A 52 year old dialysis patient of Salimalian origin has been in the UK

for 10 years presents with a 2 months history of night sweats,

intermittent fever, weight loss and lumbar pain. You suspect
tuberculosis.

WHAT INVESTIGATION WILL

YOU CARRY OUT TO
CONFIRM THIS DIAGNOSIS?
Chest X-ray, MRI spine, microscopy and culture of sputum and early
morning urine for acid-fast bacteria. Tests for immune response to
mycobacteria (tuberculin skin test or IGRA). Total and differential
white cell count and C-reactive protein to monitor treatment

WHAT ASPECTS OF THIS

PATIENTS HISTORY
SUGGEST AN INCREASED
RISK
Patient who OF
are bornTUBERCULOSIS?
in developing countries, particularly sub-

Saharan Africa and Asia, are likely to have been exposed to

tuberculosis in childhood. Clinical tuberculosis is more likely in
dialysis patients.

WHAT IS THE PATHOGENESIS

OF CLINICAL
TUBERCULOSIS?
Primary infection (usually in childhood in endemic areas) is usually
acquired by inhalation, which causes a primary focus in the lung
with associated lymphadenopathy. This usually heals with scaring
of the primary focus but may disseminate to cause military
tuberculosis with or without meningitis. Later, usually when the
immune response is compromised (e.g due to steroids,
immunosuppressive therapy, malnutrition or dialysis), reactivation
can occur, associated with caseous necrosis in the involved tissues
(most commonly thee lung) and regional lymphadenopathy.

WHAT IMAGING FINDINGS WOULD

SUPPORT A DIAGNOSIS OF
TUBERCULOSIS IN THIS CASE?
Upper or mid-zone consolidation and or cavitation, and hilar
lymphadenopathy on the chest X-ray and necrosis of the
intervertebral disc with bony erosion on MRI of the spine would all
be consistent with tuberculosis in the lung and spine respectively.

DIRECT EXAMINATION OF SPUTUM FROM THIS

PATIENT REVEALS ACID- AND ALCOHOL-FAST
BACILLI. WHAT MANAGEMENT SHOULD BE
INSTIGATED?
This indicates smear positive infection with a risk of spread. The
patient should be nursed in a negative-pressure side room and
healthcare staff should wear personal protective respiratory masks
when attending to the patients needs. The patient is considered
infectious for the first 2 weeks of therapy, which should be with
quadruple antituberculous agents for 2 months, followed by dual
therapy for 10 months. The total period of treatment is extended
from 6 to 12 months because of bone involvement. The patient
should be referred to a specialist microbiology/infectious disease
team for management.

ARE THERE PUBLIC HEALTH

ISSUES THAT NEED TO BE
ADDRESSED?
Yes. Part of the management of tuberculosis, especially for smearpositive infections, is the measures taken to trace contacts and
screen them for infection. This can be done by a combination of
tuberculin skin test/IGRA and chest X-ray. Prophylaxis or treatment
can then be given as needed.

A young, previously fit man presents with a one week history of a

flu-like illness which has worsened over the past 24 hours. His
temperature is 39.5C with a heart rate of 100 and increased
respiratory rate. His chest X-ray shows diffuse mottled shadowing
in both lung fields. A diagnosis of community-acquired pneumonia
is made and he is started on co-amoxiciav and clarithromycin. After
24 hours his condition has not improved, his temperature is 39C
and a repeat chest X-ray reveals multiple nodular shadows with the
possibility of a fluid level.

WHAT INVESTIGATION WILL

YOU CARRY OUT?
Blood and sputum cultures should b performed. Pneumonia is
frequently associated with bacteremia. The inflammatory response
should be assessed by measuring the peripheral white cell count,
C-reactive protein. The severity of sepsis should be assessed by
measuring blood gases and serum lactate.

WHAT ORGANISMS ARE THE MOST LIKELY

TO CAUSE COMMUNITY-ACQUIRED
PNEUMONIA IN A YOUNG PATIENT?
A community-acquired pneumonia (CAP) is most frequently caused
by Streptococcus pneumonia, followed in this age group by
Mycoplasma pneumonia. Other organisms that have to be
considered in an immunocompetent patient are Streptococcus
pyogenes and Staphylococcus aureus (including MRSA) and
Klebsiella pneumoniae.

WHAT ELEMENT IN THE

HISTORY MAKES ONE OF
THESE ORGANISMS MORE
LIKELY?
The history is suggestive of a viral infection preceding a worsening
of symptoms. This is suggestive of secondary infection with
Staphylococcus aureus. Klebsiella pneumoniae could also cause
this but would be more common in an older patient with preexisting lung disease.

WHAT FEATURES ARE PARTICULARLY

ALARMING IN THIS HISTORY WHAT
MIGHT THIS BE DUE TO?
It is concern that these appears to be a worsening of the X-ray
appearance and development of lung abscesses. This is consistent
with Staphylococcus aureus. This history is suggestive of infection
with a Panton-Valentine leucocidin (PVL) producing S. aureus strain.
PVL producing S. aureus infections are associated with abscesses
and severe necrotizing pneumonia.

WHAT CHANGES WOULD

YOU MAKE TO THE
ANTIBIOTIC THERAPY?
Failure to respond initially could be due to methicillin resistance, in
which case vancomycin should be used. Use of an
antistaphylococcal agent that inhibits protein synthesis would be
advisable. Clindamycin is a good choice for staphylococcal
pneumonia; however, ongoing therapy should be tailored to
sensitivity results.

WHAT LABORATORY
CHARACTERISTICS WILL
HELP IDENTIFY THIS
ORGANISMS?
Staphylococcus aureus is a Gram positive coccus. Characteristically
it is differentiated from streptococci by the clump-like configuration
of cells and production of catalase. It produces the enzyme
coagulase, which differentiates in from the coagulase-negative
staphylococci, which are common skin commensals and usually
only pathogenic in the presence of foreign material such as
intravascular catheters and prosthetic joints.

A 28 year old postdoctoral student presented to his physician with complaints

of recurrent abdominal cramps. He had grown up in Italy, come to the United
States for graduate studies, and returned home each year for the holidays.
Over a period of several years he had complained of recurrent abdominal
cramps; however, the causes were thought to be changes in diet, as well as
the usual stress associated with graduate school. During the past few
months, the symptoms had become worse and he occasionally had diarrhea,
as well. There was some speculation that he might have an ulcer.
On presentation, the patient appeared in no particular distress, and the
examination was unremarkable. The one exception was some slight
discomfort on palpation of the abdomen.
Routine stool examinations for parasites revealed the following: brown ova
with oncosphere and filaments ovalocaytes with no striations.

WHAT ORGANISMS ARE

SUGGESTED FROM GIVEN
DESCRIPTION?

WHAT GROUP OF PARASITES MIGHT BE

INVOLVED, AND ARE THESE TYPICAL
BASED ON HIS TRAVEL HISTORY?

WHAT COULD BE THE

RESERVOIR HOSTS?

WHAT CAN YOU SUGGEST AS

POSSIBLE TREATMENT?

IS IT POSSIBLE THAT THIS PARASITE CAN

CAUSE AUTOINFECTION? STATE HOW
AUTOINFECTION COULD OCCUR.