence studies of local-made amoxicillin being 

used in Siriraj Hospital. 

DEVELOPING METHOD FOR DETERMINATION OF α αα-TOCOPHEROL 

α 

IN ERYTHROCYTE : A GOOD MARKER FOR VITAMIN E NUTRITIONAL 

STATUS. 

(398) 

Piyapat Pongnarin 1 ; Sompong Ong-ajyooth 2 ; Leena Ong-ajyooth 3 ; and BoonsomWanweerakul 1 . 

1 Department of Pharmacology, 2 Department of Biochemistry, 3 Department of Medicine, Faculty 

of Medicine Siriraj Hospital , Mahidol University, Bangkok, 10700 Thailand. 

Key words : Erythrocyte α-Tocopherol, Erythrocyte vitamin E , HPLC method. 

Faculty of Medicinr Siriraj Hospital 

Peroxidation of lipids in red blood cells reflects increased generation of reactive oxygen 

species. α-Tocopherol (vitamin E) is a physiological antioxidant and protects cell membranes from oxidative 

damage. Vitamin E level in red blood cell may better reflect its nutritional status at the site of interest. 

We have recently developed an improved and reliable method for the determination of 

the α-tocopherol in human red blood cell using the technique of isocratic , reversed-phase HPLC. An 

internal standard, α-tocopheryl acetate was added to erythrocyte suspension (prewashed three times 

with normal saline solution containing 0.5% of pyrogallol), followed by 3 ml of cold methanol. The mixture

was slowly mixed on a vortex mixer for 60 seconds. The mixture was then extracted with 2 ml of 

n-hexane centrifuged at 3,000 rpm for 5 minutes. The supernatant was transferred to a separate brown 

tube with a Pasteur pipette and dried under a stream of nitrogen. The dry residues was redissolved in 100 

ml of ethanol and analyzed on a C 18 column with UV detection at the wavelength of 290 nm. The mobile 

phase was methanol : acetonitrile : chloroform in the proportion of 25:60:15 by volume. The flow rate was 

1.5 ml/min at ambient temperature. 

THE EXPRESSION OF CYCLOOXYGENASE-2 IN HUMAN UMBILICAL 

VEIN ENDOTHELIAL CELL CULTURE FROM PREECLAMPSIA. (399) 

P. Akarasereenont, K. Techatraisak, A. Thaworn, S. Chotewuttakorn. 

Department of Pharmacology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 


Key words : COX-2, HUVEC, preeclampsia 

We have showed that HUVEC from normal pregnancy contained COX-1 protein but not 

COX-2 protein and released 6-keto-PGF 1 a a 277±5 ng/ml (for 24h). In contrast, HUVEC from preeclampsia 

contained both COX-1 and COX-2 protein and released significantly lesser amounts of 6-keto-PGF 1 a a 

(159±8 ng/ml for 24h; p < 0.05). Thus, COX-2 is expressed in HUVEC from preeclampsia but not in 

normal pregnancy and affects the release of prostacyclin suggesting the involvement of COX-2 in the 

pathogenesis of preclampsia. The development of selective inhibitors of COX-2 may have a potential role 

in prevention and treatment of preeclampsia. 


PGE INHIBITED COX-2 EXPRESSED IN ENDOTHELIAL CELLS 

2 

TREATED WITH IL-1β. β. 

Akarasereenont P, Techatraisak K, Chotewuttakorn S, Thaworn A. 



Key words : PGs, HUVEC, autoregulation 

Cyclooxygenase (COX), which exists as COX-1 and COX-2 isoforms, is the first enzyme 

in the pathway in which arachidonic acid is converted to prostaglandins (PGs). PGs have numerous 

cardiovascular and inflammatory effects. PGE 2 exerts a variety of biological activities for the maintenance 

of local homeostasis in the body. Here, we have investigated the effects of PGE 2 on COX activity 

to produce various PGs (COX metabolites; PGI 2 , PGE 2 , PGF 2a and TXA 2 ) using enzyme immunoassay 

295 

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296 

(EIA) and the isoform of COX protein expression using immunoblotting in IL-1btreated endothelial 

cells. Human umbilical vein endothelial cells (HUVEC) treated with IL-1b (1 ng/ml for 24h) increased a 

variety of COX metabolites which the highest production is 6-keto-PGF 1a (stable metabolite of PGI 2 ), 

PGE 2 , PGF 2a and TXA 2 , respectively. Moreover, untreated HUVEC contained only COX-1 protein while 

IL-1b treated HUVEC contained COX-1 and COX-2 protein. When IL-1b treated HUVEC were 

coincubated with PGE 2 (0.03, 0.3 and 3 mM for 24h), the increased 6-keto-PGF 1a and PGE 2 but not PGF 2a 

and TXA 2 was inhibited in a dose dependent manner. Interestingly, COX-2 protein induced by IL-1b 

treated HUVEC can be inhibited by PGE 2 in a dose dependent manner while COX-1 protein was not 

affected by PGE 2 . The results suggested that therapeutic uses of PGE 2 in the condition which COX-2 has 

been involved may have roles. 

(Med. Inflam. 1999; 8(Suppl. 1): S16.) 

THE INDUCTION OF CYCLOOXYGENASE-2 (COX-2) IN CULTURED 

ENDOTHELIAL CELLS TREATED WITH SERUM FROM PREECLAMPSIA 

IS MEDIATED BY INTERLEUKIN-6. 

Akarasereenont P, Techatraisak K, Chotewuttakorn S, Thaworn A. 



Key words : COX-2, IL-6, preeclampsia 

COX-2 protein, but not COX-1 protein, was induced in HUVEC from women with a 

normal pregnancy (nHUVEC) treated with serum from patients with preeclampsia (pSerum), but not 

with serum from women with a normal pregnancy (nSerum). COX activity in pSerum treated nHUVEC 

was less than in nSerum treated nHUVEC. Interestingly, the induction of COX-2 protein in nHUVEC 

treated with pSerum was inhibited by antiIL-6 antibody. The decreased COX activity in nHUVEC 

treated with pSerum plus antiIL-6 antibody was also reversed in a dose dependent manner. Thus, the 

induction of COX-2 in pSerum treated nHUVEC was mediated by IL-6. Therefore, the development of 

selective inhibitors of COX-2 or of IL-6 antagonists may have a potential role in the prevention and 

treatment of preeclampsia. 



(401)

THE EFFECT OF 17 β -ESTRADIOL ON THE CYCLOOXYGENASE 

ISOFORM EXPRESSED IN ENDOTHELIAL CELLS. 

Akarasereenont P, Techatraisak K, Thaworn A, Chotewuttakorn S. 



Key words : COX-2, estrogen, endothelium 

Estrogen stimulates the production of prostacyclin (PGI 2 ), a potent vasodilator and platelet 

inhibitor which plays an important role in cardiovascular disorder. Cyclooxygenase (COX), which exist as 

COX-1 and COX-2 isoform, is the first enzyme in the pathway in which arachidonic acid is converted to 

prostaglandins including PGI 2 . The exact mechanism of rising PGI 2 in endothelium by estrogen has not 

been clearly identified. Here, we have investigated whether 17β-estradiol affects COX activity and 

isoform expressed in human umbilical vein endothelial cells (HUVEC) by using enzyme immunoassay 

and immunoblotting, respectively. 17β-estradiol (0.001, 0.01, 0.1 and 1 nM) increased COX activity by the 

production of 6-keto-PGF 1 a a in a dose dependent manner. Interestingly, COX-2, but not COX-1, was 

induced in 17β-estradiol treated HUVEC. This induction was increased in a dose dependent manner. 

Moreover, the induction of COX-2 in 17β-estradiol treated HUVEC was inhibited when cells were 

coincubated with staurosporine (protein kinase C inhibitor; 0.01, 0.1 and 1 mM). This inhibition was 

inhibited in a dose dependent manner. The increased COX activity in HUVEC treated with 17β-estradiol 

was also inhibited by staurosporine (0.01, 0.1 and 1 mM) in a dose dependent manner. These results 

suggested that the increased COX activity in 17β-estradiol treated HUVEC was mediated COX-2 induction 

via protein kinase C. 

(Abstract Book, Pharmacology in the Next Millennium: The 8 th Southeast Asian-Western Pacific 

Regional Meeting of Pharmacologists, Taipei, Taiwan, 1 st -5 th November 1999; p112.) 

THE INDUCTION OF CYCLOOXYGENASE-2 IN IL-1B-TREATED 

ENDOTHELIAL CELLS IS INHIBITED BY PROSTAGLANDIN E 2 

THROUGH cAMP. 

Akarasereenont P, Techatrisak K, Chotewuttakorn S, Thaworn A. 



Key words : COX-2, cytokines, cAMP 

Prostaglandins (PGs) have numerous cardiovascular and inflammatory effects. 

Cyclooxygenase (COX), which exists as COX-1 and COX-2 isoforms, is the first enzyme in the pathway 

in which arachidonic acid is converted to PGs. PGE 2 exerts a variety of biological activities for the 

297 

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(403)

298 

maintenance of local homeostasis in the body. Elucidation of PGE 2 involvement in the signalling 

molecules such as COX could lead to potential therapeutic interventions. Here, we have investigated the 

effects of PGE 2 on the induction of COX-2 in human umbilical vein endothelial cells (HUVEC) treated 

with IL-1b (1 ng/ml). COX activity was measured by the production of 6-keto-PGF 1a , PGE 2 , PGF 2a and 

TXB 2 in the presence of exogenous arachidonic acids (10 mM for 10 min) using enzyme immunoassay 

(EIA). COX-1 and COX-2 protein was measured by immunoblotting using specific antibody. Untreated 

HUVEC contained only COX-1 protein while IL-1b treated HUVEC contained COX-1 and COX-2 

protein. PGE 2 (3 mM for 24h) did not affect on COX activity and protein in untreated HUVEC. Interestingly, 

PGE 2 (3 mM for 24h) can inhibit COX-2 protein, but not COX-1 protein, expressed in HUVEC 

treated with IL-1b. This inhibition was reversed by coincubation with foskolin (100 mM). The increased 

COX activity in HUVEC treated with IL-1b was also inhibited by PGE 2 (0.03, 0.3 and 3 mM for 24h) in 

a dose dependent manner. Similarly, foskolin (10, 50 or 100 mM) can also reverse the inhibition of PGE 2 

on increased COX activity in IL-1b treated HUVEC. The results suggested that i) PGE 2 can be negative 

feedback regulation in the induction of COX-2 elicited by IL-1b in endothelial cells, ii) the inhibition of 

PGE 2 on COX-2 protein and activity in IL-1b treated HUVEC was mediated by cAMP and iii) the 

therapeutic uses of PGE 2 in the condition which COX-2 has been involved may have roles. 

(Med. Inflam. 1999; in press.) 

THE INDUCTION OF CYCLOOXYGENASE-2 IN ENDOTOXIN ACTIVATED 

ENDOTHELIAL CELLS IS INHIBITED BY PROSTAGLANDIN E . 2 (404) 

Akarasereenont P, Techatrisak K, Chotewuttakorn S, Thaworn A. 



Key words : COX-2, PGE 2 , endothelium 





of local homeostasis in the body. Elucidation of PGE 2 involvement in the signalling molecules such 

as COX or nitric oxide (NO) could lead to potential therapeutic interventions. Here, we have investigated 

the effects of PGE 2 on COX activity to produce various PGs (COX metabolites; PGI 2 , PGE 2 , PGF 2a and 

TXA 2 ) using enzyme immunoassay (EIA) and the isoform of COX protein expression using immunoblotting 

in endotoxin-activated endothelial cells. Human umbilical vein endothelial cells (HUVEC) activated with 

endotoxin (1 mg/ml for 24h) increased a variety of COX metabolites which the highest production is 6keto-PGF 

1a (stable metabolite of PGI 2 ; 14.44±1.04 ng/ml), PGE 2 (2.89±0.20 ng/ml), PGF 2a (0.98±0.01 ng/ 

ml) and TXA 2 (0.07±0.01 ng/ml), respectively. PGE 2 (3 mM for 24h) did not affect on COX activity in 

untreated HUVEC. When endotoxin-treated HUVEC were coincubated with PGE 2 (0.03, 0.3 and 3 mM 

for 24h), the increased 6-keto-PGF 1a and PGE 2 but not PGF 2a and TXA 2 was inhibited in a dose dependent 

manner. At the level of COX isoform expression, untreated HUVEC contained only COX-1 protein while 

endotoxin-treated HUVEC contained COX-1 and COX-2 protein. Interestingly, the induction of COX-2 

protein in endotoxin-treated HUVEC can inhibited by PGE 2 in a dose dependent manner while COX-1

protein was not affected by PGE 2 . The results suggested that therapeutic uses of PGE 2 in the 

condition which COX-2 has been involved may have roles. 

(Abstract Book, 39 th Siriraj Scientific Congress, Siriraj Hospital, 8 rd -12 th March 1999; p221.) 

THE EFFECTS OF CONDITIONED MEDIUM FROM GLIOBLASTOMA 

CELL CULTURE ON CELL PROLIFERATION IN ENDOTHELIAL 

CELL CULTURE. 

Akarasereenont P, Wongkajornsilp A, Techatrisak K, Chotewuttakorn S, Thaworn A, 

Haubprasert S, Chanyavanich V, Tisavipat N. 



Key words : endothelium, proliferation, cancer 

Angiogenesis is a crucial requirement for tumour growth and metastasis of solid tumour. 

The inhibition of angiogenesis appears to be an increasingly promising strategy for cancer treatment. 

Here, we are forming an endothelial proliferation which is the initial step of angiogenesis and have tested 

the effect of conditioned medium from Glioblastoma multiforme cell culture on the endothelial proliferation 

as a solid tumour metastasis model. We have also measured COX activity and protein expression in 

endothelial cells as well as tested the effects of GPO1986 (anticancer drugs) on this model. Human 

umbilical vein endothelial cells (HUVEC) and Glioblastoma multiforme cells (GBM) were cultured as 

standard techniques and grown to confluence until use. Confluent GBM was replaced with freshed medium 

(DMEM) without serum for 24h. After which time the conditioned medium (CM) was transferred to 

HUVEC and incubated for 3, 6, 18 and 24h. Then, the CM was collected to measured prostacyclin 

(major COX metabolite in endothelial cells) using enzyme immunoassay. The remained cells were measured 

for cell proliferation using MTT assay and COX protein expression using immunoblot analysis. CM 

expedited endothelial proliferation in a time dependent manner. However, CM did not affected COX 

activity and protein expression in HUVEC. Interestingly, GPO1986 (1 to 20 mg/ml) can inhibited endothelial 

proliferation stimulated by 24h incubation of CM in a dose dependent manner. We concluded that i) 

endothelial proliferation stimulated with CM from GBM did not associate with COX activity and protein 

and ii) The inhibition of CM-stimulated endothelial proliferation by GPO1986 suggests a potential 

antimetastatic effect of this drug in GBM. 

