Medical Technology Assessment Program with Clinical Correlations 1

Summary of Clinical Cases by Subject Area

Name of Student: Pittzman Jo R. Acosta

Subject Area: Microbiology-Parasitology

Case Title: A Case of Fulminant Sepsis Caused by Capnocytophaga canimorsus after a Dog Bite
Disease/Condition: Fulminant Sepsis
Summary of the Case Presented Textbook Information
The case involves a woman rushed in the hospital due to a condition Capnocytophaga canimorsus are common inhabitants of the oral
involving septic shock. Upon admission, she presented with cavity of animals such as cats and dogs which can be transmitted to
coagulopathy, extensive purpura, and cyanosis in addition to being human through bites (Mahon & Lehman, 2019).
tachycardic, febrile, and having low blood pressure. Upon
investigation, it was determined that she had superficial dog bite Capnocytophaga spp. is part of the fastidious Gram-negative bacilli
three days ago where she also had progressive weakness, which are also associated with sepsis (Mahon & Lehman, 2019).
hypertension, and abdominal pain. Laboratory tests show metabolic
acidosis, prolonged prothrombin time, partial thromboplastin time,
D-dimer, significantly low platelet count, and high CRP and References
procalcitonin which confirms the coagulopathy presentation. High Mahon, C., & Lehman, D. (2019). Textbook of Diagnostic
creatinine confirms multiple organ failure. Finally, blood cultures Microbiology. St. Louis, Missouri: Elsevier.
show Gram-negative rods. The patient died sixteen hours upon
admission due to cardiac arrest. The bacterium was shown to be
Capnocytophaga canimorsus. This is evidenced by it being a fastidious
Gram-negative bacillus. Although rare, it can be transmitted to
humans through dog or cat bites. Patient has alcohol abuse history
which makes her at high risk of acquiring it. It causes fulminant
septicemia leading to DIC and multiple organ failure. It suppresses
immunity by preventing phagocytosis and complement activation.
Lastly, it grows slowly with an average of 6 days before it can be
detected.
Reflection with Integration of Faith and Learning:
Addressing of incidents that may have a huge impact later in life should be taken seriously. This is in conjunction with the woman who had a
superficial bite from a dog. Cases like this should be addressed immediately because we may not know what it can do to us. Unfortunately for
the woman, this was the reason of her death. Hence, just like in our spiritual life, incidents that we feel may negatively impact us towards the
next days should be prayed to God since He is the healer of our illness and He will understand our situation if we fervently ask for His
 forgiveness and repent for all of our sins.

Case Title: No Kidding, It’s in the Brain

Disease/Condition: Pulmonary Nocardiosis
Summary of the Case Presented
Textbook Information
The case is about a 66-year-old man presenting with weeks-long dizziness, headaches, and unstable gait. Upon CT scan, progressively enlarging
mass in his cerebellum was seen. He also had lung mass. Biopsy material shows a yellow purulent substance that was sent for analysis. The
specimen grew in aerobic culture. For the direct microscopy, the specimen showed branching Gram-positive rods with beaded morphology. Acid
Fast Staining using Kinyoun Method was also positive. It grew also on blood and chocolate agar. After investigation and antimicrobial
susceptibility, the initial diagnosis of Nocardia spp. was supported by the fact that there was growth in the Nocardia Quad Plate. To further
identify the species, 16s sequencing genetic analysis determined the diagnosis of Nocardia farcinica infection. Nocardia are aerobic, Gram
positive, weakly acid-fast bacteria. Although lung cancer was thought to be the diagnosis, investigators concluded that the patient had
pulmonary nocardiosis and the brain manifestation was due to dissemination which is possible with 1/3 of the disease. This is supported by the
fact that immunosuppressed patients due to old age are at higher risk of being infected by the bacteria.
Nocardia spp. are aerobic, beaded, branched, Gram-positive bacilli. Infections occur as commonly pulmonary (Mahon & Lehman, 2019).

Taxonomy of Nocardia spp. is primarily based on 16S rRNA sequencing which can name 100 species (Mahon & Lehman, 2019).

