Case Number: 2 An otherwise healthy 22-year old man came to the emergency department with a history of urethral pain and purulent discharge that developed after he had sexual contact with a prostitute. Gram stain of the discharge revealed abundant gram-negative diplococci resembling Neisseria gonorrhoeae. The patient was treated with ceftriaxone and sent home. Two days later, the patient returned to the emergency room with a complaint of persistent, watery urethral discharge. Abundant white blood cells but no organisms were observed on Gram stain of the discharge. Culture of the discharge was negative for N. gonorrhoeae. 6. What is the most likely cause of his current complaint? a. Neisseria gonorrhoeae b. Chlamydia trachomatis c. Syphilis d. Chancroid e. HPV 7. What is the source of the infection? a. A toilet seat b. Improperly cooked food c. His own normal flora d. His sexual partner e. Deep puncture from stepping on a nail 8. Why did the ceftriaxone treatment fail? a. His strain of N. gonorrhoeae was producing beta-lactamase b. He hadn't taken his medication long enough c. He initially had a duel infection, and the ceftriaxone only killed the N. gonorrhoeae d. The drug given to him had degraded and was ineffective e. It just hasn't had time to work yet 9. Which laboratory test should be ordered to confirm the diagnosis? a. A nucleic acid test b. A serological test c. A routine culture d. A repeat Gram Stain e. A drug susceptibility test on the organism recovered two days ago. 10. What drug may be used to effectively treat this patient? a. More ceftriaxone b. Penicillin c. Azithromycin d. Rifampin e. Clindamycin
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The most likely cause of his current complaint is **Chlamydia trachomatis** since the initial treatment with ceftriaxone would have likely cleared a Neisseria gonorrhoeae infection, but not a Chlamydia infection. Show more…
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Case 2 (Respiratory Tract Infections) The patient was a 64-year-old retired postal worker with a medical history of extensive facial reconstruction for squamous cell carcinoma of the head and neck. He had a 30-year history of smoking. The patient presented with progressive shortness of breath, a persistent, productive cough, purulent sputum, and fever to 39.0°C 2 days prior to admission. On physical examination he had a temperature of 37.3°C, respiratory rate of 18 per minute, pulse rate of 103 beats/min, blood pressure of 154/107 mm Hg, and pO2 of 92 mm Hg. Chest auscultation revealed coarse breath sounds at the left lower base with bibasilar fine crackles. He was found to have a left lower lobe infiltrate on chest radiograph. His admission white blood cell count was 10,600/ul with 70% neutrophils, and his hemoglobin was 9.4 g/dl. Sputum Gram stain at admission revealed >25 polymorphonuclear cells and >25 squamous epithelial cells per low-power field. Because of the high numbers of squamous epithelial cells, the specimen was not processed further. Two blood cultures obtained at admission were positive for the organism seen in Fig. 8.1. The Gram stain from the blood culture bottle is shown in Fig. 8.2. The patient was admitted to the hospital and treated with ceftriaxone intravenously. Upon defervescence, he was discharged on a regimen of oral azithromycin based on the organism's identification and antimicrobial susceptibility results. Of note: this was the patient's third episode of this illness in the past month. Isolates from all three episodes belonged to the same serotype, type 23. Figure 8.1 Figure 8.2 1. What disease process was ongoing in this patient? What clinical prediction rules could be applied to this patient in determining whether he should be hospitalized? Why do you think the decision was made to hospitalize him? 2. What organism was causing this individual's infection? 3. What other patient populations are at risk for infection with this organism? 4. Two different virulence factors produced by the organism infecting this patient are important in disease pathogenesis. What are they, and what role do they have in the pathogenicity of this organism? 5. What strategies are available to prevent infections with this organism? Why are preventive strategies becoming of greater importance with this organism? 6. How do you explain the patients having repeated episodes of infection with the same serotype of this organism? There are at least two and possibly more explanations.
Match the microorganism that causes food- or water-borne disease with the unique characteristic that describes it. Norovirus Staphylococcus aureus Clostridium perfringens Clostridium botulinum Bacillus cereus Campylobacter jejuni Salmonella spp. Enterotoxigenic Escherichia coli Enterohemorrhagic Escherichia coli Enteropathogenic Escherichia coli (EPEC) Listeria monocytogenes Shigella spp. Salmonella typhi Vibrio cholerae A. One of most common bacterial foodborne causes of gastroenteritis, with more than half of all cases from consuming improperly prepared poultry. Rarely associated with Guillain-Barre Syndrome (GBS). B. Causes typhoid fever from fecal-oral transmission via food or water. Organisms are shed from gallbladder reservoir via intestinal tract from human carriers. 'Typhoid Mary,' a food handler (cook), was first human carrier identified for any disease. C. Causes bacillary dysentery from contaminated water or food sources via fecal-oral transmission. Very low infectious dose with ingestion of only 10-100 bacterial cells capable of causing disease. Humans are primary reservoir. D. Most common cause of foodborne intoxication. E. Produces potent neurotoxin causing flaccid paralysis and death; often associated with home canning. F. More than half of all cases caused by consumption of improperly prepared poultry or raw eggs. Often causes large, common source outbreaks. G. Major cause of infant diarrhea and mortality in underdeveloped/developing countries. H. Most common foodborne pathogen in the U.S. I. Causes frequent epidemics and pandemics of cholera, a water or food-borne disease. Loss of fluids and electrolytes, although easily treatable, often leads to death from hypovolemic (low blood volume) shock, and metabolic acidosis (pH imbalance), due to loss of bicarbonate buffer. J. Foodborne intoxication usually caused by consumption of contaminated meat. K. Most common cause of traveller's diarrhea. L. Pathogen capable of growth at refrigerator temperatures (4°C), and thus subject to frequent food recalls. Immunocompromised and pregnant women are particularly susceptible. Commonly associated with soft cheeses, luncheon meats, or hot dogs. M. Causes two different forms of foodborne disease: i) Emetic intoxication from ingesting contaminated and improperly refrigerated rice; ii) Diarrheal infection from ingesting contaminated meat or vegetables. N. May cause hemolytic uremic syndrome (HUS) and death. Often associated with ingestion of undercooked ground beef.
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