(Abstract Book, 39 th Siriraj Scientific Congress, Siriraj Hospital, 8 rd -12 th March 1999; p220.) 

299 

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300 Faculty of Medicinr Siriraj Hospital 

EFFECTS OF ELECTRICAL STIMULATION ON THE ATTENUATION 

OF ISCHEMIC NEURONAL DAMAGE IN RATS. 

Tilokskulchai K, Hunsavong T, Piyawinijwong S, Akarasereenont P, Chotewuttakorn S, Ninturk 

R. 



Key words : ischaemia, fibrinolysis, electrostimulation 

In order to seek an alternative noninvasive treatment for ischemic neuronal deaths. 

Hence, the efficacy of electrical stimulation on the attenuation of Ischemic neuronal damage was 

investigated in rats. A total of 20 male Spraque Dawley rats, weighing 350-500 g were used. The animals 

were randomly assigned into two groups of control and treatment group. Global cerebral ischemia was 

induced by permanent occlusion of right common carotid artery. Animals in the control group were 

subjected to global cerebral ischemia with no treatment. Animals in the treatment group after induced 

ischemia was subjected to electrical stimulation . Electrical stimulation was made by inserting two pairs 

of needle electrode through the skin around the cervical area. Electrical stimuli of short-train burst (20 

Hz) at repetitive rate of 2 Hz and intensity just above threshold of muscle contraction were delivered 

twice a day for four days after ischemic insult. On the fifth day after induced ischemia, animals in both 

groups were reanesthetized and the brains were fixed by buffered formalin. Following fixation, the 

brains were embedded in paraffin. Coronal sections of the brain was cut and the sections were stained 

with toluidine blue and the incidence of neuronal damage was examined by light microscope. Efficacy 

of the treatment was assessed by comparing the ischemic neuronal damage per unit volume of the brain 

of the control with the treatment group. The ischemic neuronal damage was expressed as numerical 

density of ischemic neuronal damage per unit volume of the brain (Nv). The Nv was obtained by 

counting the numbers of dead cells (NAT) per unit area(A) of the brain slice multiplied with the slice 

thickness ‘ t’. Coggeshall, 1992]. [Nv = SS N AT / SS(Ax t)] The present result demonstrated that the Nv 

of the right and the left hemisphere of the control group was 9126+1841 and 6893+1746 (mean + 

SEM), respectively. The Nv of the right and the left hemisphere of the treatment was 3780+1011 and 

2178+464, respectively, which was significantly lower than the control group(P

THE EFFECTS O F EXOGENOUS ARACHIDONIC ACID ON 

CYCLOOXYGENASE ACTIVITY AND ISOFORM EXPRESSED IN 

ENDOTHELIAL CELLS. 

Plasen D, Akarasereenont P, Techatraisak K, Thaworn A, Chotewuttakorn S. 



Key words : COX, substrates, HUVEC 

Prostaglandin (PGs) have numerous cardiovascular and inflammatory effects. 

Cyclooxygenase (COX) is the first enzyme in the pathway in which arachidonic acid is converted to PGs, 

prostacyclin (PGI 2 ) and thromboxane (TX) A 2 . PGI 2 is the major COX metabolite released from endothelial 

cells which participating in inflammation, atherosclerosis, thrombosis etcs. Endothelial cells can be activated 

by arachidonic acid (AA) and its metabolites. Here, we have investigated the effects of AA on the PGI 2 

released from human umbilical vein endothelial cell (HUVEC) by measuring the production of 6-keto- 

PGF 1 ± ± (a stable metabolite of PGI 2 ) in the supernatant at various arachidonic acid concentrations and 

variable times of AA incubation. We also studied the effects of AA on COX protein expressed in HUVEC. 

HUVEC was obtained from babies born to normal pregnancy and grown in T25 flasks with endothelial 

cell (EC) medium supplemented with 10% fetal calf serum until confluent. The cells were then subcultured 

into 96-well culture plates, allowed to grow to confluent and replaced with fresh medium containing 

AA(0.1, 1, 10 and 20 mmM). Cell were incubated at 37± ± C under 5 % CO 2 concentration in the CO 2 - 

incubator for variable periods of times (5, 10, 20 and 30 minutes). After which time, 6-keto-PGF 1 ± ± in the 

supernatant medium was measured by using enzyme immunoassay (EIA). The remained cells were 

extracted to detect COX protein expression using specific antibody to COX-1 and COX-2. Cell respiration, 

an indication of cell viability, was assessed by the mitochondrial-dependent reduction of 3-(4,5dimethylthiazol-2yl)-2,5-diphenyl 

tetrazolium bromide (MTT) to formazan. Either various concentrations 

(0.1-20 mmM) or variable periods of times (5-30 minutes) of AA had any effect on cell viability. Control 

HUVEC without AA released undetectable amount of 6-keto-PGF 1 ± ± (


THE EFFECT OF HERBAL EXTRACTS (GPO1986) ON PROLIFERATION 

OF VASCULAR ENDOTHELIUM. 

Akarasereenont P, Wongkajornsilp A, Chotewuttakorn S, Thaworn A, Haubprasert S, Kraisintu 

K. 



Key words : herb, proliferation, endothelium 




of local homeostasis in the body. Elucidation of PGE 2 involvement in the signalling molecules such 

as COX or nitric oxide (NO) could lead to potential therapeutic interventions. Here, we have investigated 

the effects of PGE 2 on COX activity to produce various PGs (COX metabolites; PGI 2 , PGE 2 , PGF 2a and 

TXA 2 ) using enzyme immunoassay (EIA) and the isoform of COX protein expression using immunoblotting 

in endotoxin-activated endothelial cells. Human umbilical vein endothelial cells (HUVEC) activated with 

endotoxin (1 mg/ml for 24h) increased a variety of COX metabolites which the highest production is 6keto-PGF 

1a (stable metabolite of PGI 2 ; 14.44±1.04 ng/ml), PGE 2 (2.89±0.20 ng/ml), PGF 2a (0.98±0.01 ng/ 

ml) and TXA 2 (0.07±0.01 ng/ml), respectively. PGE 2 (3 mM for 24h) did not affect on COX activity in 

untreated HUVEC. When endotoxin-treated HUVEC were coincubated with PGE 2 (0.03, 0.3 and 3 mM 

for 24h), the increased 6-keto-PGF 1a and PGE 2 but not PGF 2a and TXA 2 was inhibited in a dose dependent 

manner. At the level of COX isoform expression, untreated HUVEC contained only COX-1 protein while 

endotoxin-treated HUVEC contained COX-1 and COX-2 protein. Interestingly, the induction of COX-2 

protein in endotoxin-treated HUVEC can inhibited by PGE 2 in a dose dependent manner while COX-1 

protein was not affected by PGE 2 . The results suggested that therapeutic uses of PGE 2 in the condition 

which COX-2 has been involved may have roles. 

(Thai J Pharmacol 1999; 21: 205-212.) 

CNS SIDE EFFECT OF FEXOFENADINE 180 MG. TABLET 

B. Dhorranintra, S. Klyprayong 

Department of Pharmacology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 

10700. 

Key words : Fexofenadine 180 mg., CNS side effect 

Fexofenadine, the derivative of terfenadine, has been shown to produce no side effect on 

the heart, not distributed to the central nervous system (CNS), and having high selectivity for peripheral 

histamine H 1 -receptors. Fexofenadine is an effective antihistamine for the treatment of many allergic 

diseases. 

(408) 

(409)

The authors have studied the CNS depressant effects of the higher dose of Fexofenadine, 

a 180 mg. tablet, in 20 normal Thai volunteers, 10 males and 10 females, ages ranging from 25 to 52 years, 

using a double blind cross-over placebo controlled design by comparing it with chlorpheniramine 4 mg. 

tablet. The test methods were both subjective and objective, i.e., visual analogue scale, alertness rating 

scale, card sorting test, glassbead picking test, and recording of the reaction time to light stimulation. 

Neither fexofenadine 180 mg. tablet nor placebo caused any CNS side effects,while chlorpheniramine 4 

mg. tablet caused significant CNS side effects. 

(Siriraj Hosp Gaz 1999; 51:166-74.) 

IMMUNOTHERAPY OF HUMAN GLIOBLASTOMA MULTIFORME 

USING OK-432, AN IMMUNE STIMULANT. THE DETECTION OF 

TUMOR-DERIVED IMMUNE SUPPRESSOR(S). 

Rung-Arune Luankosolchai 1 , Adisak Wongkajornsilp 1 , Prasit Watanapa 2 , Sukit Haubprasert 1 

1 2 Department of Pharmacology, and Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol 

University, Bangkok 10700 

Key words : immunosuppressor, cholangiocarcinoma, OK-432 

(410) 

Approximately 20 new cases of glioblastoma multiforme have been diagnosed annually 

at Siriraj Hospital. Glioblastoma multiforme is the most invasive of the astroglial neoplasms with a tendency 

to spread widely throughout the brain. Glioblastoma is very often extensively spread by the time of 

diagnosis, leading to unresectability, inadequate local control and a consistently poor prognosis. The 

length and quality of survival have improved only minimally through neurosurgical technique, radiotherapy 

and chemotherapy. Radical surgery and radiotherapy remain the cornerstone of treatment. A very 

modest contribution is added by conventional chemotherapy. Therefore, a novel therapeutic model is 

required for this cancer. We proposed that OK-432, a heat-treated and penicillin-treated lyophilized 

powder of the Su substrain of Streptococcus pyogenes A3, could be used as an immunomodulating agent 

to treat this cancer. It has a biological response modifier like BCG. Addition of OK-432 to peripheral 

blood mononuclear cells (PBMC) of these patients should result in the enhancement of NK cell activity 

and autologous tumor killing activity. We measure the proliferation of PBMC in the present or absence of 

cultured autologous tumor cells. We found that OK-432 enhanced the proliferation of PBMC and this 

proliferation was suppressed in the presence of tumor cells in a dose-dependent relationship. This immune 

suppression is probably caused by tumor-derived immunosuppressors or by toxic metabolites excreted 

from tumor cells. Additional experiments will be performed to verify the nature of this immunosuppressor. 

Future therapeutic model may aim at the strengthening of immune system bypassing this suppression. 

(Published in Thai J Pharmacol 21(Sup. 1): S82) The funding of this article was subsidized by 

SIRIRAJ-CMB FUND Grant No 75-348-261 

303


SELF-EVALUATION OF LEARNING HABITS OF THE THIRD-YEAR 

MEDICAL STUDENTS : UNDERLYING REASONS FOR POOR 

PERFORMANCES 

Panya Khunawat, Valla Wamanutajinda, Sukit Huabprasert 

Department of Pharmacology, Faculty of Medicine Siriraj Hospital, Mahidol University. 

Key words : learning habits, medical students, poor performances 

(411) 

The study was done to test the hypothesis that poor performance in academic achievement 

among third year medical students results from inappropriate learning habits and not from being intellectually 

inferior. The questionnaires were given to 230 third year medical students to fill in the answers after they 

had just finished the third sectional exam in pharmacology regarding their learning habits with quantitative 

measures of each answer by using self-rated analog scale from 1 (poorest) to 10 (best). The answers 

from 20 students with poor performance (GPA at the end of second year < 2.5) were compared with 

those from the rest of the class (GPA 2.5 or more). Mean GPA (+ SD) of the poor performance group 

(2.29 + 0.13) was significantly different from the rest (3.19 + 0.42, P < 0.001). In comparison with the 

rest of the class, the poor performance group had less values on listening behavior (more sleepily), getting 

the main idea while listening, catching up with putting down the lectures into notes, ability to use abbreviations 

to speed up notetaking, reading speed, readiness to take the examinations and finishing the examination 

questions in time. There is no difference between the poor performance group and the rest in summarizing 

when self-studying reading materials, cramming before the upcoming examinations, preparation by reading 

studying materials before attending class, revising studying materials in the same day when the class was 

over and the ability to remember everything after reading just once. In summary, poor performance of the 

third year medical students resulted from inappropriate learning habits rather than being intellectually 

inferior or less deligent. 

(Abstract from Siriraj Scientific Congress 1999. First published in Siriraj Scientific Congress 

Abstracts held on March 8 - 12, 1999, p. 222)

PROJECT FOR EVALUATION IN EFFICIENCY AND SIDE EFFECT OF 

THAI TRADITIONAL MEDICINAL REMEDY [ PREPARATION OF 

ELEGANT AROMATIC DRUG - YAHOM NAVAKOHT ( OVER THE 

COUNTER DRUG ) / PREPARED BY THAI AYURAVEDH ] [ FOR 

FAINTNESS, VERTIGO, FEEBLENESS, LETHARGY (DROWSINESS OF 

MENTAL ORIGIN) ETC. IN ELDERLY ] 

Chaweewan Prucksunand 1 

, Sureerut Porntadavity 2 

, Korakotch Prucksunand 3 

and Sanong Paeyai 1 

1 

Division of Medicinal Plant, Department of Pharmacology, Faculty of Medicine, Siriraj Hospital, 

Mahidol University. 2 

Department of Clinical Chemistry, Faculty of Medical Technology, 

Mahidol University, Bangkok. 3 

Division of Pharmacy, Somdej Phrapinklao Hospital, Royal 

Thai Naval Medical Department, Royal Thai Navy. 

Key words : Elegant Aromatic Drug-YAHOM NAVAKOHT, 

Vertigo in Elderly, Action and Safety 

The Preparation of Elegant Aromatic Drug – YAHOM NAVAKOHT (Non-prescription 

drug/prepared by THAI AYURAVEDH) was given to three cases of Thai females of aged 58, 69 and 74 

years old. The predominant complaints of their ailment were fainting, stun, numbness, vertigo, dizziness, 

weakness (feebleness), weariness, lethargy and drowsiness. These symptoms appeared after exposure 

to hard work, dissatisfaction of sleeping and some of mental stress. Dyspepsia, maldigestion and flatulence 

were the most examined signs and diagnoses. After 3 to 5 plain tablets three times daily before 

meals in period of one month, the patients became sparing from those disturbances. The drug administration 

in lukewarm water was distinctly effective more than in solid dosage form. To take the drug at 

necessity [pro re nata (p.r.n.)] according to patient-symptoms yielded better result. 

The hematology and blood chemistry of all patients, both before and after treatment, 

were within normal limit. Only the 74 years-old women had high level of cholesterol for more than five 

years, but the value of blood was not change from that ever since. Any adjoined therapy, handling for the 

mental stress of patients, made the relief of this ailment more certainly. 

Conclusion : The Preparation of Elegant Aromatic Drug – YAHOM NAVAKOHT 

was apparently useful and safety for the vertigo in elderly. 

305 

(412)


BLOCKING EFFECT OF TURMERIC JUICE (Curcuma longa Linn.) 

ON THE ACTION POTENTIAL OF ISOLATED FROG SCIATIC NERVE 

Chaweewan Prucksunand 1 , Bandit Petchroungrong 1 , Sombat Somanas 1 and Parnkamol 

Prucksunand 2 . 

