Microbiology Test 4

Name: _________________________________ Date: ____________________ Case 1 A 24-year old female automotive technician presents herself at the doctors office. She complains of fever and of pain in her left hand. On physical examination, the patient had a deep wound on her left palm that was oozing pus. She had purplish, red streaks running up her left arm. She had enlarged lymph nodes at the elbow and under her arm. The patients skin was warm and dry. In her history, the patient had punctured her left palm with sharp metal from the undercarriage of a "real cherry" 1977 Malibu about a week earlier. She said the wound had bled for a few minutes and she thought that she had washed it "real good" with soap and water. She had covered the wound with a large "band-aid" and gone back to work. She developed a fever about three days later. For the past couple of days, she "did not feel so good" and had vomiting and diarrhea. 1. What type of infection do you believe she has in this hand? a. Streptococcus pyogenes b. Staphylococcus aureus c. Clostridium d. Pseudomonas e. Pasteurella multocida 2. From complaint and physical examination, which of the symptoms lead you to your choice of agent? a. the fever and pain in the hand b. the fever, wound with oozing pus and enlarged lymph nodes c. the lymph nodes and red streaks d. the warm dry skin e. the pain, red streaks and enlarged lymph nodes 3. From the history, which of the information confirmed your choice? a. The wound had bled for a while. b. The wound was cleaned with soap and water. c. The wound had been covered and had perhaps become anaerobic. d. She had diarrhea and vomiting. e. The cut was from a rusting car frame. 4. Which of the following is most likely to follow this infection? a. gangrene and amputation b. toxic shock syndrome c. muscle spasms d. neurological dysfunction of the hand e. arthritis

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Case 2 A 27-year old white female presented at the walking clinic of her local physician on August 15. On physical exam, the patient had a fever of 38.5C. She appeared fatigued, had tender joints, and complained of a headache, a stiff neck and a backache. The physician noticed a circular "rash" about 5 inches in diameter, with a bright red leading edge and a dim center in the form of a "bulls eye". The physician noted an irregular heartbeat. The patient complained of lack of ability to concentrate. The patient gave the following history: She is a graduate student in the wildlife program at the university in town. She was in the field for three weeks in Wisconsin during the months of May and June. She tracks small mammals in the field and studies their behavior. It had been a warm, wet spring and she complained of a large number of biting flies, mosquitoes and ticks in the area. She felt well until about 2 weeks after returning to her home. Since that time, many of her symptoms had progressed. She finally found that she could take it no more. 1. What is your best diagnosis of this case?

2. What features are critical to your diagnosis?

3. What further steps should be taken to clear up the problem?

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Case 3 A white male, 17 years of age presented at the emergency room with a severe headache, vomiting, and a stiff neck with pain running up his back. On admission, his temperature was 101F. The young man appeared to have trouble hearing during the nurses interview and also seemed to have trouble concentrating. The history revealed that the young man is a wrestler for the local high school team. He had felt as though he were getting a cold the past few days, since his last meet in Hicksville. He did not smoke or drink, but he had attended a party two days earlier thrown by his girlfriend and the other cheerleaders to celebrate his victory in the sectionals. He had been holding his weight at 162 for the season, so he ate little and did not drink on the day of meets (today is a day of the meet). On physical exam, the physician noticed several areas of small purplish spots on the skin of the back, thigh and arm. The boy thought those were from wrestling. 1. Which of the following is the most likely diagnosis? a. Neisseria gonorrhoeae induced meningitis b. E. coli induced meningitis c. Neisseria meningitidis induced meningitis d. Streptococcus pneumoniae induced meningitis e. LaCrosse encephalitis 2. Which of the following was a critical factor in your choice of diagnosis? a. The fact the he is a wrestler and he does not eat or drink much. b. The headache, vomiting, stiff neck, fever and purplish spots. c. The party he went to with the cheerleaders. d. His trouble hearing. e. The cold symptoms. 3. Which of the following will likely happen if he is not treated? a. He will continue to have a fever and stiff neck for a few days and recover. b. His symptoms will progressively worsen until he develops shock and dies. c. He may get better in a few days, but will likely have permanent hearing loss. d. It is impossible to tell, because not enough data is available for an assessment of his condition. e. He will likely recover from the acute illness, but develop chronic arthritis later.

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Microbiology Test 4
Case 4 A 22 year old construction worker was hospitalized in early December because of increasing shortness of breath and a cough with blood-stained sputum that had developed over a 2 day period. Except for various injuries suffered on the job and allergies to a variety of environmental substances, he had always been in good health. One week before hospitalization, this patient had developed a cold characterized by a mild sore throat and non-productive cough, malaise, and a generalized dull headache. The day before hospitalization, just as he was leaving work at the Army Chemical Warfare plant, the patient experienced a severe shaking chill that lasted for ten minutes. Following this, the cough became worse and more productive of sputum. It became frankly bloody a few hours before admission to the hospital. 1. What is the most likely cause of his cold?

