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Thread: Microbiology Case Studies

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    Post Microbiology Case Studies

    From Jawetz, Melnick, & Adelberg's Medical Microbiology, 24th Ed.

    Central Nervous System


    Case 1: [HIDE]Meningitis[/HIDE]


    A 3-year-old girl was brought to the emergency room by her parents because of fever and loss of appetite for the past 24 hours and difficulty in arousing her for the past 2 hours. The developmental history had been normal since birth. She attended a day care center and had a history of several episodes of presumed viral infections similar to those of other children at the center. Her childhood immunizations were current.
    Clinical Features

    Temperature was 39.5 °C, pulse 130/min, and respirations 24/min. Blood pressure was 110/60 mm Hg.

    Physical examination showed a well-developed and well-nourished child of normal height and weight who was somnolent. When her neck was passively flexed, her legs also flexed (positive Brudzinski sign, suggesting irritation of the meninges). Ophthalmoscopic examination showed no papilledema, indicating that there had been no long-term increase in intracranial pressure. The remainder of her physical examination was normal.
    Laboratory Findings

    Minutes later, blood was obtained for culture and other laboratory tests, and an intravenous line was placed. Lumbar puncture was performed less than 30 minutes after the patient arrived in the emergency room. The opening pressure was 350 mm of CSF (elevated). The fluid was cloudy. Several tubes of CSF were collected for culture, cell counts, and chemistry tests. One tube was taken immediately to the laboratory for Gram staining. The stain showed many polymorphonuclear (PMN) cells with cell-associated (intracellular) gram-negative diplococci suggestive of Neisseria meningitidis.

    Blood chemistry tests were normal. The hematocrit was normal. The white blood cell count was 25,000/L (markedly elevated), with 88% PMN forms and an absolute PMN count of 22,000/L (markedly elevated), 6% lymphocytes, and 6% monocytes. The CSF had 5000 PMNs/L (normal, 0–5 lymphocytes/L). The CSF protein was 100 mg/dL (elevated), and the glucose was 15 mg/dL (low, termed hypoglycorrhachia)—all consistent with bacterial meningitis. Cultures of blood and CSF grew serogroup B N meningitidis.
    Treatment

    Intravenous cefotaxime therapy was started within 35–40 minutes of the patient's arrival; dexamethasone was also given. The patient was treated with the antibiotic for 14 days and recovered without obvious sequelae. Further neurologic examinations and hearing tests were planned for the future. Rifampin prophylaxis was given to the other children who attended the day care center.

    Case 2: [HIDE]Brain Abscess[/HIDE]


    A 57-year-old man presented to the hospital with seizures. Three weeks earlier he had developed bifrontal headaches that were relieved by aspirin. The headaches recurred several times, including the day prior to admission. On the morning of admission he was noted to have focal seizures with involuntary movements of the right side of his face and arm. While in the emergency room, he had a generalized seizure that was controlled by intravenous diazepam, phenytoin, and phenobarbital. Additional history from the patient's wife indicated that he had had a dental extraction and bridge work approximately 5 weeks earlier. He did not smoke, drank only socially, and took no medications. The remainder of his history was not helpful.
    Clinical Features

    The temperature was 37 °C, the pulse 110/min, and respirations 18/min. The blood pressure was 140/80 mm Hg.

    On physical examination, the patient was sleepy and had a decreased attention span. He moved all his extremities, though the right arm moved less than the left. There was slight blurring of the left optic disk, suggesting possible increased intracranial pressure. The remainder of his physical examination was normal.
    Laboratory Findings & Imaging

    Laboratory tests were all normal, including hemoglobin and hematocrit, white blood cell count and differential, serum electrolytes, blood urea nitrogen, serum creatinine, urinalysis, chest x-ray, and ECG. Lumbar puncture was not done and cerebrospinal fluid was not examined because of possible increased intracranial pressure due to a mass lesion. Blood cultures were negative. CT scan of the patient's head showed a 1.5-cm localized ring-enhancing lesion in the left parietal hemisphere suggestive of brain abscess.
    Treatment

    The patient had a neurosurgical procedure with biopsy of the lesion, which was completely removed. Culture of necrotic material from the lesion yielded Prevotella melaninogenica and Streptococcus anginosus. Pathologic examination of the tissue suggested that the lesion was several weeks old. The patient received antibiotic therapy for 4 weeks. He had no more seizures and no subsequent neurologic deficits. One year later, anticonvulsant medications were discontinued and a follow-up CT scan was negative.


