Medical Microbiology pathogenic Bacteria

A 63 year old man awoke early with nausea, vomiting, and confusion and was taken to a local emergency department for evaluation. His illness, which began 5 days prior to arrival at the ED, during a trip to North Carolina, was characterized by fever, chills, sweats, malaise, anorexia, and headache. He had a dry cough for the past 2 days. No history of chest pain, myalgias, dyspnea, abdominal pain, diarrhea, or skin lesions was reported. Past medical history included hypertension and cardiovascular disease. He did not smoke. T = 39.2 C, P = 109/min, R = 24/min, BP = 110/64 mmHg. On admission, the patient was alert and interactive but spoke nonsensically. Initial pulmonary, cardiac, and abdominal examinations were reported as normal. No nuchal rigidity was observed. He was not oriented to person, place, or time. A chest x-ray showed a widened mediastinum.

Bacillus anthracis. (Anthrax) - ciprofolaxcin

One summer evening, a 63 year old white man came to the emergency department of a nearby hospital presenting with a 6 day history of fever, moderate headache, generalized myalgia, arthralgias, and fatigue. He had noticed a rash under the armpit that day that had spread rapidly, prompting him to seek medical attention. He had lived in Connecticut and had recently moved to a cottage in a wooded area outside a small town. He noted multiple tick bites after his daily walks in the woods. He had otherwise maintained good health. T = 38.8C, P = 102/min, R = 14/min, BP = 134/82 mmHg. On exam, an expanding erythematous skin lesion (erythema migrans) was noted under the axilla that had a central area of clearing.

Borrelia burgdoferi (Lyme disease LD) - ceftriaxone, doxycycline

A 38 year old man developed a flu-like syndrome with fever, headache, and anorexia. During the ensuing 8 weeks, he noted continuing fevers, sweats, 30-lb weight loss, and depression. He saw his family physician, complaining of acute pain in joints, especially his lower back. He was a computer programmer and had recently traveled to Crete to visit his grandmother. During his stay on the Mediterranean island he enjoyed drinking unpasteurized goat milk. Six weeks after his return to the United States he developed the current illness. T elevated other vitals normal. On exam, generalized lymphadenopathy and mild splenomegaly were noted. Tenderness in his sacroiliac joint was also noted. Plain x-rays of the lumbosacral spine were unrevealing.

Brucella melitensis (presumptive diagnosis of brucellosis). Treat with doxycycline and rifampin.

A 9 day old female newborn was taken to a hospital by her parents, who reported a 10 hour history of an inability to nurse and difficulty in opening her jaw. The patient's parents had noticed a foul-smelling discharge from her umbilical cord during the preceding 2 days. T = 38 C, P = 130/min, R = 36/min, BP = 94/48 mmHg. The newborn had trismus, opisthotonus, and hyper-responsiveness to external stimuli. The umbilical cord was covered with dry caly, which when retracted revealed a foul-smelling yellow-green discharge.

C. tetani (tetanus)

A 27 year old woman presented to the emergency department of a city medical center complaining of lower abdominal pain, vaginal discharge, and dysuria for 1 week. She also complained of fevers and chills for the past 2 days. She had had four sexual partners in the previous year and used a contraceptive measure (condoms) only occasionally. She had never been treated for a sexually transmitted disease (STD), and she had not seen a physician in 2 years. T = 38.4 C, P = 104/min, R = 16/min, BP = 112/68. Pelvic examination revealed a reddened cervical os. Lower abdominal tenderness, adnexal tenderness, and cervical motion tenderness were noted. The uterus, fallopian tubes, and ovaries were also tender but were not enlarged.

Chlamydia trachomatis (and anaerobes) - tx azithromycin (preferred) or doxycycline

A 3 month old female infant was brought to the emergency department of a general hospital with a 5 day history of decreased activity, decreased oral intake, upper airway congestion, and general irritability. There was no history of fever or vomiting. During the previous 2 weeks, she had been constipated, and twice her mother had given her a tablespoon of honey for treatment. T = 36.1 C, P = 120/min, R = 20/min, BP = 90/65 mmHg. On exam, the patient was listless and slightly pale but otherwise well nourished, with weight and height above the 50th percentile for age. Positive findings included moderately dry oral mucosa, upper airway congestion, a sluggish pupillary response to light, mild abdominal distention with hypoactive bowel sounds, and significant hypotonia.

