Case Studies Flashcards
52 yr old male
High temp
SUPER stiff neck
Dense consolidation of right upper and mid lung areas
Epilepsy/seizures
Cloudy CSF (supposed to be clear like water. Cloudy due to dense concentration of bacteria in spinal fluid)
PMN spike (98% of population, suggesting very acute inflammatory process)
Low glucose
Gram pos coci in pairs, with scant PMNs in the stain
Treated with copious amounts of penicillin, but patient kept having seizures for 2 days in ER. Died.
Streptococcus pneumoniae (OLD MAN’s FRIEND) (you had this thought). THIS IS A VERY PREDICTABLE SCENARIO!!! Gram stain supports this strongly too. In terms of spinal tap, it was very cloudy because the s. pneumoniae was all over it. it has a VERY fast doubling time (20 mins), Patient died because s. pneumonia is still a deadly disease. EtOH suppresses bone marrow and gag reflex, and the seizures would cause more reflexes. The bacteria tends to live in mouth.
67 yr old male
Increasing right leg pain in one month
Injured right great toe at 3, became infected.
Pus oozed from from it for 3 years, and infection site spread up leg to shin.
Had bone scraping by doc at age 6, and leg seemed to heal, but he occasionally noted discomfort in that area. Aching shin pain at age 67 one month before admission. Grew intense. Redness in area of old pretibial scars. Had chills and fevers. Treated with ampicillin for several days prior to hospital visit, to no avail. Admission physical exam: 99 degrees F temp, several deep scars in right pretibial area, surrounded by 10 x 20 cm area of erythema (skin redness due to artery dilation aka tubor), ecchymosis, edema (tubor), and tenderness (pain upon touch), warmer (calor).
Images showed bone infection ()bone is more dense, elevated peritoneum (because there’s pus under there). Pus testing came as coagulase pos, gram pos coccus, distributed in clusters. The same organism grew out of the pus that shot out of the bond upon drilling into the man’s bone. Bacteria was, at the time, INCREDIBLY susceptible to penicilin G.
Staphlococcus aureus
All you needed was coagulase positive. You should have also connected from that test that it was gram pos. Believe it or not, the guy had this aures from the injury at 3. It was not acquired later, closer to time of admission. Bone can harbor bacteria for decades. The reason ampicillin wasn’t working was because it was not getting tot he infected bone site. You can’t deliver it orally. Had to first remove then necrotic bone, then scrape bone down to point where it bleeds, then deliver the penicillin G directly.
66 year-old woman, unexplained positive blood culture. well until age 13, when she developed a
heart murmur after an episode of acute rheumatic fever. felt well until three months prior to the present hospitalization,
when she developed spontaneous pain in her right heel and was found to have an abscess there. could not recall any local trauma. The abscess was surgically drained and α-hemolytic Streptococcus grew in pure culture from the pus. Question: Why did the abscess grow there in the first place??? She remained well until several weeks later when, during an
episode of coughing, she developed an incarcerated hernia (weakness in abdominal wall, in which bowel was sticking out under skin and could not be pushed back in). This was repaired surgically. Except for fever on the second
post-operative day, her course was uneventful. On the sixth post-operative day, as she was preparing to leave the hospital, a report came from the microbiology laboratory that a blood culture, taken during the fever four days earlier,
had yielded an α-hemolytic gram-positive coccus in long chains. Physical examination revealed a well-appearing. The only remarkable finding was a cardiac murmur suggestive of mitral
insufficiency. This, together with the positive blood culture, led to the diagnosis of infective endocarditis (an infection of a heart
valve). Note that when you have a damaged heart valve, even a transient bacteremia can settle on it. she recalled that two months before she had the heel abscess, she had had prolonged periodontal treatments, for which she had been given prophylactic oral erythromycin.
Alpha hempolytic streptococcus (Viridans). Lives in oral cavity. this is NOT group A streptococcus. FOund in uppere respiratory tract, fmemeale gential tract, GI tract, oral cavity (like this patient)
The peridontal treatments were source of the blood culture long chain gram pos. The bacteria/endocardidtis chunk go to her heel by traveling through blood. Acute rheumatic faver and alpha hempolytic strep are connected beacuse: Streptococci have complicatiosn such as pus formation, rheumatic fever, and glomeritis. Depends on the strain you get. Her rheumatic fever led to her getting the endocarditis.
