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Jaika Tiglao


Case No. 1

The patient was a 19-year-old female with a history of a urinary tract infection (UTI) 4
months prior to admission for which she was treated with oral ampicillin without
complications. Five days prior to this admission she began to note nausea without chills and
noted increased urinary frequency. She noted foul-smelling urine on the day prior to
admission. She presented with a temperature of 38.8℃, and physical examination showed
left costovertebral angle tenderness. Urinalysis of a clean-catch urine sample was notable
for >50 white blood cells per high-power field, 3 to 10 red blood cells per high-power field,
and 3+ bacteria. Urine culture was subsequently positive for > 105 CFU of an organism per
ml (screen growing on culture in Fig. 1.1 [Sheep blood agar] and Fig. 1.2 [MacConkey
Agar]. Note that the organism is beta-hemolytic.

1. What do the urinalysis findings indicate? Explain your answer.

2. Why were the numbers of organisms in her urine quantitated on culture? How would
you interpret the culture results in this case?
3. Which gram-negative rods are lactose fermenters? Which one is also often beta-
4. This bacterium was resistant to ampicillin. What in this patient’s history might explain
this observation? Multidrug-resistant strains of this organism are beginning to be
seen as an important cause of UTI. Describe the mechanism of resistance that these
organisms most likely will have.
5. UTIs are more frequent in women than men. Why?
6. Did this woman have cystitis or pyelonephritis? Why is it important to differentiate
between two?
7. Briefly explain the evolution of the organism causing this infection in terms of its
ability to infect the urinary tract. What virulence factors have been shown to play a
pathogenic role in this infection?
Answers: (Case No. 1)

1. As observed in the urinalysis result, there is an elevated number of white blood cells
and bacteria; and a presence of hematuria which indicates pyelonephritis.
Pyelonephritis is a condition which leads to bacterial invasion of renal parenchyma. It
occurs as a result of ascending movement of bacteria from a lower urinary tract
infection into the renal tubules and interstitium.
2. The numbers of organisms in her urine were quantitated on culture as a standard
and is a diagnostic test that is widely undertaken to provide laboratory evidence of
urinary tract infection. In the result, there is presence of ≥ 10⁵ CFU of an organism
per mL in urine culture which indicates that the patient has a urinary tract infection.
3. The Gram-negative rods which are lactose fermenters are Enterobacter spp.,
Escherichia coli, Klebsiella spp., Citrobacter spp., Serratia spp. (But Serratia and
Citrobacter spp. Can appear initially as non-lactose fermenting due to slow
fermentation). Escherichia coli is often beta-hemolytic among this lactose fermenter
gram negative rods.
4. This bacterium which is E.coli, is resistant to ampicillin. According to patient’s history,
the patient had UTI 4 months prior to admission for which she was treated with oral
ampicillin without complications. However, The ampicillin was not effective anymore
because of her UTI.
5. The reason women are more likely to develop bladder infections than men comes
down to basic anatomy. Female urethras are much shorter than male urethras.
Approximately an inch and a half in length to be exact. This means the bacteria
doesn’t have to travel nearly as far to reach the bladder. Another risk enhancing
attribute involves the location of the urethra. Located next to the vagina and anus, it
is much easier for bacteria to travel from those two areas to the urethra.
6. The woman has E.Coli/ Pyelonephritis to differentiate this two is A pyelonephritisis an
infection in the kidneys. Both medical problems will present with burning on urination
and bloody urine. However, with a pyelonephritis you have more pain in the back
area. While the cystitis Cystitis is infection or inflammation of bladder, &
pyelonephritis a kidney infection. Both start in lining of each organ and p invariably
started as a bladder infection.Bacteria reach kidney from by bladder reflux or by
caterpillar-like bacteria which crawl up to kidney.Urinary freqency, burning and blood
in urine in both.Flank pain with p& needs antibiotics with good tissue penetration,
less so.
7. These bacteria have evolved a multitude of virulence factors and strategies that
facilitate bacterial growth and persistence within the adverse settings of the host
urinary tract. Expression of adhesive organelles like type 1 and P pili allow
uropathogenic E.coli (UPEC) to bind and invade host cells and tissues within the
urinary tract while expression of iron chelating factors (siderophores) enable UPEC to
pilfer host iron stores. Deployment of an array of toxins, including hemolysin and
cytotoxic necrotizing factor 1, provide UPEC with the means to inflict extensive tissue
damage, facilitating bacterial dissemination as well as releasing host nutrients and
disabling immune effector cells. These toxins also have the capacity to modulate, in
more subtle ways, host signaling pathways affecting myriad processes, including
inflammatory responses, host cell survival, and cytoskeletal dynamics.
Case No. 2

The patient was a 15-year-old male who was brought to the emergency room by his
sister. He gave a 24-hour history of dysuria and noted some “pus-like” drainage in his
underwear and on the tip of his penis. Urine appeared clear, and urine culture was
negative although urinalysis was positive for leukocyte esterase and multiple white cells
were seen on microscopic examination of urine. He gave a history of being sexually
active with five or six partners in the past 6 months. He claimed that he and his partners
had not had any sexually transmitted infections. His physical exam was significant for a
yellow urethral discharge and tenderness at the tip of the penis. (A Gram stain done in
the emergency room is shown in Fig. 2.1) he was given antimicrobial agents and
scheduled for a follow-up visit 1 week later. He did not return.