Nocardia is seen as partially acid-fast owing to the presence of mycolic acids. However, when compared to Mycobacterium, the amount of
mycolic acids in Nocardia is lesser than Mycobacterium making at weakly acid-fast (Mendoza, 2019).

References
Mahon, C., & Lehman, D. (2019). Textbook of Diagnostic Microbiology. St. Louis, Missouri: Elsevier.
Mendoza, F. (2019). Lecture Notes in Bacteriology for Medical Laboratory Science Students. Adventist University of the Philippines.

Reflection with Integration of Faith and Learning:

When we are ageing, we are at higher risk of acquiring infections since our immunity system weakens. However, with proper investigation and
help from our health care workers, we will be able to surmount all those challenges. Just like the 66-year-old man who was infected, he did his
best to be investigated of the masses in his body and he was able to overcome the disease. In our spiritual life, when we grow older in faith, the
devil is working hard to tempt and to distance us from God. But we should remember that when we choose to ask Jesus for guidance and
spiritual strength, then all the temptations from Satan can be overcome easily.
 Case Title: Atypical Secondary Syphilis Presentation in a patient with Human Immunodeficiency Virus Infection: A case report
Disease/Condition: Secondary Syphilis with HIV coinfection
Summary of the Case Presented Textbook Information
The case is about a homosexual man with HIV infection that was Treponema pallidum subsp pallidum is the causative agent of syphilis.
admitted due to purulent skin lesions on face, lips, and body with The secondary disease is manifested by a generalized rash and
febrile presentation. Initially upon admission, he was diagnosed with pronounced lymphadenopathy. The drug of choice for treatment is
streptococcal dermatitis and varicella pustulosa. Treatments were penicillin (Mendoza, 2019).
started but his complaints of fever and rash intensified prompting
him to visit another dermatologist. At his second doctor, he was Serology is the main diagnostic method for syphilis where 100%
referred for syphilis and HIV testing. Then, it was found out that he sensitivity to testing treponemes and treponemal antibody is
was positive with syphilis, specifically the second one due to skin expected (Mahon & Leman, 2019).
manifestations being rampant. Further microbiological examinations
on his nasal and sputum secretions confirm this. However, it was
described as atypical since the abundant purulent secretion, mostly in References
his lips, with the absence of lesions on plantar and palmar surface Mahon, C., & Lehman, D. (2019). Textbook of Diagnostic
was uncommon for secondary syphilis. Due to the delay of diagnosis, Microbiology. St. Louis, Missouri: Elsevier.
skin lesions were seen to have worsen. Treatment with ceftriaxone, Mendoza, F. (2019). Lecture Notes in Bacteriology for Medical
together with amikacin and metronidazole was initiated after Laboratory Science Students. Adventist University of the
diagnosis although penicillin is the standard. The former drugs were Philippines.
used since the latter was unavailable in Bulgaria. Antiretroviral
therapy was also initiated. The patient was discharged a month later
of treatment with better prognosis such as reversal of the lesions, a
negative RPR, a higher CD4/CD8 ratio, and an undetectable HIV viral
load.
Reflection with Integration of Faith and Learning:
If you remain at something that does not help you win your goals or achievements, try to go to other pathways. This is anchored on the case
where the patient asked for the opinion of another dermatologist since he was not getting better after being treated with now a wrong
diagnosis. In our spiritual life, we grow better when we try to divert our ways to something benefitting if we feel like we are not growing to
that old path. We always need God’s guidance in helping us tread that way so we know that the path is for our benefit.