Viridans group of Streptococcus:
1. Relatively low virulence (no toxins, easily lysed by serum and lysosomal enzymes)
2. Propensity to adhere to cardiac valves
– Correlates with production of dextran
3. S. mutans is associated with dental caries.
4. Other syndromes: bacteremia, meningitis,
pneumonia
56 year-old man, complained of pain in his left upper abdominal quadrant of several days’ duration. patient had had diabetes mellitus for many years and was well controlled with oral medications. He was feeling well several weeks prior to admission, when his garage door fell on his left foot, crushing the great toe. At the time he was wearing moccasins. The laceration of his toe eventually healed. four weeks later he noted the sudden onset of pain in his left side, near the edge of the ribcage in the area of the anterior axillary line. pain was worse with coughing. A physician elicited tenderness at the left costal margin. CT scan of the chest revealed destruction of the left twelfth rib. Something is destroying this rib. long history of dry skin which caused the patient to
scratch a great deal. the resultant excoriations (scratch marks), led doc to give patient antibiotic for several days until 2 weeks before CT scan. The temperature was 98.2 degrees F, the pulse 84/minute, the blood pressure 160/80. The skin had multiple excoriations with no
“primary” lesion. There was an upper denture; the lower teeth were in good repair. There was slight tenderness of the left costal margin in the anterior axillary line. A soft holosystolic murmur was audible along the left sternal border, radiating
toward the cardiac apex (mitral regurg is NOT it.). The The left great toenail was deformed. There were multiple splinter hemorrhages at the free margins of several fingernail beds, but none proximal to the free margins (proximal would hint to pathology. Free margin would hint to trama at that end, like you dropped something heavy on it). Histologic examination of some of the material removed by fineneedle
aspiration revealed changes of acute inflammation.
There was no evidence of malignancy.
Note: Rib destruction should have you thinking cancer. It sometimes metastasizes to bone, and this is very destructive. Blood cultures should have you thinking Staph. Staph likely entered into the body through his toe and got to his heart, Traveling through the blood eventually took it to the guy’s rib. A scan of his hear revealed a large culture of staph there at aortic valve. Staph live heart tissue…
45 year old woman had always been well. Eleven months prior to admission she developed right lower extremity deep vein thrombosis and evaluation revealed, as an incidental
finding, a mass in her right lung (person never smoked, but got massive cancer to her lung). She was found to have squamous cell carcinoma of the lung metastatic to many bones, lung, and brain.
She received whole-brain radiation therapy and aggressive chemotherapy and had an Ommaya reservoir placed into a lateral ventricle (of her brain…this si a foreign body inserted to deliver drugs. so if it gets infected, you’re wrecked. That’s what happened to hers) three months prior to admission. The surgical wound for the placement of the Ommaya dehisced (broke open) several weeks later, and never fully closed, despite extensive efforts. It was painted with a topical iodophor (povidoneiodine)
daily when all efforts at closing it failed. Progressive neurologic deterioration followed, with paraplegia
and headache. Tumor markers increased. CSF was removed via the Ommaya four days prior to admission. The next day the patient developed neck stiffness and increasing headache.
Several hours prior to admission the temperature rose to 102.5oF. The temperature on admission was 97oF, the blood pressure 95/70, the pulse regular at 90/minute, the respiratory rate 18.
Neck flexion was limited to 15o (suggests meningitis). A peripherally-inserted central
catheter was present in the right antecubital fossa. Lower
extremity strength was minimal. The Ommaya wound in the scalp had several 1 - 4 mm openings, with clear fluid oozing from some of them (fluid was csf). Essentially, there was an open conduit from the sudrachenoid space to the outside. 5500 white count. bunch of PMNs. CSF gram stain was gram pos cocci clusters
Gram stain should clue to you that it is staph…and it is. A non-aureus staphlococcus. Clinicalky this patient has meningitis (headache, stiff neck, white cells in csf). YOU CANNOT tell the species fo the staph from the gram stain. Got to her CNF through the scalp…the Ommaya. Ommaya had to come out. It was infected. The patient’s death was inevitable, and that ommaya thing sped it up.
