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Dashraath P, Chen K, Htet ZW, Chan SY, Kale A, Su LL, Yew TW. Pre-eclampsia with paradoxical polyuria: diabetes insipidus in pregnancy. Lancet 2022; 399:1809. [PMID: 35526553 DOI: 10.1016/s0140-6736(22)00565-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 02/28/2022] [Accepted: 03/15/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Pradip Dashraath
- Department of Obstetrics and Gynaecology, Division of Maternal-Fetal Medicine, National University Hospital, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
| | - Kailun Chen
- Department of Obstetrics and Gynaecology, Division of Maternal-Fetal Medicine, National University Hospital, Singapore
| | - Zaw Win Htet
- Department of Medicine, Division of Endocrinology, National University Hospital, Singapore
| | - Shiao-Yng Chan
- Department of Obstetrics and Gynaecology, Division of Maternal-Fetal Medicine, National University Hospital, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Anita Kale
- Department of Obstetrics and Gynaecology, Division of Maternal-Fetal Medicine, National University Hospital, Singapore
| | - Lin Lin Su
- Department of Obstetrics and Gynaecology, Division of Maternal-Fetal Medicine, National University Hospital, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Tong Wei Yew
- Department of Medicine, Division of Endocrinology, National University Hospital, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Aung NM, Nyein PP, Htut TY, Htet ZW, Kyi TT, Anstey NM, Kyi MM, Hanson J. Antibiotic Therapy in Adults with Malaria (ANTHEM): High Rate of Clinically Significant Bacteremia in Hospitalized Adults Diagnosed with Falciparum Malaria. Am J Trop Med Hyg 2018; 99:688-696. [PMID: 30014826 DOI: 10.4269/ajtmh.18-0378] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
It has been believed that concomitant bacteremia is uncommon in adults hospitalized with falciparum malaria. Accordingly, the World Health Organization treatment guidelines presently only recommended additional antibacterial therapy in these patients if they have a clinical syndrome compatible with serious bacterial infection. Admission blood cultures were collected from 20 consecutive adults in Myanmar, hospitalized with a positive immunochromatographic test and blood film, suggesting a diagnosis of falciparum malaria; four (20%) had bacteremia with a clinically significant pathogen. These case series' data were pooled with a previously published multicenter study from Myanmar which had also collected blood cultures in adults hospitalized with a diagnosis of falciparum malaria. Among 87 patients in the two studies, 13 (15%) had clinically significant bacteremia on admission, with Gram-negative organisms in 10 (77%) and Staphylococcus aureus in the remaining three (23%). Bacteremic patients had more severe disease than non-bacteremic patients (median [interquartile range] respiratory coma acidosis malaria score 2 [1-4] versus 1 [1-2], P = 0.02) and were more likely to die (2/13 [15%] versus 1/74 [1%], P = 0.01). However, bacterial coinfection was suspected clinically in a minority of bacteremic patients (5/13 [38%] compared with 13/70 [19%] of non-bacteremic patients, P = 0.11). Concomitant bacteremia in adults diagnosed with falciparum malaria may be more common than previously believed and is difficult to identify clinically in resource-poor settings. Death is more common in these patients, suggesting that clinicians should have a lower threshold for commencing empirical antibacterial therapy in adults diagnosed with falciparum malaria in these locations than is presently recommended.