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    Default Chest

    Case 3: [HIDE]Bacterial Pneumonia[/HIDE]


    A 35-year-old man came to the emergency room because of fever and pain in his left chest when he coughed. Five days earlier he had developed signs of a viral upper respiratory infection with sore throat, runny nose, and increased cough. The day before presentation he developed left lateral chest pain when he coughed or took a deep breath. Twelve hours before coming to the emergency room he was awakened with a severe shaking chill and sweating. Further history taking disclosed that the patient drank moderate to heavy amounts of alcohol and had smoked one package of cigarettes daily for about 17 years. He worked as an automobile repair man. He had a history of two prior hospitalizations—4 years ago for alcohol withdrawal and 2 years ago for acute bronchitis.
    Clinical Features

    Temperature was 39 °C, pulse 130/min and respirations 28/min. Blood pressure was 120/80 mm Hg.

    Physical examination showed a slightly overweight man who was coughing frequently and holding his left chest when he coughed. He produced very little thick rusty-colored sputum. His chest examination showed normal movement of the diaphragm. There was dullness to percussion of the left lateral posterior chest, suggesting consolidation of the lung. Tubular (bronchial) breath sounds were heard in the same area along with dry crepitant sounds (rales), consistent with lung consolidation and viscous mucus in the airway. The remainder of his physical examination was normal.
    Laboratory Findings & Imaging

    Chest films showed a dense left lower lobe consolidation consistent with bacterial pneumonia. The hematocrit was 45% (normal). The white blood cell count was 16,000/L (markedly elevated) with 80% PMN forms with an absolute PMN count of 12,800/L (markedly elevated), 12% lymphocytes, and 8% monocytes. Blood chemistry tests, including electrolytes, were normal. Sputum was thick, yellow to rusty-colored, and purulent in appearance. Gram stain of the sputum showed many PMN cells and lancet-shaped gram-positive diplococci. Twenty-four hours later, the blood cultures were positive for Streptococcus pneumoniae. Cultures of sputum grew numerous S pneumoniae and a few colonies of H influenzae.
    Treatment

    The initial diagnosis was bacterial pneumonia, probably pneumococcal. Parenteral aqueous penicillin G therapy was begun, and the patient was given parenteral fluids. Within 48 hours, his temperature was normal and he was coughing up large amounts of purulent sputum. Penicillin G was continued for 7 days. At follow-up 4 weeks after admission to the hospital, the lung consolidation had cleared.

    Case 4: [HIDE]Viral Pneumonia[/HIDE]


    A 31-year-old man presented with complaints of skin rash, cough, and shortness of breath. Four days previously he had begun to feel sick and developed a fever of 38 °C. The next day he developed a skin rash that initially appeared as "bumps" but soon became vesicular. Several more crops of intensely pruritic skin lesions have subsequently appeared. Two hours before admission, the patient first experienced right-sided chest pain when he took a deep breath or coughed.

    Two weeks before admission, the patient's 8-year-old daughter had developed chickenpox and he had helped take care of her. The patient did not know if he had had chickenpox as a child.
    Clinical Features

    The temperature was 39 °C, pulse 110/min, and respirations 30/min. Blood pressure was 115/70 mm Hg. The patient appeared to be acutely uncomfortable. He had a skin rash consisting of multiple crops or stages of lesions ranging from red maculopapules to vesicles that were broken and crusted over. His fingers and lips appeared to be slightly blue. Rales were heard bilaterally throughout both lung fields. The remainder of the physical examination was normal.
    Laboratory Findings & Imaging

    Chest films showed diffuse bilateral interstitial pulmonary infiltrates. Arterial blood gases showed a PO2 of 60 mm Hg with 91% hemoglobin saturation. The hematocrit, white blood cell count, and serum electrolytes and liver tests were normal.
    Treatment & Hospital Course

    The patient was hospitalized and placed on oxygen therapy, which improved his hypoxia. He was given high-dose intravenous acyclovir. Over the next several days, his respiratory status improved, and on day 6 oxygen therapy was discontinued. The acyclovir was changed to oral therapy on day 3 and continued for a total of 10 days. The patient was discharged to home care on day 7.


