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MICROBIOLOGY: CASE 3

Ballesteros, Princess M.

Castillo, Rafela Theriz C.

Dy, Nyssa Phoebe M.

Isabelo, John Daniel S.

Marquez, Mary Veronica B.

January July 2017

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Table of Contents

Title Page . 1

Table of Contents .... 2

Introduction . 3

Discussion ... 5

Conclusion .. 6

Answers to questions .. 7

Bibliography.11
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Introduction

The case involves a 16 year old schoolboy named Peter Parker who is admitted to the hospital

with a two-day history of lethargy, headache and episodes of fever and confusion. He has been

physically healthy up until now. He plays basketball regularly and has no recent travel history.

He denies any recent head trauma.

On examination, he is lying under the sheets to protect his eyes from the light. His temperature is

39C. He has marked neck stiffness. He is oriented to person and place but cant remember what

day of the week or what he has been doing over the past few days. He has no other focal

neurological signs.

He has some small, generalized lymphadenopathy. He has normal ENT and respiratory tract

examinations. On his left arm and shins, which his mother has put down to his playing

basketball, has some small, non-blanching petechiae. The rest of his examination is

unremarkable. He was given a dose of antibiotics before he went down to the CT scanner.

Blood results:

Results Reference Values

Hemoglobin 13.5 g/dL 13.5-18 g/dl

WBC count 15.4x109/L 4.5-11.5x109/L

Neutrophils 90% 56%

Platelets 238 x109/L 150-450x109/L

Blood Glucose 4.6mmol/L 2.8-4.4mmol/L

C-reactive protein 144mg/L 0.47-1.34mg/L

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Imaging

A CT scan of his brain was reported as normal.

Blood culture:

Blood cultures were taken after his first dose of antibiotics was given and did not grow anything.

Lumbar Puncture result:

CSF Result Result Reference value

Protein 0.9g/L <0.4g/L

Glucose 1.9mmol/L 60% of blood glucose

WBC count 222 3(in adults)

Neutrophils 75% 25%

Lymphocytes 25% 6234%

RBC count 128 0

Gram stain:

Gram stain of the CSF showed gram-negative intracellular diplococci

CSF culture:

No growth after five days of incubation.

AFB stain:

Negative
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Discussion

From the given information, we can infer that the patient would most likely have an acute

bacterial meningitis caused by Neisseria meningitidis.

The classical signs of meningitis include severe headache, fever, neurologic abnormalities,

change in mental status, stiff neck photophobia, nausea and vomiting, delirium and rigid spine.

These signs are exhibited by some, but not all, infected individuals. (Tille, 2014; WHO, 2015)

Our first evidence that supports our inference would be the symptoms that the patient

manifested: two-day history of lethargy, headache, and episodes of fever, marked neck

stiffness,protection of eyes from light and confusion. The release of endotoxin is associated with

the formation of a petechial rash, tiny hemorrhages into the skin, lower extremities, joints, lungs,

and adrenal glands. (Delost, 1997; Tortora & Funke, 2001). These signs were also exhibited by

the patient showing some small, non-blanching petechiae on his left arm and shins.

According to the blood examination results, the patient exhibited: increased neutrophil

and C-reactive protein; decreased blood glucose levels; and normal hemoglobin, WBC count and

platelet count. This coincides with the findings of bacterial meningitis according to Keohane,

Smith and Walenga (2016) that an increase in neutrophils would indicate bacterial infection and

Burtis, Bruns, Sawyer and Tietz (2015) that a marked decrease in glucose would signify greater

bacterial utilization and an increase in CRP would indicate detection of inflammatory diseases.

The blood culture results which showed no growth can be elucidated by Rodriguez (2014) that

N. meningitidis is sensitive to sodiumpolyanethol suflate culture broths thus explains inability of

this microorganism to grow in the culture media.

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The CSF results showing a decrease in glucose levels; increased protein, WBC count,

neutrophils, lymphocytes and RBC count. This matches with the information from Strasinger and

Schaub (2015) that bacterial meningitis shows elevated WBC count, neutrophils present, marked

protein elevation, markedly decreased glucose level, lactate level >35 mg/dL, positive gram stain

and bacterial antigen tests. The gram stain of the patients CSF showed gram negative

intracellular diplococci that did not exhibit acid fastness matching the microscopic picture of N.

meningitidis. (Cowan, 2012).

Conclusion

Peters case is a case of meningitis wherein there has been an infection within the

subarachnoidal space causing various pathologic changes throughout his body. This was most

probably caused by N. meningitidis from the environment that has entered the body, traveled the

bloodstream and into the brain. Peter once infected with this organism experiences episodes of

fever, headache, confusion, lethargy, neck stiffness, and petechiae at the same time would

display laboratory results coinciding with this disease. Immediate response and care must be

done to prevent further complication. The disease can be prevented by a conjugated vaccine,

rifampin, and tetracycline. The treatment includes Cephalosporin and Penicillin G.

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Answers to Questions

1. Differentiate bacterial, viral, tubercular, and fungal meningitis

(Strasinger & Schaub, 2014)

In BACTERIAL MENINGITIS, there is an increase WBC count predominantly

neutrophils with marked protein elevation and decreased glucose level.

Culture/ Diagnosis: Gram stain or culture of CSF, blood, rapid antigenic tests.

Prevention: Conjugated vaccine,rifampin, tetracycline

Treatment: Penicillin G, Cefotaxime, Ampicillin, Trimethoprim sulfamethoxazole

Distinctive Features: ( Petechiae & meningococcemia)

In VIRAL MENINGITIS, there is an increase WBC count predominantly lymphocytes

with moderate protein elevation.