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Affiliation(s)
- Ne Myo Aung
- University of Medicine 2, Yangon, Myanmar.,Insein General Hospital, Yangon, Myanmar
| | | | | | | | - Tint Tint Kyi
- Department of Medical Care, Ministry of Health and Sports, Nay Pyi Taw, Myanmar
| | - Nicholas M Anstey
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Mar Mar Kyi
- University of Medicine 2, Yangon, Myanmar.,Insein General Hospital, Yangon, Myanmar
| | - Josh Hanson
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia.,Kirby Institute, University of New South Wales, Sydney, Australia.,University of Medicine 2, Yangon, Myanmar
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Thit SS, Aung NM, Htet ZW, Boyd MA, Saw HA, Anstey NM, Kyi TT, Cooper DA, Kyi MM, Hanson J. The clinical utility of the urine-based lateral flow lipoarabinomannan assay in HIV-infected adults in Myanmar: an observational study. BMC Med 2017; 15:145. [PMID: 28774293 PMCID: PMC5543584 DOI: 10.1186/s12916-017-0888-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 06/06/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The use of the point-of-care lateral flow lipoarabinomannan (LF-LAM) test may expedite tuberculosis (TB) diagnosis in HIV-positive patients. However, the test's clinical utility is poorly defined outside sub-Saharan Africa. METHODS The study enrolled consecutive HIV-positive adults at a tertiary referral hospital in Yangon, Myanmar. On enrolment, patients had a LF-LAM test performed according to the manufacturer's instructions. Clinicians managing the patients were unaware of the LF-LAM result, which was correlated with the patient's clinical course over the ensuing 6 months. RESULTS The study enrolled 54 inpatients and 463 outpatients between July 1 and December 31, 2015. On enrolment, the patients' median (interquartile range) CD4 T-cell count was 270 (128-443) cells/mm3. The baseline LF-LAM test was positive in 201/517 (39%). TB was confirmed microbiologically during follow-up in 54/517 (10%), with rifampicin resistance present in 8/54 (15%). In the study's resource-limited setting, extrapulmonary testing for TB was not possible, but after 6 months, 97/201 (48%) with a positive LF-LAM test on enrolment had neither died, required hospitalisation, received a TB diagnosis or received empirical anti-TB therapy, suggesting a high rate of false-positive results. Of the 97 false-positive tests, 89 (92%) were grade 1 positive, suggesting poor test specificity using this cut-off. Only 21/517 (4%) patients were inpatients with TB symptoms and a CD4 T-cell count of < 100 cells/mm3. Five (24%) of these 21 died, three of whom had a positive LF-LAM test on enrolment. However, all three received anti-TB therapy before death - two after diagnosis with Xpert MTB/RIF testing, while the other received empirical treatment. It is unlikely that knowledge of the baseline LF-LAM result would have averted any of the study's other 11 deaths; eight had a negative test, and of the three patients with a positive test, two received anti-TB therapy before death, while one died from laboratory-confirmed cryptococcal meningitis. The test was no better than a simple, clinical history excluding TB during follow-up (negative predictive value (95% confidence interval): 94% (91-97) vs. 94% (91-96)). CONCLUSIONS The LF-LAM test had limited clinical utility in the management of HIV-positive patients in this Asian referral hospital setting.
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Affiliation(s)
- Swe Swe Thit
- University of Medicine 2, Yangon, Myanmar.,Insein General Hospital, Yangon, Myanmar
| | - Ne Myo Aung
- University of Medicine 2, Yangon, Myanmar.,Insein General Hospital, Yangon, Myanmar
| | | | - Mark A Boyd
- University of Adelaide, Lyell McEwin Hospital, Adelaide, Australia.,The Kirby Institute, University of New South Wales, Sydney, Australia
| | | | - Nicholas M Anstey
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Tint Tint Kyi
- Insein General Hospital, Yangon, Myanmar.,Department of Medical Care, Ministry of Health, Nay Pyi Taw, Myanmar
| | - David A Cooper
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Mar Mar Kyi
- University of Medicine 2, Yangon, Myanmar.,Insein General Hospital, Yangon, Myanmar
| | - Josh Hanson
- University of Medicine 2, Yangon, Myanmar. .,The Kirby Institute, University of New South Wales, Sydney, Australia. .,Menzies School of Health Research, Charles Darwin University, Darwin, Australia.
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Aung NM, Hanson J, Kyi TT, Htet ZW, Cooper DA, Boyd MA, Kyi MM, Saw HA. HIV care in Yangon, Myanmar; successes, challenges and implications for policy. AIDS Res Ther 2017; 14:10. [PMID: 28257647 PMCID: PMC5336692 DOI: 10.1186/s12981-017-0137-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 02/17/2017] [Indexed: 01/01/2023] Open
Abstract
Background Approximately 0.8% of adults aged 18–49 in Myanmar are seropositive for Human Immunodeficiency Virus (HIV). Identifying the demographic, epidemiological and clinical characteristics of people living with HIV (PLHIV) is essential to inform optimal management strategies in this resource-limited country. Methods To create a “snapshot” of the PLHIV seeking anti-retroviral therapy (ART) in Myanmar, data were collected from the registration cards of all patients who had been prescribed ART at two large referral hospitals in Yangon, prior to March 18, 2016. Results and discussion Anti-retroviral therapy had been prescribed to 2643 patients at the two hospitals. The patients’ median [interquartile range (IQR)] age was 37 (31–44) years; 1494 (57%) were male. At registration, injecting drug use was reported in 22 (0.8%), male-to-male sexual contact in eleven (0.4%) and female sex work in eleven (0.4%), suggesting that patients under-report these risk behaviours, that health care workers are uncomfortable enquiring about them or that the two hospitals are under-servicing these populations. All three explanations appear likely. Most patients were symptomatic at registration with 2027 (77%) presenting with WHO stage 3 or 4 disease. In the 2442 patients with a CD4+ T cell count recorded at registration, the median (IQR) count was 169 (59–328) cells/mm3. After a median (IQR) duration of 359 (185–540) days of ART, 151 (5.7%) patients had died, 111 (4.2%) patients had been lost to follow-up, while 2381 were alive on ART. Tuberculosis (TB) co-infection was common: 1083 (41%) were already on anti-TB treatment at registration, while a further 41 (1.7%) required anti-TB treatment during follow-up. Only 21 (0.8%) patients were prescribed isoniazid prophylaxis therapy (IPT); one of these was lost to follow-up, but none of the remaining 20 patients died or required anti-TB treatment during a median (IQR) follow-up of 275 (235–293) days. Conclusions People living with HIV in Yangon, Myanmar are generally presenting late in their disease course, increasing their risk of death, disease and transmitting the virus. A centralised model of ART prescription struggles to deliver care to the key affected populations. TB co-infection is very common in Myanmar, but despite the proven efficacy of IPT, it is frequently not prescribed.