35 year-old man was well fifteen days prior to admission, when he underwent a right inguinal herniorrhaphy. His
subsequent course was uneventful and sutures were removed on t he third post-operative day. Two days later he developed fever,
chills, and diarrhea consisting of 5 - 6 watery stools per day. The
diarrhea was accompanied by nausea and vomiting but NOT by abdominal pain. These gastrointestinal symptoms lasted for 4 days and were accompanied by what the patient described as total anuria (did not pee). He also reported what he perceived to be delusions, especially when trying to fall asleep at night. At about the same time he also
developed generalized erythroderma (redness of skin, does not blanch. looks like sunbunr), which lasted a few days. His wife, a nurse, observed petechiae on his lower legs. With all of
these symptoms he remained at home. One week after the onset of the fever his herniorrhaphy wound
opened and serosanguineous fluid began to ooze from it. He
continued to feel malaise. The day prior to admission he was seen by his surgeon, who began treatment with an oral tetracycline. However, because of the severity of his symptoms and because of abnormal blood tests, he was admitted to the hospital the next day. The only significant aspect of his past history was allergy to penicillin, manifest as hives. The temperature was 100.8oF, the pulse 90/minute and regular,
the blood pressure 130/75. The herniorrhaphy wound was open, with tender, indurated (hardened), erythematous margins. Serosanguineous
material was oozing from it. Dumb high white count, anemic (explains the petechia). There was damage to liver cells. After debridement of his wound and one day of treatment with clindamycin and tobramycin he noted distinct improvement in his
sense of well-being. His temperature fell to normal. Clindamycin IV was continued for a total of 7 days, followed by another three days orally. On about the fifth hospital day, sixteen days after the onset of his fever, he noted peeling of the skin of the palmar surfaces of his thumbs. This was followed, over the next three
days, by generalized desquamation of the skin of his hands and knees, and, to a lesser extent, his feet. The peeling made the diagnosis straight forward.
Peeling of skin = Staph aureus. No questions asked.
Patient was suffering from toxic shock syndrome. Screwed up his blood, liver, kidneys, gi, cns….
Long acting tampons can also lead to spread of staph aureus.
This 27 year-old woman, six months pregnant, was well when she cut her left
index finger 24 hours prior to this visit. About 12 hours later she noted pain in her
left hand, especially with dependence, and
tingling up her left arm. The night before this visit she noted red streaks going up her left arm. She had no fever, chills, diarrhea, or any
constitutional symptoms. She has no known allergies and, specifically, she had taken penicillin in the
past with no adverse effects. On examination, she was afebrile to touch
(Experienced docs can tell, although it is
ideal to use a thermometer.)
A 1 cm laceration was present on the lateral aspect of the proximal phalanx of
the left second finger, with a very minimal collection of purulent material within it. There was very slight erythematous streaking on the arm up to the elbow. Because of the utterly typical presentation and the relatively low degree of severity, she was treated with oral phenoxymethyl
penicillin 500 mg QID. The next day, she was much improved. The collection of pus spontaneously
drained, and she completed the prescribed course of oral penicillin.
The lymphmatic streaking (breach of integument, rapid development of lymphangitis) is notably caused by only ONE organism: GROUP A STREP. Treat with penicillin. Skin strep can cause glomerular nephritis.
This 66 year-old man complained of a “BLACK SPOT” in his visual field since the day before hospitalization.