1 Division of Medicinal Plant, Department of Pharmacology, Faculty of Medicine, Siriraj Hospital, 

Mahidol University. 2 Bachelor Degree of Science, Chulalongkorn University (1997) 

Key words : Turmeric(Curcuma longa Linn.), 

Blocked the nerve action potential, Local anesthetic action. 

There are various claimed efficacies of 

turmeric (Curcuma longa Linn.) in textbooks of 

Thai traditional medicine. Rhizomes of turmeric 

are used for treatment of insect bites, skin diseases 

and strengthening of teeth. For the treatment of 

mosquito bite, the traditional recipe is scraping the 

turmeric rhizome and rubbing on the affected area, 

it will relieve itching and inflammation. The 

properties which turmeric possess not only 

insecticidal activity but also insect repellant were 

reported in Thailand and India. 

The aim of this study was to prove the 

pharmacological effect of anti-itching activity by 

conducting experiments on action potential of long 

sciatic nerve of frog. The nerve action 

potential was recorded in height (millivolt) and was 

displayed on a screen of cathode-ray oscilloscope 

(as shown in Figure). It occured during stimulation 

with supramaximal voltage by current from Grass 

Stimulator. An aqueous solution extracted from 

rhizome of turmeric at the concentration of 6.66 

%(W/V) was used in this study. The blocking 

effect on nerve action potential appeared within 

five minutes and showed 90% reduction in height. 

After rinsing the nerve with physiological Ringer’s 

solution, the nerve completely recovered in five 

minutes, except the yellow colour of rhizome still 

remained in the nerve. It was found that the yellow 

colour of turmeric permanently stained but did not 

disturb the nerve action potential. 

(413) 

Figure Diagram of the instrument used in recording 

the nerve actionpotential 

R = Recording electrode 

G = Ground electrode 

S = Stimulating electrode 

In conclusion, turmeric juice at the 

concentration of 6.66%(W/V) blocked the nerve 

action potential approximately 90% within five 

minutes. This effect was recovered completely 

within five minutes. This phenomenon may explain 

the anti-itching and local anesthetic action 

of turmeric.

THE DEVELOPMENT OF A REVERSE TRANSCRIPTION POLYMERASE 

CHAIN REACTION SYSTEM FOR DETECTION OF ESTROGEN RECEPTOR 

IN BREAST CANCER 

(414) 

Thanongchai Siriapisit 1 , Supornpim Chearskul 1 , Sirirurg Songsivilai 2 

1 Department of Physiology, 2 Department of Immunology, Faculty of Medicine Siriraj Hospital, 


Key words : estrogen receptor, RT-PCR, breast cancer 

Estrogen receptor (ER) is widely used as an indicator of prognosis and response to 

endocrine treatment of primary breast cancer. ER phenotypes detected by conventional assays may not 

reflect their capability on binding specifically to estrogen response elements of target DNA. The reverse 

transcription polymerase chain reaction (RT-PCR) has been shown to offer the sensitive and specific 

method for measuring the ER mRNA in breast cancer tissue. The ER-mutant gene which is positively 

detected in breast tumor by biochemical or immunocytochemical assays may be negatively shown by 

RT-PCR or vice versa. PCR technique for examining expression of ER mRNA may therefore provide a 

good screening method for detection of functioning ER that will affect the selection of appropriate 

treatment and prognosis of breast cancer patients. We have developed RT-PCR assay using β 2 -microglobulin 

as internal control for detection and relative-quantitation of ER mRNA in breast cancer tissue. Preliminary 

results show that the developed assay provides a sensitive and specific method for detection of ER 

expression in breast tumor. Also, the assay procedure is simple, rapid, non-expensive and required very 

small amount of breast cancer tissue. 

( Supported by Siriraj China Medical Board Fund, grant number 75-348-288. Presented at the 

10 th Congress of the Asean Federation of Endocrine Societies, December 1-4,1999 Bangkok 

Thailand.) 

Distribution of neurons in the anterior hypothalamic 

nucleus activated by blood pressure changes in the rat. 

J. Michael Wyss 1 , Kanokwan Tilokskulchai 2 , Kathryn King 1 , Inga Kadish 1 and Thomas van 

Groen 1 

1 Department of Cell Biology, University of Alabama at Birmingham, Birmingham, AL, USA, 

2 Department of Physiology, Faculty of Medicine Siriraj Hospital, Mahidol University 

Key words : Baroreflex, Sympathetic nervous system, c-fos 

Electrophysiological and Fos-like protein immunocytochemical methods were used to 

identify the number and distribution of anterior hypothalamic neurons that are activated by changes in 

arterial pressure. First, in anesthetized, male Spraque-Dawley rats, arterial pressure increases and 

decreases led to differential activation of neurons in the anterior hypothalamic nucleus. Most of the units 

that responded to rise in arterial pressure with a decrease in activity ( pressor unit) were located in the 

central part of the anterior hypothalamic nucleus, whereas units that increased firing when arterial 

307 

(415)


pressure rose ( the depressor units) were found throughout the nucleus. Second, in awake, male 

Spraque-Dawley rats, Fos-like protein immunoreactivity was mapped following sustained arterial pressure 

changes. Within the anterior hypothalamus, reduction in arterial pressure increased the number of Foslabeled 

neurons primarily in the paraventricular nucleus and to a lesser extent in the anterior half of the 

anterior hypothalamic nucleus. In contrast, elevation in arterial pressure increased Fos labelling throughout 

the anterior hypothalamic nucleus and to a lesser extent in the paraventricular nucleus. 

( Brain Res Bull, 49, 163-172,1999.) 

The protective effects of vitamin E on ischemic neuronal 

damage in rats 

Kanokwan Tilokskulchai 1 , Jantana Shuprisha 2 , Rachawan Limviwatkul 2 , Suparp Nualplub 2 and 

Ratana Ninturk 1 

1 Department of Physiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 

Thailand , 2 Department of Physiology, Faculty of Science, Prince of Songkla University, Songkla, 

Thailand. 

Key words: antioxidant, vitamin E ischemic brain damage 

Antioxidant vitamins (i.e. vitamin E and vitamin C) in large doses are increasingly common 

self-prescribed drugs. This increase in vitamin use has, perhaps, been promoted by the claim that 

vitamin may provide protection from ischemic brain damage or prevent age-associated diseases induced 

by free radicals and lipid peroxidation. Apart from such legitimate uses of mega-dosages of vitamins, at 

present there is no conclusive evidence to support the recommendation of such use. Therefore, the 

purpose of the present study is to investigate the efficacy of short-term and long-term vitamin E supplements 

in protecting brain damage from transient global cerebral ischemia in Spraque-Dawley rats. The 

present study was designed to examine vitamin E’s effect on histological outcome 7 days after transient 

global cerebral ischemia in the treated and untreated animals. Global cerebral ischemia was induced by 

30 minutes bilateral occlusion of common carotid arteries with lowering mean arterial blood pressure to 

60-80 mmHg before occlusion. For the short-term study, animals were divided into two groups. Groups 1 

was subjected to cerebral ischemia with no medication and group 2 was fed daily with vitamin E (30 mg./ 

kg) from 2 weeks before to one week after ischemic insult. For the long-term study, global cerebral 

ischemia was induced in group 1 at the age of 15-19 months with no medication. Group 2 was fed daily 

with vitamin E (30 mg/kg) for 12-15 months before ischemic insult beginning from the age of 3 months. 

The result demonstrated that the mean percentage of cell death in the 2 weeks supplement group (17.8 

+ 0.8) was significantly less than that of the untreated group (28.0+0.8 (P

THE EFFECTS OF ELECTRICAL STIMULATION ON THE LEVEL OF 

TISSUE PLAMINOGEN ACTIVATOR, PLASMIONGEN ACTIVATOR 

INHIBITOR AND THE FIBRINOLYTIC ACTIVITY IN RATS AFTER 

PERMANENT UNILATERAL COMMON CAROTID ARTERY OCCLUSION(417) 

Kanokwan Tilokskulchai1, Pravit Akarasereenont 2 , Sirikul Chotewuttakorn 2 and Ratana 

Ninturk 1 

1 

Department of Physiology amd 2 

Pharmacology, Faculty of Medicine Siriraj Hospital, Mahidol 

University, Bangkok. 

Key words : arterial occlusion, fibrinolysis 

Substantial data reported that the acute phase of thromboembolic stroke is characterized 

by marked elevation of coagulation, but it remains unclear whether the fibrinolytic activity was 

enhanced or attenuated. In addition, the complications of using thrombolytic drugs resulted in seeking an 

alternative method to activate endogenous fibrinolytic activity. To clarify this controversy, i) the serial 

changes of the fibrinolytic activity and level of tissue plasminogen activator (tPA) and plasminogen 

activator inhibitor (PAI) before and after unilateral common carotid occlusion in rats were studied and ii) 

to investigate whether changes in fibrinolytic activity could be modulated by electrical stimulation. Eightyfive 

male Spraque Dawley rats, weighing 350-500 g were randomly assigned into two groups of control 

and treatment. The right common carotid arteries were ligated permanently in both groups. The treatment 

group was further subjected to electrical stimulation for a period of 30 minutes, twice a day for 4 days 

after arterial occlusion . Then blood samples of all animals were collected by tail-cut at one day before 

and at day 1, day 2, and day 3 after arterial occlusion and assess fibrinolytic activity using euglobulin 

lysis time, (ELT) and the level of tPA and PAI using enzyme immunoassay (EIA). In general, the 

sequential changes of mean ELT (mean + SEM)(minutes) after arterial occlusion could be divided into 

two subgroups. Group I, only the mean ELT of day1 was significantly higher than the control level 

(P


BODY MASS INDEX OF THE ELDERLY IN RURAL AREA OF CENTRAL 

PART OF THAILAND 

Preyanuj Yamwong, 1 Prasert Assantachai, 1 Siriya Chokvivatvanich, 2 

1 Department of Preventive and Social Medicine, 2 Research Center for Nutrition Support, 

Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand 10700. 

Key words : body mass index, nutritional status, elderly 

Body mass index (BMI) is an indicator for nutritional status which correlates with 

mortality. Studies in the past indicated that undernutrition was one of the major nutritional problems in 

elderly Thais especially in the rural area. The objective of this study is to determine the BMI of the 

elderly who live in rural areas of central Thailand. Random sampling of volunteers age ±± 60 years in 3 

districts of Samut Songkram and Rajaburi provinces was done. One hundred and ninety-three elderly 

people, 77 men and 116 women, age 60-87 years old, were included in the study. BMI of male and female 

participants was 22.76 + 3.81 and 24.51 + 3.94 kg/m 2 respectively. Women had significantly higher BMI 

than men. When used a BMI of

made. When ideal body weights were used as cut-off points, 14% were underweight and 35.5% were 

obese. Fourteen percents had a body mass index (BMI) < 20 kg/m 2 and 21.4% had BMI >24.9 kg/m 2 . 

Seven and 14% of them had triceps skinfold thickness or mid arm muscle area below the 5 th percentile 

and above the 95 th percentile respectively. All of the patients were anemic. Lymphopenia, hypoalbuminemia, 

hypokalemia, hyperphosphatemia and hyperlipoproteinemia were present in 50%, 14%, 36%, 64% 

and 71% of the patients respectively. Sixty-two percent of them received >80% of their energy requirement. 

Protein intake was 0.97 + 0.39 gm/kg/day while protein loss was 6.5 + 1.4 gm/day into the dialysate and 

0.3 + 0.04 gm/day in the urine. There were large variations in nutritional status in patients undergoing 

continuous peritoneal dialysis. The patients should have appropriate energy intake, taking into account 

the energy from glucose absorbed from the dialysate, and protein intake should be increased to cover the 

losses. Nutritional counseling should be made individually. 

(Siriraj Hosp Gaz 1999;51:692-700.) 

PREVALENCE OF DISSEMINATED M.A.C. I N AIDS PATIENTS AT 

SIRIRAJ HOSPITAL 

Suwanagool S, Techasathit W, Chuenarom V, Anekthananon T. 

Department of Preventive and Social Medicine, Faculty of Medicine Siriraj Hospital, Mahidol 

University, Bangkok, 10700, Thailand. 

Key words : disseminated MAC, AIDS 

(420) 

During January 1998 - December 1998, 289 adult AIDS patients were admitted at Siriraj 

Hospital. The leading causes of admission were tuberculosis, cryptococcosis, pneumocystosis, diarrhea, 

salmonellosis and toxoplasmosis. In order to determine the prevalence of disseminated MAC (DMAC) 

blood culture for mycobacteria with Bactec 9240 media was obtained from each patient if suspected 

disseminated mycobacterial disease. The prevalence of DMAC is 8.9% (26/289). Prolonged fever (100%), 

weight loss (88.5%), diarrhea (69.2%), hepato and/or splenomegaly (65.4%) were often found associated 

with DMAC as well as anemia, (mean Hb=8.29 m/dL), low CD 4 cells count (mean = 6.5/mm 3 ) and 

high alkaline phosphatase. Eleven patients (42.3%) died during hospitalization. We concluded that DMAC 

infection is common in Thai AIDS patients and should be considered in advanced AIDS patients with 

prolonged fever, weight loss, diarrhea and anemia. In clinical practice guidelines of 1997 USPHS/IDSA 

should be followed to give chemoprophylaxis against DMAC disease in patients with advanced HIV 

infection and a CD 4 count less than 50 cell/mm 3 . 

Presented at the Eighth Asian Congress of Agricultural Medicine and Rural Health, Guangzhou, 

China, 11-14 November 1999. 

311


FEASIBILITY OF AMPHOTERACIN B ONCE A WEEK FOR MAINTENANCE 

THERAPY IN HIV-1 INFECTED PATIENTS WITH CRYPTOCOCCAL 

MENINGITIS IN DEVELOPING COUNTRIES 

(421) 

Techasathit W, Suwanagool S, Chuenarom V, Chuengprasert N. 

Department of Preventive and Social Medicine, Faculty of Medicine Siriraj Hospital, Mahidol 


Key words : cryptococcal meningitis, amphoteracin B 

The cost of oral fluconazole for maintenance therapy in HIV-1 infected patient with 

cryptococcal meningitis is considerably high which such a patient in any developing country hit hardly by 

the HIV epidemic would not afford it. Amphoteracin B 50 mg. once a week might be an alternative 

therapy to save cost in this regard. We have observed a small cohort to look into the feasibility of this 

therapy to prevent the recurrent disease at Siriraj Hospital in Bangkok. Seven males and two females all 

having CD4

and/or chief of the product section from different department stores in Bangkok. The above mentioned 

data was recorded, analyzed and classified into 3 main groups such as:1] liquid oil spray 2] aerosol and 3] 

miscellaneous group. It was found that out of 23 trade names in liquid oil spray, 20 [86.96%] contained 

dichlorvos or DDVP mixed with other solvents or other toxic substances such as pyrethroid, fenitrothion, 

etc.; the second group belongs to aerosol with 42 trade names, 31[73.81%] contained DDVP mixed with 

other solvents was almost the same as in group one while the miscellaneous group with 66 trade names 

such as bait, coil, granule, powder, dust, mat, bar, lotion, towellete, or refreshing tissue contained active 

ingredient which may be fenitrothion, propoxur, phoxim or synthetic pyrethroid, and others. 



