Thoughts on diagnoses for the mystery illness in Cambodia

[alert]

Re: Thoughts on diagnoses for the mystery illness in Cambodia

The latest articles say we will know more testing results tomorrow. It is now about 2am in Cambodia, so tomorrow is only a few hours away. The fact that they think they might know more so soon might indicate that a known cause is suspect, rather than a novel one.

In addition to Nipah and EV71, articles have now raised the possibility of several illnesses (that these cases simply represent the 60 most severe febrile illnesses in children in Cambodia in the past three months, due to multiple causes).

The fact that a couple days of investigation has not yet revealed many milder cases (nor many missed severe ones) might be a clue.

 

[Emily]

Re: Thoughts on diagnoses for the mystery illness in Cambodia

The demographic of the patients at the reporting hospital is reported here:

http://www.beat-richner.ch/Assets/richner_present.html

Every child has a right to proper medication unhampered by corruption
All of the 2,230 Cambodian staff at Kantha Bopha earn a modest living on which they can get by (something which is not possible on the usual salary of US$ 20 paid to local staff in Cambodia). By paying our staff a wage they can live on, we seem to have found a way of successfully fighting corruption, which is otherwise widespread in Cambodia. To this day there have been no thefts at the hospital, no cases of medicine simply vanishing into thin air rather than being administered to the patient in need. The hospital operates 24 hours a day, and part of our staff is working shifts. No money is taken under the table from patient?s families, and none of our staff has to rely on a second job outside the hospital in order to make a living. Medical care is freely available to all children. 85% of all children needing hospitalisation come from families who are too poor to pay even the smallest fee. For these children Kantha Bopha represents the only chance to get any medical care at all. It is our belief that every child has a right to proper medication. This, in turn, can only be achieved with the assistance of modern and fully functioning equipment, proper and effective medicine, and sufficient disposable medical material, all of which has very little indeed to do with luxury, and even less with first-class medicine.

This video shows that they treat a large number of children in the affected age group.

<object width="560" height="315"><param name="movie" value="http://www.youtube.com/v/SPJAbVJ7igs?version=3&hl=en_US"></param><param name="allowFullScreen" value="true"></param><param name="allowscriptaccess" value="always"></param><embed src="http://www.youtube.com/v/SPJAbVJ7igs?version=3&hl=en_US" type="application/x-shockwave-flash" width="560" height="315" allowscriptaccess="always" allowfullscreen="true"></embed></object>

This sounds like an excellent hospital, and I think they would have zeroed in on problems with medications used at the hospital already if that were the problem, unless there are some complex interactions involved.

A tainted OTC medication with limited distribution or complex interactions might be a possibility. An environmental cause or new zoonosis are my other thoughts.

 

[alert]

Re: Thoughts on diagnoses for the mystery illness in Cambodia

I had forgotten about it, but Cambodia reported cases of fatal atypical pneumonia during the SARS outbreak that turned out not to be SARS, but that could not be diagnosed. I posted the link in the news thread.

You might be right about some kind of previously unidentified zoonosis.

 

[Giuseppe]

Re: Thoughts on diagnoses for the mystery illness in Cambodia

I suspect that the WHO has some ideas about this illness because other unexplained children ailments in the south-east Asia haven't caused agency's statement before.

The likelihood of the emergence of a novel reassortant strain of influenza virus is increasing at this point.

This may explain the low incidence (if any) in older children and adults or the presence of mild or asymptomatic infections.

 

[Ronan Kelly]

Re: Thoughts on diagnoses for the mystery illness in Cambodia

Hospital is in desperate need of our help
Friday, 06 July 2012 Chanthy Sam

Dear Editor,

I was sad to learn there is apparently no public sympathy for the financial crisis the Kantha Bopha Hospital is facing.

Several reports in local and international media have highlighted that the hospital urgently needs help if it is to survive. Indeed, this is an extremely urgent issue for us all.

Unlike the Koh Pich stampede in 2010 or the fighting on the Cambodia-Thai border, this in-house health crisis is largely ignored by Khmers.

The Kantha Bopha Hospital has greatly enhanced the lives of the next generation of Cambodians by generously treating thousands of infants and young children whose impoverished parents could not afford proper medical care.

Many of them would have died were it not for the treatment provided by this hospital.

I have followed up the news about the fund-raising, and it appears few people have made their contribution; most of us continue to ignore it.
...

Chanthy Sam
Bangkok, Thailand

 

[alert]

Re: Thoughts on diagnoses for the mystery illness in Cambodia

Well, we can discard Nipah now, as well as influenza and SARS.

That would likely leave an enterovirus, perhaps a novel one, at the top of the list of suspects.