Case Title: Educational Case: Neisseria Meningitis

Disease/Condition: Acute Bacterial Meningitis
Summary of the Case Presented
Textbook Information
The case is about an 18-year old dormitorian rushed to the hospital for fever and stiff neck. Past medical history was insignificant with only
recreational marijuana use and alcohol ingestion as prominent notes. Her physical examination showed febrile temperature, petechial trunk
rashes, and a positive Kernig and Brudzinski signs which are classic tests for meningitis. Hematological findings show leukocytosis,
thrombocytopenia, prolonged PT and APTT, high INR, and increased D-Dimer. Analysis of CSF showed neutrophilia, high protein, low glucose,
and gram-negative diplococci suggesting a bacterial type of meningitis. Due to these differential diagnoses, the patient was diagnosed with acute
bacterial meningitis with Neisseria meningitidis as the causative agent. The noted disseminated intravascular coagulopathy (DIC) was further
evidence that the bacterium was the agent since it is one of the commonly causes of this complication. Due to the aggressive nature of the
patient’s condition, she died of bleeding and seizure.
Neisseria meningitidis is a gram-negative diplococci and is an endemic and epidemic etiologic agent of meningitis. The epidemic type of
meningitis can occur in young adults especially those who live in closed populations such as barracks and college dormitories (Mendoza, 2019).

Most cases of meningitis in the United States caused by Neisseria meningitidis can cause intravascular coagulation, hemorrhage in the adrenal
glands, and septic shock (Mahon & Leman, 2019).

References
Mahon, C., & Lehman, D. (2019). Textbook of Diagnostic Microbiology. St. Louis, Missouri: Elsevier.
Mendoza, F. (2019). Lecture Notes in Bacteriology for Medical Laboratory Science Students. Adventist University of the Philippines.

Reflection with Integration of Faith and Learning:

As a former dormitorian myself, I got surprised that this causative agent can affect me while I am studying in AUP. This taught me to reflect my
personal routine and how my habit of grooming with my roommate at the time. I learned in my dormitory life that we should always
communicate properly with who we share our unit. This is not just on hygiene, cleanliness, but also spiritual and social way. We must pray to
God that He guides us in maintaining good communication with our dormitory roommates. This may help us avoid contracting the bacteria, but
to also blossom a friendship that may last forever even when you are not roommates anymore.

Case Title: A Case Report From the State of Uttarakhand

Disease/Condition: Diphtheria
Summary of the Case Presented
Textbook Information
The case is about a young adolescent boy who was rushed to the medical center due to intermittent fever, difficulty in swallowing foods,
expectoration of yellow sputum, and noisy breathing. Upon oropharyngeal examination, tonsils were seen with grayish-white membranous
patches. Laboratory findings show low hemoglobin, leukocytosis with neutrophilia suggesting bacterial infection. Bacteriologic studies gram-
positive bacilli with swollen ends that arrange in palisades fashion using Albert and Gram stains. Finally, the isolate was tested for MALDI-TOF-
MS system which was confirmed as Corynebacterium diphtheriae. However, toxin production analysis was not performed. Antibiotic therapy was
initiated but the patient’s condition had worsened rapidly and needed mechanical ventilation. It was also found out that he was partially
immunized against diphtheria. Unfortunately, diphtheria antitoxin was unavailable since the worsening prognosis may be stemming from the
toxins produced by the bacteria. Hence, the patient died of pneumothorax with significantly low oxygen saturation where resuscitation was not
successful.
Corynebacterium diphtheriae is a slightly acid fast, gram-positive bacilli that causes respiratory and cutaneous diphtheria. The etiologic agent
forms a gray to white pseudo membrane in the airways that may lead to patient’s suffocation (Mendoza, 2019).

The toxin of Corynebacterium diphtheriae can lead to cardiac failure as a resulting death. Although it was shown in the case study that antitoxin
against diphtheria was unavailable, a toxoid vaccine is available as part of the trivalent DPT vaccine. Children receive this in five series with
succeeding booster shots that follow a 10-year interval (Mahon & Leman, 2019).

References
Mahon, C., & Lehman, D. (2019). Textbook of Diagnostic Microbiology. St. Louis, Missouri: Elsevier.
Mendoza, F. (2019). Lecture Notes in Bacteriology for Medical Laboratory Science Students. Adventist University of the Philippines.

