MICROBIOLOGY CASE 5-4 Courtney Lower

Jack and Diane R., a 25-year old newlywed couple, reported to the emergency room with
abdominal pain and diarrhea of 4 days duration. They state that they initially thought they
picked up a summer stomach flu because they recently returned from a 5-day camping trip.
Jack added, We were really roughin it, Doc. It was great until the weather got miserable, rainy,
and cold the last two days of the trip!

The symptoms began shortly after their return and included fever, headache, myalgia, and
malaise. The diarrhea started the next day and was mild at first with 2 to 3 loose bowel
movements per day. The diarrhea became more seer and was up to 7 to 9 watery bowel
movements per day with sever cramping. The physician asked many questions about the trip to
collect a complete history. The couple denied drinking any water from the lake near their
campsite, although after further question, they admitted to skinny-dipping in the lake one
evening before the weather got bad. Diane mentioned that although this trip was Jacks idea
of roughin it, they were careful to use only bottled water for drinking. She went on to explain
that they bathed and used the sanitary facilities provided at the campsite and used only potable
water from that facility for washing dishes and cooking. They described the food they had eaten
during their trip, including hamburgers, hot dogs, chicken, roasted corn, canned beans,
macaroni salad, and cole slaw (cabbage salad). They transported the meat frozen and were
careful to keep all the food on ice as much as possible. Diane mentioned that she thought the
chicken they ate for lunch their last day may have been undercooked, but she did not want to
make Jack go back out in the rain to cook it longer.

Physical examinations of both Jack and Diane were unremarkable except for slight dehydration
and elevated temperature (Jack 100.9F, Diane 100.2F). Both patients had slight diffuse
abdominal tenderness upon palpitation. Stool specimens were collected from both patients and
processed for ova and parasite examination. Routine stool culture for bacterial pathogens was
also ordered.

Parasitology report: No ova or parasites seen.

Observation of the bacteriology plates showed many lactose-positive organisms on the gram-
negative selective agar. Specialized selective media had only rare colonies of lactose-positive
organisms in the area of the primary inoculum. The CAMPY agar plate showed moderate
growth.

QUESTIONS:

1. Why might the physician suspect that parasites could be a possibility in these patients?

The symptoms given, such as: diarrhea, fever, headache, and malaise in combination
with their recent camping trip may cause the physician to suspect they picked up a
possible parasite on their trip.

2.What parasites might the physician have suspected?

The parasites commonly seen in the United States that the physician may have
suspected include: Giardia lamblia, Enterobius vermicularis, Ancylostoma duodenale,
Necator americanus, and Entamoeba histolytica.

3. How should a stool culture for routine bacterial pathogens be processed? Be sure to include
appropriate media and atmosphere of incubation?

Stool that is going to be tested for routine bacterial pathogens should be received in the
lab promptly to be processed as soon as possible. Media used includes: MacConkey
(Lactose non-fermenters), HE agar, XLD agar, and Campy-Blood agar (if Campylobacter
is suspected). For a routine bacterial stool culture, you would set up a BAP, MAC, HE (or
XLD), and Campy-Blood agar. BAP, MAC, HE, and XLD should be incubated at 35
degrees Celsius in ambient air for 48 hours (can be read first at 24 hours). Campy-Blood
agar should be incubated at 42 degrees Celsius in a microaerophilic incubator for 48-72
hours (can be read first at 24-48 hours).

4. What bacterial pathogens should be included in the screening of a routine stool culture, and
how would the clinical laboratory scientist processing the culture recognize these potential
pathogens?

Bacterial pathogens included in a routine stool culture include: Salmonella species,
Shigella species, and Campylobacter species. Some less common bacterial species
include: Plesiomonas species, Aeromonas species, E. coli O157:H7, Yersinia species,
and Vibrio species. Salmonella and Shigella will not ferment lactose, producing colorless
or transparent colonies on MAC agar. Salmonella and Shigella will also produce green to
blue-green colonies on HE agar (Salmonella species will have black precipitate as well).
Shigella species will produce colorless or red colonies on XLD and Salmonella will
produce colorless or red colonies with or without black precipitate on XLD.
Campylobacter will produce flat, gray, non-hemolytic colonies on Campy-Blood agar.

5. When a stool specimen is bloody, additional testing is often recommended or suggested to
the physician (especially with children or the elderly). What pathogen is of concern in that
situation, and how is this specimen processed?

Clostridium difficile is another organism that could be tested for if the stool sample is
bloody. In order to process correctly, it is important to ensure that the stool sample is
not solid; if the sample is solid, it has to be rejected and cannot be used for the test.
Various labs have different methods for testing for C. difficile. At Peoria Methodist
hospital, they had a 2-hour rapid test for confirming the presence of C. difficile.

6. Other more unusual bacterial pathogens may also cause diarrheal disease, and physicians
may request additional testing for these organisms. What organisms might be suspected, and
what media and atmosphere of incubation are used to isolate these organisms?

Some less common bacterial species include: Plesiomonas species, Aeromonas species,
E. coli O157:H7, Yersinia species, and Vibrio species. Media used for the less common
bacterial pathogens include: BAP (if Plesiomonas/Aeromonas are suspected), Sorbitol-
MacConkey agar (if E. coli O157:H7 is suspected), CIN agar (if Yersinia is suspected), and
TCBS (if Vibrio is suspected). BAP should be incubated at 35 degrees Celsius in ambient
air for 48 hours (can be read first at 24 hours). Campy-Blood agar should be incubated at
42 degrees Celsius in a microaerophilic incubator for 48-72 hours (can be read first at 24-
48 hours). MacConkey Sorbitol agar should be incubated at 35 degrees Celsius in
ambient air for 48 hours (can be read first at 24 hours). CIN agar should be incubated at
25 degrees Celsius in ambient air for 72 hours (can be read first at 24 hours). E. coli
O157:H7 does not ferment sorbitol and colonies will appear color or colorless. Yersinia
will ferment mannitol and forms clear colonies with a red center on CIN agar.
7. Based on the history and laboratory results presented, what is the most probable cause for
the diarrheal disease in these patients?

Due to the Campy-Blood agar plate showing moderate growth, the most probable cause
for the diarrheal disease in these patients would be Campylobacter species. Further
testing would need to be completed in order to confirm the species. Campylobacter
jejuni is the most commonly Campylobacter species seen to cause foodborne diarrheal
disease in the United States.