1. Based on the Gram stain results, with what organism is this patient infected? What is
the reliability of the Gram stain for establishing the diagnosis in this patient? How
reliable is the Gram stain for detection of this organism in vaginal specimens from
infected women? What other direct detection technique is available for laboratory
diagnosis of the organism causing this patient’s infection?
2. Are his urinalysis and urine culture findings consistent with his illness? Explain.
3. Why did his partners have a negative history for sexually transmitted infections? For
what complications are his sexual partners (whom he may have infected and/or who
infected him) at increased risk?
4. What virulence factor(s) made by this organism is responsible for his symptoms?
5. Given his history for what organisms is he at increased risk? Why do you think this
patient was asked to return for a follow up visit?
6. What antimicrobial agent(s) was he given in the emergency room? How has
antimicrobial therapy for this infection evolved over the past 25 years and why was
that evolution necessary?
7. Why is there no reliable vaccine against the organism causing this individual’s
Answers: (Case No. 2)

1. The patient was infected by Neisseria Gonorrhoeae. The Gram stain shows that the
patient is infected by this Neisseria Gonorrhoeae. The last women who had sex with
the patient also is infected with Neisseria Gonorrhoeae. Specimen culture is one of
the laboratory test to confirm the organism causing the patient’s infection.
2. Yes, because urine is one of the specimen types suitable for nucleic acid tests
for diagnosing N. gonorrhoeae infections in males and females. His test
results show that gonorrhea causes his illness: a positive test for leukocyte
esterase that suggests there are white blood cells in the urine indicates
Urinary Tract Infection. His physical examination also suggests that he
acquired Urethritis.
3. Some people may be infected for months before signs or symptoms occur, so
for the past months, the sign and symptoms were not active. Complications
like Urethra but not UTI because it is not transmitted through contact
4. The pathogenic mechanism involves the attachment of the bacterium to
nonciliated epithelial cells via pili and the production of lipopolysaccharide
endotoxin. Similarly, the lipopolysaccharide of N. gonorrhoeae is highly toxic,
and it has an additional virulence factor in the form of its antiphagocytic
capsule. Both pathogens produce IgA proteases which promote virulence
5. The organism is Neisseria Gonorrhoeae. He should be going to a follow up check-up
or rather to say that he is required to have a follow up check-up. For able to him to
have a knowledge or for him to know the stage of his infection that he is involved in
caused by Neisseria Gonorrhoeae.
6. The cephalosporins and spectinomycin have few contraindications. Fluoroquinolones,
on the other hand are generally considered to be contraindicated for children below
18 years of age and for pregnant women.these contraindication are based on
extrapolation from animal studies and not on human studies or clinical experience.
7. Progress on gonorrhoea vaccines has been slow; however, recent advances justify
significant effort in this area. Conserved vaccine antigens have been identified that
elicit bactericidal bodies and, or play key roles in pathogenesis that could be targeted
by a vaccine-included response. A murine genital-tract infection model is available for
systematic testing of antigens, immunization routes and adjuvants, and transgenic
mice exist to relieve some host restriction.
Case No. 4

The patient was a 20-year-old female who presented to the emergency room with a
4-day history of fever chills and myalgia. Two days prior to this she had noted painful genital
lesions. On the day of admission, she developed headache, photophobia, and a stiff neck.
Previously she had been in good health. She admitted to being sexually active but had no
history of sexually transmitted infections.

On physical examination, she was alert and oriented. Her vital signs were normal
except for a temperature of 38.5℃(101.3℉); pulse rate was 80 beats/min, and blood
pressure was 130/80 mm Hg. A general examination was unremarkable except for slight
nuchal rigidity. Her throat was clear, and there was no lymphade-nopathy. A pelvic
examination revealed extensive vesicular and ulcerative lesions on the left labia minora and
majora with marked edema. The cervix had exophytic (outward-growing) necrotic

General laboratory tests were unremarkable. A vaginal swab was collected for
Neisseria gonnorboeae and Chlamydia trachomatis nucleic acid amplification test (NAAT), a
swab of the lesions was sent for herpes simplex virus (HSV) NAAT, and an RPR (rapid
plasma reagin) was performed. A lumbar puncture was also done, which had a normal
opening pressure. The cerebrospinal fluid (CSF) showed a mild pleocytosis with a leukocytes
and 79% mononuclear cells, a glucose level of 46 mg/dl, and a protein level of 68 mg/dl
(slightly elevated). The RPR and a CSF VDRL test were negative. A NAAT was positive from
the lesion as well as from her CSF. The patient’s condition improved after 2 days of
intravenous therapy. She was discharged home on oral medication.

