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Medical Microbiology Case Study 2

Last August ,5 students from the same boarding school were admitted to hospital suffering with pneumonia. Streptococcus
pneumoniae was isolated from blood cultures done on these.Further surveillance revealed another 20 students from the school
who were suffering from pneumonia. These occurred during a period of widespread influena infections. The authorities decided to
close the school for a period and no further cases were reported.
!n view of "our recentl" ac#uired $nowledge, interpret and discuss the case from
the above information provided b" the health authorities.
CASE NOTES (RESPONSE PREP)
Pneumonia; infection of the aleoli of the lun!"#
$nfectiou" a!ent"% eithe& i&al o& 'acte&ial ina(e the a&ea" "u&&oun(in! the linin! of the
lun!" an( aleoli#
)lui( on the lun!"; (ifficult* '&eathin!#
$nflammato&* &e"+on"e to infection initiate( '* ma"t cell"% mac&o+ha!e" an(
(en(&itic cell" cau"e( ,hen T-R" 'in( to ta&!et anti!en" an( a&e actiate(#
T&i!!e&" &elea"e of c*to.ine"% to "timulate immune actiit* an( (eal ,ith the
infection# C*to.ine" &e"+on"i'le fo& (ialation an( moement of ,hite 'loo( cell"
into the infecte( a&ea% the lun!" aleoli#
The (ea( cellula& matte& an( ,hite 'loo( cell" in the infecte( "ite fo&m" a +u"/flui(
in the aleoli "ac"# Thi" hin(e&" o0*!en a'"o&+tion% accountin! fo& "ho&tne"" of
'&eath an( flui( on the lun!"#
Cou!hin!
&efle0 a" +a&t of 1
"t
line of immune "*"tem to e0+el fo&ei!n +a&ticle"
)ee&
P*&o!en" f&om immune "*"tem% inte&leu.in21 +&oo.e &ai"e( 'o(* tem+e&atu&e to
"+ee( immune &e"+on"e an( inhi'it 'acte&ial !&o,th#
The"e "tu(ent" hae all come f&om the "ame 'oa&(in! "chool% ,ith 23 &eco&(e( ca"e" of
+neumonia an( 3 confi&me( a" 'acte&ial streptococcus pneumonia#
Occu&&e( "imultaneou"l* ,ith ,i(e"+&ea( i&al influen4a infection"
5oa&(in! "chool" inole "tu(ent" in clo"e +&o0imit* to one anothe&6 "ha&e( liin! a&ea"%
an( u"e of ai& con(itionin!#
Stu(ent" inole(6 li.el* to 'e 'et,een 13 an( 23 *ea&" of a!e# -i.el* to hae health*%
,ell2(eelo+e( immune "*"tem"#
7i&al influen4a can lea( to i&al +neumonia th&ou!h "*"tematic infection; moin! ia the
'loo("t&eam f&om the u++e& &e"+i&ato&* t&act an( na"ao2+ha&*n0#
Thu"% i&al +neumonia i" "i!nificantl* le"" common in a(ult" than chil(&en a" l*m+hatic
&e"+on"e ,ill 'e fa"te& in a(ult"
8&eate& effectiene"" of ,hite 'loo( cell &eco!nition of i&al +&otein" an( natu&al
.ille& cell" &eco!nition of infecte( cell" in the o&i!inal "ite of infection "+ee("
&ecoe&* in a(ult"
a'ilit* of anti!en +&e"entin! cell" to &eco!ni"e i&al anti!en" an( +&oo.e an a(a+tie
&e"+on"e% an( "imila&it* 'et,een influen4a infection" (ealt ,ith +&eiou"l* in a(ult"
al"o "+ee( immune &e"+on"e#
8ien the a!e of the 'oa&(in! "tu(ent"% it can 'e "ai( that the* hae health* an(
(eelo+e( immune "*"tem"# $t i" mo&e li.el* that the ca"e" of +neumonia that ,e&e not
i"olate( (the 20) ,e&e al"o 'acte&ial% a" i&al +neumonia i" uncommon fo& a(ult" an( the
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'acte&ia i" ea"il* cont&acte( an( +atho!enic#
Streptococcus pneumonia ma* 'e +a&t of a +e&"on9" natu&al &e"+i&ato&* flo&a 'ut can 'ecome
+atho!enic un(e& ce&tain ci&cum"tance"% "uch a" an immuno2com+&omi"e( ho"t% o& a" a
"econ(a&* o& co2infection# (Roth'e&!% 2008) (:eunch% 2013)
Can 'e t&an"mitte( f&om lun!" of ho"t to othe& ho"t" ia cou!hin!; in(i&ect fomite on
(&o+let" e0hale( f&om ho"t# A" thi" i" out'&ea. occu&&e( a 'oa&(in! "chool% 'oth the i&al
influen4a an( 'acte&ial +neumonia a&e li.el* to hae 'een "+&ea( in thi" ,a*# The clo"e
contact of "tu(ent" account" fo& the concent&ation of ca"e" amon!"t "tu(ent"#
Clo"u&e of the "chool aime( at '&ea.in! the !a+ of +e&"on to +e&"on t&an"mi""ion ia
in(i&ect fomite# 5* +&eentin! infecte( +e&"on" f&om 'ein! in con"tant contact an( in
clo"e( &oom"% the ae&o"ol" of thei& '&eath o& cou!hin! (o not infect fu&the& +eo+le% an(
thu" thi" mea"u&e i" effectie#
The 'acte&ia +neumonia i" li.el* to hae 'een a "econ(a&* o& co2infection#
Althou!h the o&i!inal "ou&ce of the 'acte&ia ma* hae 'een f&om a +e&"on9" no&mal flo&a%
a" a "econ(a&* o& co2infection to influen4a% the +atte&n of a +oint2"ou&ce e+i(emic
"u!!e"t" that a "in!le +e&"on "+&ea( thi" 'acte&ia to the othe& &e"i(ent" of the 'oa&(in!