ANALYSIS OF VITAMIN LEVELS IN THE ELDERLY IN NORTHERN 

PART OF THAILAND. 

(423) 

Prasert Assantachai. 

Department of Preventive and Social Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol 


Key words : vitamin, elderly 

The elderly worldwide is the most common group of population suffering from malnutrition 

not only in institution but also in the community especially in the rural area as a result of poor dietary 

intake. One the other hand, average life expectancy at birth of the Thai elderly is lengthened satisfactorily 

over the period of 1947-1998. The vitamin status in this high-risk group is therefore needed for the 

national planning of health promotion and prevention of malnutrition-related disorders. The elderly living 

in northern part of Thailand amounted to 594 cases were recruited in the cross-sectional survey. High 

performance liquid chromatography was used to determine blood level of vitamin A, betacarotene, vitamin 

C and vitamin E, while transketolase assay, radiodilution assay and microbiological assay were employed 

to measure the blood levels of vitamin B1, B12 and red cell folate respectively. The prevalence of 

deficiencies of vitamin A, B1, B12, folate, vitamin C and E were 0%, 49.3%, 0%, 45.7%, 1% and 42.9% 

respectively for the male elderly and 1.8%, 40.3%, 0%, 28.8%, 2.5% and 29.2% respectively for the 

female elderly. Only the levels of betacarotene, red cell folate and vitamin E were statistically higher 

among the female than the male elderly. Interestingly, the levels of betacarotene, vitamin B12 and E 

among the male elderly gradually decreased significantly with increasing age. This justifies the further 

research of the causes of high prevalence of thiamin, vitamin E and folate deficiencies in this part of the 

country as well as the clinical implication of vitamin E deficiency especially in the male elderly. 



313

314 

NORMAL APPEARANCES OF TECHNETIUM-99M DIMERCAPTOSUCCINIC 

ACID IN CHILDREN ON PLANAR IMAGING 

(424) 

Pawana Pusuwan, Leonardo Reyes, Isky Gordon 

Department of Radiology, Great Ormond Street Hospital for Children NHS Trust, London 

WC1 N 3JH, UK. 

Key words: Technetium-99m dimercaptosuccinic acid, Renal cortical imaging , Normal appearances 

Thirty-two children who underwent renal arteriography with normal results also underwent 

technetium-99m dimercaptosuccinic acid (DMSA) imaging. Variations in the normal appearance of 

99 mTc~DMSA images are described in these children. Criteria for high-quality 99 mTc DMSA images are 

defined in terms of kidney outline and contrast between the inner and the outer part of the kidney. Most 

of the images in this study were of high quality. The two most common features of normal 99 mTcDMSA 

images were a round-shaped (50%) or flat (either lateral or medial aspect) (24.8%) contour. A small 

number of unusual appearances were observed and these have been illustrated. The mean differential 

function of the left kidney was 51% with a range of 45%—57%. 

(Eur J Nucl Med (1999) 26:483-488) 


DESCRIPTIVE ANALYSIS OF DIFFERENTIATED THYROID CARCINOMA 

(DTC) PATIENTS ADDRESSING FOR RADIOACTIVE IODINE THERAPY 

AT FIRST PRESENTATION : A 10-YEAR EXPERIENCE AT SIRIRAJ 

HOSPITAL 

(425) 

Jiraporn Mangkharak, Pawana Pusuwan, Sunantha Chiewvit, Busara Satayaban, Vipa 

Boonnamsiri, Rudee Pleehachinda 

Division of Nuclear Medicine, Department of Radiology, Siriraj Hospital, Bangkok, Thailand 

The aim of this study was to evaluate the patient characteristics, types of tumor histology 

and metastatic evidence in thyroid cancer patients referred for radioactive iodine (RAI) therapy at 

first presentation. METHODS: A retrospective study of patients with DTC registered at Nuclear Medicine 

Section, Siriraj Hospital during January 1988 to December 1997 was reviewed. The patients with 

unspecified histology and ones who were previously treated with RAI treatment from other institutions 

were excluded. RESULTS: The total 550 patients, aged 9-96 years, including 426 women and 124 men 

were analyzed. The overall female/male ratio was 3.4:1. According to the histopathology, 304 papillary 

carcinomas (55.3%), 204 follicular carcinomas (37.1%), 38 mixed papillary and follicular carcinomas 

(6.9%), 4 Hurthle cell carcinomas (0.7%) were found. The female/male ratio of papillary cancers was 

2.9:1 and that of follicular carcinomas was 4.2:1. The age of the patients in these two groups of cancer 

is similar. Overall 227 cases (41.3%) showed at least one organ metastasis at first presentation. These 

included almost half (148/304) of papillary carcinomas and about one-third (71/ 208) of follicular carcinomas. 

Metastases from papillary thyroid carcinoma more often occur in lymph nodes (84.5%) rather

than lung (17.6%), and bone (8.1%). On the other hand, those from follicular thyroid carcinoma 

are more commonly seen in bone (50.7%) than lymph nodes (36.2%) and lung (27.5%). CONCLUSION: 

DTC is predilection in women rather than men, particularly in the cases of follicular carcinoma. Papillary 

carcinoma is the most common histologic type followed by follicular carcinoma. Almost half of all patients 

with DTC had metastases at first presentation. Papillary carcinoma most often produces lymphatic 

metastases but follicular carcinoma more often hematogenously metastasize to bone and lung. 

PREOPERATIVE DIAGNOSTIC USE OF I-131 MIBG SCINTIGRAPHY 

IN PHEOCHROMOCYTOMA 

Pongpija Tuchinda M.D. and Jiraporn Mangkharak M.D. 

Division of Nuclear Medicine, Department of Radiology, Siriraj Hospital, Bangkok, Thailand. 

Metaiodobenzylguanidine (MIBG) has been reported to accumulate in various neuroendocrine 

tumors such as neuroblastoma, pheochromocytoma, carcinoid tumor, etc. The aim of this study 

was to evaluate common clinical presentations and sensitivity of I-131 MIBG scan, serum catecholamine, 

urinary catecholamine and urinary VMA in the diagnosis of pheochromocytoma. Methods: Between 

December 1993 and October 1998, 17 patients finally proved by histopathological examination to have 

pheochromocytoma underwent I-131 MIBG scintigraphy preoperatively. Following thyroid blockade, the 

patients were injected intravenously with 0.5-1.0 mCi of I-131 MIBG then whole-body images were 

obtained at 24h, 48h (and 72h). Intensity of MIBG uptake was semiquantitatively compared to the activity 

of the liver. Results: Six patients had incomplete medical records and thus, the remaining 11 cases were 

analyzed, including 3 males and 8 females (age 7-70 y, median 32 y). The common symptoms included 

headache (9 in 10 patients; 90%), palpitation (8 in 10; 80%) and sweating (4 in10; 40%). Hypertension 

was found in all (100%). The sensitivity of abnormal level of serum and urinary catecholamine, urinary 

VMA according to the number of the tests were 100%, 90%, 88% and those according to the number of 

the cases were 100%, 87.5%, 90% respectively. The sensitivity of significant positive level (at least 3 

times of upper normal limit) of serum and urinary catecholamine, urinary VMA according to the number 

of the tests were 95%, 80%, 36% and those according to the number of the cases were 100%, 87.5%, 

60% respectively. MIBG scintigraphy revealed abnormal uptake in all 11 patients. The sensitivity of 

MIBG studies was 100%. Conclusion: MIBG scan is a very useful study for diagnosis and localization 

of pheochromocytoma preoperatively. 

THYROID CANCER DOSIMETRY USING CLEARANCE FITTING 

Eli Furhang, Steven M. Larson, Puangrat Buranapong* and John L. Humm 

Department of Medical Physics and Nuclear Medicine, Memorial Sloan Kettering Cancer 

Center, New York, New York; and *Division of Nuclear Medicine, Department of Radiology, 

Siriraj Hospital, Mahidol University, Bangkok, Thailand 

Since 1962, Memorial Sloan Kettering Cancer Center has used an individually optimized 

dosimetry method for patients with thyroid carcinoma undergoing radioiodine therapy. This traditional 

dosimetry method involves a determination of the maximum tolerated activity or the activity 

(426) 

(427) 

315

316 

that will deliver 2 Gy to the blood (A max ), and the corresponding ablative lesion dose (D lesion ). However, 

the traditional calculations of A max and D lesion were based on empirical assumptions. The objective of this 

work was to develop a dosimetry method that eliminates these assumptions by incorporating patient 

kinetics and that is not restricted to 131 I as a tracer and therapeutic agent. 

Methods: Patient kinetics were incorporated into the dosimetry algorithm by fitting 

parameters to patient clearance measurements. The radioiodines 123 I, 124 I and 131 I were accommodated 

as tracers and therapeutic agents by incorporating their physical half lives and by precalculating photonabsorbed 

fractions for these radionuclides for several thousand patient geometries using Monte Carlo 

simulations. 

Results: A max and D lesion have been calculated using the traditional and new method for 

a group of patients and errors associated with each of the above assumptions were examined. Assuming 

that the initial blood activity is distributed instantaneously in 5 L was found to introduce an error in A max of 

up to 30%, whereas assuming physical decay beyond the last data point introduced error of up to 50% 

Conclusion: Individualized fitting of clearance data is a practical method to accurately 

account for inter-patient kinetics variations. The substitution of standard kinetics beyond measured data 

might lead to substantial errors in estimating A max and D lesion . In addition, gamma camera images, rather 

than neck probe readings, should be used to determine lesion uptakes for thyroid cancer patients. 

Key Words: radioiodine; thyroid cancer; dosimetry 

J Nucl Med 1999; 40:131-136 

MEASURMENT OF TUMOR UPTAKE OF 99MTC-DTPA – 10B-CARBORANE COMPLEX IN BRAIN TO EVALUATE 10B ABSORBED DOSE FOR NCT. (428) 

Nisarut Ruksawin 

Department of Radiology, Siriraj Hospital and Medical School, Mahidol university. 

Key words : NCT, radionuclide-labelling, tumor uptake. 


Although neutron capture therapy (NCT) is a very promising technique for the treatment 

of brain tumors, it is very difficult to clearly evaluate the dose absorbed by the brain tumor. This 

paper will show how to use nuclear medicine to evalutate the 10 B dose aborbed by the brain tumor. 10 B 

carborane gadolinium complex was labelled with 99m Tc and quality control showed 95 % of radiochemical 

purity. Scinticamera can tell the %uptake of 99m Tc-DTPA – 10 B-carborane complex in brain tumor by 

selecting area of interest on tumor, the count rate was read and divided by the activity injected. Using 

%uptake of 99m Tc-DTPA – 10 B-carborane complex of the tumor in brain, dose of 10 B absorbed by brain 

tumor can be evaluated. Nulcear medicine can be used instead of MRI only for the compound which 

can be labelled with suitable radionuclide. 99m Tc is at the present time the most popular radinuclide for 

this purpose.

FOOD IRON AVAILABILITY FROM DIFFERENT QUALITIES OF RICE 

FROM VARIOUS REGIONS IN THAILAND 

Nopamon Sritongkul and Malulee Tuntawiroon 

Section of Nuclear medicine, Department of Radiology, Faculty of Medicine Siriraj, Mahidol 

university 

Key words: Iron, availability, rice 

Rice samples obtained from different parts of Thailand included Bangkok were divided 

by qualities into polished rice, 5% and 15% broken polished rice and unpolished rice. These samples 

were analyzed chemically for total iron and phytate contents, and under control conditions as in the 

gastrointestinal digestion and absorption system, food iron availability was determined by measuring its 

in-vitro ionisability by radiometric 59 Fe method. Unpolished rice contained 1 to 2 mg of iron per 100g of 

dry rice or 2.5 times higher than the polished rice . Their phytate contents varied widely depending on 

milling technique. The higher the phytate content the lower its availability for iron. Phytate content in 

unpolished rice was 5 times higher than the polished and their iron was ionised to only 70% of the polished 

rice. The 5% and 15% broken polished rice contained 2 to 9 mg of iron per 100g and 2 to 4 times higher 

phytate content than the polished rice. It is ionised to 80% of the polished rice. For polished rice, the daily 

intake of phytate is 30 mg per 100g of dry rice . To counteract the inhibitory effect of phytate to maintain 

good iron nutrition, meat and ascorbic acid rich vegetables should be regularly consumed. 

EFFECTS OF COOKING PROCESS ON AVAILABILITY FOR IRON 

FROM MEALS WITH COMMON VEGETABLES 

(430) 

Malulee Tuntawiroon and Nopamon Sritongkul 

Section of Nuclear medicine, Department of Radiology, Faculty of Medicine Siriraj Hospital, 


Key words: Iron, vegetables, cooking process 

A radiometric 59 Fe method was used to determine the effect of raw and cooked vegetables 

on food iron availability by measuring food iron ionisability in-vitro. Different methods of vegetable 

preparations had been shown to influence food iron ionisability (p


could not counteracting the inhibitory effect of tannin. With vegetables, the dietary iron absorbed from 

basal meal increased 1.9 to 2.6 times (0.49 mg per day for basal meal versus 0.95 to 1.28 mg per day for 

basal meal with vegetables). However, these amounts could not meet the daily requirements for adolescent, 

lactating and menstruating women. Basal meal with meat and ascorbic acid-rich vegetable is 

recommended to improve iron nutrition in these population groups. 

COMPARISON OF SERUM THYROGLOBULIN MEASUREMENTS BY 

RADIOIMMUNOASSAY AND IMMUNORADIOMETRIC ASSAY 

Vipa Boonnamsiri 1 

, Panee Jampathong 2 

, Busara Satayaban 1 

, Boontham Amorngitticharoen 1 

1 

Division of Nuclear Medicine, Department of Radiology, Faculty of Medicine Siriraj Hospital, 

Mahidol University, Bangkok 10700.; 2 

Department of Radiology, Sappasittiprasong Hospital, 

Ubonrajchathani, Thailand. 

Key words : Thyroglobulin, Radioimmunoassay, Immunoradiometric assay 

Serum thyroglobulin (Tg) concentrations are widely used as a tumour marker for monitoring 

the patients with differentiated thyroid carcinoma. Precise and reproducible Tg measurements are 

critical, especially when patients are judged to have a high risk for recurrence. The clinical utility of two 

different Tg methods (RIA and IRMA) was compared and evaluated focusing on measurement methodology. 