2. The symptoms that brought him to the hospital are most likely due to _____? a. Reactivation of his cold b. Allergy c. Strep throat d. Nitrogen oxide or chlorine gas poisoning e. Pneumonia Physical examination revealed a temperature of 104 and a pulse rate of 130/min; blood pressure was 112/70, and respirations were 38/min. Each respiration was accompanied by an audible grunt. The chest was hypo-resonant to percussion and filled with inspiratory and expiratory wheezes. Fine crackling rales were heard on inspiration over the lower anterior chest just to the right of the sternum. 3. What organisms should be included in the differential diagnosis? a. Klebsiella, Legionella, Mycoplasma, Chlamydia b. Streptococcus pneumoniae, Klebsiella, Staphylococcus aureus c. Pseudomonas aeruginosa, Brucella abortis, E.coli d. Afipia felis, Vibrio cholera, Campylobacter jejuni e. Listeria monocytogenes, Francisella, Chlamydia Initial laboratory data included a total leukocyte count of 12,100 wbc/mm3 with 71% segmented neutrophils, 17% band forms, 11% lymphocytes and 1% eosinophils. Freshly collected sputum was Gram stained and revealed many neutrophils and a mixture of Gram positive rods and cocci. Chest x-ray showed a distinct infiltrate

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involving the right middle lobe. Blood and sputum cultures were done. From the two blood cultures, a Gram positive lancet shaped cocci was isolated. It was catalase negative, alpha hemolytic and optochin sensitive. The third blood culture was negative and the sputum culture grew only normal oropharyngeal microbes. 4. What organism was in the blood culture?

5. What is the major virulence factor for the causative organism?

6. Why was the sputum culture negative? a. This organism is never isolated from sputum b. 50% of persons with this type of pneumoniae have negative sputum cultures c. The sputum is contaminated with saliva d. This organism is an obligate intracellular pathogen and cannot be cultured in the laboratory e. All of the organism was in the blood so there was none in the lungs 7. What was the relationship of the young mans cold to his subsequent pneumoniae? a. The pneumonia and cold were caused by the same organism b. The interferon induced by the cold virus stimulated the bacterium c. The cold virus denuded the ciliated epithelium and interfered with the natural mechanism by which bacteria are cleared from the lung d. The cold virus inactivated the IgG in the lung e. There was no relationship it was coincidental

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Microbiology Test 4
Case 5 This 21 year old man presented to the emergency room with 3 days of abdominal pain, which began as a diffuse, dull, continuous pain. The pain became crampy in the midgastric and lower abdomen. He noted a decrease in appetite but no nausea, vomiting or diarrhea. On examination, the patient was febrile to 39.2C, tachycardic with a heart rate of 150 beats/min and tachypneic with a respiratory rate of 52/min and had a blood pressure of 108/60 mmHg. His physical examination was notable for midgastric and right lower quadrant abdominal tenderness. The white blood cell count was normal. Blood cultures were obtained on admission and were subsequently positive for an anaerobic, gram negative rod, at which time the patient was taken to the operating room for an exploratory laparotomy. 1. To which genus do you think this organism belongs and why?

2. Upon learning of the positive blood culture, the surgical team opted for abdominal surgery. What type of lesion would you suspect they would find in the abdomen?

3. How is this intra-abdominal lesion treated?

4. What would surgical samples of this lesion be likely to grow on culture?

5. What other types of infections does this organism cause?

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Case 6 This 63 year old alcoholic was taken to the emergency room of a hospital with obvious gangrene of both feet. He was stuporous. During that evening, he had a seizure and was treated with phenytoin and barbiturates. By the night of transfer he was noted to have opisthotonic posturing and to have developed increasing rigor, respiratory distress, and unresponsiveness. On examination, he had a temperature of 41.7C rectally, a blood pressure of 70/30 mmHg, a heart rate of 110 beats/min, and a respiratory rate of 40/min. Examinations were notable for marked trismus. The neck was stiff and hyperextended. Necrotic, blackened areas were present over both feet and several draining ulcers were noted on the heels and toes. Neurologically, the patient responded to deep pain with a grimace. On the basis of these findings, specific therapy, in addition to supportive care was initiated and the patient ultimately recovered. 1. What is the etiology of his infection? What virulence factor produced by the etiological agent of his infection was responsible for his trismus?

2. How did this patient become infected with this organism? What was the role of his gangrenous feet in the development of this infection?

3. What was the specific therapy used to treat this infection?

4. How might this infection have been prevented?

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Microbiology Test 4
Case 7 The patient was an 18 month old female who presented to the ER with fever, a diffuse rash (onset 5 days ago) and a swollen right hand. On examination she was irritable but alert. Her temperature was 39C and her heart rate was increased at 180 beats/min. She had diffuse vesiculopustular lesions over her entire body, with some areas showing older, crusted lesions. She had cellulitis of the right hand manifested by marked erythema, swelling and tenderness. There were no mouth lesions, the lungs were clear, and the liver and spleen were not enlarged. Laboratory data were significant only for leukocytosis with a WBC count of 15,800/mm3 with 88% neutrophils. The chest x-ray was clear. A radiograph of the right hand showed only soft tissue swelling. The patient was treated with intravenous cefazolin. Improvement in the condition of her right hand was notable within 48 hours. This patient had a systemic viral infection with a complication of bacterial super infection (cellulitis). 1. This patient had a characteristic rash at various stages of evolution. What is the differential diagnosis? What was her underlying viral illness?

2. Which complications other than bacterial super infection can be seen as a result of this viral infection?

3. After acute primary infection with this virus, latent infection develops. Which illness may occur years later as a result of viral reactivation? How do the clinical manifestations of this reaction differ from those of the primary infection?

4. What are the hospital infection control issues related to this patients illness?

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