"chool ("u((en% multi+le ca"e" of "imila& con(ition" ,ith a clea& common +o&tal of
ent&*)#
Simultaneou" influen4a actiit* in the "chool "u!!e"t" that i&al influen4a a""i"te( the
"ettlement of the lun!" of the affecte( in(ii(ual" ,ith +atho!enic streph pneumonia
'acte&ia#
Secon(a&* an( l*m+hatic immune &e"+on"e" occu+ie( ,ith i&al infection; le""
aaila'le to (eal ,ith 'acte&ial infection#
$nfluen4a i&u"e" lea( to hi!h neu&amini(a"e actiit*6 co&&elate" to 'ette& a(he"ion of
'acte&ial matte& to &e"+i&ato&* cell" in the ai&,a*% inc&ea"in! +atho!enicit* of
'acte&ia# (-utte&% 2010)
P&o2a+o+to+ic +&otein" e0+&e""e( '* i&al influen4a" in(uce" lun! +atholo!*% an(
the&efo&e the "econ(a&* challen!e '* +neumoniae 'acte&ia in the lun!" +&oo.e" a
!&eate& inflammato&* &e"+on"e% (ama!in! the cell" of the lun! an( +&oi(in! the
&e;ui"ite nut&ient" fo& 'acte&ial !&o,th# (-utte&% 2010)
$t i" mo&e li.el* that 'acte&ial +neumonia ,a" a "econ(a&* infection than a co2infection
a" the i&al infection
Refe&ence"6
:eunch et al% (2013) Pneunococcal Infections, :e("ca+e
Roth'e&! et al, (2008) Complications of Viral Influenza, The Ame&ican <ou&nal of :e(icine#
-utte& et al% (2010) Bench-to-bedside review: Bacterial pneumonia with influenza - pathogenesis and clinical
implications% C&itical Ca&e
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Medical Microbiology Case Study 2
Last August ,5 students from the same boarding school were admitted to hospital suffering with pneumonia. Streptococcus
pneumoniae was isolated from blood cultures done on these. Further surveillance revealed another 20 students from the school
who were suffering from pneumonia. These occurred during a period of widespread influena infections. The authorities decided to
close the school for a period and no further cases were reported.
!n view of "our recentl" ac#uired $nowledge, interpret and discuss the case from
the above information provided b" the health authorities.
Disease & Pathophysiology
!t is stated that 25 students are recorded to have contracted pneumonia while at boarding school. !n
pneumonias of microbial origin, the infectious agent invades the tissue of the lung, ad%acent to the alveoli.
The organism responsible is most often bacterial, but can also be viral or rarel" fungal & parasitic. Antigens
originating from the infectious organism bind to the TL' of dendritic cells, macrophages and mast cells,
triggering an immune response. This includes the release of c"to$ines, prompting inflammation through
dilation of surrounding blood vessels, enabling the movement of white blood cells and l"mphoc"tes into the
alveoli and alveoli sacs. This cellular matter lea$s into the alveolar sacs, and inhibits o("gen upta$e in the
lungs, harming the affected person. )ther notable c"to$ines include interleu$in*+ and p"rogens, which
cause a fever, to raising bod" temperature, speeding the immune response and thermall" inhibiting
bacterial growth.
Epidemiology & Transmission
The infected students originate from a common boarding school, with a total of 25 individuals affected with
pneumonia. As the students were li$el" between +0 and +, "ears of age, the" are li$el" to have well*
developed immune s"stems.