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Nyein PP, Aung NM, Kyi TT, Htet ZW, Anstey NM, Kyi MM, Hanson J. High Frequency of Clinically Significant Bacteremia in Adults Hospitalized With Falciparum Malaria. Open Forum Infect Dis 2016; 3:ofw028. [PMID: 26989752 PMCID: PMC4794945 DOI: 10.1093/ofid/ofw028] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 02/05/2016] [Indexed: 11/14/2022] Open
Abstract
Background. African children with severe falciparum malaria commonly have concomitant Gram-negative bacteremia, but co-infection has been thought to be relatively rare in adult malaria. Methods. Adults with a diagnosis of falciparum malaria hospitalized at 4 tertiary referral hospitals in Myanmar had blood cultures collected at admission. The frequency of concomitant bacteremia and the clinical characteristics of the patients, with and without bacteremia, were explored. Results. Of 67 adults hospitalized with falciparum malaria, 9 (13% [95% confidence interval, 5.3%-21.6%]) were also bacteremic on admission, 7 (78%) with Gram-negative enteric organisms (Escherichia coli [n = 3], typhoidal Salmonella species [n = 3], nontyphoidal Salmonella [n = 1]). Bacteremic adults had more severe disease (median Respiratory Coma Acidosis Malaria [RCAM] score 3; interquartile range [IQR], 1-4) than those without bacteremia (median RCAM score 1; IQR, 1-2) and had a higher frequency of acute kidney injury (50% vs 16%, P = .03). Although 35 (52%) were at high risk of death (RCAM score ≥2), all 67 patients in the study survived, 51 (76%) of whom received empirical antibiotics on admission. Conclusions. Bacteremia was relatively frequent in adults hospitalized with falciparum malaria in Myanmar. Like children in high transmission settings, bacteremic adults in this low transmission setting were sicker than nonbacteremic adults, and were often difficult to identify at presentation. Empirical antibiotics may also be appropriate in adults hospitalized with falciparum malaria in low transmission settings, until bacterial infection is excluded.
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Affiliation(s)
| | | | | | | | - Nicholas M Anstey
- Menzies School of Health Research, Charles Darwin University , Darwin , Australia
| | | | - Josh Hanson
- Menzies School of Health Research, Charles Darwin University , Darwin , Australia
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Aung NM, Kaung M, Kyi TT, Kyaw MP, Min M, Htet ZW, Anstey NM, Kyi MM, Hanson J. The Safety of a Conservative Fluid Replacement Strategy in Adults Hospitalised with Malaria. PLoS One 2015; 10:e0143062. [PMID: 26581060 PMCID: PMC4651424 DOI: 10.1371/journal.pone.0143062] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 10/22/2015] [Indexed: 12/29/2022] Open
Abstract
Background A conservative approach to fluid resuscitation improves survival in children with severe malaria; however, this strategy has not been formally evaluated in adults with the disease. Methods Adults hospitalised with malaria at two tertiary referral hospitals in Myanmar received intravenous fluid replacement with isotonic saline, administered at a maintenance rate using a simple weight-based algorithm. Clinical and biochemical indices were followed sequentially. Results Of 61 adults enrolled, 34 (56%) had Plasmodium falciparum mono-infection, 17 (28%) Plasmodium vivax mono-infection and 10 (16%) mixed infection; 27 (44%) patients were at high risk of death (P. falciparum infection and RCAM score ≥ 2). In the first six hours of hospitalisation patients received a mean 1.7 ml/kg/hour (range: 1.3–2.2) of intravenous fluid and were able to drink a mean of 0.8 ml/kg/hour (range: 0–3). Intravenous fluid administration and oral intake were similar for the remainder of the first 48 hours of hospitalisation. All 61 patients survived to discharge. No patient developed Adult Respiratory Distress Syndrome, a requirement for renal replacement therapy or hypotension (mean arterial pressure < 60mmHg). Plasma lactate was elevated (> 2 mmol/L) on enrolment in 26 (43%) patients but had declined by 6 hours in 25 (96%) and was declining at 24 hours in the other patient. Plasma creatinine was elevated (> 120 μmol/L) on enrolment in 17 (28%) patients, but was normal or falling in 16 (94%) at 48 hours and declining in the other patient by 72 hours. There was no clinically meaningful increase in plasma lactate or creatinine in any patient with a normal value on enrolment. Patients receiving fluid replacement with the conservative fluid replacement algorithm were more likely to survive than historical controls in the same hospitals who had received fluid replacement guided by clinical judgement in the year prior to the study (p = 0.03), despite having more severe disease (p < 0.001). Conclusions A conservative fluid resuscitation strategy appears safe in adults hospitalised with malaria.