Culture/ Diagnosis: Initially, absence of bacteria/ fungi/ protozoa

Treatment: Usually none (unless specific virus identified and specific antiviral exists)

Distinctive Features: Generally milder than bacterial or fungal

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In TUBERCULAR MENINGITIS, elevation of WBC is seen particularly lymphocytes

and monocytes. There is also a moderate to marked protein elevation and a decreased

glucose level.

In FUNGAL MENINGITIS, elevated WBC count is observed. Lymphocytes and

monocytes predominates.

Culture/ Diagnosis: Negative staining, biochemical tests, DNA probes

Treatment: Amphotericin B and fluconazole

Distinctive Features: Acute or chronic, most common in AIDS patients.

(Cowan, 2012)

2. What are the common causes of meningitis related to the age and risk factors?

AGE GROUPS

Neonates: Group B Strep, Escherichia coli, Listeria monocytogenes,

andElizabethkingia meningseptica

This group has the highest infection rate for meningitis due to immature neonatal

immune system, increased permeability of blood brain barrier and the presenc eof

colonizing bacteria in the female vaginal tract that can pass to the infant during childbirth

4 months to 5 years of age- Haemophilus influenzae Type B

This has greatly declined due to incorporation of Hib into the childhood

immunization program

Young adults- Neisseria meningitidis, Listeria monoytognes, Staphylococcus

aureus and various gram negative bacilli

This is the typical agent associated with meningitis and has been identified in

epidemics among young adults in crowded conditions.

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Young children and elderly- Streptococcus pneumoniae

Most common cause in immunocompromised patients

RISK FACTORS

Alcoholism

Splenectomy

Diabetes Mellitus

Prosthetic devices particularly CNS and ventriculoperitoneal shunts

Immunosuppression

(Tille, 2014)

3. What is the most likely organism and explain how is it acquired?

The organism most likely causing Peters disease is most likely Neisseria meningitidis.

Meningitis bacteria are transmitted from one person to another by aerosol droplets from

the respiratory system or throat. This disease is very contagious and the droplets can be

spread through coughing, sneezing, or kissing an infected individual. Drinking after or

sharing utensils with an infected person can cause the spread of meningitis.(WHO, 2015)

Since Peter plays basketball regularly, and is exposed to crowded areas (basketball room

lockers) his risk of getting infected with the organism is high.

4. What would you do to confirm the suspected diagnosis?

Suspicion of bacterial meningitis constitutes a medical emergency, and differential

diagnosis must be done with great haste and accuracy. It is most important to confirm (or

rule out) meningococcal meningitis, because it can be rapidly fatal. Treatment is usually

begun with this bacterium in mind until it can be ruled out. Cerebrospinal fluid, blood, or
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nasopharyngeal samples are stained and observed directly for the typical gram-negative

diplococci.

Cultivation may be necessary to differentiate the bacterium from other species.

Specific rapid tests are also available for detecting the capsular polysaccharide or the

cells directly from specimens without culturing. It is usually necessary to differentiate

this species from normal Neisseria that also live in the human body and can be present in

infectious fluids. Immediately after collection, specimens are streaked on Modified

Thayer-Martin medium (MTM) or chocolate agar and incubated in a high CO2

atmosphere.

Presumptive identification of the genus is obtained by a Gram stain and oxidase testing

on isolated colonies.

Further testing may be necessary to differentiate N. meningitidis and N. gonorrhoeae

from one another, from other oxidase-positive species, and from normal biota of the

oropharynx that can be confused with the pathogens.

If no samples were obtained prior to antibiotic treatment, a PCR test is the best bet for

identifying the pathogen.

(Cowan, 2012)

5. What empiric antimicrobials would you start to treat the infection?

Penicillin G is the most potent of the drugs available for meningococcal infections; it is generally

given in high doses intravenously. Patients may also require treatment for shock and

intravascular clotting. When family members, medical personnel, or children in day care or

school have come in close contact with infected people, preventive therapy with rifampin or
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tetracycline may be warranted. Chloramphenicol is used in those who are sensitive to

penicillin.(Cowan, 2012; Delost, 1997)

Bibliography

Burtis, C. A., Bruns, D. E., Sawyer, B. G., &Tietz, N. W. (2015). Tietz fundamentals of clinical

chemistry and molecular diagnostics (5th ed.). St. Louis: Elsevier.

Cowan, M. K. (2012). Microbiology: a systems approach (3rd ed.). New York, NY: McGraw-

Hill.

Delost, M. D. (1997). Introduction to diagnostic microbiology a text and workbook (Illustrated

ed.). St. Louis: Mosby.

Keohane, E. M., Smith, L. J., &Walenga, J. M. (2016). Rodak's hematology: clinical principles

and applications (6th ed.). St.Louis: Saunders.

Strasinger, S. K., &Schaub, D. L. (2014). Urinalysis and body fluids (6th ed.). Philadelphia: F.A.

Davis Company.

Tille, P. M. (2014). Bailey & Scott's diagnostic microbiology (13th ed.). St. Louis, MO: Elsevier

Mosby.

Tortora, G. J., Funke, B. R., & Case, C. L. (2001). Microbiology: an introduction (7th ed.). San

Francisco: Benjamin Cummings.

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World Health Organization.(2015, November). Meningococcal meningitis. Retrieved April 22,

2017, from http://www.who.int/mediacentre/factsheets/fs141/en/

Mcpherson, R. A., Pincus, M. R., Abraham, N. Z., Ashihara, Y., &Banki, K. (2011). Henry's

clinical diagnosis and management by laboratory methods (22nd ed.). Philadelphia, PA:

Elsevier Saunders.