CASE 1 History: A 12 years old female patient present with fever and sore throat since 4 days.

On examination, tonsils enlarged and pharynx inflamed.

Q1 : Discuss about specimen collection. Ans: Specimen to be collected throat swab. The mouth is held wide open and tongue is depressed. Sterile swabs are firmly rubbed on the tonsils and pharyngeal mucosa to collect any purulent material that is present. Q2 : Following investigation is performed. Grams stains smear of specimen is prepared. What is your observation? Ans : Gram positive cocci arranged in chains with plenty pus cells are seen.

Q3 : Culture is performed on sheep blood agar. What is your observation? Ans : On blood agar, colonies are small (0.5-1.0mm), circular, semi transparent, low convex within area of clear haemolysis around them.

Q4 : Additional tests are performed to identify the isolate. a) Grams stain smear of the colony. Ans : The given smear shows Grams positive cocci arranged in chains. b) Catalase test Ans : No effervescene seen. Hence the test is negative. c) Bacitracin Susceptibility Test Ans : Wide zone of inhibition is seen, showing susceptibility to Bacitracin

Q5 : Identify the pathogen isolated. Ans: Pathogen isolated is Streptococcus Pyogenes.

Q6 : Which are the possible complications of this condition? Ans : Suppuratic lesions like otitis media, mastoditis, quinsy, Ludwigs angina, suppuratic adenitis, Streptococcal pneumonia. Non-suppuratic lesions like acute rheumatic fever and acute glomerular nephritis.

Q7 : Which are the other diseases caused by this organism? Ans : Skin and soft tissue infections like erysipelas, impetigo, cellulitis, necrotizing fasciitis, pyoderma. Genital infection like puerperal sepsis. Other suppuratic infections like abscess in internal organs such brain, lungs, liver, kidney, septicaemia and pyemia Non-suppurative complication like acute rheumatic fever and acute glomerular nephritis.

CASE 2 History : A 35 years old male patient present with abscess in lower jaw.

Q1 : How is the specimen collected? Ans : The area is cleaned with spirit and tincture iodine. With help of a syringe and needle, the pus is aspirated and send to laboratory for the further processing.

Q2 : Following investigation is performed. Grams stain smear of specimen is prepared. What is your observation? Ans: The Grams stain smear of sample shows plenty of pus cells and Grams positive cocci arranged in grape-like clusters.

Q3 : The culture is performed on sheep blood agar. What is your observation? Ans : The given blood agar plate shows colonies which are large, circular, convex, smooth, shiny, opaque with golden yellow pigmentation and clear haemolysis around the colonies.

Q4 : The cultural tests are performed to identify the isolates. Write the results of these tests. Ans : Grams stain smear of colony : Grams stain smear colony shows Grams positive cocci arranged in grape like structure. Catalase test ; Effervescene is seen indicating the test is positive. Tube coagulase test : Coagulum in seen. On tilting the test tube, the coagulum does not flow indicating coagulase test is positive. Mannitol fermentation test : Mannitol is fermented indicating test is positive.

Q5 : Identify the isolate. Ans : Depending on the given isolate maybe Staphylococcus aureus.

Q6 : Which are the other diseases caused by this organism? Ans : Inflammatory staphylococci diseases : Staph skin infection include impetigo, folliculitis, furuncles, carbuncles, paronychia, bletheritis, surgical wound infection. Bacteraemia and septicaemia may occur from any localised lesion. Endocarditis of normal or prosthetics heart wall. Osteomyelitis and arthritis. Pneumonia in post-operative patients. Deep ____ abscess. Toxic mediated staphylococcal diseases : Staphylococcal food poisoning, Staphylococcal toxic shock syndrome, Staphylococcal scalded skin syndrome.

Q7 : What is MRSA? Add note on its role in nosocomial infection. Ans : MRSA is Methicillin Resistant Staphylococcus Aureus. First reported in 1961, MRSA strains where resistant not only to penicillin, but also to all other beta lactom antibiotics including 3rd generation cephalosporins and carbapenems. The commonest site of MRSA carriage is the anterior nose. The significant risk factor for acquisition of MRSA is done during hospital stay. Hospital staff harbouring MRSA are the chief source of infection for the patient. This strain can pass wide range of infection for the patient including bacteraemia, endocarditis and pneumonia and are increasingly recognise as important agent of hospital acquired infection in hospitalised patient. Treatmen : MRSA strains can be treated with glycopeptides antibiotics like vancomycin and teicoplanin in serious systemic infection. MRSA are sensitive to one or more 2nd line drugs which include erythromycin, clindamycin, quinolones, fucidic acid, primethoprim, chloramphenicol, tetracycline and rifampicin. The proper hand washing and use of topical agents such as mupirocin and chlorohexidine on skin and nose to eradicate the agents, are effective to prevent and control nosocomial infection caused by MRSA.

CASE 3 History A 12 years old male patient is admitted to emergency ward following a high fever, headache, vomiting and neck rigidity since 2 days.

Q1 : What is possible diagnosis? Ans: The possible diagnosis is meningitis.

Q2 : Which are the different organisms that can produce similar condition? Ans : Acute pyogenic meningitis In children and adults : Nisseria meningitis, streptococcus pneumoneae, haemophilias influenzae, Staphylococcus aureus, E.Coli, Protease sp. , Klebshella sp., Citrobactor sp., Interobactor sp. And Serrapia sp. In neonates and infants : E.coli, Group B streptococci, haemiphilias influenzae, listeria Monocytogenes, streptococcus pneumoneae, Klebshella sp. Tuberculous meningitis : Aseptic viruses like enterovirus, mumpsvirus, HSV, veracella, zoster virus, measles virus, adenovirus and arbovirus. Bacteria like mycobacteria tuberculosis, listerium monocytogenes, treponema pallidum. Fungi like creptococcus, neoformans, cannide albicans. Protozoa like acanthamoeba, toxoplama gonidi.

Q3 : Discuss of specimen collection. Ans : The specimen to be examined is CSF. It is to becollected by Lumbar Puncture, between L3 and L4. Procedure attempted only by trained personnel and rigorous aseptic precaution must be taken to prevent introduction of infection. Only 3.5ml of fluid should be collected with rate of collection of about 4-5 drops per second. It should be collected in sterile screw cap container and specimen dispatch to laboratory as soon as possible. If there is any delay, it should be kept in room temperature ir incubated at 37C. Q4 : Grams stain smear of sample is made. What is your observation? Ans : The given smear shows Grams positive diplococcic both inside the polymorphs and extra cellularly.

Q5 : The sample inoculated into chocolate blood agar. Describe the colony morphology. Ans : On blood agar after the incubation for 18 hours, the colonies are small (0.5-1.0mm), dome shape, glistering with an area of greenish discolouration ( haemolysis) around them. On further incubation, the colonies become flat with raised edges and central depressed. So that concentring rings are seen on surface when view from above (Drawsman / carom coin appear).

Q6 : Additional tests are performed to identify the isolate. Write the results. Ans : Catalase test : No effervescence, indicating test negative. Aptochin susceptibility test : White zone inhibition is seen indicating organism susceptibility to Aptochin.

Bile solubility test

: Pneumococci are bile soluble bacteria. The culture is clear due to lyses of cocci.

Inulin fermentation test : Inulin fermented with acid but no gas.

Q8 : Identify the pathogen isolated. Ans : Depending on the biochemical reactions, the given isolate maybe pneumococci.

Q9 : Which are the other diseases caused by the organism? Ans : Otitis media, sinusitis, lobar pneumonia, bronchy pneumonia, emphyma, pericarditis, conjunctivitis.