Once-daily rabeprazole, levofloxacin, clarithromycin-MR, and bismuth for Helicobacter pylori eradication: A randomized study of 7 or 14 days (ONCE study)

OBJECTIVE

Most therapies for Helicobacter pylori eradication utilize multiple drugs given 2-4 times daily. Patient adherence has been an impediment to reliably achieving high success. This study evaluated a once-daily dosing H pylori eradication regimen.

METHODS

A prospective randomized pilot study of H pylori eradication compared once-daily treatment regimen containing levofloxacin (750 mg), clarithromycin-MR (1 g), rabeprazole (60 mg), and bismuth subsalicylate (1,048 mg) for a 7 or 14 days. CYP2C19 genotype and antibiotic susceptibility tests were performed. Successful eradication was defined as negative 13C-urea breath test at least 4 weeks after completion of treatment.

RESULTS

100 subjects were randomized (40 men, 60 women with mean age =54 years). The eradication rates were as follows: 94% (47/50; 95%CI 0.87-1.01) and 84% (42/50; 95%CI 0.73-0.95) with 14-day and 7-day therapy (OR 0.34; 95%CI 0.08-1.35, P = 0.06), respectively. Resistance rates were as follows: 13.0% for clarithromycin, 26.0% for fluoroquinolone, 2.9% for dual clarithromycin-fluoroquinolone resistance, and 62.8% for metronidazole. The 14-day regimen provided 100% eradication in patients with levofloxacin susceptible strain irrespective of the presence of clarithromycin resistance. CYP2C19 genotypes had no effect on cure rates.

CONCLUSIONS

The once-daily 14-day rabeprazole-, levofloxacin-, clarithromycin-MR-, and bismuth-containing therapy provided high eradication rate suggested that triple therapies with a PPI, bismuth, and clarithromycin-MR or levofloxacin would be highly effective for once-a-day tailored therapy or as empiric therapy for first-line regimen.

High Effective of 14-Day High-Dose PPI- Bismuth-Containing Quadruple Therapy with Probiotics Supplement for Helicobacter Pylori Eradication: A Double Blinded-Randomized Placebo-Controlled Study

Background:

Helicobacter pylori (H. pylori) infection is important risk factors for chronic gastritis, peptic ulcer and gastric cancer. Bismuth-containing quadruple therapy has recently been the first-line regimen recommended in many European countries but has limited efficacy in ASEAN especially Thailand. This study was aim to evaluate efficacy of high dose PPI Bismuth-containing quadruple therapy with probiotics supplement for H. pylori eradication.

Methods:

In this double-blind randomized placebo-controlled study, H. pylori infected patients were randomized to receive 7-or 14-day high dose PPI- bismuth-containing quadruple therapy with or without probiotics supplement. Probiotic was 37.5 mg Lactobacillus reuteri (Biogaia^®) in tablet twice daily. CYP2C19 genotyping and antibiotic susceptibility tests were also done. H. pylori eradication was defined as a negative 13C-urea breath test at least 4 weeks after treatment.

Results:

100 subjects were enrolled (72 females, 28 males, mean age=54 years). Antibiotic resistance was 15.6% for clarithromycin, 34.1% for metronidazole. CYP2C19 genotyping was performed in both group and revealed 13%, 50% and 37% for poor, intermediate and rapid metabolizers, respectively. Overall eradication rates of 7-day and 14-day regimens with probiotic were 68% and 96%; P value=0.027. The eradication rate for all patients with poor and rapid metabolizers were 100% with 14-day regimen. 14-day regimen with probiotics can provide 100% eradication with clarithromycin resistance, metronidazole resistance or dual clarithromycin and metronidazole resistance group. Furthermore, the incidence of nausea and vomiting, abdominal discomfort, and bitter taste were significantly lower in patients with probiotics group compared with placebo (6%vs.26%, P=0.002,OR=0.126,95% CI=0.03-0.53; 4%vs.18.0%, P=0.017, OR= 0.155,95% CI=0.03-0.81 and 4%vs.26%, P= 0.001,OR= 0.08, 95%CI= 0.016-0.41, respectively).

Conclusions:

The 14-day high dose PPI- bismuth-containing quadruple therapy with probiotic can provide an excellent cure rate for H. pylori infection as first line treatment irrespective of CYP2C19 and antibiotic resistance pattern. Adding probiotic also significantly reduced treatment-related adverse events and improve the patients’ compliance.