He had a long history of non-insulin-dependent diabetes mellitus. He had been feeling well until one week earlier, at which time he noted the sudden onset of shaking chills lasting about 20 minutes. The chills were accompanied by low back pain that radiated into
the medial aspect of both thighs and occurred several times over the next few days. About two days after the onset of the chills he
developed pain, swelling, and erythema of his left hand. The next day he noted a “black spot” obscuring part of his vision with his
right eye. The next day he had complete loss of vision in this eye. An ophthalmologist detected a hypopyon (collection of us in anterior chamber) of the right eye and treated him with a subconjunctival injection of gentamicin 80 mg
and methylprednisolone (a glucocorticoid anti-inflammatory) 40
mg, together with gentamicin eye drops and atropine (an anticholinergic)
eye drops. The back and hand pain became worse the
next day and, because the hypopyon had become much worse the
following day, the ophthalmologist admitted the patient to the hospital. A small amount of frank pus was aspirated from the anterior chamber of the right eye just before he was sent to the hospital. The patient’s diabetes had been well controlled with an oral agent
and diet. There was no history of ocular trauma. The temperature was 97.8oF, the pulse regular at 90/minute and the blood pressure 160/90. The right cornea was opaque. A dense hypopyon along its lower half obscured the retina on attempted
funduscopic examination. The intraocular pressure was palpably
increased.
There were erythema, swelling, warmth, tenderness, and very
decreased range of motion of the third, fourth and fifth MCP joints
of the left hand. A small, healing laceration was noted on the left shin. The WBC was 16,500/μL (78% PMNs, 20% band forms and 2
lymphocytes).
Note that uncontrolled DM screws up PMNs, so that they are no longer good phagocyThe paitent had pus buildup in his eye, and he showed all the signs of artheritis (warmth, tenderness, swelling, erythema, decreased range of motion).
Always start with a gram stain. Always. IN this patient, it was gram pos cocci. White cells were present in stain. Some of the cocci were in chains. This is strep cocci.
Guy had endocarditis. got to the blood stream. Streptococci got in from his initial shin injury.
This 25 year old woman developed fever the day after the birth ofher second child. She had always been well and had emigrated from India to the US seven years earlier. Her first pregnancy, four years later, resulted
in a healthy baby girl, who was well at home throughout the patient’s second pregnancy. The patient was admitted to the hospital in active labor at the term of her second pregnancy.
Vaginal examination revealed meconium-stained amniotic fluid (feces from the baby. Never normal. Means baby is in trouble), and so the patient was taken to the operating room for emergency Cesarean section. Prior to the administration of anesthesia, labor had progressed to the point that a healthy, full-term female infant was delivered vaginally. The mother developed a temperature of 102oF on the first postpartum day. She was treated with oral ampicillin 500 mg every
6 hours. Temperatures continued to peak at 101 – 102oF, accompanied by mild headache and a sense of chilliness. Further questioning at the time of the consultant’s visit indicated that the patient is a vegetarian and had, during the week prior to
parturition, consumed several meals consisting of pizza with extra
Mexican-style cheese. Her three year-old daughter had had otitis media two weeks before the patient went into labor, but was well
at home at the time the patient was admitted to the obstetrical unit. Physical examination done in the early afternoon of the third postpartum
day revealed an alert woman in no distress. The temperature was 99oF. The general physical examination was within normal limits. The uterus was enlarged as expected following a delivery. The lochia was normal in amount, appearance, and odor.
The blood count was within normal limits, as was the chest film. Blood cultures, taken when the fevers began, yielded an aerobic,
motile, β-hemolytic gram-positive rod.
“aerobic, motile, β-hemolytic gram-positive rod.”, Vaginal growth. Had tumbling motility. Caused infection in a parturient woman. This is none other than lysteria. Lysterisa grows best in fridge temp. Cook your food. The source of infection for the cheese she ate. The only reason ampicillin failed here was becasue it was taken by mouth. Wrong path to get to blood. SHe woould need to take an IV version of it.
This 56 year-old man was admitted because of progressive lethargy of two days’ duration. He had been well until several weeks before admission, when a
complete blood count done for his annual physical examination
was noted to be abnormal. Further studies led to the diagnosis of
a B-cell proliferative disorder which could not be well characterized
but was felt, for practical purposes, to be a lymphoma. He
was treated with vincristine and prednisone (potent drugs which
are active against this type of malignancy). He remained in his usual state of health until two days prior to
admission, when he was noted by his family to be increasingly
lethargic. On the day of admission he was unable to walk, even
with assistance.
At the time of admission his temperature was 105oF and his neck
was rigid. He was confused and dysphasic (had difficulty naming
common objects). The remainder of the physical examination was
unremarkable. The peripheral white blood cell count was 6100/μL, with 50%
polymorphonuclear leukocytes, 14% bands and 32% lymphocytes.