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    Default Heart

    Case 5: [HIDE]Endocarditis[/HIDE]


    A 45-year-old woman was admitted to the hospital because of fever, shortness of breath, and weight loss. Chills, sweats, and anorexia started 6 weeks before admission and increased in severity until admission. Persistent back pain developed 4 weeks prior to admission. Her shortness of breath on exertion increased to one block from her usual three blocks of walking. At the time of admission, she reported a 5-kg weight loss.

    Rheumatic fever had been diagnosed in childhood, when she had swollen joints and fever and was confined to bed for 3 months. Subsequently, a heart murmur was heard.
    Clinical Features

    Temperature was 38 °C, pulse 90/min, and respirations 18/min. Blood pressure was 130/80 mm Hg.

    Physical examination showed a moderately overweight woman who was alert and oriented. She became short of breath while walking up two flights of stairs. Examination of her eyes showed a Roth spot (a round white spot surrounded by hemorrhage) in the retina of her right eye. Petechiae were seen in the conjunctiva of both eyes. Her head and neck were otherwise normal. Splinter hemorrhages were seen under two fingernails of her right hand and one finger of the left hand. Osler's nodes (tender, small, raised, red or purple lesions of the skin) were seen in the pads of one finger and one toe. Her heart size was normal to percussion. On auscultation, a low-pitched diastolic murmur consistent with mitral valve stenosis was heard at the apex; a loud mitral valve opening snap was heard over the left chest. Examination of her abdomen was difficult because of obesity; one observer felt an enlarged spleen. The remainder of her physical examination was normal.
    Laboratory Findings & Imaging

    The films from a chest x-ray showed a normal heart size and normal lungs. The ECG showed a normal sinus rhythm with broad P waves (atrial conduction). Echocardiography showed an enlarged left atrium, thickened mitral valve leaflets, and a vegetation on the posterior leaflet. The hematocrit was 29% (low). The white blood cell count was 9800/L (high normal), with 68% PMNs (high), 24% lymphocytes, and 8% monocytes. The erythrocyte sedimentation rate was 68 mm/h (high). Blood chemistry tests, including electrolytes and tests of renal function, were normal. Three blood cultures were obtained on the day of admission; 1 day later, all three were positive for gram-positive cocci in chains that were viridans streptococci and subsequently identified as Streptococcus sanguis.
    Treatment

    Endocarditis of the mitral valve was diagnosed. Intravenous penicillin G and gentamicin were begun and continued for 2 weeks. The patient was afebrile within 3 days after starting therapy. Following the successful treatment of her endocarditis, she was referred for long-term management of her heart disease.

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    Default Abdoman

    Case 6: [HIDE]Peritonitis & Abscesses[/HIDE]


    An 18-year-old male student was admitted to the hospital because of fever and abdominal pain. He had been well until 3 days prior to admission, when he developed diffuse abdominal pain and vomiting following the evening meal. The pain persisted through the night and was worse the following morning. He was seen in the emergency room, where abdominal tenderness was noted; x-rays of the chest and abdomen were normal; the white blood cell count was 24,000/L; and other laboratory tests, including tests of liver, pancreas, and renal function, were normal. The patient returned home, but the abdominal pain and intermittent vomiting persisted and fever to 38 °C developed. The patient was admitted to the hospital on the third day of illness.

    There was no history of use of medication, drug or alcohol abuse, trauma, or infections, and the family history was negative.
    Clinical Features

    Th
    e temperature was 38 °C, the pulse 100/min, respirations 24/min. The blood pressure was 110/70 mm Hg.