High Efficacy of Rapid Urine Test for Diagnosis of Helicobacter pylori Infection in Thai People

Background:

Accurate diagnosis of Helicobacter pylori (H. pylori) infection plays an important role in further effective treatment. Rapid urine test (RAPIRUN) is a test developed for qualitative detection of urine H. Pylori antibody and use for determine the sensitivity, specificity and accuracy. However, the test needs validation in Thai population before using in clinical practice.

Objective:

This study aimed to compare performance of different diagnostic tests on H. pylori detection in Thai population.

Methods:

Total of 94 patients with dyspepsia who referred to Thammasat University Hospital, Pathumthani, Thailand, between December 2012 and April 2013 were enrolled in this study. All patients underwent gastroscopy. Then, 3 biopsies at antrum were taken for H. pylori diagnosis. including rapid urease test (Pronto Dry, Eisai, Thailand), H. pylori culture, and histopathology. Urine samples were also collected at the same time for rapid urine test (RAPIRUN H. pylori Antibody, Otsuka Pharmaceutical Co., Ltd.). Patients were diagnosed with H. pylori-positive if their culture or rapid urease tests plus histopathology yielded positive results.

Results:

Total of 29 patients (30.9%) were infected with H. pylori. Prevalence of H. pylori infection by rapid urease test, histopathology, culture and rapid urine test were 25.5%, 28.7%, 29.8%, and 32.9% respectively. We observed that rapid urease test, histopathology, culture, and rapid urine test had sensitivity of 82.8%, 93.1%, 93.1% and 86.2%; specificity of 100%, 100%, 100%, and 90.8%; and accuracy of 95.7%, 97.9%, 97.9%, and 89.4%, respectively.

Conclusion:

Rapid urine test (RAPIRUN) provided a reliable result for diagnosis of H. pylori infection. Furthermore, this rapid urine test demonstrated high accuracy, reliable, safe handle and easy to use. We suggested rapid urine test for diagnosis of H. pylori infection in Thai population since we found it less invasive and with higher reliable efficacy.

CYP2C19 Genotype, CagA Genotype and Antibiotic Resistant Strain of Helicobacter pylori Infection

Background: H. pylori is a class I carcinogen and major cause of gastric cancer. Few previous studies reported relationship between H. pylori infection, CYP2C19 genotype and functional dyspepsia (FD) subtype. The aim of this study was to determine relationship between CYP2C19 genotype and FD subtype patients(host factor) with antibiotic resistant strains of H. pylori infection and CagA genotype(bacterial factor). Methods: FD patients who were investigated with gastroscopy at Thammasat University Hospital, Thailand during March 2017-November 2017 were enrolled. Two antral gastric biopsies were obtained for rapid urease test, E-test and cultures. CagA genotypes (CagA1a and CagA2a) were determined by PCR and CYP2C19 genotype was determined by PCR-RFLP. FD patients were categorized as epigastric pain syndrome(EPS) and postprandial distress syndrome (PDS). Results: 93 FD patients with H. pylori infection were enrolled (37 male, 56 female, mean age 54.5 years). There were 33 patients with EPS and 60 patients with PDS. CYP2C19 genotype revealed 55.9% rapid metabolizer (RM), 40.9% intermediate metabolizer (IM) and 3.2% poor metabolizer (PM) genotypes. Antibiotics susceptibility tests demonstrated 62.8% resistant to metronidazole, 12.9% resistant to clarithromycin and 27.1% resistant to fluoroquinolone. CagA 1a and CagA 2a were demonstrated in 6 patients(11.5%) and 46 patients(88.5%). CagA2a genotype was more prevalent in PDS than EPS patients (94.3%vs.76.5%; P =0.08) without significance. In intermediate metabolizer (IM), CagA2a genotype was significant higher in PDS than EPS(100% vs.25%; P=0.004). Conclusions: PDS, CYP2C19 RM genotype and CagA 2a gene of H. pylori infection were the predominant type of FD in Thailand. Metronidazole remain the most common antibiotic resistant strain of H. pylori infection in FD patients. PDS (host factor) was significantly related to CagA2a genotype (bacterial factors) only in patients with intermediate metabolizer. Appropriate dose of proton pump inhibitor (PPI) and correct regimens for H. pylori eradication in FD patients should be consider to improve clinical outcomes.