I think the reference to 74 cases under investigation, with 56 of 57 having died, is probably the result of completion of surveillance, and might reflect what they think is 17 unrelated cases. Without a diagnosis, there is no way to know for sure which cases are due to the mystery illness and which are background noise. I guess they didn't find that many symptomatic mild cases after all, at least not ones with symptoms close enough to the fatal cases.

 

[Giuseppe]

Re: Thoughts on diagnoses for the mystery illness in Cambodia

Apart the preliminary exclusion of influenza viruses, SARS CoV and Nipah, I would like to know further data about how they reached some of the conlcusions we know by the WHO an newswires.


-- Have they diagnosed the encephalitis through clinical neurological objectivity alone or with the help of neuroimaging?

-- What were the results from lumbar puncture and liquour examination?

-- Were Liver, blood and kidney funcions altered?

-- Had necropsies been performed?

Despite the negative results for influenza A there is the chance that a novel reassortant strain may be involved.

Further, we should know whether children have been treated empirically with antibiotics for the pneumonia. Other drugs, supportive treatments?

Some sort of contaminats could be present in these drugs or in the hospital equipment, for example Serratia Spp. bacteria or toxic chemicals.

The rapid exitus of these patients suggests a septic shock syndrome and as I suspected at the beginning - they had already done some tests to exclude some of the scourges circulating in the area.

 

[alert]

Re: Thoughts on diagnoses for the mystery illness in Cambodia

There is a major problem in the investigation of this illness that is starting to become apparent. There is no case definition, and no obvious candidate for one. In the early SARS and H1N1 outbreaks, the H2H nature of the spread made it easy to exclude other known illnesses from the case definition by requiring some sort of exposure, such as "contact with a previously identified case" or "travel to a location with previously documented transmission". We don't have that option here.

Any attempt I can imagine to formulate a case definition is going to have great difficulty avoiding counting unrelated illnesses, such as meninigtiis and influenza. And today's WHO report already indicates some suspicion that some unrelated cases are being considered.

 

[alert]

Re: Thoughts on diagnoses for the mystery illness in Cambodia

FYI, Treyfish has just posted a report that none of the children have had autopsies.

 

[Treyfish]

Re: Thoughts on diagnoses for the mystery illness in Cambodia

So far, he said little is known of the disease other than that it ?affects children, (and is) very fatal,? with its mode of transmission unknown, and causative organism unknown.

In other posts on his Twitter account, Tayag said symptoms of the disease include fever and respiratory and/or neurological symptoms followed by death within 24 hours.

Another sign of the disease includes an elevated white blood cell count, he added.

 

[Treyfish]

Re: Thoughts on diagnoses for the mystery illness in Cambodia

I thought the children had no elevated white cell counts.. and without an autopsy.. they dont know crap.. like how bad the lungs really are :magnify:

 

[alert]

Re: Thoughts on diagnoses for the mystery illness in Cambodia

I thought the children had no elevated white cell counts.. and without an autopsy.. they dont know crap.. like how bad the lungs really are :magnify:

We might know something from blood samples taken while they were alive. As far as how bad the lungs really are, we know they are bad enough to kill the child within hours. I'd say that's pretty bad.

Might an elevated white blood cell count indicate a bacterial infection? I thought I remember SARS and H5N1 cases having decreased white blood cell counts.

Here's an off the wall, unlikely, suggestion. What would happen if some children's medicine was contaminated with anthrax spores? Inhalational anthrax in an environment like this would be close to 100% fatal, and I believe several of the fatal anthrax cases in 2001 in the US had neurological complications. And about a dozen adults in Europe have died in the past couple years from using illegal drugs contaminated with anthrax spores:

http://www.flutrackers.com/forum/showthread.php?p=455020

 

[Treyfish]

Re: Thoughts on diagnoses for the mystery illness in Cambodia

The X Ray and CT are showing that the alveolus [pockets in the lung for oxygen exchange] are destroyed within hours before passing away.?

.. although platelet counts, liver and renal functions were found normal.


http://www.flutrackers.com/forum/showpost.php?p=459262&postcount=7

Can't see where they actually took a lung sample yet, and no autopsies at all?.. yet.

 

[Giuseppe]

Re: Thoughts on diagnoses for the mystery illness in Cambodia

Journal of Forensic Sciences:
http://onlinelibrary.wiley.com/doi/...enticated=false&deniedAccessCustomisedMessage=


CASE REPORT PATHOLOGY/BIOLOGY

Characterization of Microorganisms Isolated from Counterfeit Toothpaste

Jennifer L. Brzezinski Ph.D., David L. Craft Ph.D.Article first published online: 17 APR 2012

DOI: 10.1111/j.1556-4029.2012.02130.x
? 2012 American Academy of Forensic Sciences

Issue
Journal of Forensic Sciences
Early View (Online Version of Record published before inclusion in an issue)
Brzezinski, J. L. and Craft, D. L. (2012), Characterization of Microorganisms Isolated from Counterfeit Toothpaste. Journal of Forensic Sciences. doi: 10.1111/j.1556-4029.2012.02130.x
Author Information:
United States Food and Drug Administration, Forensic Chemistry Center, 6751 Steger Drive, Cincinnati, OH 45237.

