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Treatment of Survivors after the Tsunami
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     To the Editor: The tsunami that struck the Asian subcontinent and Africa on December 26, 2004, caused the deaths of more than 200,000 people. In Thailand more than 10,000 people were treated in ambulatory health centers. After a tsunami, the effects on people occur in three phases. The injuries that are incompatible with life (e.g., severe cardiovascular events, head injury, and blunt injury) happen in the first minutes; then, over the following hours, complications such as massive hemorrhage, hemopneumothorax, and pulmonary embolism are seen. These are followed, in turn, by the late complications, including infectious diseases that develop over days to weeks.1

    A tsunami directly injures the victims by the mechanism of blunt trauma and penetrating injury to any part of the body.1 Soil, small pieces of wood, and glass in the contaminated saltwater penetrate the soft tissue of victims at high velocity. Most of those who survived the disaster also had saltwater aspiration. In most of those admitted to health care facilities with cellulitis, progressive fasciitis developed unless there was prompt treatment with appropriate antibiotics and aggressive débridement.2 Other common complications included bony fractures, soft-tissue contusions, hypoxic encephalopathy, and acute stress disorder.

    The volunteer medical team at Rajavithi Hospital in Bangkok, Thailand, treated 37 patients with serious medical complications. All 37 had aspirated saltwater contaminated with soil and had soft-tissue infections. Aspiration pneumonia (in 17 patients), pneumothorax (in 7), and pneumomediastinum (in 3) were the major respiratory problems. In eight patients the acute respiratory distress syndrome developed, with a progressive course in three, rapid resolution followed by severe pneumonia in three, and rapid resolution followed by mild-to-moderate pneumonia in two.

    Burkholderia pseudomallei is endemic in this region.3 We encountered one human immunodeficiency virus (HIV)–positive patient with a B. pseudomallei lung abscess and one patient with diabetes mellitus in whom acute B. pseudomallei lobar pneumonia developed (Figure 1). Table 1 summarizes the clinical findings in these two patients, who had melioidosis after the disaster. Both were febrile, with cough, dyspnea, and sputum production, and required respiratory support.

    Figure 1. B. pseudomallei Lung Abscess in a Patient after the Tsunami.

    Panel A shows a radiograph of the chest, obtained eight days after the aspiration of soil-contaminated saltwater in a patient with an acute B. pseudomallei lung abscess of the left middle lung zone. Gram's staining of sputum for B. pseudomallei (Panel B) shows the "safety-pin" appearance (bipolar staining appearance) of these gram-negative rods.

    Table 1. Clinical Findings in Two Patients with B. pseudomallei Infection and Melioidosis after the Tsunami.

    Among all the patients, cultures of blood, sputum, or pus contained the following organisms: Pseudomonas aeruginosa (in four patients), B. pseudomallei (in two), Stenotrophomonas maltophilia (in one), Acinetobacter baumanii (in five), Escherichia coli (in three), klebsiella (in three), enterobacter (in two), neisseria (in one), citrobacter (in one), corynebacteria (in two), and viridans streptococcus (in two). All the patients were treated with combination antibiotic therapy (imipenem plus cotrimoxazole [trimethoprim–sulfamethoxazole]) that is active against pseudomonas and B. pseudomallei.

    In summary, the tsunami hit in an area where B. pseudomallei is endemic,3,4,5 and the patients needed treatment for B. pseudomallei and also treatment with antibiotics that are active against anaerobic bacteria, débridement, and respiratory care.

    Subsai Kongsaengdao, M.D.

    Sakarn Bunnag, M.D.

    Napa Siriwiwattnakul, M.D.

    Rajavithi Hospital

    Bangkok 10400, Thailand

    skhongsa@gmail.com