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Affiliation(s)
| | - Myat Kaung
- Hpa-an Hospital, Hpa-an, Kayin State, Myanmar
| | | | - Myat Phone Kyaw
- Department of Medical Research (Lower Myanmar), Yangon, Myanmar
| | - Myo Min
- Myanmar Medical Association, Yangon, Myanmar
| | | | - Nicholas M. Anstey
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | | | - Josh Hanson
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
- * E-mail:
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Kaung M, Kyi TT, Aung NM, Kyaw MP, Min M, Htet ZW, Anstey NM, Kyi MM, Hanson J. The prognostic utility of bedside assessment of adults hospitalized with malaria in Myanmar: a retrospective analysis. Malar J 2015; 14:63. [PMID: 25881290 PMCID: PMC4323221 DOI: 10.1186/s12936-015-0549-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 01/06/2015] [Indexed: 01/03/2023] Open
Abstract
Background Data collected in clinical trials have been used to develop scoring systems that identify adults with malaria at greatest risk of death. One of these, the RCAM score, can be simply determined by measuring a patient’s Glasgow Coma Score and respiratory rate on admission to hospital. However the safety of using the RCAM score to define high-risk patients has not been assessed outside of the clinical trial setting. Methods A retrospective audit of medical records of all adults admitted with a diagnosis of malaria to two tertiary referral hospitals in Lower Myanmar in 2013 was undertaken. An RCAM score was calculated in all patients and related to their subsequent clinical course. Results The recent decline in malaria hospitalizations at both sites continued in 2013. During the year 90 adults were hospitalized with malaria; 62 (69%) had Plasmodium falciparum mono-infection, 11 (12%) had Plasmodium vivax mono-infection, 17 (19%) had mixed infection. All seven (7.7%) deaths occurred in patients infected with P. falciparum. An admission RCAM score <2 identified all the patients that would survive to discharge (positive predictive value (95% confidence interval (CI)) 100% (94.9-100%) and also predicted a requirement for less supportive care: 9/70 (13%) patients with an admission RCAM score <2 required supportive care (blood transfusion, vasopressor support or oxygen supplementation) during their hospitalization compared with 12/20 (60%) patients with an admission RCAM score ≥2 (p < 0.0001). No patient with P. vivax mono-infection required supportive care during their hospitalization. Patients with an oxygen saturation ≤95% on room air on admission were more likely to die before discharge (odds ratio 17.3 (95% CI: 2.9-101.2) than patients with a higher oxygen saturation (p = 0.002). Conclusions Even outside a clinical trial setting the RCAM score reliably identifies adults with malaria who are at greatest risk of death and can be safely used in the initial triage and management of these patients.
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Affiliation(s)
- Myat Kaung
- Hpa-an Hospital, Hpa-an, Kayin State, Myanmar.
| | | | - Ne Myo Aung
- Insein Hospital, Insein Township, Yangon, Myanmar.
| | - Myat Phone Kyaw
- Department of Medical Research (Lower Myanmar), Yangon, Myanmar.
| | - Myo Min
- Myanmar Medical Association, Yangon, Myanmar.
| | - Zaw Win Htet
- Insein Hospital, Insein Township, Yangon, Myanmar.
| | - Nicholas M Anstey
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia.
| | - Mar Mar Kyi
- Insein Hospital, Insein Township, Yangon, Myanmar.
| | - Josh Hanson
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia.
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