*Additional information and reprint requests: Jennifer L. Brzezinski, Ph.D. United States Food and Drug Administration Forensic Chemistry Center 6751 Steger Drive Cincinnati, OH 45237 E-mail: jennifer.brzezinski@fda.hhs.gov

Publication History
Article first published online: 17 APR 2012
Received 17 Mar. 2011; and in revised form 5 July 2011; accepted 19 July 2011.


Abstract:  The appearance of potentially counterfeit ?Colgate? toothpaste on the American market prompted a criminal investigation by the United States Food and Drug Administration (FDA), including the collection of c. 60,000 tubes of toothpaste from retail outlets and product distributors. Microbiological testing was performed based on the FDA Bacteriological Analytical Manual, which determined the presence and number of bacteria present in the products. Bacteria were isolated from each ?Colgate? variety; up to 2 ? 106 cfu/g were isolated from some of the product units. Using conventional microscopic and biochemical bacterial identification methods, most of the bacteria isolated from these samples were Gram-negative rods of several genera, including Pseudomonas, Serratia, and Klebsiella. Most of the organisms isolated represent opportunistic pathogens, and therefore, counterfeit ?Colgate? toothpaste containing high levels of bacteria pose a human health hazard.


-
-----

 

[alert]

Re: Thoughts on diagnoses for the mystery illness in Cambodia

ProMED has posted a second time, suspecting JE or Banna virus. Neither of them, however, causes respiratory symptoms, so if they are indeed behind the encephalitis, something else must be causing the respiratory failure. JE, in particular, is also probably too mild to be responsible for this severe outbreak, as hundreds, if not thousands, of missed milder cases would be needed to get the CFR to balance. Personally, I think an enterovirus fits the description we have much better.

If this is an enterovirus, it would force us to re-examine the claims by some researchers in India that some of the AES in that country may be caused by enteroviruses.

 

[Ronan Kelly]

Re: Thoughts on diagnoses for the mystery illness in Cambodia

Just from keeping track in India for the past few years - If it's JE, I would expect a greater age range involved. Generally JE affects all ages. In the Indian situation, any time it's all kids, it never tests positive for JE. JE has a cfr up around 10%, non JE AES is usually higher. In the most recent AES outbreak in Bihar the cfr stands around 37%.

 

[alert]

Re: Thoughts on diagnoses for the mystery illness in Cambodia

Yeah, JE here is pretty much a non-issue here, and Banna isn't much better. Do the Indian AES cases that some people blame on enteroviruses present any respiratory symptoms? I know that some enteroviruses can (EV71, for example), but the problem with EV71 as a diagnosis here is the lack of characteristic HFMD rash. I know that polio, which is an enterovirus, can produce enough respiratory symptoms to seem flu-like (as in 2010 in Congo), but I don't think of that one as causing destruction of the lungs (and polio in children is <10% CFR).

Personally, I have never liked enterovirus as a diagnosis for AES for precisely the reason of this outbreak. Enteroviruses spread widely and would spread quickly across the entire country, as this outbreak has. That doesn't happen in India; AES cases are confined to certain regions.

 

[alert]

Re: Thoughts on diagnoses for the mystery illness in Cambodia

Well, it looks like it was an enterovirus after all, but a known one.

I guess we had all suspected that EV71 would be excluded locally before international help was called in, but I guess that was not the case.

We should expect the international containment measures such as travel screening to be dropped shortly; EV71 is already present in much of Asia, if not the entire world, so there is no reason for such measures.

With respect to the Indian cases, I wonder if they are testing their AES cases for EV71.

 

[Ronan Kelly]

Re: Thoughts on diagnoses for the mystery illness in Cambodia

I have not seen much reporting on respiratory symptoms in any India outbreak, but many times the patients do need respirators, which are in short supply.

In a recent paper (2009) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2657625/ on Uttar Pradesh no mention is made of respiratory symptoms, found enteroviruses in 21% of samples, 13% JE, and smaller numbers of coxsakie viruses A, B1, B3, and echoviruses 11 and 20.

In Assam, a recent outbreak was 77% JE, 12% West Nile, but again no mention of resp. symptoms. http://wwwnc.cdc.gov/eid/article/17/5/10-0479_article.htm

In Kerala 1996, JE was found in 33% of cases, Bagaza virus in 15% http://vir.sgmjournals.org/content/90/11/2644.full

More questions than answers, I'm afraid.

 

[Treyfish]

Re: Thoughts on diagnoses for the mystery illness in Cambodia

I thought EV71 was highly contageous