Clostridium botulinum.

A 67 year old man presented with fever, abdominal cramping, and frequent diarrhea (six to nine bowel movements per day) for 4 days. Three weeks before the current episode, he had undergone a hip replacement and was rehabilitating in an orthopedic unit. During that hospitalization, he developed a nosocomial pneumonia and was treated empirically with cefuroxime and clindamycin. He gradually improved and was discharged a week before his current presentation, with maintenance oral antibiotics, to recuperate at home. His wife had no similar symptoms. T = 39C, P = 114/min, R = 18/min, BP = 94/50 mmHg. The patient appeared confused and very pale. He could not answer questions about his current condition. His skin showed decreased turgor, and his oral mucosa was dry. Sigmoidoscopy revealed erythematous and friable colonic mucosa.

Clostridium difficle - tx metronidazole, vancomycin

A 9 year old girl presented with low grade fever, sore throat, and malaise for 2 days. These symptoms developed 10 after arriving at a summer camp operated by a religious group. Recently, she was noted to have a dry cough and difficulty breathing. Her parents then brought her to the emergency department. The family had emigrated from Ukraine one year before. The child's immunization status could not be determined. She had been otherwise healthy. T = 38.9 C, P = 140/min, R = 45/min, BP = 92/50 mmHg. On exam, the patient was in sever distress; respiratory stridor was prssent; exudative pharyngitis and bilateral cervical adenopathy ("bull neck") were noted. A yellowish, leathery, thick membrane extending to the uvula and soft palate was also seen. Chest x-ray was normal.

Corynebacterium diptheriae (diptheria) - erythromycin

A 75 year old man experienced the acute onset of sever abdominal cramps. Later in the morning, watery diarrhea occuring every 15 - 30 minutes developed, initially with small amounts of visible blood. Diarrhea subsequently became markedly bloody. He was nauseated but not vomiting. Worried about his illnes and his age, his son took him to a nearby hospital emergency department for evaluation. Recent food intake history was remarkable for eating a hamburger at a back yard BBQ 2 days earlier. The patient recalled that the meat inside was pink. He said his teenage grandson ate at the BBQ and the same illness but with milder symptoms. Elevated T and P. Normal R and BP. On exam, clinical examination of the abdomen was unremarkable except for increased bowel sounds. Stool was grossly bloody. Abdominal x-ray was normal.

E. coli serotype O157;H7 or EHEC. Treat by giving supportive therapy and monitoring for HUS (dialysis if gets serious)

A 24 year old sexually active woman visited a family practice clinic because of burning pain during urination, increased frequency, and urgency for 1 day. She also complained about blood-stained debris at the end of urination. Symptoms had rapidly worsened in the past 6 hours. On exam, mild suprapubic tenderness was noted.

Escherichia coli treat with amoxicillin or cephalosporin group but depends on profile.

In late September, a 51 year old man with a one week history of fever, headache, and muscle aches was taken to a clinic. He noted an ulcer on his right hand that had not healed and pain in his right axilla. The patient lived in Oklahoma and had a hobby of sewing together tanned rabbit hides to make more blankets. In the week before the onset of his illness, he had skinned and tanned a rabbit killed by the family dog. T, P, and BP elevated. On exam, remarkable physical findings included an indurated erythematous rash with an ulcerated lesion on the dorsal skin the right hand and painful axillary adenopathy.

Francisella tularensis (presumptive diagnosis of tularemia). Treat with Streptomycin or gentamycin/doxycycline alternatives.

