SUMMARYPurpose: To identify risk factors for hyperammonemia in pediatric patients with epilepsy. Methods: A total of 2,944 pediatric patients (ages 0-15 years) were classified into the following three groups: a group without drug treatment (n = 445, group I), a group receiving antiepileptic drugs other than valproic acid (VPA) (n = 673, group II), and a VPA-treated group (n = 1,826, group III). Hyperammonemia was defined as a plasma ammonia level exceeding 100 lg/dl with reference to the standard range and previous reports. Key Findings: The mean ammonia level of groups I, II, and III was 36.0, 56.0, and 86.8 lg/dl, respectively, and the incidence of hyperammonemia was 1.6%, 7.7%, and 31.7%, respectively. In each group, the mean ammonia level of patients aged 3 years or younger was significantly higher than that of patients aged 4-15 years. In group II, concomitant use of topiramate and zonisamide were risk factors for hyperammonemia (adjusted odds ratio [OR] 3.9, 95% confidence interval [CI] 1.7-9.2, and OR 3.5, 95% CI 1.9-6.5, respectively). In group III, the ammonia level increased in a VPA dose-dependent manner. At a VPA dose of 30 mg/kg, there was 4.3-fold increase in the incidence of hyperammonemia. The other significant risk factors identified were female gender (OR 1.3, 95% CI 1.0-1.6), symptomatic generalized epilepsy (OR 1.4, 95% CI 1.1-1.8), and the concomitant use of phenytoin (OR 4.7, 95% CI 3.3-6.9), phenobarbital (OR 2.2. 95% CI 1.6-3.2), acetazolamide (OR 6.6, 95% CI 2.5-17.2), topiramate, or zonisamide. Significance: A young age and concomitant use of carbonic anhydrase inhibitors are associated with an increased risk of hyperammonemia regardless of whether the patient is taking VPA. In patients receiving VPA, concomitant use of phenytoin and/or phenobarbital enhances the risk of hyperammonemia. An increase in ammonia can be caused by multiple factors. Our results may help clinicians to avoid problems of hyperammonemia. KEY WORDS: Hyperammonemia, Epilepsy, Children, Risk factor, Valproic acid, Phenytoin.Hyperammonemia is a frequent problem associated with antiepileptic drugs (AEDs) that can lead to vomiting, aggression, ataxia, and exacerbation of seizures. Acute hyperammonemia can also cause cerebral edema and severe brain damage (encephalopathy), whereas chronic hyperammonemia due to metabolic disorders is associated with developmental delay and intellectual disability (Cagnon & Braissant, 2007;Lichter-Konecki, 2008). Among the AEDs, valproic acid (VPA) is recommended as a first-line treatment for generalized epilepsy. Although VPA can cause an increase of the blood ammonia level, VPA therapy is rarely associated with hyperammonemic encephalopathy.The exact relationship between symptoms and the ammonia level remains unclear. Murphy and Marquardt (1982) reported that patients with hyperammonemia not exceeding 240 lg/dl were asymptomatic. In contrast, Coulter and Allen (1981) recommended reducing the VPA dose when the ammonia level exceeded 100 lg/dl. Our data (see later) indicate that hyperammo...

