Micro cases - unit 4

How is this disease treated? Does the state health department need to be notified?

- Combination of antibiotics (multi drug therapy) - Given by IV (intravenously) - Antibiotics are usually taken for 60 days because it can take spores that long to germinate - If anthrax toxins have been released in the body, one possible treatment is an antitoxin. Antitoxins target anthrax toxins in the body. Antitoxins must be administered simultaneously with other treatments - Serious cases require aggressive treatment, such as continuous fluid drainage and help breathing through mechanical ventilation - All levels of health departments get notified, including state and the CDC

What do you think Rhonda has? Why would her stools be black?

- Gastritis and Gastric Ulcers - Ulcers cause irritation in the esophagus and stomach which causes bleeding. That blood mixes with digestive fluids to turn stool black.

What do you think George's test will reveal?

- George's test will reveal he has the Herpes simplex 2 virus - This is a sexually transmitted infection - HSV-2 is a latent virus meaning it can be asymptomatic for periods and then symptomatic periods

Are there other disease caused by this organism?

Bacillus anthracis causes cutaneous, inhalation, gastrointestinal, and injection anthrax Cutaneous anthrax: Caused when anthrax spores get into the skin, usually through a cut or scrape (affects skin and surrounding tissue) Injection anthrax: symptoms similar to cutaneous anthrax, but infection is deeper to the skin or in the muscle where drug was injected. Have never been reported in the US. Gastrointestinal anthrax: occurs when person eats raw meat from animal with anthrax.

What are the TORCH infections?

Infections in newborns that can lead to things such as jaundice, bleeding under the skin, difficulty feeding, organ abnormalities, and/or delayed growth and maturation. - Toxoplasmosis - Rubella - Cytomegalovirus - Herpes simplex - Other organisms including syphilis, parvovirus, and Varicella zoster. Zika virus is newly considered part of the TORCH infections.

What other types of infections can this organism cause in kids?

Otitis media (middle ear infection) Bacterial conjunctivitis (Pink eye) Epiglottitis

Another friend says that her sister gives her baby apple juice every day. Why might she be concerned?

Outbreaks of E. coli have been associated with unpasteurized apple juice and apple cider made from apples contaminated with E. coli. A baby's immune system is not very strong, so E. coli could be hard for the baby to fend off. In young children, E. coli can lead to a serious complication called hemolytic uremic syndrome which, in the worst cases, can lead to kidney failure.

Case #1

Renee, your cousin, is about to undergo fertility treatments. Her doctor insists that she receive the rubella vaccination and then wait a few weeks before beginning treatment. Renee calls you and wants to know why she has to do this. You ask her if she has a record of having been vaccinated for rubella (German measles). She says no. "But I had German measles when I was in second grade!" she says. "I remember that I was really sick and missed almost a month of school." You suggest that she follow her doctor's advice and get the immunization.

Case #7

You are at a UVA basketball game when a fan in the stands next to you experiences dizziness and nearly faints. You tell him that you are a nursing student and that you have your stethoscope and blood pressure cuff with you. He reports that he has had a headache off and on since he had a tooth extracted four days ago. This evening he is feeling weak. His blood pressure is normal. When you listen to his heart you note that he has a pronounced murmur. He reports having had rheumatic fever 15 years ago. You examine his fingernails and fine one that has tiny petechial hemorrhages under it.

Case #10

You are at dinner with some of your friends. A local outbreak of E. coli O157:H7 has been in the news. They turn to you to ask you if you think they should order hamburger or steak. You tell them to order the steak.

Case #3

You are the school nurse at Hermitage Elementary School. This morning Miss Johnson brings in a first grade girl named April. Her right eye is swollen and bloodshot. The lining of the lower lid is bright red. There is a thick yellow discharge in the corner of the eye.

Why steak instead of hamburgers?

- Ground beef is more dangerous than steak because pathogens are generally found on the surface of the meat, so when it is ground up, the pathogens disperse throughout the meat, beyond the surface. If the pathogens have been dispersed throughout the ground beef, the burger must be cooked completely through, otherwise the person eating will be at risk. Steak is typically seared on both sides (where the pathogens are found), which will kill off any lingering pathogens. - E. Coli is commonly found in the intestines, and since hamburger is usually different parts of the cow ground together, it could include parts of the intestines more easily than steak (which is usually one cut)

Should he break up with Lisa or is it possible that she never knew that she carried this pathogen?