    Physical examination showed a normally developed young man who appeared acutely ill and complained of diffuse abdominal pain. The chest and heart examinations were normal. The abdomen was slightly distended. There was diffuse periumbilical and right lower quadrant tenderness to palpation with guarding (muscle rigidity with palpation). There was a suggestion of a right lower quadrant mass. Bowel sounds were infrequent.
    Laboratory Findings & Imaging

    The hematocrit was 45% (normal), and the white blood cell count was 20,000/L (markedly elevated) with 90% polymorphonuclear cells (markedly elevated) and 12% lymphocytes. The serum amylase (a test for pancreatitis) was normal. Electrolytes and tests of liver and renal function were normal. X-ray films of the chest and abdomen were normal, though several distended loops of small bowel were seen. CT scan of the abdomen showed a fluid collection in the right lower quadrant with extension into the pelvis.
    Treatment

    The patient was taken to the operating room. At surgery, a perforated appendix with a large periappendiceal abscess extending into the pelvis was found. The appendix was removed, about 300 mL of foul-smelling abscess fluid was evacuated, and drains were placed. The patient was treated with gentamicin, ampicillin, and metronidazole for 2 weeks. The drains were advanced daily and totally removed 1 week after surgery. Culture of the abscess fluid revealed at least six species of bacteria, including Escherichia coli, Bacteroides fragilis, viridans streptococci, and enterococci (normal gastrointestinal flora). The patient recovered uneventfully.


    Case 7: [HIDE]Gastroenteritis[/HIDE]


    Four members of a migrant farm worker family came to the hospital because of diarrhea and fever starting 6–12 hours earlier. The father was 28, the mother 24, and the children 6 and 4 years of age. The previous day, the family had a meal of mixed green salad, ground meat, beans, and tortillas prepared by another person in the encampment. Another child in the family, 8 months old, had not eaten the same meal and remained well. Approximately 24 hours after the meal, the children developed abdominal cramps, fever, and watery diarrhea. These symptoms had persisted for the preceding 12 hours, and in both children the diarrhea had become bloody. The parents had developed similar symptoms 6 and 8 hours earlier but did not have blood visible in their stools.

    The parents stated that several other people in the camp had similar illnesses during the previous 2 weeks. The sanitation facilities in the camp were primitive.
    Clinical Features

    On physical examination, the children had temperatures of 39–39.5 °C and the parents 38 °C. All had tachycardia and appeared acutely ill. Both children appeared dehydrated.

    White blood cell counts ranged from 12,000 to 16,000/L, with 55–76% polymorphonuclear cells. Multiple white blood cells were seen in the fecal wet mounts. Stools from the children were grossly bloody and mucoid. Cultures of the stools from each of the patients subsequently grew Shigella flexneri.
    Treatment

    Both children were admitted to the hospital and given intravenous fluids and ampicillin. The parents were treated as outpatients, with oral fluids and oral ciprofloxacin. All recovered uneventfully. Public health follow-up led to improved sanitation conditions at the camp.

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    Default Urinary Tract

    Case 8: [HIDE]Acute Uncomplicated Bladder Infection[/HIDE]


    A 21-year-old woman presented to the university student health service with a 2-day history of increasing urinary frequency along with urgency and dysuria. Her urine had been pink or bloody for about 12 hours. She had no history of prior urinary tract infection. The patient had recently become sexually active and was using a diaphragm and spermicide.
    Clinical Features

    The temperature was 37.5 °C, pulse 105/min, and respirations 18/min. The blood pressure was 105/70 mm Hg.

    On physical examination, the only abnormal finding was mild tenderness to deep palpation in the suprapubic area.
    Laboratory Findings

    Laboratory tests showed a slightly elevated white blood cell count of 13,000/L; 66% were PMNs, also elevated. Blood urea nitrogen, serum creatinine and glucose, and serum electrolytes were normal. The urine sediment contained innumerable white cells, moderate numbers of red cells, and many bacteria suggestive of urinary tract infection. Culture yielded more than 105 colony-forming units (CFU)/mL of E coli (diagnostic of a urinary tract infection). Antimicrobial susceptibility tests were not done.
    Treatment

    The patient was cured by 3 days of oral sulfamethoxazole-trimethoprim therapy.