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BackgroundDuring the 2013 outbreak, 4638 infection cases and 32 deaths have been recorded in the southern part of Laos. In recent years, the chikungunya virus (CHIKV) emerged in the part of the country bordering Cambodia. Dengue virus (DENV) and CHIKV are transmitted by common mosquito vectors. Both diseases have similar clinical presentations; therefore, CHIKV infections might go undiagnosed in DENV-endemic areas. Thus, rapid detection and accurate diagnosis are crucial for differentiating between the two viruses (DENV and CHIKV). In this study, we demonstrated that CHIKV and two serotypes of DENV are circulating in Laos. In addition, we encountered patients that had been concurrently infected with multiple DENV serotypes or DENV and CHIKV.MethodsPlasma samples were collected from 40 patients with suspected DENV infections during an outbreak between July and August 2013. The reverse transcription polymerase chain reaction was performed to detect the four DENV serotypes and CHIKV using specific primers. Specifically, the complete envelope gene sequences of the viruses were sequenced and subjected to phylogenetic analysis.ResultsForty acute-phase plasma samples from patients with suspected dengue infections were tested for the presence of DENV viral RNA using molecular methods. Among the 40 samples, 14 samples were positive for DENV, 2 samples were positive for both viruses (DENV-2 and DENV-3), whereas DENV-1 and DENV-4 were not detected during the study period. We also encountered 10 samples that were positive for CHIKV. Of the 10 CHIKV-positive samples, 3 samples were co-infected by DENV-2, and 2 samples were co-infected by DENV-3. Phylogenetic analysis revealed that the 2013 dengue outbreak in Laos involved DENV-2 genotype Asian I and DENV-3 genotype II. Moreover, the Laotian CHIKV strains grouped together with those isolated during outbreaks on the Indian Ocean Islands within the East Central South African genotype.ConclusionsThese findings revealed that two serotypes (DENV-2 and DENV-3) and CHIKV were detected. Furthermore, infection of multiple DENV serotypes and CHIKV was also observed in the 2013 dengue outbreak. This is the first documented evidence of co-infection with CHIKV and one of two DENV serotypes.

Background Aedes aegypti, which is widely distributed in the Lao People’s Democratic Republic (PDR), is the primary vector of arboviral diseases. Chemical insecticides have been intensively used to eliminate mosquito-borne diseases, resulting in the development of insecticide resistance. However, little is known about the insecticide resistance of mosquito populations in Lao PDR and the mechanisms responsible for it, which have important implications for vector management programs. Here, we examined the phenotypic and haplotypic profiles of insecticide resistance in populations of Ae. aegypti larvae from central Lao PDR. Methods Ae. aegypti larvae were collected from four sites in Lao PDR, and their susceptibility to temephos, deltamethrin, permethrin, and Bacillus thuringiensis israelensis (Bti) was tested using larval bioassays. Synergistic tests were also conducted to evaluate the activity of insecticide-metabolizing enzymes in the larvae. Deltamethrin-resistant and Deltamethrin-susceptible larvae were then genotyped for knockdown resistance (kdr) mutations to determine the associations between each genotype and resistance. Results Ae. aegypti larvae from central Lao PDR were considered to be “resistant” (<98% mortality) to organophosphates and pyrethroids. The bio-insecticide Bti remains effective against such larvae. The resistance mechanisms of Ae. aegypti larvae were found to vary among populations, especially for pyrethroid resistance. Kdr mutations were significantly associated with deltamethrin resistance in Ae. aegypti from the Xaythany population. In contrast, synergist assays with piperonyl butoxide suggested that cytochrome P450 monooxygenases played an important role in the resistance seen in the Khounkham and Thakhek populations. Conclusion This study obtained information that will aid the design and implementation of insecticide-based vector management of Ae. aegypti in central Lao PDR. Ae. aegypti larvae from central Lao PDR were highly susceptible to Bti, while they were resistant to temephos at a diagnostic dose of 0.0286 mg/L. Given the limited number of insecticides that are approved for vector control, it is important to alternate between temephos and other larvicides, such as Bti and pyriproxyfen. The differences in pyrethroid resistance mechanisms seen among the Ae. aegypti populations highlight the need to tailor vector-control strategies to each region to increase the success of dengue control in Lao PDR.

BackgroundHepatitis E virus (HEV) causes an acute viral hepatitis that is transmitted enterically. It is epidemic in Africa, Asia, the Middle East, and Central America. It is known that HEV can cause extrahepatic manifestations. Here, we report the first case of acalculous cholecystitis as an extrahepatic symptom of HEV.Case presentationA 24-year-old Japanese woman with no notable past medical history presented with complaints of fever and nausea while she was traveling in Australia; within the previous 2 months, she had also traveled to India and Africa. She visited a local hospital in Australia, and the laboratory tests showed significantly elevated levels of transaminase, so she was checked for viral hepatitis. After excluding hepatitis A, B, and C, as well as other causes of hepatitis, it was revealed that the patient was positive for HEV-IgM. Since she was a visitor to Australia, she was sent back to Japan and was transferred to our hospital. On day 4, the patient complained of right upper quadrant pain. Ultrasonography of the abdomen showed a thickened gallbladder wall without calculi. Acalculous cholecystitis was diagnosed from her course. No antibiotics were administered against it because there was no evidence of bacterial infection. The edematous wall showed significant improvement on day 11 and had returned to normal by day 14. The patient was discharged on day 16 because all of the symptoms had disappeared.ConclusionsWe found that HEV can cause acalculous cholecystitis as an extrahepatic manifestation. In addition, the cholecystitis could be resolved without any antibiotics.