- He should NOT break up with Lisa, she likely contracted HSV-2 before they started dating - It is possibly that Lisa never knew she had the HSV-2 - 1 and 5 women have the virus, but it can be dormant in the body (not showing symptoms) - Most people who are infected are unaware (87.4% of people ages 14-49 are unaware)

Can Joe go to kindergarten today? Why or why not?

- Joe can go to Kindergarten today! - According to Cleveland Clinic, a child is no longer contagious with Fifth disease once a rash appears. However, he may have spread it before and during the time he had symptoms.

What is the most likely diagnosis? What would the causative microorganism look like in a gram stain?

- Lyme Disease (Borrelia burgdorferi) - Rickettsia rickettsi - Gram -, loosely coiled spirochete

Why did you look at his fingernails?

- Patients with bacterial endocarditis can develop petechial hemorrhages. - These are sometimes referred to as splinter hemorrhages because they resemble small, dark splinters under the skin. - Hemorrhaging is caused by clots that damage small capillaries underneath nails, or swelling of blood vessels.

Why would a fertility specialist recommend the rubella vaccine?

- Pregnant women are at increased risk for miscarriages, stillbirths, or having an infant with birth defects characterizing Congenital rubella syndrome (CRS) if contracting the virus. - Potential risks of CRS include blindness, deafness, and heart defects.

Does the description of Renee's second grade disease sound more like rubeola (measles) or rubella (German measles)? Why?

- Renee's second grade disease sounds more like rubeola. Rubeola is more severe than rubella and lasts longer. - If Renee had rubella, she probably would not have missed a month of school.

What are the symptoms of E. coli O157:H7 infection?

- Stomach cramping or pain - Vomiting - Nausea - Diarrhea (ranges from mild to severe and bloody)

Although the diagnosis should be confirmed with lab tests, the tests should probably not be performed in the hospital lab. Why not?

- The botulinal toxin is extremely toxic and is one of the primary hazards in a laboratory - Inhalation or ingestion can lead to serious problems - Hospital laboratories avoid this test for the safety of the workers and patients

What is the most likely causative organism and the diagnosis?

- The causative organism is most likely Haemophilus Influenzae. - Her diagnosis is meningitis.

Would there be a way to test Renee to see if she had either been vaccinated against rubella or hard rubella?

- The doctor could take nasopharyngeal swabs/aspirates or blood samples from Renee. - The nasopharyngeal swabs/aspirates can be cultured or PCR tested (create large amounts of DNA from a small sample) to detect prior vaccination. - IgG and/or IgM antibodies can be searched for in the blood samples.

How should George be treated? Will he be cured?

- There is currently no commercially available vaccine for herpes - George can take antiviral medication to prevent/shorten his herpes outbreaks - Also, if George takes antiviral medication for herpes daily, he can reduce the likelihood of transmission to his partners However, there is currently no cure for herpes

Which cardiovascular infection do you think this is?

- This cardiovascular infection is subacute endocarditis - The subacute endocarditis is a result of pre existing heart conditions from the rheumatic fever and brought on by a-Hemolytic Streptococci - Viridans Group - Subacute endocarditis is a more serious infection that allows blood borne bacteria to settle and grow on the heart

What should be administered to Kevin at the earliest opportunity?

- We believe that Kevin should be administered the botulinum antitoxin immediately, which will work to block the effects of the toxin from working on his CNS. - We will NOT be administering Penicillin G, as the bacterial cell death can cause more harm than good in cases of infant botulism.

Why are young children vaccinated?

- Young children receive the vaccine because like immunosuppressed adults, they are typically asymptomatic and decreases the risk of the child getting liver disease and liver cancer. - Also prevents children from becoming future carriers of the virus. - Children in the first 5 years of life are usually highly contagious, so the disease could be spread unknowingly since it is asymptomatic. - Younger babies could potentially be spreading it through their drool (also found in saliva)

Is this infection rare?

- common viral infection among school-aged children because it is spread by direct contact with nose and mouth fluids and mucus - it is a mild infection, so a percentage of the infected are unaware they have it - it is rare in infants and adults

If her test is positive, what are four medications that will probably be used to treat her?