Helicobacter pylori management in ASEAN: The Bangkok consensus report

Helicobacter pylori (H. pylori) infection remains to be the major cause of important upper gastrointestinal diseases such as chronic gastritis, peptic ulcer, gastric adenocarcinoma, and mucosa-associated lymphoid tissue lymphoma. H. pylori management in ASEAN: the Bangkok consensus report gathered key opinion leaders for the region to review and evaluate clinical aspects of H. pylori infection and to develop consensus statements, rationales, and grades of recommendation for the management of H. pylori infection in clinical practice in ASEAN countries. This ASEAN Consensus consisted of 34 international experts from 10 ASEAN countries, Japan, Taiwan, and the United States. The meeting mainly focused on four issues: (i) epidemiology and disease association; (ii) diagnostic tests; (iii) management; and (iv) follow-up after eradication. The final results of each workshop were presented for consensus voting by all participants. Statements, rationale, and recommendations were developed from the available current evidence to help clinicians in the diagnosis and treatment of H. pylori and its clinical diseases.

Effectiveness of 7-Day and 14-Day Moxifloxacin-Dexlansoprazole Based Triple Therapy and Probiotic Supplement for Helicobacter Pylori Eradication in Thai Patients with Non-Ulcer Dyspepsia: A Double-Blind Randomized Placebo-Controlled Study

Background: Helicobacter pylori (H. pylori) is important cause of peptic ulcer and gastric cancer. Moxifloxacin is effective antibiotic for treatment for H. pylori. However, there were limited studies as first line therapy. Probiotics had been shown to decrease therapy-related side-effect and increase eradication rate. Aim of this study was to evaluate the efficacy of moxifloxacin-dexlansoprazole based triple therapy with probiotic for H. pylori treatment in Thailand. Methods: Patients with H. pylori infected gastritis were randomized to receive 7- or 14-day moxifloxacin-dexlansoprazole based triple therapy with probiotic or placebo. Regimen consisted of 60 mg dexlansoprazole twice daily, 400mg moxifloxacin once daily, 1g clarithromycin MR once daily. Probiotic used in this study was 282.5mg Saccharomyces boulardii (S. boulardii) in capsule prescribed twice daily. CYP2C19 genotyping, antibiotic susceptibility tests, and CagA genotyping were also done. Successful eradication was defined as a negative 13C-urea breath test at least 4 weeks after treatment. Results: Total of 108 subjects was enrolled (27 each to 7-and 14-day regimens with probiotic or placebo). Antibiotic susceptibility tests showed 29% fluoroquinolone, 19% metronidazole and 4% clarithromycin resistance. CYP2C19 genotyping demonstrated 43%, 47% and 11% were rapid, intermediate and poor metabolizers, respectively. CagA genes were positive in all patients. Eradication rates of 7-day and 14-day regimens with probiotic were 100%, and 93% respectively. There were no significant differences between eradication rate of 7-day and 14-day regimen with or without probiotics. Regarding side-effects, incidence of nausea, abdominal discomfort, bitter taste, and diarrhea were significantly lower in regimen with probiotic group compared with placebo(7.4%vs. 22.2%; p=0.028, 0.00%vs.14.8%; p=0.003, 35.2%vs.70.4%; p=0.0002, and 0.00%vs.9.3%; p=0.028, respectively). Conclusions: 7-day moxifloxacindexlansoprazole therapy plus S. boulardii provide an reliable cure rate of H. pylori in non-ulcer dyspeptic patients in Thailand, independent of CYP2C19 genotype. Probiotic adding also decreased side effects during the treatment.

Colorectal Cancer and Precancerous Lesions Associated with Ulcerative Colitis in Thailand

Background:

Ulcerative colitis(UC) is important risk factor of colorectal cancer. Many evidences from western countries confirmed this relationship but limited studies were reported in ASEAN. This study was aimed to investigate prevalence, clinical presentations, endoscopic findings, histopathology, disease progression and risk for colorectal cancer(CRC) of UC patients in Thailand.

Methods:

We conducted a retrospective cohort study using computer data base from Thammasat University Hospital, Pathumthani, Thailand between September 2011 and December 2015, follow-up through May 2016. Diagnosis of UC was confirmed by histopathology and whole clinical course.