A 54 year old woman presented to her family physician complaining of abdominal pain that had been worsening for the past 2 weeks. She stated that it often improved immediately after meals or taking antacids. She also noted occasional heartburn but denied fevers, nausea, or vomiting, diarrhea, or bloody stools. The patient was a schoolteacher who worked with a crowded class of seven students under stressful conditions. There were no other notable prior social or medical histories. T elevated other vitals normal. Abdominal exam revealed mild midepigastric tenderness with no rebound. Rectal exam was normal; no blood on Hemoccult testing was noted.

H. pylori (peptic ulcer disease). Treat with PPI, amoxicillin, and clarithromycin.

A 66 year old white man presented with a cought, fever, night sweats, and chest pain. He also noted a 12 lb weight loss over 3 weeks. He was a homeless man, who admitted to drinking 2 quarts of vodka per day. He vaguely remembered he was cough free a month ago, and his coughs had become progressively worse since then. In the last several days he had produced abundant, thick, tenacious , and blood tinged (currant jelly) sputum. On exam, an ill-appearing man in soiled, torn clothes; he had rales and rhonchi at the right lung base and an enlarged liver with mild tenderness. A chest x-ray revealed right upper lobe infiltrate with cavitary lesion.

Klebsiella pneumoniae (bacterial pneumonia) treat with piperacillin.

A 41 year old white man was admitted with a day history of high fever and dry cough. His initial symptoms progressed to include headaches, muscle aches, and confusion. Past history was unremarkable except for his being a chain smoker for the last 15 years. he had recently started working in a home-improvement center in the show room area with whirlpools and spas. T = 40.3 C, P=88/min, R = 40/min, BP = 110/60 mmHg. Examination revealed a distressed patient with inspiratory rales. He had a cough that was productive of scanty, clear sputum. Serum analysis showed low sodium levels. A chest X-ray revealed bilateral lower lobe patchy (intersitial) infiltrates.

Legionella pneumophila (legionellosis) - tx erythromycin

A 64 year old woman was brought to the emergency department with 5 days of fever, headache, and confusion. She had had diarrhea for 2 days that resolved a few day before her current symptoms began. She had a history of rheumatoid arthritis, for which she had been taking prednisone daily for the past several months. T and P elevated. R normal. BP slightly elevated. On exam, the patient was unable to answer simple questions and appeared agitated; exam revealed no nuchal rigidity and no focal neurological deficits. Head CT was normal. Brain MRI showed meningeal enhancement but no focal lesions.

Listeria monocytogenes . Treat with amoxicillin and gentamycin.

A 32 year old hispanic woman presented with a cough for several weeks and 15-lb weight loss. She also had night sweats and subjective fevers and felt fatigued. Despite erythromycin treatment for suspected pneumonia given by her family physician, her fever and cough progressively got worse. She complained about coughing blood-tinged sputum. She had emigrated from Venezuela to the United States three years before her illness, but she frequently returned to Venezuela to visit relatives. T = 38.6 C, P = 96/min, R = 18/min, BP = 112/60 mmHg. Examination was remarkable for bilateral rales and lymphadenopathy. A chest X-ray revealed right upper lobe infiltrates.

Mycobacterium tuberculosis - tx isonazid, rifampin

A 55 year old woman presented with pain and swelling on her right hand. She had a high fever, chills, and pain in the axilla. The patient had been bitten on her right hand two days before by her cat. She had otherwise been in good health. Elevated temp and BP. On exam, the patient's right hand was erythematous, swollen and tender. A small wound was noted on dorsum of her first finger. Axillary tenderness and lymphadenopathy were also noted.

Pasteurella multocida (pasteurellosis). Treatment is penicillin G. Alternatives are Amoxicillin/clavulanate then cephalosporins.

An 18 year woman presented with a worsening of her chronic cough for the past week. She had had a low=grade fever, as well as fatigue and shortness of breath. The cough was productive of greenish sputum that was thick and tenacious. She was diagnosed with cystic fibrosis at age 4 and had had multiple hospital admissions for respiratory infections. On examination, the patient was a pale, chronically ill-appearing young woman with increased respiratory effort and rapid breathing. Lung examination revealed bilateral rales and wheezing; heart exam demonstrated distant heart sounds. A chest x-ray showed a small heart, hyper inflated lung fields, and patch bilateral infiltrates.