1. Isoniazid. 2. Rifampin (Rifadin, Rimactane) 3. Ethambutol (Myambutol) 4. Pyrazinamide.

Name 2 types of medications that might be prescribed

Antibiotic medications to kill H. Pylori: - Clarithromycin - Amoxicillin

Are there steps the teacher should take to prevent the spread of this infection in the classroom?

April should be sent home until all of her symptoms clear up which should be in two to five days if she receives treatment. The teacher should clean every commonly used surface in her classroom since this is highly contagious and easily spread. She should also watch for any symptoms in her other students.

What is another name for this? How might Lane have contracted this disease?

Another name for anthrax is woolsorter's disease because anthrax is commonly associated with wool. Lane could have contracted this from the drums which were made of a spore-contaminated animal hide.

What is your suspicion, based on what seem to be nervous system symptoms?

Botulism Nervous System Symptoms: - Blocks neuromuscular transmission by hindering the release of AcH from motor nerve endings - Paralytic ileus leading to constipation - Gastric Dilation - Slowed Reflexes - Paralysis with weak muscles, including eye muscles - Urinary Retention

Are there any areas here in the U.S. where we might be concerned about getting either disease?

Cases of Dengue Fever in the contiguous United States are rare and usually arise from travelers who were infected elsewhere. However, it is common in Puerto Rico, the Virgin Islands, and American Samoa. Zika virus is no longer in the United States and has not been seen here since 2016/2017.

What do you think Mark is suffering from? Is there any significance to the lack of a sanitation system in the village he was visiting?

Cholera The village's lack of sanitation more than likely was the reason for him getting the disease, as there is no way to decontaminate and get rid of bacteria from feces. If everyone is drinking from the same shallow well, it is very possible that the water Mark drank was contaminated, especially after a heavy rain.

What is the most likely diagnosis and what are the main pathogens that may have caused it?

Diagnosis: Bacterial Conjunctivitis ("pink eye") Main pathogens: Haemophilus influenzae or Streptococcus pneumoniae; Chlamydia trachomatis

What is your diagnosis? Why was his throat checked?

Fifth Disease. His throat was checked to rule out scarlet fever, as scarlet fever is associated with strep throat and could have a very red sore throat and different kinds of spots in the mouth. It also helps to rule out Rubeola (measles) as you can check for Koplik spots in the mouth.

Case #14

George and Lisa's whirlwind romance began six months ago with a blind date, followed by long walks along the lake, candlelit dinners and a shared love of classic films. One morning George feels a burning sensation when he urinates. He then notices small red bumps on his penis that hurt when he touches them. In the next few days, the lesions enlarge into blisters. George feels achy and tired. He also notices that the lymph nodes in his groin are swollen. Alarmed, George visits the urgent care clinic. At the clinic they swab the lesion and send it to a lab for testing. George can't believe what is happening. He and Lisa had been dating exclusively.

Should George and Lisa be tested for other STDs? Is this a notifiable disease?

George and Lisa, as sexually active adults, should be tested for STDs at least once per year. Since they are exclusive, they might not feel that they should, but keep in mind that some STDs, like HIV, can sometimes be only detectable months after exposure, so testing positive for them doesn't mean they cheated if they have been dating exclusively only recently. Herpes is not a notifiable disease, since it's not required by law to report it to government authorities.

Why was the child's unvaccinated status helpful in diagnosis?

HIB is a commonly required childhood vaccine and since she has not gotten it, we could not rule out that as the cause.

The ER doctor says he wants to order an endoscopy and biopsy? Which bacterium would they be looking for?

Helicobacter pylori

Your brother-in-law comes on the phone and states, "The vaccine is not safe! It's one of those genetically engineered things!" How do you respond?

Hepatitis B vaccine is FDA approved and is normally given to children from a young age. Due to this we would say it would be more unsafe to not vaccinate the child. The HBV vaccine has an 80-100% rate of prevention, therefore their child's chance of acquiring HBV would be greatly reduced.

Are there any complications associated with this infection?

If the child is healthy there are normally no complications. - However if the person (usually an adult) infected with Fifth disease has a weakened immune system due to cancer, organ transplant, or HIV there can be serious complications. (chronic anemia) - infection during pregnancy can sometimes affect red blood cells in the fetus.