Results:

We identified 6,082 patients who diagnosed with colitis during the study period. Of whom, only 22 patients(<1%) was confirmed of UC. Male to female ratio was 13:9 (mean age of 47.2 years). Clinical presentations were bloody diarrhea in 86.4%, watery diarrhea in 31.8% and abdominal pain in 59.1%. According to Montreal classification, disease extensions were ulcerative proctitis in 22.7%, distal UC in 50%, and pancolitis in 27.3%. Disease grading was mild in 31.8%, moderate in 9.1%, and severe in 59.1%. The prevalence of precancerous lesions were 2/22 patients(9.1%). There was no definite invasive colorectal cancer patient during study period. However, history of malnutrition was significantly higher in patients with dysplasia than those without dysplastic lesions(50%vs.0%, P-value=0.045). There was no difference in duration and disease extension between 2 groups. Interestingly, subgroup analysis demonstrated that pancolitis was significantly more common in female than male (55.6%vs.7.7%, P-value=0.02, OR=15.0, 95%CI=1.3-169.9). Furthermore, patients’ age> 35 years had significantly more severe colitis than younger group (81.25%vs.0%, P-value=0.0006)

Conclusions:

Although UC is rare disease in ASEAN, precancerous lesions for CRC were not uncommon. UC with pancolitis was common in female whereas severe colitis was common in elderly patients. Proper screening program and careful surveillance for precancerous lesions in patients at risk might be appropriate approach for early detection and improvement the treatment outcome.

Low Re-infection Rate of Helicobacter pylori after Successful Eradication in Thailand: A 2 Years Study

Background:

H. pylori is an important cause of chronic gastritis, peptic ulcers and gastric cancer. Re-infection rates after successful eradication vary in different regions of the world but only limited studies have been performed in ASEAN Countries to clarify this important issue. The present study was designed to evaluate the H. pylori re-infection rate and predictors of re-infection in Thailand.

Methods:

We recruited patients with chronic gastritis after 1 and 2 years successful H. pylori eradication from Thammasat University Hospital, Pathumthani (Central urban area) and Maesod district, Tak (Northern rural area), Thailand. 13C-UBT was performed to evaluate re-infection status after cessation of PPI, H2 blocker and antibiotics for at least 4 weeks. Statistical analysis was performed using SPSS for Windows Version 22.0 (IBM Corp., Armonk, NY).

Results:

A total of 105 subjects were enrolled (40 M and 65F with a mean age of 53.1 years). The overall re-infection rate was 6/105 (5.7%). The 1-year and 2-year H. pylori re-infection rates after successful eradication were only 5.1% (2/39) and 6.1% (4/66). 1-year and 2-year reinfection rates in urban areas were 2/39 (5.1%) and 1/26 (3.8%), while the 2-year reinfection rate in rural areas was 3/40 (7.5%). Location (urban vs rural area) and sex did not show any association with either 1-year or 2-year H. pylori re-infection. With 2-year reinfection, the mean age of H. pylori re-infected patients was significantly higher than those who remained cured (63.0 years vs. 51.6 years, p-value = 0.01). The annual H. pylori infection rate was 2.9%.

Conclusions:

1-year and 2-year H. pylori re-infection rates after successful eradication in Thailand appear low in both rural and urban areas. H. pylori eradication for prevention of significant upper GI disease should be recommended and confirmation of successful eradication should be the aim. Patients at higher risk such as the elderly should be monitored for possible risk of H. pylori re-infection.

Gastric Cancer and Gastrointestinal Stromal Tumors Could be Causes of non-Helicobacter Pylori non-NSAIDs Peptic Ulcers in Thailand