Abstract. We developed a combined conventional polymerase chain reaction (PCR) and real-time PCR (qPCR)-based assay for detecting and discriminating between Opisthorchis viverrini and Haplorchis taichui parasite infections. The first PCR amplifies the mitochondrial cytochrome c oxidase subunit I (COI) genes of parasites, and differential diagnosis is achieved by performing qPCR with specific primers and SYBR Green I. The detection limit of the assay was found to be 2.0 × 10 2 plasmid copies in a test in which a stool sample was spiked with a single egg, which is equivalent to 5 eggs per gram (EPG). The testing of 34 clinical stool samples that had been demonstrated to contain "Opisthorchis-like" eggs by microscopy showed that the novel assay exhibited a sensitivity of 100% for "Opisthorchis-like" parasitic infections, and 71% and 91% of these samples were found to be infected with O. viverrini and H. taichui, respectively. A further four parasitic infections were diagnosed in the 16 negative samples, and the microscopic findings of these samples were confirmed to be false negatives by sequencing analysis. The assay also displayed high specificity during the testing of 10 samples containing other common parasites. The fact that our qPCR SYBR Green I-based assay detected submicroscopic traces of parasitic DNA and was able to differentiate between parasites that produce eggs with similar morphologies indicates that it has a good potential for development of diagnostic application to use in areas where multiple parasites coexist.

Background Solomon Islands, a country made up of tropical islands, has suffered cyclic dengue fever (DF) outbreaks in the past three decades. An outbreak of dengue-like illness (DLI) that occurred in April 2016 prompted this study, which aimed to determine the population’s immunity status and identify the arboviruses circulating in the country. Methods A household survey, involving 188 participants in two urban areas (Honiara and Gizo), and a parallel hospital-based clinical survey were conducted in April 2016. The latter was repeated in December after a surge in DLI cases. Arbovirus IgG ELISA were performed on the household blood samples to determine the prevalence of arboviruses in the community, while qPCR testing of the clinical samples was used to identify the circulating arboviruses. Dengue virus (DENV)-positive samples were further characterized by amplifying and sequencing the envelope gene. Results The overall prevalence rates of DENV, Zika virus, and chikungunya virus were 83.4%, 7.6%, and 0.9%, respectively. The qPCR positivity rates of the clinical samples collected in April 2016 were as follows: DENV 39.6%, Zika virus 16.7%, and chikungunya virus 6.3%, which increased to 74%, 48%, and 20% respectively in December 2016. The displacement of the circulating serotype-3, genotype-1, with DENV serotype 2, genotype cosmopolitan was responsible for the outbreak in 2016. Conclusions A DENV outbreak in Solomon Islands was caused by the introduction of a single serotype. The high prevalence of DENV provided transient cross-protection, which prevented the introduction of a new serotype from the hyperendemic region for at least 3 years. The severe outcomes seen in the recent outbreak probably resulted from changes in the causative viruses and the effects of population immunity and changes in the outbreak pattern. Solomon Islands needs to step up surveillance to include molecular tools, increase regional communication, and perform timely interventions.

Drug interactions caused by enzyme-inducing AEDs, especially phenytoin, are closely related to the development of hyperammonemia. This study demonstrated that introduction of new AEDs changed the co-prescribing pattern in patients receiving valproic acid, resulting in a marked decrease of hyperammonemia. Although their higher cost may be problematic, new AEDs are beneficial for reducing the risk of drug interactions.