Case #2

In late September, a woman brings her 12-year old daughter, Sophie, to the family doctor. Sophie shows the doctor the back of her thigh where there are pale red, non-raised discolorations. The rash covers a wide area of the thigh and seems to be roughly circular. The center of the circular area appears normal. Sophie has no other symptoms, but her mother brought her in because the rash has been present for almost a month. The doctor asks Sophie about whether she has been in woods and whether her joints hurt? Sophie reports that she spent the previous month at summer camp in Vermont.

How do babies acquire this condition?

Infants up to 12 months of age can acquire infant botulism through: - Raw Honey - Contaminated home canned food - Contaminated soil or dust

What are the recommendations to travelers to try to prevent contracting this disease? Can you describe if there a vaccine available in the United States?

It is recommended that travelers receive a vaccination for cholera before going anywhere. Vaxchora, a single-dose oral vaccine, was approved in 2016 by the FDA and is currently the only FDA-approved vaccine for cholera in the United States.

What type of microbe causes this infection? What would it look like under the microscope if you Gram stain it?

It is the bacterium Vibrio Cholerae. Under the microscope, it is a gram-negative bacilli.

Why does the doctor ask if Sophie's joints hurt?

Joint pain is a common symptom if left untreated Bacteria can cause inflammation of the tissues which leads to joint pain - especially in the knees

What do you think the diagnosis might be? Which organism causes this?

Lane Kim has Inhalation Anthrax. Inhalation Anthrax is caused by Bacillus anthracis, a gram positive spore-forming bacillus.

Case #16

Lane Kim, a 20 year old drummer, is doing her best to ignore the cold sweat that is breaking out all over body. She has actually been feeling weak and short of breath for the last 3 days or so. She makes it to the end of the second set, but the noise from the clapping and cheering seems to come from far away. She stands up to bow and collapses. She is admitted to a local ER with a mild fever and severe shaking. She is able to tell the admitting nurse that she also has had a dry cough for the last few days. The attending physician orders a chest X-ray and sputum analysis. The X-ray shows bilateral pneumonia. The lab reports Gram positive spore forming rods. The attending physician is astonished.

What is the illness?

Malaria

Case #15

Maria is in Brazil having the vacation of a lifetime. She spends her mornings scuba diving and in the afternoons she lounges on the beach. Aside from a sunburn and a few mosquito bites, she truly feels like she is relaxing in paradise. Shortly after returning from vacation, however, Maria comes down with a pounding headache and a high fever. Her joints hurt, a rash appears on her arms, and she feels a stabbing pain behind her eyes. She calls her brother (who is taking Microbiology at a big university in Southwestern Virginia) and he tells her not to worry because she isn't pregnant.

Case #12

Mark is a nurse in Charlottesville. Every summer he spends a few weeks in Africa volunteering in a rural village. The village has no sanitation system and gets it water from a nearby shallow well. During the last week of Mark's most recent trip, torrential rains hit the country causing flash floods. Soon after, Mark returns to Charlottesville. A day later, he begins experiencing diarrhea. At first, he brushes it off as "traveler's diarrhea". However, over the following days his symptoms worsen. The diarrhea is more severe than anything he has ever experienced before; it is watery and contains flecks of mucus and smells fishy. Mark also develops nausea, vomiting, and muscle cramps. He tries over-the- counter diarrhea medicine, but nothing he does relieves the symptoms?

When do most children in the U.S. receive their rubella immunization?

Most children in the U.S. receive the MMR vaccine that protects them from measles, mumps and rubella. The first dose is often given between 12 and 15 months, and the second dose is given between 4 and 6 years.

What bacterium was Pippa exposed to on the flight?

Mycobacterium tuberculosis

One of your friends says that she'll order a salad instead. Will that guarantee her safety?

No. This strain of E. Coli is just as likely to be found in beef as it is lettuce. Furthermore, while there is a chance that E. coli could be killed off through cooking, this does not apply to a salad.

Can a person with this infection transmit it to others? Explain.

Not directly. Malaria is an infectious disease, but it is not a communicable disease. It is not airborne or transmitted from person to person. In fact, malaria is a mosquito-borne disease which means that it is transmitted through mosquito bites.

