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Micro Cases 2007

Micro Cases 2007

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USTNotesGroup2009
Micro Case 1-10 arrange by A. AbadCase 1-8 from Sec C, Case 9 from Sec A, Case 10 by Sec C/A1
 Microbiology Case 1
A 14 year old male sought consult at the Out Patient Departmentbecause of high fever and sore throat of 4 days duration.Accompanying symptoms were headache, chills and nasal discharge,which was initially watery becoming mucopurulent. He is fond ofblowing his nose one nostril at a time. Two days after, he complainedof pain on his right ear.PE showed an awake, alert, irritable patient. VS: T = 39
°
C,RR=20/min CR=100/min, pink palpebral conjunctivae, non ictericsclerae, throat congested, exudates on tonsillar areas.Otoscopy showed congested ear drum on the right ear. There wastenderness on the area of the frontal and maxillary sinuses. Othersystems were unremarkable.
1. Diagnosis
Viral
PatientBacterial
Anteriorstoma-titisConjunct-ivitisCoryzaCoughHoarsenessFatigue /malaiseDiarrheaAbsence ofFeverFeverSore ThroatChillsNasal DischargeExudates ontonsillar areasPain on R earCongested eardrum on R earTenderness onfrontal andmaxillary sinusesFeverPharyngealerythemaand swellingTonsillarexudatesComplication:Otitis MediaPalatalpetechiaeNo rhinorrheaNo coughNo conjunct-tivitis
2. Common Etiologic Agents
Streptococcus pyogenes*
Neisseria gonorrhea
Neisseria meningitidis
Moraxella catarrhalis
Epstein-Barr virus
Streptococcus pyogenes
Gram (+) cocci
Groups A streptococcus
Contains the groups A antigen
Beta hemolytic
Associated with local or systemic invasion and poststreptococcaldisorders
PYR positive
Streptococcus pyogenes
Epidemiology
Members of the normal flora of the human body
Produce disease only when they occur in parts where they arenot normally foundPathogenesis of
S. pyogenes
Pyogenic inflammation
Locally at the site of the organism in the tissue
Exotoxin production
Widespread systemic symptoms
Immunologic
When antibody against a component of the organism cross-reacts with normal tissue or forms immune complexes thatdamage normal tissueDiseases caused by
S. pyogenes
Pyogenic diseases
o
Pharyngitis
o
Cellulitis and erysipelas
o
Impetigo
Toxigenic diseases
o
Scarlet fever
o
Toxic shock syndrome
Immunologic diseases
o
Rheumatic fever
o
Acute glomerulonephritis
Neisseria gonorrhea
Gram-negative diplococci
Nonmotile and nonsporforming
Oxidase-positive
Humans are the only hosts
Sites: urethra, anal canal, conjunctivas, pharynx and endocervix
Neisseria gonorrhea
Epidemiology
Worldwide
Transmitted by sexual contact often by women and men withasymptomatic infection
Gonococcal pharyngitis results usually from orogenital contact
Neisseria gonorrhea
Risk factors: sexual behavior, illness behavior and accessibility to healthcare
20% of homosexual men or heterosexual women who engage in fellatiowith men who have urethral infectionIncidence in:
Heterosexual men: 0.2-1.4%
Homosexual men: 5-25%
Women: 5-18%Pathogenesis of
N. gonorrhea
Attack mucous membranes of the genitourinary tract, eye, rectum andthroat
o
Producing acute suppuration that might lead to tissue invasion
Followed by chronic inflammation and fibrosis
o
In males – urethritis with yellow creamy pus and painfulurination or may be asymptomatic
o
In females – primary infection in the endocervix, urethra andvagina; mucupurulent discharge
Neisseria meningitidis
Pathogenesis
Humans are the only hosts
Nasopharynx is the portal of entry
Organisms may form part of the transient flora without producingsymptoms or may produce an exudative pharyngitis
Moraxella catarrhalis
Previously
Branhamella catarrhalis
Morphologically and biochemically resembles
Neisseria
Aerobic coccobacilli and oxidase positive
Fails to utilize carbohydrates in CTA reactions
DNase positive and produces beta-lactamases
Normal member of the flora of the respiratory tract, particularlynasopharynx, and do not produce disease
Causes bronchitis, pneumonia, pharyngitis, sinusitis, otitis media andconjunctivitis
Infect immunocompromised individuals
Epstein Barr Virus
Human herpesvirus 4
Gammaherpesvirinae
Ubiquitous
Has 2 types: EBV-1 & EBV-2
Targets B lymphocyteEpidemiology
Common in all parts of the world
Transmitted by contact with oropharnyngeal secretions
90% of adults are seropositive
In developing countries, 90% of children are infected at age 6
Industrialized nations, more than 50% are delayed until late adolescenceand young adulthood
100,000 cases of infectious mononucleosis annually in US
Inapparent infections result to permanent immunity to infectiousmononucleosis
Immunocompromised people at highest risk for neoplastic diseasePathogenesis of EBVPrimary Infection
Transmitted by infected saliva
Initiates infection through oropharynx
Viral replication through epithelial cells of the salivary glands andpharynx
Children - Subclinical
Young adults -Acute infectious mononucleosisReactivation from Latency
Increased levels of virus in saliva
Increased levels of virus in DNA blood cells
Clinically silent
Can be activated by immunosuppressionTumors of EBV
Burkitt’s lymphoma
Nasopharyngeal carcinoma
o
Elevated levels of virus-specific antigens
o
Contains EBV DNA
o
Express limited number of viral genes
Hodgkin’s disease
1
 