    Case 9: [HIDE]Complicated Urinary Tract Infection[/HIDE]


    A 67-year-old man developed fever and shock 3 days after a transurethral resection of his enlarged prostate gland. Two weeks earlier he had urinary obstruction with retention secondary to the enlargement; benign prostatic hypertrophy had been diagnosed. Urinary bladder catheterization had been necessary. Following the surgery, an indwelling urinary bladder catheter attached to a closed drainage system was left in place. Two days after surgery, the patient developed fever to 38 °C; on the third postoperative day, he became confused and disoriented and had a shaking chill.
    Clinical Features

    The temperature was 39 °C, the pulse was 120/min, and the respirations were 24/min. The blood pressure was 90/40 mm Hg.

    On physical examination, the patient knew his name but was disoriented to time and place. His heart, lungs, and abdomen were normal. There was mild costovertebral tenderness over the area of the left kidney.
    Laboratory Findings

    Laboratory tests showed a normal hematocrit and hemoglobin but an elevated white blood cell count of 18,000/L; 85% were PMNs (markedly elevated). Blood urea nitrogen, serum creatinine, serum glucose, and electrolytes were normal. Urine was obtained from the catheter port using a needle and syringe. The urine sediment contained innumerable white cells, a few red blood cells, and numerous bacteria, indicating a urinary tract infection. Urine culture yielded more than 105 CFU/mL of Klebsiella pneumoniae, confirming the diagnosis of urinary tract infection. Blood culture also yielded the K pneumoniae, which was susceptible to third-generation cephalosporins, gentamicin, and tobramycin.
    Treatment & Hospital Course

    The patient had urinary tract infection associated with the bladder catheter. The left kidney was presumed to be involved based on the left costovertebral angle tenderness. He also had secondary bacteremia with shock (sometimes termed gram-negative sepsis and shock). He was treated with intravenous fluids and antibiotics and recovered. The same strain of K pneumoniae had been isolated from other patients in the hospital, indicating nosocomial spread of the bacteria.

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    Default Bone & Soft Tissue

    Case 10: [HIDE]Osteomyelitis[/HIDE]


    A 34-year-old man suffered an open fracture of the middle third of his tibia and fibula when his motorized three-wheel vehicle tipped over in a field and fell on him. He was taken to a hospital and promptly to the operating room. The wound was cleaned and debrided, the fracture was reduced, and the bone aligned. Metal plates were placed to span the fracture, align it, and hold it in place. Pins were placed through the skin and bone proximal and distal to the fracture to allow splinting and immobilization of the leg. One day after surgery, the leg remained markedly swollen; a moderate amount of serous drainage was present on the dressings. Two days later, the leg remained swollen and red, requiring opening of the surgical wound. Cultures of pus in the wound grew Staphylococcus aureus resistant to penicillin G but susceptible to nafcillin. The patient was treated with intravenous nafcillin for 10 days, and the swelling and redness decreased. Three weeks later, pus began to drain from a small opening in the wound. Cultures again grew S aureus. Exploration of the opening showed a sinus tract to the site of the fracture. An x-ray film of the leg showed poor alignment of the fracture. Osteomyelitis was diagnosed, and the patient was returned to the operating room, where the fracture site was debrided of necrotic soft tissue and dead bone; the pins and plates were removed. Bone grafts were placed. The fracture was immobilized by external fixation. Cultures obtained during surgery grew S aureus. The patient was treated with intravenous nafcillin for 1 month followed by oral dicloxacillin for 3 additional months. The wound and fracture slowly healed. After 6 months, there was no x-ray evidence of further osteomyelitis, and the patient was able to bear weight on the leg.