Background and aim: H. pylori and nonsteroidal anti-inflammatory drugs (NSAIDs) remain the major causes of peptic ulcer disease. Nevertheless, non- H. pylori non-NSAIDs peptic ulcers or idiopathic peptic ulcer disease (IPUD) constitute a growing problem associated with many complications. Gastric cancer and gastrointestinal stromal tumor (GIST) have also been reported as a cause of IPUD. This study was aimed to investigate prevalence and clinical characteristics of IPUD in Thailand. Materials and Methods: Clinical information, histological features, endoscopic findings, history of H. pylori status and NSAIDs usage were collected for patients diagnosed with PUD in Thammasat University Hospital during January 2003 – December 2013. Results: Total of 1,310 patients was diagnosed with PUD in our institution during the study period, of which 71 (5.4%) had a definitive diagnosis of IPUD (45 men and 26 women, mean age of 59±16.5 years). Common locations were gastric antrum (43.7%), duodenum (25.3%) and gastric body (12.7%). Common causes of IPUD were idiopathic (43.7%) and alcohol consumption (39.4%). Gastric cancer and GIST were also demonstrated in 1(1.4%) and 1(1.4%) respectively. Major complications were upper GI bleeding (73.2%) and peptic perforation (2.8%). Recurrent upper GI bleeding was detected in 23.9%. Interestingly, male patients aged<50 years with alcohol related peptic ulcer were significantly more common than female patients aged ≥ 50 years (57.8% vs 7.7%;P-value= 0.00002, OR= 16.4, 95%CI= 3.5-78 and 68.4% vs 28.9%); P-value= 0.002, OR= 5.3, 95% CI= 1.7-16.7). Conclusion: Common causes of IPUD in Thailand are idiopathic followed by alcohol consumption and steroid usage. Gastric cancer and GIST are also possible causes of IPUD. These particular ulcers had a high likelihood of developing severe complications. Appropriate screening and high level of suspicion of fatal causes eg. gastric cancer and GIST should be appropriate ways to reduce complications and improve the treatment outcome.

High Prevalence of Hepatocellular Carcinoma in Patients with Chronic Hepatitis B Infection in Thailand

BACKGROUND

Chronic hepatitis B (CHB) infection is one of the important causes of hepatocellular carcinoma (HCC) in Thailand, involved in the pathogenesis and leading to a development of HCC with or without cirrhotic changes of the liver. This study was aimed to investigate the predictive factors for HCC among CHB patients in a tertiary care center in Thailand.

MATERIALS AND METHODS

We conducted a retrospective study of CHB patients with or without HCC during the period of January 2009 and December 2014 at Thammasat University Hospital, Pathumthani, Thailand. Data on clinical characteristics, biochemical tests and radiologic findings were collected from review of medical records.

RESULTS

A total of 266 patients were diagnosed with CHB in Thammasat university hospital during the study period. However, clinical information of only 164/266 CHB patients (98 males, 66 females with mean age of 49.4 years) could be completely retrieved in this study. The prevalence of HCC in CHB infection in this study was 38/164 (23.2%). CHB patients with HCC had a mean age older than those without HCC (59.5 vs 47 years, P-value = 0.01). Furthermore, history of upper GI bleeding, tattooing, blood transfusion, and chronic alcoholism were significantly more common in CHB patients with HCC than patients without HCC (13.2% vs 3.2% P-value 0.03, OR = 4.6, 95%CI = 1.2-18.1, 20% vs 3.9%, P-value = 0.01, OR= 6.1, 95% CI= 1.6-23.6, 20% vs 6.3%, P-value = 0.03, OR = 3.8, 95%CI =1.1-12.7, 62.2% vs 30.3%, P-value <0.0001, OR = 3.7, 95%CI= 1.7-8.1 respectively). Interestingly, more CHB patients with HCC had evidence of cirrhosis than those without HCC (78.9% vs 20.4%, P-value <0.0001, OR = 14.6, 95%CI = 5.8-36.7). In CHB patients with HCC, surgical therapy provided longer survival than radiofrequency ablation (RFA) (72 vs 46.5 months, P-value= 0.04). The mean survival time after HCC diagnosis was 17.2 months.

CONCLUSIONS

HCC remains a major problem among patients with CHB infection in Thailand. Possible risk factors are male gender, history of upper GI bleeding, chronic alcoholism, tattooing, blood transfusion and evidence of cirrhosis. For early stage HCC patients, surgical treatment provided longer survival time than RFA. Most HCC patients presented with advanced disease and had a grave prognosis. Appropriate screening of CHB patients at risk for HCC might be an appropriate approach for early detection and improvement of long-term outcomes.

Relationship between vasoactive intestinal peptide and intrapulmonary vascular dilatation in children with various liver diseases

AIM

To evaluate the potential of vasoactive intestinal peptide (VIP) as a pathogenic factor of intrapulmonary vascular dilatation (IVD) in hepatopulmonary syndrome (HPS).