Examination of his cerebrospinal fluid (CSF) revealed 1384
WBC/μL, of which 96% were PMNs. The protein concentration was
111 mg/dL, the glucose concentration was 7 mg/dL. Gram stain of
the “whole” CSF revealed numerous PMNs but no visible bacteria.
Gram stain of the CSF sediment after centrifugation revealed
occasional gram-positive rods among many PMNs. When cultured
they exhibited “tumbling” motility and β-hemolysis.
This guy was cliniclally presenting with meningitis. Low glucose = acute bacterial process of CNS. Tumbling = listeria. end of story. Looks like chinese characters. The lymphoma made invasive infections like listeria more likely. Also, if they knew it was listeria int he beginning, they would have used ampicillin instead. The listeria took advantage of the powered T cell function.
This 39 year-old woman was admitted with fever and cough which
had been present for several days. The patient had a long history of productive cough and in 1976
invasive studies documented bronchiectasis (repeat damage of the same part of the lung, screwing up ability to treat bacteria in that area.). She was treated with
antibiotics and had no further physician contact until 1982, when she developed pneumonia. This resolved with antibiotics. She had
daily cough productive of green sputum and was treated with inhaled bronchodilators for “asthma.”. In 1991 she again developed pneumonia. Non-invasive studies
confirmed bronchiectasis of the left lower lobe and lingula. With
antibiotics this pneumonia resolved, and for several months prior
to admission she took a second generation cephalosporin one out
of every four weeks. This was changed to azithromycin shortly before admission, and, because of increasing fever and productive
cough, to trimethoprim-sulfamethoxazole. Her symptoms became
worse and she agreed to be admitted to the hospital.
There was no exposure to dusts, fumes, danders or toxins. A parrot was the only house pet. The temperature was 103oF. She was alert and in no distress. The
chest was resonant throughout with diffuse coarse wheezes. The
fingers and toes were mildly clubbed. The chest film revealed right lower lobe pneumonia. Expectorated
sputum showed many filamentous, branched gram-positive rods.
These failed to grow in cultures on this occasion but had grown,
aerobically, from sputum cultured in 1991.
Clubbed finger s and toes, pneumonia, gram pos rod that were aerobic. bacteria: Nocardia. Note Actinomyces looks exactly like this, but it grow ANAEROBICALLY.
This 32 year-old man complained of pain and swelling of his left
forearm for eight days.
He had always been well. At 14 years of age he began to inject himself with heroin and cocaine. Eight days before admission he
missed his vein while injecting his left forearm. The area became tender, swollen, warm, and red in the next few days. The day before admission he again injected his left forearm, near the previous site, again missing the vein. By the next day he had developed fever, chills, and sweats, and the pain in his forearm had become intolerable. He was therefore admitted to the hospital. In addition to a temperature of 102.4oF, remarkable findings were
confined to the left forearm, which was swollen and exquisitely tender, with erythema and increased warmth. Crepitus (bubble wrap feelin) was absent. He was treated with intravenous nafcillin, and over the next two days the signs of inflammation of his forearm increased markedly
and progressed proximally. X-ray of the forearm, initially having shown only soft tissue swelling, now revealed gas within the soft tissues. The antibiotic regimen was changed to clindamycin and gentamicin,
and the patient was taken to the operating room, where he
underwent exploration of the forearm and debridement of foulsmelling
necrotic tissue. Gram stain of this material demonstrated
gram-positive cocci and rods and gram-negative rods of several different
sizes, in a field of polymorphonuclear leukocytes. Cultures
yielded α-hemolytic Streptococci, an anaerobic diphtheroid, and
Prevotella buccae.