Therefore, complete quality control profiles were performed and assessed. The results revealed 

that the sensitivity (low detection limit) of the assays for Tg-RIA (DPC) and Tg-IRMA (CIS) was 2.28 

ng/ml and 0.62 ng/ml, respectively. The assay precision of both intra- and inter-assays had coefficient of 

variation (C.V.) of 5.49-15.63% for Tg-RIA and 5.56-8.27% for Tg-IRMA. The accuracy of the two 

assays was 96.9-121.3% for Tg-RIA and 97.6-104.3% for Tg-IRMA. No cross-reaction and no drift 

effect were obtained in both assays. The results showed complete parallelism between Tg standards and 

serial dilutions of Tg-containing serum. The hook effects were indicated with both assays at very high 

concentration of Tg. The quality of Tg-IRMA (CIS) was proved to be superior to Tg-RIA (DPC). 

(Foundation : Government budget) 

(431)

ANGIOGRAPHIC FINDINGS OF HEPATOCELLULAR CARCINOMA 

IN SIRIRAJ HOSPITAL 

Kruatrachue Chutakiat, Prabhasavat Krisdee, Iemsawasdikul Krienskrai, Vanaprunks Saroj, 

Chaiyasoot Walailak, Danpukdee Kanijana. 

Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University. 

Five years collection of 126 cases of celiac and hepatic angiography of hepatocellular 

carcinoma were done and analysed in the aspects of sex,age and angiographic findings,such as 

,neovascularity,vascular distortion,etc.The most common finding was neovascularity(88%),the least findings 

were avascularity(5%),and normal angiographic finding(5%).Comparison between eighteen cases of 

pathological diagnosis with the other study was alos performed. 

KALLMANN SYNDROME : A CASE REPORT OF MRI FINDINGS 

Orasa Chawalparit, Suthisuk Suthipongchai 

Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University. 

The MRI findings of a case of Kallmann syndrome was reported. A 16 years-old 

female patient came with a history of primary amenorrhea and hyposmia. The hormonal studies were 

shown as hypogonadotropic hypogonadism. The MRI. of olfactory region reveals absent of olfactory 

bulb and hypoplasia of the olfactory sulci. The imaging was shown and a review of literatures was 

presented. 

Kallmann syndrome is a form of congenital hypogonadotropic hypogonadism with anosmia 

or hyposmia. The prevalence has been estimated to be one in 10,000 males and one in 50,000 females. 2 

The MR imagings have been reported with absent or hypoplasia of the olfactory bulb and tract as well as 

hypoplasia of olfactory sulci. We reported one case of MR imaging with clinical suspected to be this 

disease in a girl, which is a rarer prevalece in the sex-distribution. 

(432) 

(433) 

319


SAPHENOUS NERVE CONDUCTION STUDY IN SIRIRAJ HOSPITAL 

Harnphadungkit K. 

Department of Rehabilitation Medicine, Faculty of Medicine Siriraj Hospital, Mahidol 

University. 

Key words : Saphenous nerve, Nerve conduction study 

Saphenous nerve conduction was studied in 50 healthy adults (27 male, 23 female). The 

surface recording electrodes were placed at the medial malleolus. The stimulating electrodes were 

placed 12 centimeters proximally along the medial border of the tibia. The initial and peak latency of the 

sensory nerve action potential (SNAP) were 2.53 ± 0.23 and 3.17 ± 0.28 milliseconds respectively. The 

SNAP amplitude was 6.78 ± 2.62 microvolts. 

(Harnphadungkit K. Saphenous nerve conduction study in Siriraj Hospital. J Thai Rehabil. 

1999; 9(1): 18-21.) 

NORMATIVE STUDY OF MEDIAN SOMATOSENSORY EVOKED 

POTENTIALS (SEPS) IN SIRIRAJ HOSPITAL 

Lukkanapichonchut P., Harnphadungkit K., Tosayanonda O. 

Department of Rehabilitation Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University. 

Key words : Median Nerve, Somatosensory Evoked, Potentials (SEPS) 

There is no single method of performing evoked potentials studies so the normal values 

of SEP of median nerve were studied in Siriraj Hospital. The study was performed in 35 healthy volunteers 

(21 females and 14 males). Their age ranged from 14 to 50 years (average female 29 ± 9 and male 26 

± 5 years). The methods are similar to the Evoked Potentials Committee of the American Association of 

Electromyography and Electrodiagnosis (AAEE - EPC). There is no statistically significant difference in 

absolute and interpeak latency between right and left side in each sex. However, there is statistically 

significant differences between sex, male has longer absolute and interpeak latency than female except 

N13-N20 interpeak latency. 

Peak Latency (ms) mean ± SD p-value 

Male Female 

EP 9.43 ± 0.70 8.96 ± 0.50 < 0.05 

N11 11.30 ± 0.77 10.51 ± 0.45 < 0.05 

N13 13.14 ± 0.66 12.23 ± 0.39 < 0.05 

N20 18.85 ± 0.72 17.80 ± 0.54 < 0.05 

EP - N13 3.71 ±0.53 3.26 ± 0.45 < 0.05 

N13 - N20 5.71 ± 0.69 5.57 ± 0.43 NS 

Normative data for median SEPs, compare between sex. 

(Lukkanapichonchut P, Harnphadungkit K, Tosayanonda O. Normative Study of Median Somatosensory 

Evoked Potentials (SEPs) in Siriraj Hospital. J Thai Rehabil 1999; 8(3): 255-259.) 

(434) 

(435)

PREVALENCE OF DEMENTIA IN 1,034 THAI ELDERLY IN BANGKOK (436) 

Senanarong V, 1 Harnphadungkit K, 1 Poungvarin N, 1 Thongtang O, 1 Sukhatunga K, 2 

Vannasaeng S. 1 

1 Division of Neurology, Department of Medicine, 2 Department of Psychiatry, Faculty of Medicine 


Objectives : A cross-sectional survey was conducted to determine the prevalence of 

dementia in three district areas of Bangkok during 1997-8. 

Method : Thai version of Mini-Mental State Examination (TMSE) was applied to 1,034 

Thai elderly aged 60 years old and over who lived in three districts near Siriraj Hospital in Bangkok. 

Those who scored less than 24 were interviewed and examined by neurologists or psychiatrists. History 

regarding onset of memory loss, fluctuation courses, neuro-psychiatric manifestation and activities of 

daily living were taken from both the elderly and their relatives. Verbal fluency, clock drawing and threedimensional 

object drawing were also operated in this study. DSM IV criteria was employed to diagnose 

dementia. CT brain scan was carried out in some cases. 

Results : Of one thousand and thirty four Thai elderly, one hundred and eighty three 

(17070%) were scored less than 24 on TMSE. Fifty-three (5.13%) were diagnosed as having dementia. 

Their mean age was 74.57 (+8.29) years old (range 61-96). CT brain scan was done in only 39.62% of 

these demented elderly. The prevalence of Alzheimer’s disease was 3.48%, of vascular dementia was 

0.58%, of neurosyphilitic dementia was 0.19%, of alcohokic dementia was 0.48%, of Parkinson’s dementia 

was 0.097% and of unknown cause of 0.19% 

Conclusion: This study showed that the prevalence of dementia in Thai elderly was 

similar to other Asian countries but vascular dementia was the second commonest cause of dementia in 

this population. 

(The Celebrations on the Auspicious Occasion of his majesty the King’s 6 th Cycle Birthday Anniversary 

5 th December 1999. 157p.) 

321

322 

THE RELATIONSHIP BETWEEN MYOFASCIAL TRIGGER POINTS OF 

GASTROCNEMIUS MUSCLE AND NOCTURNAL CALF CRAMPS. 

Prateepavanich P., Kupniratsaikul V., Charoensak T. 

Department of Physical Medicine and Rehabilitation, Siriraj Hospital, Mahidol University. 

Key word : Trigger Point, Cramp. 

To support that myofascial pain syndrome (MPS) of gastrocnemius muscle is one 

cause of nocturnal calf cramps, quantitative assessment of the efficacy of trigger point (TrP) injection 

compared with oral quinine in the treatment of nocturnal calf cramps (NCC) associated with MPS of 

gastrocnemius muscle was designed. Twenty four subjects with NCC and gastrocnemius TrPs were 

randomly divided into two groups of twelve for each treatment. Patients in group 1 were treated with 

xylocaine injection at the gastrocnemius TrP, and 300 mg of quinine sulfate p.o. was prescribed for 

patients of group 2. The treatment period was four weeks with a follow-up 4 weeks later. Cramps 

were assessed quantitatively (in terms of frequency, duration, pai intensity, cramp index, and pain 

threshold of the gastrocnemius TrPs) before treatment, after treatment and at the end of the followup 

respectively. The outcome of treatment in both groups showed a statistically significant reduction 

in all quantitative aspects of cramps (95% confidence interval). Also the pain threshold of the 

gastrocnemius TrP was significantly increased in group 1 only when comparing the pre-treatment and 

at the end of follow-up. In comparing the two groups we found no statistical difference during the 

period of treatment. The benefit of both strategies lasted up to four weeks following cessation of the 

treatment but the outcome of all measures (except pain threshold) were found to be significantly better 

in the group treated with TrP injection. The results of this study support that gastrocnemius trigger 

point is one cause of NCC and show that the TrP injection strategy for NCC associated with 

myofascial pain is not only as effective as oral quinine during the treatment period but also better in the 

prolonged effect at follow-up. 

GRIP STRENGTH, PINCH STRENGTH AND QUADRICEPS STRENGTH 

IN THAI ELDERLY. 

Kuptniratsaikul V, 1 Wongsaranuchit Y,1 Ratanachoti P,2 


1Department of Rehabilitation Medicine, Facutly of Medicine Siriraj Hospital, Mahidol 

University. 2Out Patient Department Orthopaedics Unit, Faculty of Medicine Siriraj 

Hospital, Mahidol University. 

Key word : Grip Strength, Quadriceps Strength, elderly 

A study of grip strength, pinch strength, and quadriceps strength in Thai elderly people 

at the Geriatric clinic, Siriraj Hospital was performed. One hundred and sixty two elderly, 63 males 

and 99 females, with mean age (x±SD) 70±6 years were evaluated by using hand 

dynamometer, pinch gauge and leg dynamometer. The grip and pinch strength of dominant hand were 

different from the non-dominant hand with p value < 0.001. The quadriceps strength was decreasing 

significantly as the patients got older (p

than female. Those muscle strengths were not affected by the type and frequency of exercise. 

The grip strength, pinch strength and quadriceps strength decreased rapidly after the age of seventy, 

the decline was prone rapid in male than in female. The normal value of these muscle strengths 

would be benefit for early detection of neuromuscular diseases in the elderly. 

VOCATIONAL AND AVOCATIONAL ACTIVITIES AFTER TRAUMATIC 

SPINAL CORD INJURY 

Kuptniratsaikul V, 1 Kaewnaree S, 1 Leurcharusamee A, 1 Chavasiri C, 2 

1 Department of Rehabilitation Medicine, 2 Department of Orthopaedic Surgery, Faculty of 


Key word : Vocation, Avocational activity 

Vocational and avocational activities of the thoracic and lumbar level of the spinal cord 

injury patients, Orthopaedic Department, Siriraj Hospital were studied. There were 55 patients from the 

total of 78 answering the questionnaire. The vocational ability was found in 29.1 percent (16/55 

patients) : 8 persons worked for the whole day, 5 persons did half-day work and 3 persons did less than 

a half-day work. The reasons for not working were disability, the condition of the working place and 

lack of transportation ; 32, 18 and 15 percent respectively. There were significant difference of the 

income and severity of diseases between the two groups (people who can work and can’t work) with p 

value of 0.0006 and 0.007. Sixty-nine percent of patients had avocational activities and the most favorite 

activity was reading. Modification of the working place or the job and improvement of public transportation 

system should be performed in order to increase the number of working peoples. 

SCITHE POSSIBILITY OF MAB METHOD F OR CONTROLLING 

SPASTICITY. 

Tetinantana S., 1 Chavasiri C., 2 Viboolchareon S. 3 

1 Department of Rehabilitation Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 

2 Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol 

University, 3 Department of Pharmacy, Siriraj Hospital, Mahidol University. 

Muscle afferent block method (MAB) for controlling spasticity was studied in six paralyed 

patients who had severe spasticity of bilateral adductor muscles by injecting 0.5 percent xylocaine + 99.5 

percent ethanol (10 : 1 cc) and 5 percent phenol directly into right and left adductor muscles respectively 

without making any attempt to locate the nerve sites. The study evaluated the treatment by passive 

abduction and spastic scale. The result showed that spasticity could be decreased both sides. 5 percent 

pheonol produced better result and longer duration of 3-4 days compared with 1-2 days when 0.5 

percent xylocaine + 99.5 percent ethanol used. 


(439) 

(440) 

323


THE THAI NASALITY TEST FOR CLEFT PALATE PATIENTS 

Nantana Pracharitpukdee 1 , Sriwimon Manochiopinig 2 , Sirikanya Lertsarunyapong 3 Pongsri 

Sutantawibon 1 

1 Department of Rehabilitation Medicine, King Chulalongkorn Memorial Hospital. 2 Department 

of Rehabilitation Medicine, Siriraj Hospital, Mahidol University. 3 Department of Otolaryngology, 

Rajavithi Hospital. 

Key words : Resonance disorders, Thai nasality test, Cleft palate. 

The evaluation of resonance disorders is an important and necessary guide for 

effective management of patients with cleft palate. Perceptual assessment and instrumental measurement 

in nasality have been recognized by clinical specialists. Although speech as standard stimulus 

items for assessment is required for both methods, the stimulus items are not available for Thai 

language. Aim of this study was to design a Thai language test to measure nasality in cleft palate 

patients. Subjects were 32 post-operative cleft palate patients who never received speech therapy and 

32 normal subjects matched in sex and age with the cleft palate group. The designed nasality test 

consists of three passage types : a) Hyponasality test “Manee” (40 nasal consonant occurrences), b) 

Hypernasality test “Tuk Tuk” (no nasal consonant phonemes), and C) the Thai standard passage “Sai 

Yok Water Fall” (all consonant phonemes with 28% occurrences of nasal consonant phonemes). The 

test was used by the specialists in the perceptual assessment, and an instrument assessment using the 

model 6200-3 Nasometer. Results of the two assessments agreed well with the purpose of the nasality 

test. Based on a 7-point rating scale in perceptual assessment, the cleft palate patients showed results 

of moderate (+2) and severe (+3) hypernasality. Results also showed significant differences between 

normal and cleft palate groups in responding to the “Tuk Tuk” (p=0.02) and the “Sai Yok Water fall” 

(p=0.05). Non-significant difference between groups was found as there was no hyponasal problem in 

any subjects. Mean nasalance scores of the normal subjects were 59.36% (SD=9.88) for the 

“Manee”, 15.01% (SD=8.26) for the “Tuk Tuk”, and 37.63% (SD=7.68) for the “Sai Yok Water Fall”. 

And mean nasalance scores of the cleft palate patients were 66.21% (SD=6.74) for the “Manee”, 

53.62 (SD=9.48) for the “Tuk Tuk”, and 58.81% (SD=8.46) for the “Sai Yok Water Fall”. In 

conclusion the Thai nasality test can be clinically used as a standard pattern to identify nasality in cleft 

palate patients both by perceptual and instrumental assessment. 