The isolation of strephtococus pneumonia from the blood of 5 of the affected students suggests that the
infectious agent responsible for pneumonia was this organism, as bacteremia occurs in advanced stages of
bacterial pneumonia infections. These cases of confirmed bacterial pnuemonia occurred concurrentl" with
a widespread viral influena infections, which can also cause pneumonia. Transmission of the pneumonia in
either case -bacterial or viral. involves a fomite of water droplets e(pelled from the infected person/s lungs
when coughing, sneeing or breathing. These, when inhaled, can establish themselves and cause further
infection. 0iven the circumstance of a boarding school1 multiple persons in shared living areas, sleeping,
eating and stud"ing in a common area, the transmission of airborne droplets from person to person via
fomite seems to be the most li$el" means of transmission.
Although all affected students with pneumonia were not confirmed to have bacterial pneumonia, the
ade#uate chain of transmission and the nature of viral pneumonia -to be discussed. means that it is ver"
probable that all the cases of pneumonia were caused b" a common organism.
Organisms implicated and mechanism
Although viral influena can lead to viral pneumonia, it is li$el" that bacteria pneumonia was responsible in
this case as a secondar" or co*infection.
2iral influena can lead to viral pneumonia in advanced stages of infection, as the viral agent enters the
bloodstream from the initial site of infection in the nose or upper throat and infects the lungs -'othberg,
200,.. Therefore, viral pneumonia is relativel" rare in adults or those with well*developed immune s"stems.
The greater effectiveness of white blood cell recognition of viral proteins speeds recover" before s"stemic
infection, and a well*developed immune s"stem is more able to recognise viral antigens and provo$e an
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adaptive response to the infection, repressing it before it can enter the bloodstream. 0iven the age of the
boarding students, the presence of a read" and ade#uate chain of transmission and that another possible
causative bacteria has been found, it is unli$el" that viral pneumonia was responsible for these cases of
pneumonia.
Although there are a variet" of bacteria potentiall" responsible for pneumonia, streptococcus pneumonia is
the most common organism responsible - between 30 and ,04 . and was isolated in the serious cases of
hospitalised patients. !t e(ists as natural respirator" flora, generall" onl" becoming pathogenic in an
immuno*compromised host or as a secondar" or co*infection -5eunch, 20+6.. Therefore, it is li$el" that it
acted as an opportunistic pathogen, colonising the lung of a student with influena, who then spread the
bacterial infection via formite of aerosol to other students, giving those with influena a secondar"
infection of streptococcal pneumonia.
Academic material demonstrates that viral influena assists the colonisation of lungs with bacterial
pneumonia b" three mechanisms. Firstl", the host/s immune s"stem is occupied with the viral influena, and
is less able to resist a secondar" pathogen, aiding the abilit" of the bacteria to colonise the lungs where is is
otherwise hard for it to become established. Secondl", viral influena leads to high neuraminidase activit"7
correlating to better adhesion of bacterial matter to respirator" cells in the airwa", which increases the
pathogenicit" of bacteria -Lutter, 20+0.. Thirdl", viral influena e(presses pro*apoptopic antigenic proteins
that amplif" the immune response to the secondar" infection in the lungs 8 the greater inflammator"
response damages the lungs and cellular tissue of the alveoli, providing nutrients to assist in colonisation of
bacteria in the lungs -Lutter, 20+0.. Lutter et al notes that viral influenas precede most cases of bacterial
pneumonia1 stating that these mechanisms are crucial in allowing streptococcal pneumonia to successfull"
colonise the lungs and cause pnuemonia.
As the boarding school had an outbrea$ of influena, it is highl" li$el" that strephtococus pneumonia,
perhaps from the natural flora of a student, was a secondar" infection that was then spread to other
students, and is responsible for the pneumonia at that boarding school.
Procedures of treatment and control
!t is stated that the treatments provided were hospitalisation -and assumed relevant treatment. and the
temporar" closure of the school. 9ospitalisation, perhaps involving treatment with antibiotics, $ills the
bacteria involved and assists the bod" in controlling and eventuall" eliminating the lung infection, while
managing the fluids on the lung, fever and associated respirator" discomfort.
The success of temporar" closure of the school confirms that airborne fomites in aerosol were responsible
for the spread of infection7 infected persons, whether s"mptomatic or not, cannot mi( with their peers and
transmit the bacteria b" putting these bacteria into the air, to be inhaled b" another health" individual. The
case demonstrates a point*source outbrea$1 !t was a sudden case, with multiple students e(hibiting similar
s"mptoms, where the removal of a common portal of e(it&entr" b" closing the school and preventing
contact with e(pelled fomites prevented further infection.
'eferences7
+. 5eunch et al, -20+6. Pneunococcal Infections, 5edscape
2# Roth'e&! et al, (2008) Complications of Viral Influenza, The Ame&ican <ou&nal of :e(icine#
6. Lutter et al, -20+0. Bench-to-bedside review: Bacterial pneumonia with influenza - pathogenesis and clinical
implications, :ritical :are