Pseudomonas aeruginosa (pneumonia) - tx ceftazidime

On a hot summer day, a 23 year old man was brought to the emergency department 3 days after the onset of fever, severe headache, and muscle pain. He was also experiencing nausea, vomiting, and abdominal pain. A fine, spotted rash was seen on his extremities and trunk; the patient said the rash had appeared earlier that day. He lived in North Carolina and had no prior history of illness. He had received all appropriate childhood immunizations. T, P, R elevated BP slightly low. On exam, the patient appeared ill and had an erythematous maculopapular and petechial rash on his extremities, including on his palms and soles.

Rickettsia rickettsii (Rocky Mountain Spotted Fever). Treat with doxycycline.

A 71 year old male returned home after a 2 week stay in Mexico. The day after his return, he experienced an acute onset of fever, crampy abdominal pain, and watery diarrhea. By the next day, he had tenesmus and noticed mucus and a bloody tinge of the stool. The stool became grossly bloody and increased in number. Worried about his condition, his daughter took him to a hospital emergency department. During his stay in Mexico the patient was in a rural area and had drunk water on several occasions from a well, but he had not come in contact with other sick persons. Elevated T and P. Normal R. Lower BP. On exam, a sick-appearing, somnolent, elderly man with lower abdominal tenderness, mild dehydration, and hyperactive bowel sounds; rectal exam was very painful and showed gross blood. Abdominal x-rays were unremarkable, and sigmoidoscopy showed ulcers and an erythematous, friable mucosa.

Shigella flexneri (bacillary dysentery). Treatment is mainly supportive but TMP/SMX has been choice for years, if resistant can give fluroquinolones.

An 18 year old male college student was brought to the emergency department of a hospital with the complaints of fever, chills, and pain while walking. The patient had experienced progressively spreading boils on his left leg for the past week. The boils were painful and tender, and he had fever. He had not sought medical attention earlier, hoping the infection would resolve spontaneously. T = 39.4 C, P = 112, R = 18/min, BP = 124/70 mmHg. On exam, the lower left leg was swollen and tender. The overlying skin was warm and red with multiple necrotic-appearing lesions. The knee joint was normal with full range of motion.

Staphylococcus aureus - naficillin, vancomycin

A 24 year old man was brought to a local hospital emergency department because of severe pain and swelling that had developed in his left thigh that day. The pain had progressed rapidly; before seeking treatment he developed a high fever and became extremely weak and was unable to walk without assistance. The patient had always been in good health, but the day before this illness, a minor injury occurred to his leg while he was playing soccer. He noted that it started as a small area of redness at the site of the injury on his left thigh, but in the last several hours it appeared more grayish. T = 40 C, P = 138/min, R = 24/min, BP = 70/40 mmHg. On exam, a young male in moderate distress due to pain who appeared to be acutely ill. The left thigh was dusky and purplish, swollen and tense. Pulses in that leg were diminished. CT showed edema of the soft tissues and possible compression of the vessels.

Streptococcus pyogenes - beta lactams

A 31 year old African American woman presented with low grade fever, malaise, and a rash. She recalled having had painless ulcers, which appeared on the vulva one month before this new episode. She did not seek medical attention at that time, and the ulcers spontaneously resolved in 10 days. The patient revealed that she had had four sexual partners in the month preceding the development of ulcerative lesions. She had not traveled outside the United States in recent months. T = 38.1 C, P = 90/min, R = 14/min, BP = 124/72 mmHg. Examination was remarkable for inguinal lymphadenopathy, a generalized rash on palms and soles, and pustular cutaneous lesions and condylomata lata on her face.

Treponema pallidum - penicillin V

A 31 year old man returned to the United States in late summer from a 3 week long trip to Bangladesh. On the second day after his return, he presented with sudden, severe, profuse watery diarrhea. In the emergency department, he passed a large, watery stool with a rice-water appearance. He vomited several times and became slightly sweaty. He complained of muscle cramps and dizziness. He was on an H2 blocker drug for ulcer disease. Otherwise, he had always maintained good health. T, R, P elevated BP very low. On exam, he was somewhat anxious; his pulse was rapid and weak.