BACKGROUND

HPS comprises a triad comprising liver dysfunction, IVD and hypoxaemia. Although the pathogenesis of the process has not been elucidated, many vasodilating substances, such as VIP, have been implicated in the development of pulmonary vascular abnormalities. IVD can be detected by contrast-enhanced echocardiography (CEE) before the development of abnormal gas exchange.

METHODS

Forty-two children (20M, 22F; mean age 4.39 +/- 4.17 y) with various liver diseases who attended the paediatric liver clinic of King Chulalongkorn Memorial Hospital between March 2000 and February 2001 were recruited to the study. Each patient was tested for transcutaneous O2 saturation, CEE (applying the agitated normal saline technique), liver function test and serum VIP level.

RESULTS

Fourteen of the 42 patients (33%) were CEE positive. Only one of the 14 patients had associated hypoxia and clinical cyanosis. The serum VIP levels of children with liver disease were significantly higher than those of the controls (60.21 +/- 35.04 pg/ml vs 43.71 +/- 34.61 pg/ml, p = 0.03). CEE-positive children tended to have higher serum VIP levels than CEE-negative children (72.65 +/- 40.31 vs 53.99 +/- 31 pg/ml, p = 0.3). The serum VIP levels of biliary atresia (BA) patients with favourable outcomes (serum bilirubin < or = 34 micromol/L) were not significantly different from those with unfavourable outcomes (serum bilirubin > 34 micromol/L) (42.95 +/- 14.53 pg/ml vs 66.07 +/- 32.17 pg/ml, p = 0.5).

CONCLUSIONS

CEE is a non-invasive test for early detection of IVD in children with liver disease. VIP is not solely responsible for the pathogenesis of IVD in HPS. Further studies are required to determine which substances cause the development of IVD.

Atrial tachycardia from enhanced automaticity in children: diagnosis and initial management

Ten patients (aged 0-9 years) with the diagnosis of automatic atrial tachycardia (AAT) from August 1997 to August 2000 were reviewed. Three patients had paroxysmal (repetitive) AAT and the tachycardia was incessant in six (defined as presence of AAT for more than 90% of the time). The type of AAT in one patient was unknown. Four patients presented with congestive heart failure (CHF), one with pre-syncope, one with palpitation, and four were asymptomatic. Six patients (60%) had depressed left ventricular ejection fraction. All patients with CHF had incessant AAT with atrial rate > 220/min and ventricular rate > 200/min at admission. After treatment with antiarrhythmic medications, all patients had adequate control of the AAT (9 had complete elimination of AAT and 1 partial control). Amiodarone (alone, or in combination with digoxin) was effective in 5 of 6 cases (83%), although complete elimination of the AAT was usually delayed (median = 5 days, range 30 minutes to 17 days). Other effective medications were digoxin, digoxin + propranolol and atenolol (all in patients who did not have CHF on presentation). At the time of this report, 3 patients had no AAT off antiarrhythmic medication, 5 patients were still receiving treatment (with good control) and 2 patients died from sepsis during the same admission even though AAT was controlled. All surviving patients had normal ventricular ejection fraction on follow-up. AAT in children is rare, but when it occurs in persistent form at a fast rate, it is usually associated with CHF and is difficult to treat. Amiodarone (+/- digoxin) effectively controls the arrhythmia in the majority of cases, although full effect may take several days. With successful treatment, most patients do well and some can be taken off the medication(s) without recurrence of the arrhythmia.