Reflection with Integration of Faith and Learning:

The problem with this case is that the patient was not immunized fully against diphtheria when the vaccines are openly available. There is also a
problem that the diphtheria antitoxin was unavailable due to the fact that this disease is not prevalent. For the first problem, we must be willing
to complete the series of vaccine so that it functions in the maximal level. This is also related to our spiritual life, if we do not commit ourselves
fully to God in all our endeavors, then it is up to us to change that for the better. For the second problem, we must always be ready when it
comes to these disease, albeit rare, so that people that may be affected with these may not face severe consequences. Relative to our faith,
when we slack due to the feeling that we are not fazed by Satan’s temptations, then we are more vulnerable to his snares. So, we must not be
contented with our spiritual life as if we know what tomorrow holds. We must live our lives as if we are challenged by the devil’s temptations
and always ask for God’s presence in everything that we do.

Case Title: Hepatic fascioliasis in Mashhad, Northeast Iran: First Report

Disease/Condition: Hepatic Fasciolasis
Summary of the Case Presented
Textbook Information
The case revolves on a 57-year old mountaineer man, which upon admission, complained of fever, abdominal discomfort, weight loss, dyspepsia,
and lack of appetite. He had a history of traveling to a forest where consumption of freshwater plants and unsafe water was noted. Physical
examination, upper gastrointestinal endoscopy, and sonography on his abdomen was performed. The latter showed a 12-millimeter nodule on
his right hepatic lobe with parenchymal heterogeneity. This led to performing a CT scan focusing on his liver. Then, it was found that he had
irregular, nodular lesions on his right hepatic lobe. Therefore, he was initially diagnosed with hemangioma. His condition, however, worsened.
Laboratory tests were then performed which showed eosinophilia, and elevated ALT and AST which points the condition being of parasitic
nature. Stool examination was negative for ova and parasite. The hepatic mass, upon admission, led to investigators to think it may be
helminthic disease. He tested negative for schistosomiasis, toxocariasis, and ascariasis which led to the suspicion of a fluke disease. Then, an
antibody test for flukes was performed wherein an IgG antibody against Fasciola hepatica was found to be positive. The patient was then treated
with a single dose of triclabendazole. Thereafter, his condition became better with follow-up tests within a week showing disappearance of the
initial symptoms upon his admission.
Tissue damage of Fasciola hepatica results in eosinophilia. The organism in adult form lives in the liver which can cause obstruction and
destruction (Mahon & Lehman, 2019).

The primary diagnostic stage of flukes, in general, is the examination of eggs (Mahon & Lehman, 2019).

An individual acquires the infection when one ingests the metacercaria. For the case of Fasciola hepatica, the infective stage is attached to water
plants (Mahon & Lehman, 2019).

References
Mahon, C., & Lehman, D. (2019). Textbook of Diagnostic Microbiology. St. Louis, Missouri: Elsevier.

Reflection with Integration of Faith and Learning:

When you have all the resources to look into what you want to look for, what you need is the persistence and patience to know it. Just like in the
case, the investigators did a good job in determining the causative agent of the patient’s condition. It may have used a lot of resources, but it
was successful in the end. In our spiritual life and in this age of technology, we all have the resources to know God’s word. Sometimes, it is even
due to the simple availability of these resources that we tend to be lazy in finding God’s word. Hence, we should value the availability of these
resources because there may come a time that they may not be ready at your expense.
Case Title: A case report of primary amebic meningoencephalitis in North Florida
Disease/Condition: Primary Amebic Meningoencephalitis
Summary of the Case Presented Textbook Information
A 13-year old, upon attending a waterpark camping trip after three Primary amebic meningoencephalitis, caused by Naegleria fowleri, is
days, complained of headaches, vomiting, and fever. In his check-up, common in the state of Florida where the patient had been
laboratory values showed a normal metabolic profile, leukocytosis reportedly exposed to. It occurs in young children with no conditions
with significant neutrophilia, and an increased CRP. His conditioned that may increase the risk of acquiring it. the common cause of
worsened. Hence, he was admitted. Thereafter, he demonstrated acquiring it is from activities that involves water like swimming in
hemodynamic instability, meningeal signs, and altered mental status. artificial lakes and muddy waters (Mahon & Lehman, 2019.
A CT scan was prompted upon seeing increased intracranial pressure.
A lumbar puncture was also performed where CSF analysis showed Naegleria fowleri is a free-living amebae that is thermotolerant. It can
neutrophilia, increased glucose and protein, increased opening endure a broad array of temperatures. They can gain access by
pressure, and turbidity. It was then initially thought to be of bacterial inhalation and goes to the central nervous system for inhabitation
etiology. An MRI was ordered which suggested leptomeningeal signs. (Mahon & Lehman, 2019).
As his symptoms persisted, a CT scan was performed which suggested
transtentorial herniation. A CSF sample of patient was microscopically
analyzed which demonstrated amebic trophozoites. Despite care References
interventions, there were no more response in his repeat Mahon, C., & Lehman, D. (2019). Textbook of Diagnostic
neurological examination. His CSF sample was sent to CDC where a Microbiology. St. Louis, Missouri: Elsevier.
real-time PCR test has confirmed Naegleria fowleri. This finding was
consisted with his CSF analysis along with his history of swimming in
the camping trip prior to the symptom presentation. Diagnosis of
primary amebic meningoencephalitis (PAM) was shown to be
challenging as it mimics bacterial meningitis. Hence, the case would
prompt a better access to molecular testing techniques so that
infections caused by the parasite can be detected early.
Reflection with Integration of Faith and Learning:
As parents, we are responsible for the activities that our children will be doing. Part of it is knowing the place or the safety of the activity. we
must always be cautious of what can go wrong to the place which may endanger the lives of our children. If any harms were inflicted, we must
react quickly and ask for the assistance of those who can help us like the healthcare professionals. God has appointed us as the one who shall
guide our children. Hence, we must be responsible in doing our best in nurturing our children spiritually and for their safety as well.
Case Title: Two weeks in Africa
Disease/Condition: Malaria
Summary of the Case Presented Textbook Information
A 16-year American came from a 2-week trip in Sudan. Two weeks Plasmodium falciparum, among the five causative agents of malaria,
after his trip, he suffered from fever, diarrhea, nausea, and vomiting. is the species that is most commonly seen in cases and fatalities. In
He also developed orthostatic hypotension with significant weight more than half of these cases, travel to the endemic areas is deemed
loss of 15 pounds. In his admission laboratory tests, he had to be the reason of being infected (Mahon & Lehman, 2019).
thrombocytopenia, leukopenia, low RBC count, hemoglobin, and
hematocrit. His differential count showed lymphocytosis, Chloroquine is currently the drug of choice for malarial infections and
monocytosis, and neutropenia. This prompted a microscopical prophylaxis (Mahon & Lehman, 2019).
examination of his blood. His blood smear showed polychromasia and
schistocytes. The major finding in his smear stemmed from the References
demonstration of ring form organisms within his red blood cells Mahon, C., & Lehman, D. (2019). Textbook of Diagnostic
accompanied by the banana-shaped organisms in the picture. His Microbiology. St. Louis, Missouri: Elsevier.
final diagnosis was then malaria caused by Plasmodium falciparum.
Tetracycline and chloroquine treatment with rehydration was shown
to be helpful in this case as discussed. For monitoring, parasite load
and count could be helpful.
Reflection with Integration of Faith and Learning:
It really is a blessing to see God’s wonders by traveling to different countries. It makes us appreciate the creation and how God, as the
masterful artist, had made the earth. With this, we must also be cautious and take safety precautions in traveling to countries, especially to
countries where certain diseases are endemic. In appreciating God’s wonders, we must be protected. It is our duty to be responsible in
traveling and protecting ourselves. How exciting is it to appreciate the nature while knowing that you are freed from thinking that something
may happen to you badly, travel-wise.