What's the connection, if any, with rheumatic fever?

Rheumatic fever: pharyngitis in children; carditis with extensive valve damage Persons with preexisting heart diseases such as rheumatic fever are at higher risks for developing subacute endocarditis due to potentially extensive valve damage As mentioned in the case study, the fan reported having rheumatic fever 15 years ago - His heart was already weaker and more susceptible to other infections

Case #13

Rhonda is a Biology major who takes a full load of classes during the day and works at Boylan Heights four times a week. Rhonda loves spicy food and she eats a lot of it. She also likes to drink wine with dinner on the weekends and sneaks an occasional cigarette. One night Rhonda noticed a burning pain in her upper abdomen. It disappears after a few minutes but then comes back a couple of nights later. Pretty soon she is feeling the pain every night, sometimes accompanied by nausea. Then one day she notices that her stools are black. She rushes to the ER.

How should Sophie be treated?

Should be treated with antibiotics

Your sister says that she'll also remind him that there were three hepatitis outbreaks traced back to restaurants last year. Is that a good argument?

Since Hepatitis B is not spread through food or eating utensils, it would not be considered a good argument to trace it back to restaurants. Hepatitis A, however, is linked to food. Hep. A like Hep. B also affects the liver, however, Hep B spreads through blood to blood contact while Hep A can spread through through the consumption of contaminated water or via the fecal-oral route.

The medical student mentions that he has heard that you can do a breath test to diagnose this. What is he talking about and how does it work?

The breath test is used to detect active Helicobacter pylori The patient is asked to breathe into a bag. This air will be used as a base for comparison. The patient will swallow a capsule or liquid solution containing urea, which is made from an isotope of carbon. After 15 minutes, they will breathe into another bag. The two samples are then compared to check for an increase in carbon dioxide. - If H. pylori is present in the stomach, the urea is broken up and turned into carbon dioxide.

What does Maria's brother think she may have? What do YOU think Maria may have gotten on this dream vacation aside from a tan? Should she take her brother's advice or should she seek medical attention?

The brother thinks she has Zika virus We have diagnosed her with Dengue Fever She should definitely seek medical attention

Why does she have to wait so long to be tested?

The disease is in its incubation period. The infection will take several weeks before it will cause a type IV hypersensitivity reaction in her skin.

Is your sister's husband correct about the transmission of the virus? Elaborate.

The husband is correct when stating that Hepatitis B is transmitted by sexual contact and drug use but he is incorrect when he states it is the most common mode. There are other risk factors that contribute to increased exposure such as through household contact, tattooing, and needlesticks (blood transfusion). In the case that the child in the future wanted to receive a tattoo, have blood drawn, or comes in contact with an individual who is a carrier, it is in his best interest to be vaccinated.

What is the treatment for this condition? Is the condition communicable?

The treatment for this condition is applying antibiotic drops or ointment to the affected eye. Pink eye is highly contagious. Early diagnosis and treatment will help to shorten the length of infection and reduce the spread to others. With treatment April can expect to return to school in 2 to 5 days. Without treatment it could take up to 2 weeks for symptoms to go away and the risk of transmission to be gone.

Case #9

The jet finally takes off from the airport in Addis Ababa, Ethiopia. Pippa, a second year law student, just spent two months volunteering for a law firm specializing in human rights issues. The next stop, 15 hours later, is Washington, D.C. Pippa is about to settle in to study, but is interrupted by the constant, deep coughing of a woman sitting next to her. The woman is very thin and looks pale and tired. She turns down the meals offered to her. Her loud coughing continues for the entire flight and she rubs her chest as if it hurts. A month later, Pippa opens a letter from state department of health and learns that she was exposed to a potentially deadly bacterium on that flight. The letter advises her to get a skin test to determine whether she has been infected, but it tells her to wait for eight more weeks before getting this test.

What are two main places in the human body that are exploited by the microorganism that causes this disease?

The liver and red blood cells are exploited by the microorganism. Once you're infected, the parasites travel to your liver, and as they mature they leave the liver and infect your red blood cells. This is usually when symptoms begin.

If while on these medications, she becomes jaundice, what do you suspect?

The medications she is on is causing liver damage and failure.