1. What is the differential diagnosis of ulcerative genital lesions? Which rapid test was
used so that specific therapy could be started?
2. Which complication of her underlying illness did she develop?
3. If she had been pregnant at the time of her infection, for what would her fetus be at
4. Briefly describe the natural history of this infection.
5. Briefly describe the epidemiology of the agent causing her infection.
6. There are two different serotypes of the agent causing her infection. What
similarities do they share and what are the differences between these agents?
Answers: (Case No. 4)

1. The differential diagnosis of ulcerative genital lesion is RPR (rapid plasma reagin) and
Nucleic Acid Amplification Test. The rapid test was used so that specific therapy
could be started is NAAT(Nucleic Acid Amplification Test)
2. The complication of her underlying illness she developed is Chlamydia Trachomatis.
3. If she had been pregnant at the time of her infection. Of course, her fetus would be
also infected as well.
4. Chlamydia trachomatis is an intracellular bacterial pathogen and a major cause of
genital and eye disease. It comprises three human biovars. One causes trachoma,
the most common form of blindness worldwide, and particularly prevalent in Africa. A
second is the cause of lymphogranuloma venereum, a sexually transmitted infection
(STI) mainly of gay men in the developed world. The third biovar that consist of
serovars D to K, is the topic of monograph. It is a major cause of PID, EP and TFI in
women. Epididymitis in men, neonatal conjunctivitis and neonatal pneumonia in new-
borns. Chlamydia Trachomatis is transmitted by oral, vaginal, or anal sex and can
also be transmitted from mother to new-born during a vaginal delivery. Diagnosis is
generally based on nucleic acid amplification test (NAATs) carried out on cervical or
vaginal swabs in women, urethral swabs in men or on urine samples. NAAT has
largely replaced culture or enzyme immunoassays for diagnostic testing. However,
culture played a key role in earlier epidemiological studies and the lower sensitivity of
culture, 60%-80% needed to be taken into account when interpreting the earlier
research results.
5. Approximately 75% of incident infections in women are asymptomatic. Although
studies of the duration of asymptomatic infection have produced a wide range of
estimates – between 1 and 18 months, it is evident that the infection can clear
spontaneously in the absence of treatment as a consequence of the adaptive and
innate immune responses.

The risk of transmission of infection from one episode of sexual intercourse is

estimated to be between 10% and 20%. Given the high sensitivity of current NAATs
for detecting CT, and the fact that non-host DNA and sperm can be recovered from
the female genital tract up to 7 days following sexual intercourse, this strongly
implies that at least some women who test CT positive (CT+) ar4e probably only
passively infected. This is consistent with the observation of Joyner et al that a
proportion of women testing CT+ without treatment become CT NAAT-negative
within 2 weeks.

Prevalence of CT can be studied by population surveys, using NAATs on

genitourinary specimens. As with most STIs, incidence and prevalence are highest
among young people, and decline steeply with age. Infection is more common
among the more sexually active individuals, with the greatest number of sexual
6. Chlamydia Trachomatis and Neisseria Gonorrhoeae are among the most common
causes of sexually transmitted infections. Infection with these organisms is often
asymptomatic, which hinders diagnosis or treatment. Persistent infection can have
serious negative consequences, including pelvic inflammatory disease and infertility.
Untreated and undiagnosed infection also contribute to the further spread of the
disease. Screening programs are recommended to prevent these consequences. Of
the various testing methods currently available, nucleic acid amplification tests are
among the most sensitive and specific methods for detection of C. Trachomatis and
N. Gonorrhoeae organism in clinical specimens. The high sensitivity of nucleic acid
amplification tests allows them to be used with less-invasive clinical samples, such as
first-catch urine, which facilitates establishment of screening programs. The assay
described here combines sequence-specific sample preparation and isothermal
amplification for the detection of C. Trachomatis and N. Gonorrhoeae infections.
Sequence-specific sample preparation is based on antibody capture of DNA-RNA
hybrids. Ribo-oligonucleotide probes hybridizes to specific target sequences, and the
resulting hybrid are captured by antibodies specific for DNA-RNA hybrids. This
process enriches the desired nucleic acid sequences in the sample. Antibodies are
coupled to magnetic beads.