B-cell lymphoma
o
Immunodeficient patients
3.Laboratory ProceduresGram stain
Gram-positive cocci often singly or in pairs rather than definitechains.
May appear Gram-negative if bacteria are no longer viable.
Rarely contributory to diagnosis since group A streptococcicannot be differentiated from viridans streptococci which arenormally present in the throat.
Throat culture
Most confirmatory diagnostic test for streptococcal pharyngitis
Culture technique
o
Inoculum from throat swab
o
5% blood agar
o
Bacitracin disk (0.04 units)
o
Incubated overnight at 35-37
o
C
Results:
o
Beta-hemolysis around colonies
o
Inhibited by bacitracin
Additional test: PYR test
o
Detects presence of the enzyme L-pyrroglutamyl-aminopeptidase.
Antigen Detection Tests
For rapid detection of group A streptococcal antigen from throatswabs
EIA or agglutination to demonstrate presence of antigen
60-90% sensitive and 98-99% specific compared to culturemethods
4.Possible Complications
Suppurative Complications:
o
Acute otitis media
o
Sinusitis
o
Cervical lymphadenitis
o
Peritonsillar or retropharyngeal abscess
o
Bacteremia
o
Necrotizing fasciitis
o
Mastoiditis
o
Meningitis
Nonsuppurative Complications:
o
Rheumatic fever
o
Post-streptococcal glomerulonephritis
5.Management
Antibiotics
o
risk for Rheumatic fever
o
spread of infection esp. (overcrowding and closecontact)
o
symptomatic manifestation
o
Oral penicillin - 50mg/kg/day PO bid for 10 days
o
Amoxicillin - 45mg/kg/day PO bid or tid for 10 days
o
Benzathine penicillin - 25,000 units/kg IM OD (forthose at risk for RF)
o
Cephalexin - 50mg/kg/day PO qid for 10 days
o
Amoxicillin (90mg/kg/day) & Clavulanate(6.4mg/kg/day) PO bid for 10 days
Eat fruits and drink plenty of water or fluids
Oral hygiene
o
saline sol’n or antiseptic mouth wash
REST
MICROBIOLOGY – CASE 2 by C5Salient Features
45 years-old, M
Diabetic
1. What would be the probable diagnosis on the first time of consultation?
Symptoms
 – 
Fevers and chills of 1 week duration
 – 
Headache and body malaise
 – 
Cough with blood-tinged sputum
Diagnostic Examination: Chest X-ray
 – 
Patches of infiltrates
Treatment
 – 
Amoxicillin 500mg, 3x a day for 1 weekFever and Hemoptysis
DiseaseAccompanyingSymptomsRadiologicFindingsChronicBronchitis
Mucopurulent sputum,chronicExertional dyspneaObvious bullae,paucity ofparenchymalmarkings,
Pneumonia
Fevers and chillsPleuritic chest painShrotness of breathInfiltrates(localizedopacification)
DiseaseAccompanyingSymptomsRadiologicFindingsLung Abscess
Putrid smell of sputumWeight lossMalaise, night sweats,feverClubbing of fingers if >3weeksPresence of cavitywith air-fluid level
Bronchiectasis
Copious mucusproductionDyspnea and wheezingNormal in milddiseaseProminent cysticspaces
PulmonaryEmbolism
DyspneaPleuritic chest painLow grade feverSyncope and cyanosis (ifmassive)Normal to near-normalWeatermark’s sign(focal oligemia)Hampton’s hump(peripheral wedge-shaped densityabove thediaphragm)Palla’s sign(enlarged rightAmoxicillin – penicillinase sensitiveSusceptible Organisms:Common streptococci, menigococci, gram-positive bacilli, spirochetesEnterococci,
Listeria monocytogenes
,
Escherichia coli
,
Proteus mirabilis
,
Haemophilus influenzae
,
Moraxella catarrhalis
Probable Diagnosis:Bacterial Pneumonia
2. What other laboratory exams would you request at this time to supportyour diagnosis?
Additional tests that may be done include a
complete blood count
,
gramstain
and
culture
ofsputum, blood, pleural fluid
Organism thatcause pneumoniaLaboratory Exams
S. pneumoniaeH. influenzaeS. aureusK. pneumoniaeE. coliP. aeruginosaM. catarrhalis
Gram stain and culture ofsputum, blood, pleuralfluid
Legionella sp.M. pneumoniae
PCR and culture of sputum
C. pneumoniae
Microimmunofluorescencewith TWAR antigen andPCR
Pneumocystis jiroveci
Methenamine silver,Giemsa, or DFA stains ofsputum or bronchoalveolarlavage fluid
Laboratory Tests:
Sputum test
Blood test
Urine test
Polymerase chain reaction (PCR)
Imaging Techniques:
X-Rays
Computed tomography (CT) scans
Magnetic resonance imaging (MRI) scans
Invasive Diagnostic Procedures:
Thoracentesis
Lung Biopsy
Lung Tap
4. What is your diagnosis during the second consultation?
Salient features
Low grade fever in the afternoon
Easy fatigability
Anorexia
2
 