(441)

THE POSSIBILITY OF MAB METHOD FOR CONTROLLING 

SPASTICITY 

Tetinantana S., 1 Chavasiri C., 2 Viboolchareon S3 (442) 

1 Department of Rehabilitation Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 

2 Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol 

University, 3 Department of Pharmacy, Siriraj Hospital, Mahidol University. 

Muscle afferent block method (MAB) for controlling spasticity was studied in six paralyed 

patients who had severe spasticity of bilateral adductor muscles by injecting 0.5 percent xylocaine + 99.5 

percent ethanol (10 : 1 cc) and 5 percent phenol directly into right and left adductor muscles respectively 

without making any attempt to locate the nerve sites. The study evaluated the treatment by passive 

abduction and spastic scale. The result showed that spasticity could be decreased both sides. 5 percent 

pheonol produced better result and longer duration of 3-4 days compared with 1-2 days when 0.5 

percent xylocaine + 99.5 percent ethanol used. 


325


PREDICTING THE LIKELIHOOD OF RESIDUAL DISEASE IN WOMEN 

TREATED FOR DUCTAL CARCINOMA IN SITU 

(443) 

Adune Ratanawichitrasin, Lisa A Rybicki, Ezra Steiger , Sharon Grundfest-Broniatowski, Robert 

E Hermann, and Joseph P Crowe 

Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol Univesity, Bangkok, 

Thailand. 

Background : To identify women at risk for residual disease after excision of ductal 

carcinoma in situ (DCIS), we assessed the relationship between characteristics of the initial biopsy and 

the presence of residual DCIS at a subsequent operation. 

Study Design : We identified 134 consecutive “paired” operations from 112 women 

who had undergone 2 or more operations for DCIS between February 1995 and December 1996. 

Cancer status of the margins, patient age’ and leading presentation, tumor subtype and grade, and the 

presence of multifocal-extensive disease were assessed as potential predictors. 

Results : Residual DCIS was found in 60 patients (45%) : in 2 of 12 patients (17%) 

with negative margins, in 11 of 36 (31%) with close margins (< 2 mm), in 30 of 52 (58%) with positive 

margins, and in 17 of 34 patients (50%) with margins of unknown status. Patients with positive or 

unknown margins were 7.7 and 8.3 times, respectively, more likely to have residual disease than patients 

with negative margins (95% CI 1.1-59.1;1.1-66.4). Patients with clinical presentations were 8.0 times 

more likely to have residual disease than patients who presented with abnormal mammograms (95% CI 

2.3-27.6). Multifocal- extensive DCIS was associated with residual disease (adjusted odds ratio [OR] 

=7.7, 95% CI 2.9-20.5) as was comedo subtype (OR = 2.7, 95% CI 1.1-6.7) 

Conclusions : Positive or unknown biopsy margins, a clinical presentation, multifocalextensive 

cancer, and the comedo subtype are associated with higher risk of residual DCIS. 

(J Am Coll Surg 1999;188:17-21).

TOUCH IMPRINT CYTOLOGICAL ANALYSIS OF SENTINEL LYMPH 

NODES FOR DETECTING AXILLARY METASTASES IN PATIENTS 

WITH BREAST CANCER 

A. Ratanawichitrasin, C. V. Biscotti*, L. Levy and J. P. Crowe 

Breast Center, Department of General Surgery and *Department of Pathology, The Cleveland 

Clinic Foundation, Cleveland, Ohio, USA 

Correspondence to : Dr A. Ratanawichitrasin, Department of Surgery, Faculty of Medicine 

Siriraj Hospital, Mahidol University, Bangkok noi, Bangkok 10700, Thailand 

Background : Sentinel lymph node biopsy is a procedure that examines the first tumour-draining 

lymph node. Touch imprint cytology may provide a quick method for intraoperative screening 

of sentinel lymph nodes for the presence of metastases. 

Methods : Touch imprint cytological analysis of sentinel lymph nodes was compared 

prospectively with the findings obtained on routine paraffin sections. Touch imprint slides from 55 patients 

with breast cancer were prepared during operation from multiple sections of sentinel lymph nodes, stained 

with haematoxylin and eosin. A cytopathologist blinded to the histological results interpreted the smears. 

Results :The concordance between touch imprint and paraffin sections of sentinel 

lymph nodes was 98 per cent(54 of 55). When touch imprint analysis of sentinel lymph nodes was 

compared with paraffin sectioning of all lymph nodes from the axillary node dissection, the concordance 

was 95 per cent (52 of , 55). The sensitivity and specificity of sentinel lymph node touch imprints in 

detecting metastases were 82 and 100 per cent respectively. The positive and negative predictive values 

were 100 and 93 per cent respectively. 

Conclusion : Touch imprint cytology is potentially useful for the intraoperative 

evaluation of sentinel lymph nodes in patients with breast cancer.British Journal of surgery 1999,86,1346- 

1348. 

TRANSPOSITION OF THE LINGUAL THYROID : A NEW ALTERNATIVE 

TECHNIQUE 

Supakorn Rojananin, 1 Kitirat Ungkanont2 (445) 

1 Division of Head Neck and Breast Surgery, Department of Surgery, Faculty of Medicine, 

Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand; 2 Department of Otolaryngology, 

Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand 

Background. In symptomatic lingual thyroid, surgical transposition of the gland with its 

vascular supply intact seems to have superior results to those obtained by surgical ablation and autotransplantation. 

However, the procedure should be simple, reproducible, reliable, and cause less morbidity as 

well as providing simple access to and evaluation of the gland post-operatively 

Methods. We present the case of a 33-year-old female with lingual thyroid who was 

treated by transposing the whole gland to the lateral pharyngeal wall through a lateral pharyngotomy 

incision. The transposed lingual thyroid was nourished by a random toungue muscle pedicle flap. 

(444) 

327

328 

Result.At the 5-month postoperative stage, iodine scanning reviewed the radioactivity 

uptake of the transposed gland. Even though the patient was not on postoperative thyroid hormone 

supplement, her thyroid function gradually returned to normal after initially showing hypothyroid postoperatively. 

Conclusion. This new technique for transposition of lingual thyroid is simple and reliable 

and should be considered as an alternative method in the management of symptomatic patients. 

(©1999 John Wiley & Sons, Inc. Head Neck 21:480-483, 1999.) 

PROPHYLACTIC ANTIBIOTIC IN MINOR TRAUMATIC WOUND ; IT 

IS WORTH? 

(446) 

Muangman P 1 , Siltharm S 1 , Chuntrasakul C 1 , Karunpong W 2 , MoongniranaA 1 , IttiplinK 1 , 

Bunampon D 1 , Suttipong A 3 , Amarttayakul M 3 , Natnitivittaya A 3 , Sammarat P 3 

1 Department of Surgery, 2 Department of Microbiology, 3 Nursing,Department, Faculty of Medicine 

Siriraj Hospital, Mahidol University, Bangkok, Thailand 10700. 

Introduction : Antibiotics in minor traumatic wounds may not be useful if the wounds 

are not severely contaminated and received appropriate management since the chance of infection is 

usually low. Our objective is to determine the value of antibiotics in minor traumatic wounds. 

Method : A randomized control trial was done in 166 patients (123 males,43 females),aged 

between 6 and 60 years, with minor traumatic wounds. Most wounds were located on head and extremity 

regions. Cultures were done before suturing in all wounds. The wounds were cleaned and sutured as 

usual, then divided into two groups, group B treated with antibiotics for at least 3 days, group A no 

antibiotics was used. Antibiotics were given in 83 wounds. One hundred wounds were completely followed 

up, 50 with oral antibiotic treatment (penicillin v , cloxacillin or erythromycin). Infection rates of those 

with and without antibiotic treatment were compared using Chi-square test. 

Result : Initial cultures showed 91 positive wound cultures (54.6%). Staphylococcus 

coagulase negative was the major organism (69.2%) found. Four wounds were infected though oral 

antibiotics were given (group B), where as in the non-antibiotic group(group A) 2 wounds were 

infected. Comparison with Chi-square test showed no statistical significant difference(p>0.05). 

Conclusion : We conclude that usage of antibiotics in minor traumatic wound does not 

reduce wound infection rate. Prophylactic antibiotic in minor traumatic wound should be limited because 

the incidence of infection is too low to justify the expense and risk of antibiotic administration. 

Wound debridement and cleansing are more advantageous than antibiotic alone. 

(Siriraj Hosp Gaz 1999;51:708-714. ) 

Faculty of Medicine Siriraj Hospital

FACTORS INFLUENCING POSTOPERATIVE INFFCTION OF 

MANDIBULAR FRACTURE 

Preecha Siritongtaworn 1 , Nuntigar Sonsuwan 2 

(447) 

1 Department of Surgery. Faculty of Medicine Siriraj Hospital. Mahidol University. Bangkok.; 

2 Department of Oto-rhino-laryngology. Faculty of Medicine. Chiangmai University. Chiangmai. 

Infection is a common complication, following the operations for mandibular fracture. 

We had studied the factors that increased the incidence of infection. From 1 January 1991 to 31 

December 1995, there were 693 cases of mandibular fracture received treatment in the Division of 

Trauma Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital. This included 925 sites of 

fracture (484 cases with single fracture,186 cases with double fractures and 23 cases with triple 

fractures). We excluded 149 cases who had not been operated and 7 cases who were referred to us 

for the treatment of complication, so the number of fracture sites to be studied was reduced to 686. 

The methods of operations were intermaxillary fixation without open reduction, (264 sites) wiring 

the fracture site (264 sites), and rigid fixation with plate & screws (134 sites). It was found that the 

infection rate of the operations 2.6, 18.4 and 7.4% respectively (P < 0.05). No statistical 

difference was found in the duration after injury before the operation (6.6 days for the non-infected 

group and 6.5 days for the infected group, P = 0.6467). Fractures in the tooth-bearing part had more 

infection rate (13.6%) than fractures in the non tooth-bearing part (1.5%), P < 0.0001. Open fractures 

had more infection (16.8%) than closed fractures (7.6%), P = 0.0005. No statistical difference in the 

rate of infection was found between the simple fracture group (9.7%) and the comminuted fracture 

group (17.3%), P = 0.123. There was no infected complication found in the 5 HIV+ patients. The 

knowledge from this study may help in considering the method of operation, post operative care and 

the prognosis of the patients. 

329


EARLY COMPLICATIONS OF GASTRIC TRANSPOSITION 

OPERATION 

Ravit Ruangtrakool 1 , Lewis Spitz 2 

1 Division of Paediatric Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, 

Mahidol University, Bangkok 10700, Thailand; 2 Department of Surgery, Institute of Child 

Health and Great Ormond Street Hospital for Children NHS Trust, University of London, 

United Kingdom. 

Key words : Oesophageal substitute, Oesophageal replacement, Gastric transposition 

Gastric transposition was performed in 100 children as a definitive procedure for oesophageal 

replacement between 1982 and 1997 for 69 oesophageal atresia (41 with distal 

tracheooesophageal fistula, 20 isolated oesophageal atresia and 8 with proximal tracheooesophageal 

fistula), 16 severe caustic stricture, 7 intractable peptic reflux stricture and 8 miscellaneous causes. Six 

mortalities were recorded. Sixty-five patients had complications postoperatively and respiratory complication 

was the most common complication especially in oesophageal atresia patients. Swallowing difficulty, 

particularly in oesophageal atresia, occurred in 21% of the patients. Ten patients developed cervical 

leakage with spontaneous closure and 8 patients suffered from anastomosis stricture. Six jejunostomy 

revisions were required. Three of five pyloromyotomy obtained inadequate gastric drainage post gastric 

transposition and required the conversion to pyloroplasty. Because of the distinctive low major lifethreatening 

morbidity and low mortality, we concluded that gastric transposition was a safe, easy and 

preferable procedure for oesophageal replacement in children. 

GASTROSTOMY BUTTON : CLINICAL APPRAISAL 

Ravit Ruangtrakool 1 , Tat Hin Ong 2 

1 Division of Paediatric Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, 

Mahidol University, Bangkok 10700, Thailand; 2 Department of Surgery, Royal Children’s 

Hospital, Brisbane, Australia. 

Key words: Gastrostomy button; Gastrostomy tube; Enteral feeding 

We retrospectively studied all gastrostomy buttons inserted in the Royal Children’s 

Hospital, Brisbane between 1988 and 1995. One hundred and thirty-two patients (M = 60, F=72) and 388 

buttons were analysed. Intellectual handicap and cystic fibrosis comprised the majority of patients. Thirtythree 

patients had gastrostomy buttons inserted primarily, whereas, 99 patients received gastrostomy 

buttons inserted into matured gastrostomy stoma. The average longevity of all determined buttons (n = 

280) was 360.43 days (SD = 310.24). The first buttons inserted primarily (n = 25) had longer longevity 

than the first buttons inserted into matured gastrostomy stoma (n = 82) with statistical significance. The 

average longevity of subsequent buttons was significantly less than the first buttons. Valve incompetence 

and leakage of gastric content around the shaft were the most common causes of button removal. We 

concluded that the gastrostomy button is the method of choice for long term enteral feeding in children. 

(448) 

(449)

PRIMARY GASTROSTOMY BUTTON : A MEANS OF LONG TERM 

ENTERAL FEEDING IN CHILDREN 


1 Division of Paediatric Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, 

Mahidol University, Bangkok 10700, Thailand; 2 Department of Surgery, Royal Children’s 

Hospital, Herston, Brisbane, Australia. 

Key words : Gastrostomy button; Gastrostomy tube; Enteral feeding 

Between June 1992 and December 1997, forty-two patients (M 19, F 23) received 94 

primary gastrostomy buttons due to 22 intellectual handicap, 7 cystic fibrosis, 4 severe gastrooesophageal 

reflux, 2 bronchopulmonary dysplasia, 2 tumours in the neck region and 5 miscellaneous causes. Open 

fundoplication concomitant with primary button, primary open button and laparoscopic fundoplication 

concomitant with primary button were performed in 20,15 and 7 patients respectively. The average 

longevity +,- standard deviation of all buttons was 388.36 +,- 360.35 days. The average longevity of the 

buttons of laparoscopic fundoplication group was significantly lower than the others. The major causes of 

removal of Bard buttons were valve incompetence and flap damage where as the balloon leakage was 

the major cause of removal of Mic-key button. There were merely minor stomal complications and no 

gastric separation and peritonitis. Because of the acceptable longevity of the buttons and minimal 

complications, we concluded that the primary gastrostomy button was the preferable method of long 

term enteral feeding in children. 