What is the most likely causative agent? Would netting for their beds help prevent the disease?

The most likely causative agent is plasmodium parasites. Transmission occurs through the bite of a mosquito. Treated nets are one way to reduce malaria cases. When the mosquitos try to eat through treated netting they are killed.

What is the most likely causative pathogen and the route of transmission?

The most likely causative pathogen is a-Hemolytic Streptococci (Viridans Group) - Includes Streptococcus mutans, S. oralis, S. Salivarus, S. Sanguis, S. milleri, S. mitis Dental and surgical procedures allow entrance - People with pre-existing heart conditions may need prophylactic antibiotics before these procedures The bacteria is capable of settling and growing on the heart

What is causing the cloudiness in the CSF?

The phagocytic white blood cells within the CSF is what is causing the cloudy CSF.

What sign leads you to believe that the infection is bacterial in origin?

The thick yellow discharge, i.e. pus, is a sign that the infection is bacterial.

Is there a treatment? What is the best prevention?

Treatment - No specific treatment - Rest, plenty of fluids, and acetaminophen for the fever Prevention - Avoid mosquito bites by applying plenty of bug spray and wearing long sleeves and pants - A vaccine (Dengvaxia®) has been approved in the US for children age 9-16 living in areas where Dengue is common (American Samoa, Puerto Rico and the US Virgin Islands)

Mark comes over to your house and collapses. You call 911 and he is transported to the ER. Based on the diagnosis, what is the first intervention likely to be performed when the patient arrives?

We believe that Mark has collapsed due to dehydration and because of this would be given fluids first once he is at the hospital.

Would the above diagnosis be less likely if Sophie had attended a camp in Idaho? What is another disease that is transmitted in a similar way and what microorganism causes it?

Yes, deer ticks are not found in Idaho Rocky Mountain Spotted Fever (aka Tickborne Typus Fever) - Rickettsia rickettsi

Case #6

You are working in the emergency room and a 15 week boy is brought in who has become listless and is having trouble breathing. The parents report that the baby used to smile, but lately he has not smiled, nor has he had other noticeable facial expressions in the last two days. His eyes are open when he comes in, but he does not seem to be focusing. You place your out-stretched finger under his fingers and he fails to grasp it. You lift his foot and it drops back to the mattress. The parents report that he has not had a bowel movement in three days.

Case #5

You're doing a rotation in the hospital's lab. A sample of cloudy CSF arrives and you're told to Gram stain it and then to plate it on blood agar and chocolate agar. In the Gram stain you find gram-negative rods. You also find a lot of bacteria inside phagocytic cells. Later, the nurse tells you that the patient, a 3 year old girl, has not received any childhood vaccinations.

Case #8

You've decided to work in the Peace Corps right after graduating from nursing school. Your assignment is in a rural area in South Africa. In your first week you see several children with high fever, lots of sweating, and muscle aches. They all turned out to have the same infectious condition, on that you continued to see throughout your stay in South Africa. Up to half of the sick children did not survive this illness.

Case #4

Your nephew Joe is 5 years old. One day he comes down to breakfast with a bright red face. When you look more closely you see hundreds of tiny red bumps. He isn't acting sick and doesn't have a fever. He had chicken pox when he was 3 and his immunization schedule is up to date. He sticks his tongue out and his throat looks normal. Your sister mentions that he has had a runny nose and didn't feel well about a week ago, but seemed to be getting better. You suspect something viral.

Case #11

Your sister called you yesterday, upset about her recent visit to the pediatrician (she has a baby boy). Actually, she was upset about the discussion she had afterward with her husband who was adamantly opposed to having their son vaccinated against hepatitis B virus (HBV). Your sister called you because the doctor said that it is routine to vaccinate young children, but her husband believes that hepatitis B is mostly acquired through sexual contact and drug use and that it is ridiculous to vaccinate a child. Your sister wants your advice.

Compare the two diseases including signs/symptoms and how they are transmitted?

Zika Virus -Mild Fever -Rash -Joint or muscle pain -Headache -Red eyes (conjunctivitis) Dengue Fever -High fever (104+) -Headache -Muscle, bone, joint pain -Nausea/vomiting -Pain behind the eyes -Rash Similarities: Transmission by Aedes species mosquito bite, can be passed from pregnant mother to child