Complete heart block in children at King Chulalongkorn Memorial Hospital

The etiologies of complete heart block in thirty-one children (mean age 5.5 +/- 5.2 years, range 0-14 years) diagnosed at King Chulalongkorn Memorial Hospital between 1990-2001 were reviewed. Three main groups of patients were identified: 1) patients who presented in utero or in the newborn period (congenital heart block, n = 6), 2) patients who had complete heart block after cardiac surgery (postoperative heart block, n = 10), and 3) children outside the newborn period with a new diagnosis of complete heart block unrelated to cardiac surgery (unknown etiology, n = 15). Among 15 patients in the last group, 5 were asymptomatic (or minimally symptomatic) with complete heart block unexpectedly found. These patients probably had previously undetected congenital heart block. Two patients had complete heart block associated with mild viral illness, but no bradycardia-related symptom. The etiology for heart block in these 2 patients was unknown. Eight patients probably had recent onset heart block because of new bradycardia-related symptoms, or a previously documented normal heart rate. All patients in this group were female (mean age 4.3 +/- 4.3 years, median 3.5 years). All were diagnosed between August and January, and the majority (75%) had a history of non-specific viral illness in the preceding 2 weeks. Seven patients (87.5%) were acutely symptomatic. Syncope and/or seizure were the most common presenting symptoms. Left ventricular systolic dysfunction was found in only one patient. The etiology of complete heart block in these patients probably was an acute viral myocarditis that preferentially affected the conduction system. Two of these eight patients had complete recovery of the atrioventricular conduction. The rest had no improvement or had only partial recovery and subsequently underwent permanent cardiac pacemaker insertion.

Morbitz type I second degree AV block during recovery from dengue hemorrhagic fever

Two patients with serologically-proven dengue virus infection and Morbitz type I second degree atrioventricular (AV) block are described. A 7 years old boy (patient 1) with grade 2 and a 7 years old girl (patient 2) with grade 3 illness were admitted to the hospital on the 3rd and the 5th day of the illness, respectively. Both had typical resentation for dengue hemorrhagic fever including fever, hepatomegaly, thrombocytopenia and signs of extravascular leakage. The 7 year old girl also had epistaxis and anemia (Hct 24%). Morbitz type I second degree and 2:1 AV block developed on day 7 (patient 1) and day 8 (patient 2) of the illness, both during recovery periods. Patient 1 also had occasional monomorphic premature ventricular contraction (PVC). There was no other abnormality in the 12-lead EKGS and echocardiograms showed normal ventricular systolic function in both. Other than mild hypokalemia (3.3 and 3.4 mgq/l), serum electrolytes were normal. Neither patients had elevation of serum creatine phosphokinase (CPK). In patient 1, exercise (on day 10) normalized AV conduction and abolished the PVC. Follow up EKG and physical examination at 10 months after the illness was normal. The rhythm in patient 2 resolved to 1st degree AV block (with occasional morbitz type I second degree at night) on day 12. In this patient, exercise resulted in shortening of the PR interval and Valsalva maneuver resulted in further PR prolongation. The patient was well at 1-month follow up with a mormal EKG. Morbitz type I second degree AV block during recovery from dengue hemorrhagic fever may be a transient functional impairment of the AV node, in which altered autonomic tone may play a role.

A Thai boy with hereditary enzymopenic methemoglobinemia type II

Individuals with methemoglobin exceeding 1.5 g/dl have clinically obvious central cyanosis. Hereditary methemoglobinemia is due either to autosomal dominant M hemoglobins or to autosomal recessive enzymopenic methemoglobinemia. Four types of enzymopenic methemoglobinemia have been described. In addition to methemoglobinemia, individuals with type II, which is the generalized cytochrome b5 reductase deficiency, have severe and progressive neurological disabilities. Here we report a 3-year-old Thai boy with type II hereditary enzymopenic methemoglobinemia. He was born to a second-cousin couple. His central cyanosis was first observed around 10 months of age. His neurological abnormalities were seizures beginning at 1 year of age, microcephaly, and inability to hold his head up. His cardiovascular and pulmonary evaluations were unremarkable. Methemoglobin level by spectral absorption pattern was 18 per cent. A qualitative enzymatic assay confirmed the deficiency of the cytochrome b5 reductase enzyme. With this definite diagnosis, a prenatal diagnosis for the next child of this couple will be possible.

Ventricular functions in children with human immunodeficiency virus infection after ACE-inhibitors

Nine pediatric symptomatic patients infected with human immunodeficiency virus with elevated pulmonary arterial pressure (MPA pressure) and ejection fraction (EF); and with fractional shortening, (FS) mean velocity of circumferential fiber shortening (MVCfc) and left ventricular peak systolic wall stress (PS) were prospectively evaluated using 2-dimensional and M-mode serial echocardiography and Doppler cardiography after administration of an ACE inhibitor (Inhibace 0.025 mg/kg/D orally) for 12 weeks. The MPA pressure was not decreased, however the MVCfc and PS improved significantly (p < 0.05). Further, long term evaluation is required to determine its effect in preventing dilated cardiomyopathy and elevated mean pulmonary pressure.