weight loss
Occasional chest pain
Poorly developed, poorly nourished, aesthenic
BP: 130/80 (prehypertensive)
PR: 80/min (N)
RR: 28
Temp: 37.9 C
BMI:
Decreased breath sounds on L LLF
Moist rales on L ULF
Mycoplasma pneumoniaeKlebsiella pneumoniaeHaemophilusinfluenzae
-Initial non-prodcough-Bloody sputum-Chest pain-Most common(interstitial &peribronchialpneumonitis,necrotizingbronchiolitis)-Hemorrhagicnecrotizingconsolidation-UTI-Bacteremia w/focal lesions indebilitated pxs-children-meningitis-Involves sinuses andmiddle ear-in adults, bronchitisor pneumonia
Chlamidia pneumoniaeStreptococcus pneumoniaeMycobacteriumtuberculosis
- Pharyngitis iscommon- Sinusitis and otitismedia may occur w/lower airwaydisease-sudden onset-Fever-Chills-Sharp pleural pain- Bloody sputum- Initially high fever-Anorexia-Fatigue-Weakness-Weight loss-Fever-General malaise-Pleuritic chest pain-Low grade,intermittent feverRales (Crackles)
RALES
Abnormality of
lungs
(in pneumonia, fibrosis, earlycongestive heart failure) or
airways
(bronchitis orbronchiectasis)
DiscontinuousBREATH SOUNDS
Pneumothorax
Liquefactive necrosis and cavity formation
5. Give the risk factors involved in this case.
Risk Factors for Bacterial Pneumonia Infection
Extremes of age
Chronic disease e.g. CHF, COPD, DM
Congenital immune deficiencies
Acquired immune deficiencies
Impaired splenic functionRisk Factors for TB
Elderly
Poor
DM
Hodgkin’s Lymphoma
Chronic lung disease esp. silicosis
CRF
Malnutrition
Alcoholism
Immunosuppression
6. What are the laboratory exams will you request at this time?
AFB microscopy
Presumptive dx
Kinyoun(cold) or Ziehl-Neelsen(hot) technique
Collect sputum by “deep cough method” early in themorning for three consecutive days
(+) red AFB bacilliCulture
Use Lowenstein-Jensen or Middlebrook 7H10 (eggor agar based medium)
Incubate at 37°C under 5% carbon dioxide for 4-8 weeks
Presumptively identified on basis of growth time, colonypigmentation and morphology
Identification by other biochemical tests
liquid media for isolation and speciation by nucleic acidprobes or high-pressure liquid chromatography of mycolicacids (2-3 weeks)Radiographic Procedures
In initial suspicion in high risk patients
“classic” upper lobe infiltrates with cavitation
For AIDS patients, no radiographic pattern can beconsidered pathognomonicPPD Skin testing
Mantoux test
Diameter of induration is measured 48 hrs after injection
Interpretation depends on host statusNucleic Acid Amplification
To permit diagnosis in as little as several hours
High cost
Low sensitivityAFB smear <NA amplification <cultureDrug Susceptibility
Suspectibility to isoniazid, rifampicin and ethambutol
Directly- with clinical specimen
Indirectly-with mycobacterial cultures
Liquid or solid media
Results are obtained most rapidly by direct susceptibility on liquidmedium ( 3weeks)
Indirect on solid ( 8 weeks or more)Cytokine Release Assays
QuantiFERON-TB test- commercially available whole-blood cytokineassay
Night incubation of peripheral bood smear with PPD and controlantigens followed by measurement if IFN-gamma released bysensitized lymphocytes in an ELISA
Recommended for screening for latent TB infection in populationsat low to moderate risk
7. How will you manage your patient?
Should patient be hospitalized?Other factors to consider:
Availability of home support
Probability of compliance
Availability of alternative settings forsupervised care.
Preferred antimicrobials for most patients (in no special order):
Macrolide: erythromycin, clarithromycin, or azithromycin
Fluoroquinolone: levofloxacin, sparfloxacin, grepafloxacin,trovafloxacin, or another fluoroquinolonewith enhanced activity against
S. pneumoniae.
Doxycycline
Further Care:
Adequate follow-up evaluations.
3

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