Case Title: Bilateral Candida keratitis in an HIV patient with asymptomatic genitourinary candidiasis in Uganda
Disease/Condition: Bilateral Candida Keratitis
Summary of the Case Presented Textbook Information
The case is about a 35-year old man which presented with a red and Candida albicans is a part of agents of opportunistic mycoses which
painful left eye. His history was not significant where he had the same are mostly monorphic fungi and are pervasive in the normal flora of
painful eye years ago that had healed. By this time, he was unaware humans (Mendoza, 2019).
that he was HIV-positive. To start, corneal scrapings were used for
microscopy. Upon direct examination, Calcofluor White (CFW) stained In HIV patients which acquired candidiasis, systemic dissemination in
specimen showed fungal elements. Candida spp. was also found in other parts of the body can be possible. (Mahon & Lehman, 2019).
the cultures of blood agar, potato dextrose agar, chocolate agar, and
brain heart infusion. As protocol for Candidiasis infections in Uganda,
he was tested for HIV. This came back positive. Unfortunately, his eye
did not recover, and the doctors had to perform its removal. Five
months later, he went back to the same hospital presenting the same
case. The same techniques were performed for direct examination
and culture with potassium hydroxide and gram stain showing
hyphae. Urine culture was additionally performed and had come back
with growth of the suspected causative agent. With a now more
aggressive way of treatment, the patient was able to recover with his
remaining eye and evisceration was not performed.
In immunocompetent patients, infections caused by Candida are only
localized whereas immunocompromised patients experience can
form secondary manifestations as a result of dissemination in almost
any site (Mahon & Lehman, 2019).
References
Mahon, C., & Lehman, D. (2019). Textbook of Diagnostic
Microbiology. St. Louis, Missouri: Elsevier.

Mendoza, F. (2019). Lecture Notes in Bacteriology for Medical

Laboratory Science Students. Adventist University of the
Philippines.

Reflection with Integration of Faith and Learning:

We should be responsible of ourselves when we do something that may lead us to harm. The patient at first was not aware of HIV-positive
status. This played an important as to why his eye infection became so severe that it lead to the surgical removal of his eye. Just like in our
lives, our past can play an important role in our future. We must address it if we know that it can negatively affect us in the long run. We must
always ask God for this guidance in helping us address the things that we may have irresponsibly done in the past.

Case Title: Disseminated histoplasmosis in an immunocompetent patient - utility of skin scrape cytology in diagnosis
Disease/Condition: Disseminated Histoplasmosis
Summary of the Case Presented Textbook Information
The case is about a 46-year old man which presented with fever and Histoplasma capsulatum appear as small yeast cells which are seen
weight loss in 5 months, numerous red papules and a month-old inside macrophages and monocytes (Mendoza, 2019).
cough. By these, he was suspected of having malaria and was treated
as it is. The only significant thing in his history is his selling of teas Inhalation of microconidia is the most common way of acquiring
under a tree which means that he was chronically exposed to bird Histoplasma capsulatum. In cultures, the species grow as a mold form
droppings. For his laboratory results, he had leukocytosis and high C- having a pigmentation of white to brownish (Mahon & Lehman,
reactive protein. Scrape cytology was used on his am blisters were 2019).
performed. For cultures, toluidine smears showed multinucleated
cells, epithelioid granulomas, inflammatory cells with numerous
histiocytes. He was negative for Ziehl-Neelsen and mucicarmine. He References
tested positive for Gomori Methenamine Silver. Saboraud dextrose Mahon, C., & Lehman, D. (2019). Textbook of Diagnostic
agar showed mold colonies with brown cottony appearance. Microbiology. St. Louis, Missouri: Elsevier.
Lactophenol blue had thick walled macroconidia with septate hyphae.
In the latter parts of testing which started with mucicarmine, Mendoza, F. (2019). Lecture Notes in Bacteriology for Medical
suspected agents such as L. donovani, C. neoformans, P. marneffei Laboratory Science Students. Adventist University of the
was cancelled out and Histoplasma capsulatum was the causative Philippines.
agent to have been seen as a diagnosis. He was then treated after the
diagnosis.
Reflection with Integration of Faith and Learning:
It is not easy to find a living. We must find a suitable place by which we can do our business. In his fifteen years of selling teas, the risk of bird
droppings as a source of his present condition had played a role. So, whenever we are planning to do something, we must include all the
necessary strengths and weaknesses that may come up with. When we tread on our spiritual mission of sharing the gospel to others, we must
know first the people we are ministering in addition to knowing who we are. If this is practiced, we can win more souls to Jesus.