    Case 11: [HIDE]Gas Gangrene[/HIDE]


    A 22-year-old man fell while riding his new motorcycle and suffered an open fracture of his left femur and severe lacerations and crushing injury to the thigh and less extensive soft tissue injuries to other parts of his body. He was rapidly transported to the hospital and immediately taken to the operating room, where the fracture was reduced and the wounds debrided. At admission, results of his blood tests included a hematocrit of 45% and a hemoglobin of 15 g/dL. The immediate postoperative course was uneventful, but 24 hours later pain developed in the thigh. Fever was noted. Pain and swelling of the thigh increased rapidly.
    Clinical Features & Course

    The temperature was 40 °C, the pulse 150/min, and respirations 28/min. The blood pressure was 80/40 mm Hg.

    Physical examination showed an acutely ill young man who was in shock and delirious. The left thigh was markedly swollen and cool to touch. Large ecchymotic areas were present near the wound, and there was a serous discharge from the wound. Crepitus was felt, indicative of gas in the tissue of the thigh. An x-ray film also showed gas in the tissue planes of the thigh. Gas gangrene was diagnosed, and the patient was taken to the operating room for emergency extensive debridement of necrotic tissue. At the time of surgery, his hematocrit had fallen to 27% and his hemoglobin to 11 g/dL; his serum was red-brown in color, indicating hemolysis with free hemoglobin in his circulation. Anaerobic cultures of the specimen obtained at surgery grew Clostridium perfringens. The patient developed renal failure and heart failure, and died 3 days after his injury.

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    Default Sexually Transmitted Diseases

    Case 12: [HIDE]Urethritis, Endocervicitis, & Pelvic Inflammatory Disease[/HIDE]


    A 19-year-old woman came to the clinic because of lower abdominal pain of 2 days' duration and a yellowish vaginal discharge first seen 4 days previously on the day following the last day of her menstrual period. The patient had had intercourse with two partners in the previous month, including a new partner 10 days before presentation.
    Clinical Features

    Her temperature was 37.5 °C; other vital signs were normal. Physical examination showed a yellowish mucopurulent discharge from the cervical os. Moderate left lower abdominal tenderness was present. The bimanual pelvic examination showed cervical motion tenderness and adnexal tenderness more severe on the left than on the right.
    Laboratory Findings

    Culture of the endocervix for Neisseria gonorrhoeae was negative. Culture for Chlamydia trachomatis was positive.
    Treatment

    A diagnosis of pelvic inflammatory disease was made. The patient was treated as an outpatient with a single dose of ceftriaxone plus doxycycline for 2 weeks. Both of her partners came to the clinic and were treated.

    Case 13: [HIDE]Vaginosis & Vaginitis[/HIDE]


    A 28-year-old woman came to the clinic because of a whitish-gray vaginal discharge with a bad odor, first noted 6 days previously. She had been sexually active with a single partner who was new to her in the past month.
    Clinical Features

    Physical examination showed a thin, homogeneous, whitish-gray discharge that was adherent to the vaginal wall. There was no discharge from the cervical os. The bimanual pelvic examination was normal, as was the remainder of the physical examination.
    Laboratory Findings

    The pH of the vaginal fluid was 5.5 (normal, < 4.5). When KOH was added to vaginal fluid on a slide, an amine-like ("fishy") odor was perceived. A wet mount of the fluid showed many epithelial cells with adherent bacteria (clue cells). No polymorphonuclear cells were seen. The diagnosis was bacterial vaginosis.
    Treatment

    Metronidazole twice daily for 7 days resulted in rapid clearing of the disorder. The decision was made not to treat her male partner unless she had a recurrence of vaginosis.


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    1. first case.. bacterial meningitis.. at this age.. MC organism is H influenza

    2. Old man.. dental extraction.. obtundation.. so probably Frontal brain abcess due to streptoccoci, bacteroids., fusobacterium..

    3. Lobar Pneumonia.. Pneumoccocus

    4 Viral Broncho pneumonia due to varicella

    Rest 2 moror..
    "It's psychosomatic. You need a lobotomy. I'll get a saw." - Calvin in Calvin and Hobbes


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    Case 5. Strep., viridans endocarditis

    Is is really some kind of Test.. I dont think so.. they seem to hav all the facts on u need..
    "It's psychosomatic. You need a lobotomy. I'll get a saw." - Calvin in Calvin and Hobbes


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    Wow these cases are great thanks.

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