COMPARISON BETWEEN MUSHROOM-TYPE AND BALLOON-TYPE 

GASTROSTOMY BUTTONS 



Mahidol University, Bangkok 10700, Thailand; 2 Department of Surgery,Royal Children’s Hospital, 

Brisbane, Australia 

Key words : Gastrostomy button; Gastrostomy tube; Enteral feeding, 

The gastrostomy button has been improved rapidly over the last ten years. The gastrostomy 

button was divided into two groups. The first group had a mushroom tip and, in this study, the Bard 

button represented this group. The other had a balloon as an internal stabiliser and the Mic-key button 

represented this group. We retrospectively studied all buttons inserted at the Royal Children’s Hospital, 

Brisbane between 1988 and 1995. The average longevity of Bard and Mic-key buttons were 378.82 and 

259.62 days respectively. Valve incompetence was the most common cause of removal of the Bard 

button (38%) whereas balloon rupture was the major cause of removal of Mic-key button (44%). Each 

type of gastrostomy button had its own advantages and disadvantages and these special characteristics 

will be discussed. 

(450) 

(451) 

331


SACROCOCCYGEAL TERATOMA : 25 YEAR EXPERIENCE 

Ravit Ruangtrakool 1 , Att Nitipon 2 , Mongkol Laohapensang 1 , Danai Meekaewkunchorn 1 , 

Surasak Sangkhathat 1 , Chana Sathornkich 1 , Polpatt Talalak 1 

1 Division of Paediatric Surgery, Department of Surgery, Siriraj Hospital, Faculty of Medicine, 

Mahidol University, Bangkok 10700, Thailand; 2 Phayathai III Hospital. 

Key words : Sacrococcygeal teratoma; Germ cell tumour; Sacral mass 

We retrospectively studied all thirty-five children (M 6, F 29) with sacrococcygeal teratomas 

admitted to Siriraj Hospital between 1974 and 1999. Although an abdominal delivery is recommended 

for lesions greater than 5 cm to avoid dystocia, the average diameter of masses which required interventions 

from dystocia (n = 3) was not different from vaginal delivery (n = 27). All except two first presented 

with sacral masses recognized at birth. One patient presented with an abdominal mass and the last one 

was diagnosed after suffering from difficulty in urination. Ninety- seven percent of cases were completely 

excised initially (32 sacral, 2 abdomino-sacral approaches), however, six patients required other treatment 

for recurrent diseases. One mature teratoma recurrence was resected. Two patients who had malignant 

recurrences following complete benign excisions, died from advanced malignancy. Four presented with 

malignancy initially. Wound infection, bladder atony and UTI were the most common complications 

postoperatively. Advanced malignancy was the major cause of death. No patient died directly from the 

procedure. 

NECROTIZING ENTEROCOLITIS : A COMPARISON BETWEEN 

FULL -TERM AND PRE - TERM NEONATES. 

Ravit Ruangtrakool 1 , Mongkol Laohapensang 1 , Chana Sathornkich 1 , Polpatt Talalak 1 



Key words: Necrotizing enterocolitis; Enterocolitis; Surgery 

A retrospective study comparing between 16 full-term and 18 pre-term neonates with 

NEC operated in Siriraj Hospital between 1987 and 1999 was performed. Major risk factors leading to 

NEC in full-term neonates included sepsis, SGA, birth asphyxia, severe jaundice requiring exchange 

transfusion and chorioamnionitis. Although full-term neonates developed NEC earlier than pre-term neonates 

did (8.56 days vs. 12.78 days), the average ages of operation in both groups were the same. There 

was no difference in CBC and bacteriological culture’s results between term and pre-term patients. The 

decision to conduct operative treatments for full-term neonates with NEC was mostly based on only 

clinical signs of peritonitis (56.25%) before the pneumoperitoneum developed (31.25%). Ileo-caecal 

region was the most common site of bowel necrosis in both premature and full-term infants. Although 

term infants had a better 3-month survival rate than pre-term neonates did (75% and 61% respectively), 

both groups had the same surgical complication rates. 

(452) 

(453)

SURGICAL TREATMENTS FOR CONGENITAL DUODENAL 

OBSTRUCTION 

Ravit Ruangtrakool 1 , Mongkol Laohapensang 1 , Akkrapol Mungnirandr 1 , Chana Sathornkich 1 


Mahidol University, Bangkok 10700, Thailand 

Key words : Duodenal obstruction; Duodenal atresia; Duodenal web 

(454) 

Thirty-four congenital duodenal obstructions (19 duodenal atresia, 7 duodenal web, 7 

annular pancreas and one duodenal stenosis) were surgically treated in Siriraj Hospital between 1990 and 

1999. Eleven percents of duodenal atresia had no bile-stained vomiting. Duodenal web which received 

web excision and duodenoplasty in 43% of cases, also presented with bile-stained vomiting. Duodenoduodenostomy, 

duodeno-jejunostomy and web excision with duodenoplasty were performed in 29, 2 and 

3 patients respectively. Duodeno-duodenostomy and web excision with duodenoplasty had no difference 

in the feeding capability. There was no statistically significant difference in duration of TPN, ability to be 

early fed, post-operative onset of full feeding and hospital staying period between diamond-shaped (n = 

18) and side-to-side (n = 11) duodeno-duodenostomy. Although transanastomotic feeding tube (n = 4) 

decreased a percentage of TPN requirement and made early feeding possible, the onset of full feeding, 

duration of TPN and hospital staying period were not different from those who had no transanastomotic 

tube (n = 30). 

333

Mahidol University Annual Research Abstracts 2000 

SURGICAL TREATMENTS FOR CONGENITAL DUODENAL 

OBSTRUCTION 

Ravit Ruangtrakool 1 , Mongkol Laohapensang 1 , Akkrapol Mungnirandr 1 , Chana Sathornkich 1 


Mahidol University, Bangkok 10700, Thailand 

Key words : Duodenal obstruction; Duodenal atresia; Duodenal web 

(454) 

Thirty-four congenital duodenal obstructions (19 duodenal atresia, 7 duodenal web, 7 

annular pancreas and one duodenal stenosis) were surgically treated in Siriraj Hospital between 1990 and 

1999. Eleven percents of duodenal atresia had no bile-stained vomiting. Duodenal web which received 

web excision and duodenoplasty in 43% of cases, also presented with bile-stained vomiting. Duodenoduodenostomy, 

duodeno-jejunostomy and web excision with duodenoplasty were performed in 29, 2 and 

3 patients respectively. Duodeno-duodenostomy and web excision with duodenoplasty had no difference 

in the feeding capability. There was no statistically significant difference in duration of TPN, ability to be 

early fed, post-operative onset of full feeding and hospital staying period between diamond-shaped (n = 

18) and side-to-side (n = 11) duodeno-duodenostomy. Although transanastomotic feeding tube (n = 4) 

decreased a percentage of TPN requirement and made early feeding possible, the onset of full feeding, 

duration of TPN and hospital staying period were not different from those who had no transanastomotic 

tube (n = 30). 

333

DISTAL RENAL TUBULAR ACIDOSIS AND HIGH URINE CARBON 

DIOXIDE TENSION IN A PATIENT WITH SOUTHEAST ASIAN 

OVALOCYTOSIS 

C. Kaitwatcharachai, S. Vasuvattakul, P. Yenchitsomanus, P. Thuwajit, P. Malasit, D. Chuawatana, 

S. Mingkum, M. L. Halperin, P. Wilairat and S. Nimmannit. 

Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 

Thailand. 

Southeast Asian ovalocytosis (SAO) is the best-documented disease in which mutation 

in the anion exchanger-1 (AE1) causes decreased anion (chloride [Cl-]/bicarbonate [HCO3-]) 

transport. Because AE1 is also found in the basolateral membrane of type A intercalated cells of the 

kidney, distal renal tubular acidosis (dRTA) might develop if the function of AE1 is critical for the net 

excretion of acid. Studies were performed in a 33-year-old woman with SAO who presented with 

proximal muscle weakness, hypokalemia (potassium, 2.7 mmol/L), a normal anion gap type of metabolic 

acidosis (venous plasma pH, 7. 32; bicarbonate, 17 mmol/L; anion gap, 11 mEq/L), and a low rate 

of ammonium (NH4+) excretion in the face of metabolic acidosis (26 &mgr;mol/min). However, the 

capacity to produce NH4+ did not appear to be low because during a furosemide-induced diuresis, 

NH4+ excretion increased almost threefold to a near-normal value (75 &mgr;mol/L/min). Nevertheless, 

her minimum urine pH (6.3) did not decrease appreciably with this diuresis. The basis of the renal 

acidification defect was most likely a low distal H+ secretion rate, the result of an alkalinized type A 

intercalated cell in the distal nephron. Unexpectedly, when her urine pH increased to 7.7 after sodium 

bicarbonate administration, her urine minus blood carbon dioxide tension difference (U-B Pco2) was 

27 mm Hg. We speculate that the increase in U-B Pco2 might arise from a misdirection of AE1 to the 

apical membrane of type A intercalated cells. 

(Published in the Am J Kidney Dis 1999;33:1147-52.) 

AUTOSOMAL RECESSIVE DISTAL RENAL TUBULAR ACIDOSIS 

ASSOCIATED WITH SOUTHEAST ASIAN OVALOCYTOSIS 

S. Vasuvattakul, P. T. Yenchitsomanus, P. Vachuanichsanong, P. Thuwajit, C. Kaitwatcharachai, 

V. Laosombat, P. Malasit, P. Wilairat and S. Nimmannit. 

Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 

Thailand. 

Background : A defect in the anion exchanger 1 (AE1) of the basolateral membrane 

of type A intercalated cells in the renal collecting duct may result in a failure to maintain a cellto-lumen 

H+ gradient, leading to distal renal tubular acidosis (dRTA). Thus, dRTA may occur in 

Southeast Asian ovalocytosis (SAO), a common AE1 gene abnormality observed in Southeast Asia 

and Melanesia. Our study investigated whether or not this renal acidification defect exists in individuals 

with SAO. METHODS: Short and three-day NH4Cl loading tests were performed in 20 individuals 

with SAO and in two subjects, including their families, with both SAO and dRTA. Mutations of AE1 

gene in individuals with SAO and members of the two families were also studied. RESULTS: Renal 

acidification in the 20 

(456) 

(457) 

335

336 

individuals with SAO and in the parents of the two families was normal. However, the two clinically 

affected individuals with SAO and dRTA had compound heterozygosity of 27 bp deletion in exon 11 

and missense mutation G701D resulting from a CGG—>CAG substitution in exon 17 of the AE1 gene. 

Red cells of the two subjects with dRTA and SAO and the family members with SAO showed an 

approximate 40% reduction in sulfate influx with normal 4,4'-di-isothiocyanato-stilbene-2,2'-disulfonic 

acid sensitivity and pH dependence. 

Conclusion :These findings suggest that compound heterozygosity of abnormal AE1 

genes causes autosomal recessive dRTA in SAO. 

(Published in the Kidney Int 1999;56:1674-1682) 

A NOVEL SPLICE-ACCEPTOR SITE MUTATION (IVS13-2>T) OF 

POLYCYSTIC KIDNEY DISEASE 1 (PKD1) GENE RESULTING IN 

AN RNA PROCESSING DEFECT WITH A 74-NUCLEOTIDE DELETION 

IN EXON 14 OF THE mRNA TRANSCRIPT 

Wanna Thongnoppakhun, Nanyawan Rungroj, Prapon Wilairat, Kriengsak Vareesangthip, 

Chintana Sirinavin, and Pa-thai Yenchitsomanus 

Key words : Polycystic kidney disease 1; PKD1; long RT-PCR; cryptic splice-site; splicing defect; 

allele specific amplification; ASA; Thailand 

Autosomal dominant polycystic kidney disease (ADPKD) occurs mainly from mutations 

of polycystic kidney disease 1 (PKD1) gene. A novel mutation of the PKD1 gene due to a 

nucleotide substitution in splice-acceptor site of IVS13 (AG->TG) was identified by analyses of 

PKD1-cDNA and genomic DNA. The IVS13-2A>T substitution resulted in an inactivation of this 

splice site and utilization of cryptic splice acceptor site in exon 14, causing a 74-nucleotide deletion of 

this exon in the PKD1-mRNA transcript. The abnormal transcript was present ectopically in the 

patients’ lymphocytes. The partial deletion of PKD1-mRNA leads to frameshift translation and introduces 

a termination signal at codon 1075. The truncated protein with about one quarter of the fulllength 

polycystin-1 is most likely inactive. Thus, the effect of this mutation would be ‘loss-of-function’ 

type. Allele specific amplification (ASA) was developed to detect the mutation in DNA samples of 

other family members. The mutation was present in 11 affected but absent in 13 unaffected family 

members, corresponding to the results of linkage analysis. In addition, it was not observed in DNA 

samples of 57 unrelated healthy individuals. 

(© 1999 Wiley-Liss, Inc.) 


(458)

COMPOUND HETEROZYGOSITY OF AE1 GENES CAUSE RECESSIVE 

DISTALRENTAL TUBULAR ACIDOSIS IN SOUTHEAST ASIAN 

OVALOCYTOSIS 

S. Vasuvattakul 1 , P. Yenchitsomanus 2 , P. Thuwajit 3 , C. Kaitwatcharachai 4 , P. Vachuanichsanong 4 , 

V. Laosombat 4 , P. Malasit 2 , P. Wilairat 3 and S. Nimmannit 1 

1 Renal Division and 2 Medical Molecular Biology Unit, Siriraj Hospital, 3 Department of Biochemistry, 

Faculty of Sciences, Mahidol Universtity, 4 Songklanakarin Hospital, Prince of Songkla 

University, Thailand. 

Southeast Asian ovalocytosis (SAO), a hereditary condition resulting from mutations of 

the anion exchanger 1 (AE1) gene, has been reported to associate with distal renal tubular acidosis 

(dRTA). However, our previous study showed that no abnormal renal acidification were detected in 20 

individuals with SAO after NH 4 Cl loading tests. Here, we report a novel AE1 mutations linked to a 

recessive dRTA in SAO. The two clinically affected individuals in a family had compound heterozygosity 

of 27-bp deletion in exon 11 and missense mutation R602H in exon 15 of the AE1 gene. Red cells of the 

two subjects with dRTA and SAO showed 70% reduction in sulfate influx with normal 4,4’diisothiocyanostilbene-2,2’-disulfonic 

acid sensitivity and pH dependence whereas the family members 

with SAO or AE1 R602H showed only 30-40% reduction in the anion transport activity. 

SAO 

SAO/R602H R602H SAO/R602H 

(459) 

In conclusion, these findings suggest that compound heterozygosity of 27-bp 

deletion in exon 11 and missense mutation R602H cause autosomal recessive dRTA in SAO. 

(Presented at the American Society of Nephrology, 32 nd Annual Meeting, Florida, USA. 5-8 

November 1999.) 

337


ON THE PATHOGENESIS OF DENGUE SHOCK SYNDROME (DSS) 

Panisadee Avirutnan 1 , Prida Malasit1, Sucharit Bhakdi 2 , Matthias Husmann 2 

(460) 

1 Medical Molecular Biology Unit, Office for Research and Development, Faculty of Medicine, 

Siriraj Hospital, Mahidol University, Bangkok, Thailand, 2 Institute of Medical microbiology 

and Hygiene, Johannes Gutenberg University, Mainz, Germany. 