Inintailly treated with naficillin becasue it was thought htata staph was introduced through the injections. Gas within soft tissue + soft tissue swelling. Patient had both gram pos and neg in the smear. Culture was alpha-hempolytic streptococci. The fact that the organsim produced gas means nothing. Too many organisms do that. The foul small came from the FAs that it metabolized. FA breakdown smells foul. The cocaine is a vasoconstrictor, so it sets up an anaeerobic environment (strep is anaerobic.) Factors that favor anaerobic growth:
1. Compromised vascular supply
2. Trauma (needle sticking)
3. Tissue destruction (needle sticking)
4. Antecedent aerobic infection, leading to
necrosis and reduced tisssue oxidationreduction
potential and reduced tissue
oxygen concentration
This 63 year-old man was seen in consultation because of an abrupt
deterioration in his clinical status. He had had a long history of diabetes mellitus and peripheral vascular
insufficiency. He was admitted to the hospital for treatment of an ulcer which had been present on his left great toe for several
months. Because of inability of medical therapy to resolve the ulcer, he underwent amputation of his left leg below the knee. On
the first post-operative day he developed a temperature of 101oF, and on the second post-operative day he became disoriented and
his temperature reached 105.2oF. His stump was mottled and violaceous (purple), with the most distal areas frankly necrotic. Crepitus (bubble wrap) was palpated up to his patella, and an x-ray showed soft tissue gas extending to the level of the distal femur. Gram stain of material from a crepitant area of the stump showed abundant large gram-positive rods, smaller gram-negative rods, and
many polymorphonuclear leukocytes. Based on the clinical picture and the gram stain, he was treated
with massive doses of penicillin and gentamicin and was taken
promptly to the operating room, where he underwent a mid-thigh
amputation. He remained febrile and toxic for two days following
the second amputation, but the subsequent post-operative course
was uneventful. His hemoglobin was stable at normal levels both
before and after the surgery
Large gram pos rods with central spores. “Crepitus at the operative site and rapidly advancing gas on x ray” suggests that the gas is H, as would be produced by Clostridium profinges. The gas = virulence factor, as it allows the bacteria to travel proximal plane. DM amputation stumps are more predisposed to these bacteria. Clostridium propogates an alpha toxin, which kills rbcs.
This 58 year-old woman was admitted to the hospital with the abrupt onset of swelling and blisters of her left arm. The patient had been in good health until the day before admission.
She had been working in her garden and thought she might have pricked her elbow on a thorn. The next morning she awoke with
swelling and redness of her elbow. Within two hours the redness and swelling had spread to her entire left arm and her anterior and
posterior chest wall. She was alert and quite apprehensive. The temperature was 101oF,
the pulse 88/minute, and the blood pressure 110/70. The left upper extremity was swollen, purple-red and tender, and there
were bright erythema and many areas of purpura in a patchy
distribution involving much of the anterior and posterior chest wall.
In addition, within the areas of redness, swelling and purpura there
were many bullae, some measuring several centimeters in size.
These were tense and filled with cherry-red fluid.
HELLA LARGE BULLAE with Red Fluid within, spread all across region (arm in this case)+ Rapidly spreading gas + drop in hemoglobin + large gram pos rods + alpha toxin. This is clostridium septicum. Treat with penicillin + hyperbolic chamber (clos is anaerobic). THIS IS GANGRENE. Proven by the cancer of the cecum discovered in autopsy.
This 60 year-old woman was seen in consultation because of a skin
lesion and fever which had been present for 24 hours.
She had been in failing health for many years because of chronic
active hepatitis (almost certainly hepatitis C). Recently, because of
progression of liver disease, oral prednisone at a dose of 60 mg daily had been begun (because at that time specific anti-viral
therapy was still decades away). The day prior to admission to the
hospital she developed fever and chills. When she arrived at the
hospital she complained of pain in her right knee and thigh. On physical examination she was stuporous with minimal response to painful stimuli. The temperature was 100oF. Remarkable
findings, in addition to her mental status, included pitting edema of
the right thigh and leg and areas of erythema of both thighs and
legs. On the medial aspect of the right lower extremity, proximal
and distal to the knee, there was an area of purpura. Within this
area there were bullae, one of which was filled with red fluid. Floating within this fluid were many tiny bubbles. Palpation of the
leg and thigh did not reveal crepitus. Passive extension of the wrists brought out marked asterixis.
Bullae, CNS issues, liver failure, bubbles in the bullae, PITTING edema, gram stain: gram neg rods. THIS IS E. COLI! Gas was proably CO2, as is produced by E Coli. Person was presenting with hepatitis C…and this is currently a curable disease.