Dengue Shock Syndrome (DSS) is a severe complication of secondary dengue virus 

infection. It remains a major health problem in SE Asia, Central America and the Pacific region, 

representing one of the major causes of child death in several countries. Vascular leakage, hemorrhagic 

diathesis and complement activation are the hall marks of the disease. The short lived nature of the 

plasma leakage syndrome has led to the conclusion that altered permeability is most likely effected by 

soluble mediators. Hypotheses have implicated complement activation or deregulated cytokine responses 

in the pathogenesis of this condition. In the present work we show that infection of human endothelial 

cells with DV induces activation of NFkkB, subsequent transcriptional up-regulation and secretion of 

RANTES and IL-8, and apoptosis. Extremely high levels of IL-8, and in some cases of RTANTES, 

were detected in plasma and pleural fluid samples from patients with DSS. Immunofluorescence analysis 

of DV infected NFkkB knock out cell lines revealed a reduced production of viral antigen, suggesting 

that DV might trigger and up regulatory loop involving transcription factor NFkkB. Further, in the 

presence of anti dengue antibodies, we observed formation of non-lytic complement complexes on the 

surface of infected cells. We propose a model of DFF where DV and chemokines are targeted to 

serosal tissues via their binding to heparan sulfate. Chemokines, apoptotic cell death and the activation of 

complement may act in concert to cause the fulminant leakage syndrome. Shedding of heparan sulfate 

(the binding site for DV and chemokines) by C5a, and phagocytosis of apoptotic cells may provide a 

mechanism for the sudden disappearance of the infectious agent and the short lived duration of the 

disease. 

(Presented at the XIth International Congress of Virology, Sydney Convention and Exhibition 

Centre, Sydney, Australia 9-13 Aug 1999; Abstract VW9B.06 p141)

INVESTIGATIONS INTO THE PATHOGENIC MECHANISMS RESPONSIBLE 

FOR THE INCREASED SUSCEPTIBILITY TO INFECTIONS IN THALASSEMIC 

PATIENTS 

Prapat Suriyaphol1 , Prida Malasit1 , Prapon Wilairat2 , Suthat Fucharoen3 , Sucharit Bhakdi4 (461) 

1 Medical Molecular Biology Unit, Office of Research & Development, Faculty of Medicine, Siriraj 

Hospital, Mahidol University, Bangkok. 2 Department of Biochemistry, Faculty of Science, Mahidol 

University, Bangkok; 3 Haematology Unit, Department of Medicine, Siriraj Hospital, Mahidol University, 

Bangkok; 4 Institute of Medical Microbiology and Hygiene, Mainz University, Germany 

It has long been observed that thalassemic patients, particularly those who have been 

splenectomized, are more susceptible to repeated infections and showed abnormalities in the platelet and 

coagulation functions. Wide spectrum of infectious agents including bacteria, viruses and fungi has been 

found in severe cases of thalassemia. Acquired complement deficiency has been reported and might be 

one of the important factors for increased susceptibility to infection. Platelet microthrombi are also found 

in pulmonary vasculatures of severe patients. However, no clear explanation has been offered for the 

mechanisms leading to hypocomplementemia, abnormal platelets, and coagulation system in thalassemia. 

The primary defect in thalassemia is the reduction of globin chain synthesis, 

which leads to the abnormalities of RBCs. Many biochemical and structural defects are 

found in thalassemic RBCs, including depletion of cytoplasmic ATP, oxidative damage to the 

membrane and complement activation on the surfaces. It is known that RBC with such 

defects will shed parts of their membranes in the form of small vesicles. 

Our investigations centered on the search for mechanisms that lead to the defects listed 

above, in particular whether red cell vesicles exist in vivo. We have successfully shown that red cell 

vesicles were indeed present in the patients’ plasma with highest amount in splenectomized bb thalassemia/HbE 

patients, followed by non-splenectomized bb-thalassemia/HbE and non-splenectomized aathalassemia. 

The vesicles were spherical or oval in shape, with an average diameter of 0.3 mmm. They 

were devoid of spectrin, a major erythrocytic cytoskeletal protein, and exposed phosphatidylserine on 

their surface. Shortened clotting time was found when thalassemic vesicles were incubated with recalcified 

plasma, indicating that the vesicles possess procoagulant activity. The vesicles could efficiently activate 

the complement system via the alternative pathway. 

These findings are unique and significant; they serve as linkages between the defective 

hemoglobin synthesis, red cell perturbation and a group of clinical complications found in thalassemia. 

The fact that significant amounts of red cell vesicles has been found to be constantly generated in vivo, 

and the vesicles are functionally active in complement activation, and consumption of coagulation factors 

suggests that they represent important factors responsible for the complications described. Mechanisms 

leading to the generation of vesiculation remain to be elucidated and the understanding of the pathophysiology 

of this phenomenon could lead to new approaches in the treatments of patients with thalassemia. 

Presented to the 7 th International Conference on Thalassemia and the Hemoglobinopathies (the 

9 th Thalassemia Parent and Thalassemics International Conference. 31 st May-4 th June 1999 at 

the Imperial Queen’s Park Hotel, Bangkok.) 

339


PRODUCTION AND CHARACTERIZATION OF ANTIBODY AGAINST 

STRUCTURAL PROTEIN OF AEDES PARVOVIRUS (AaPV) 

(462) 

Kobporn Bunnak, Kusawadee Eku, Sa-nga Pattanakitsakul, Thaneeya Duangjinda, Pattamaporn 

Kittayapong * and Prida Malasit 

Division of Medical Molecular Biology, Office for Research and Development, Faculty of Medicine, 

Siriraj Hospital, and * Department of Biology, Faculty of Science, Mahidol University 

Aedes albopictus parvovirus (AaPV) is small single-stranded DNA, non-enveloped virus 

which belongs to the family Parvoviridae. This virus is classified within the subfamily Densovirinae 

which infects only invertebrate, mostly insect. AaPV was first isolated from an Aedes albopictus cell line 

(C6/36) and its genome has been sequenced. 

We have studied a virus which was isolated from a C6/36 cell line believed to contain an 

inoculum from A aegypti caught in Thailand, from the section of Vector Biology, Dept. of Epidemiology 

and Public Health, Yale Universty School of Medicine. The gene of the virus has been partially sequenced 

and cloned. The sequence showed close homology to the sequence reported in the original 

AaPV isolated from A albopictus cells. 

To attempt to study the pathogenesis of the virus in mosquito and cell lines, an antibody 

against the structural protein of the virus has been developed. The rabbit antibody was produced by 

immunization with a recombinant fusion protein containing the structural protein of AaPV together with 

a carrier protein, maltose binding protein (MBP). This antibody was shown to be specific for this virus by 

western blot analysis of AaPV-infected C6/36 cells. Use of this antibody in immuno-histochemical 

staining of AaPV infected cells was hampered by high background brought about by non-specific antibodies 

to the mosquitoes cells. Prior absorption of the antibody by uninfected C6/36 did not decrease the 

non-specific staining to a satisfactory levels. The antibody has thus been used to identified the virus in 

infected cells solely by western blot technique. 

(This work has been supported by the Senior Research Fellowship Grant to Dr.Prida Malasit, 

from the Thailand Research Fund (TRF)).

LONG RT-PCR AMPLIFICATION OF THE ENTIRE CODING SEQUENCE 

OF THE POLYCYSTIC KIDNEY DISEASE 1 (PKD1) GENE. 

(463) 

Wanna Thongnoppakhun 1,2 , Prapon Wilairat 2 , Kriengsak Vareesangthip 3 , and Pa-thai 

Yenchitsomanus 4 

1 Molecular Genetic Unit, Office for Research and Development, Faculty of Medicine Siriraj 

Hospital, 2 Department of Biochemistry, Faculty of Science, Mahidol University Rama VI Road, 

Phyathai, Bangkok 10400, Thailand; 3 Renal Unit, Department of Medicine, Faculty of Medicine 

Siriraj Hospital; 4 Molecular Genetic and Medical Molecular Biology Units, Office for Research 

and Development, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Prannok Road, 

Bangkok-noi, Bangkok 10700, Thailand 

Key words : Long reverse transcription and polymerase chain reaction (long RT-PCR), 

Polycystic kidney disease 1 (PKD1), Full-length transcript 

Characterization of mutations of the PKD1 gene has been limited by the fact that threefourths 

of this gene at its 5' end is homologous to sequences of at least three other genes on the same 

chromosome. We have therefore developed a method of long reverse transcription PCR for selective 

amplification of the entire coding sequence of the PKD1 gene from its mRNA. A PCR primer specific 

to the sequence in the 3' unique region of the PKD1 gene was synthesized for use coupled with a primer 

binding to sequence in the homologous region at a distance of about 13.6 kb apart. The commercial 

availability of RNase H-free reverse transcriptase for long cDNA synthesis and of an enzyme mixture 

containing Taq and Pfu DNA polymerases for long-range PCR have made this development possible. 

The long PCR product was proven to be derived from PKD1-mRNA. The results clearly indicated that 

the long PCR product contained the coding sequence derived from PKD1-mRNA. To our knowledge, 

this is the first report of a procedure that can reproducibly isolate full-length PKD1 coding sequence from 

its mRNA transcript, which will prove useful for screening and characterization of mutations in the 

PKD1 gene. 

*Source: Biotechniques 1999 Jan;26(1):126-32. (This work was partly supported by a grant from 

Siriraj-China Medical Board and Faculty of Medicine Siriraj Hospital, Mahidol University) 

341

342 

EVALUATION OF MONOCLONAL ANTIBODY REAGENTS FROM 

THREE DIFFERENT MANUFACTURERS USING FLOW CYTOMETRIC 

TWO-COLOR IMMUNOPHENOTYPING 

Kovit Pattanpanyasat, Charin Thepthai, Aunrean Thepthai, Surada Lerdwana and Janice M. 

Darden 

Center of Excellence for Flow Cytometry, Division of Instruments for Research, Office for 

Research and Development, and Department of Immunology, Faculty of Medicine Siriraj 

Hospital, Mahidol University. 

We evaluated a flow cytometric (FCM) two-color immunophenotyping of CD3+/CD4+ 

T-helpher and CD3+/CD8+ T-suppressor lymphocytes in whole blood samples from HIV-infected individuals 

using monoclonal antibody reagents from three different manufacturers. Lymphocytes were 

firstly determined using CD45/CD14 in association with a forward scatter/side scatter gating strategy. 

CD3+/CD4+ and CD3+/CD8+ were then determined and compared. Reagents from all manufacturers 

showed good separation of lymphocytes, monocytes and granulocytes with high purity and recovery. 

There was a good correlation of the percentage of CD3+/CD4+ and CD3+/CD8+ lymphocytes amongst 

each of the manufacturer’s reagents, but the fluorescent intensities of positive cells were not the same. 

This difference can result in poor discrimination of positive and negative non CD3 cells leading to erroneous 

results. 

(Asian Pacific Journal of Allergy and Immunology (1998) 16:185-192.) 


IMPAIRMENT OF PLASMODIUM FALCIPARUM GROWTH IN 

THALASSEMIC RED BLOOD CELLS : FURTHER EVIDENCE BY 

USING BIOTIN LABELING AND FLOW CYTOMETRY 

Kovit Pattanapanyasat, Kosol Yongvanitchit, Pongsri Tongtawe, Kalaya Tachavanich, Wanchai 

Wanachiwanawin, Suthat Fuchareon, Douglas S Walsh. 

Center of Excellence for Flow Cytometry, Office for Research and Development; Department 

of Pediatrics, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University; 

Us Army Medical Component, Armed Forces Research Institute of Medical Sciences 

(AFRIMS) 

Centain red blood cell (RBC) disorders, including thalassemia, have been associated 

with an innate protection against malaria infection. However, many in vitro correlative studies have been 

inconclusive. To better understand the relationship between human RBCs with thalassemia hemoglobinopathies 

and susceptibility to in vitro infection, we used an in vitro coculture system that involved biotin 

labeling and flow cytometry to study the ability of normal and variant RBC populations in supporting the 

growth of Plasmodium falciparum malaria parasites. Results showed that both normal and thalassemic 

RBCs were susceptible to P falciparum invasion, but the parasit multiplication rates were significantly 

reduced in the thalassemic RBC populations. The growth inhibition was especially marked in RBCs 

from a-thalassemia patients (both a-thalassemia /a-thalassemia and a-thalassemia heterozygote). Our 

1 

2 

1 

observations support the contention that thalassemia confers protection atgainst malaria and may explain 

why it is more prevalent in malaria endemic areas. 

(Blood, Vol 93, No 9 (May 1), 1999: pp 3116-3119.) Supported in part by Siriraj -China Medical 

Board. Grant No. 75-348-221 and by the malaria Program of the US Army Medical Research and 

Material Command, Ft Detrick, MD. 

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(465)

ROLE OF FCGAMMARI (CD64) IN ERYTHROCYTE ELIMINATION 

AND ITS UP-REGULATION IN THALASSAEMIA 

Wiener E, Allen D, Porter RJ, Wickramasinghe SN, Porter JB, Chinprasertsuk S, 

Siripanyaphinyo U, Pattanapanyasat K, Fucharoen S, Wanachiwanawin W. 

Department of Haematology, Imperial College School of Medicine, St. Mary’s Campus, London. 

Department of Medicine, and Office for Research and Development, Faculty of Medicine 

Siriraj Hospital, Mahidol University, Bangkok, Thailand. 

To examine any role of the high affinity Fcgamma class I receptor (FcgammaRI) (CD64) 

in erythrocyte elimination by mononuclear phagocytes (MP) in thalassaemia (thal), we investigated the in 

vitro interaction of beta-thalassaemic erythrocytes with monocytes (Mo) whose FcgammaR expression 

had been modulated by cytokines. Treatment of Mo with interferon (IFN)-gamma or interleukin (IL)-10 

which up-regulate FcgammaRI, caused a dose-dependent increase in binding of beta-thalassaemic 

erythrocytes, whereas stimulation with IL-4 which down-regulates the receptor, reduced this interaction, 

in a dose-dependent manner, to that of normal erythrocytes. Binding of thalassaemic erythrocytes by 

IFN-gamma or IL-10-treated Mo was inhibited by FcgammaRI-specific reagents. In addition, Mo 

expression of FcgammaRI and HLA class II DR was determined by flow cytometry in Thai patients with 

HbH disease (alpha1/alpha2 or alpha1/Hb Constant Spring) (n=15) or beta degrees -thal/HbE (n=16). In 

both groups of patients FcgammaRI expression was increased as compared to normal controls (n=14): 

mean fluorescence intensity (+/-SD) 124.79+/-38.77 in HbH disease and 121.86 +/-18.23 in beta degrees 

-thal/HbE verus 91.94 +/-17.36 in normal controls (p

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