Vibrio cholerae (cholera). Rehydration is absolutely key but doxycycline and ciprofloxacin can be used.

A 27 year old man was broguht to the emergency department of a hospital with high, spiking fevers, severe diffuse pain over the ower abdomen, and loss of appetite. Two weeks earlier he first noticed mild abdominal pain and anorexia, which gradually progressed to include fevers and night sweats. The day before admission his abdominal pain became severe, and his fever became constant. T = 39.5 C, P = 118/min, R = 20/min, BP = 92/50 mmHg. Examination revealed tenderness in the right lower quadrant of his abdomen, with rebound tenderness. CT scan showed an intra-abdominal fluid collection consistent with an abscess in the right lower quadrant.

Bacteroides fragilis - tx clindamycin or metronidazole

A 2 month old white girl suffered from cough for more than 2 weeks. The patient's mother became concerned when the child turned blue after a series of coughing spells that ended with vomiting. She brought her to a pediatrician. The patient had not yet received any vaccinations. She had been healthy without any underlying medical problems. Vitals normal. On exam, paroxysmal cough, whoop, and post-tussive vomiting were noted during examination. Conjunctival hemorrhages and facial petechiae were also noted. There were no signs of lower respiratory illness. Chest x-ray did not reveal any pulmonary infiltrates.

Bordetella pertussis (pertussis). Supportive care and then treat with erythromycin if needed. Vaccine part of DTaP.

A 66 year old white man underwent surgery for colon carcinoma, and 2 days later he experienced severe pain at the surgical wound site. Within several hours, local edema and tenderness developed at the wound, as well as a thin, brownish discharge. Prior to surgery and this episode, he had always maintained good health. His social history was unremarkable. T = 37.6 C, P = 136/min, R = 26/min, BP = 90/52 mmHg. The patient appeared very ill. The surgical wound site exhibited discoloration of skin and hemerrhagic bullae. There was a serosanguineous discharge from the infected wound. The affected muscles showed failure to bleed, and there was extensive gas in the soft tissues.

Clostridium perfringens (gas gangrene) - tx clindamycin

An 18 year old male high school student presented with a 48 hour history of painful urination with a yellowish penile discharge. He returned 2 days ago from Daytona Beach, where he had been sexually active with several female partners during spring break. He denied previous such episodes, and said he was generally in good health. Vitals = normal. On exam, purulent urethral discharge was noted. No sign of genital ulcers was found. No rash or skin ulcers were seen, and the inguinal lymph nodes were not enlarged or tender.

Neiserria gonorrhoeae - tx ceftriaxone, azithromycin, doxycycline

A 64 year old man presented to a clinic with complaints of low-grade fever, productive cough of yellow-green sputum, and worsening of his chronic shortness of breath for several days. He had recovered from a mild cold just before the current symptoms began. He had long history of chronic obstructive pulmonary disease (COPD) and had been on oxygen for the past 2 years. He had been taking his inhalers as directed. Vitals are all elevated. On exam, thin male in moderate respiratory distress; lung exam revealed diffuse wheezes and rhonchi. Chest x-ray revealed hyper-inflated lungs but no infiltrates.

Haemophilus influenzae Treat with ceftriaxone and a macrolide.

A 35 year old white man went to an urgent care clinic twice over the course of 3 days befroe being admitted in the month of AUgust to the hospital with high fever, myalgies, and sever headache. Additional symptoms included phhotophobia, nausea, and anorexia. The social and medical histories were unremarkable. Ten days before his first visit to the clinic, he had returned from a boating trip. T = 38.8 C, P = 116/min, R = 16/min, BP = 110/64 mmHg. On exam, an ill=appearing patient with erythematous and swollen conjuctiva.

Leptospira interroganas (a presumptive diagnosis of leptospirosis) - penicillin g

A 21 year old white woman developed fever, headache, and a gradually progressive dry cough. Over the next 2 days, her cough worsened, becoming productive of small amounts of clear sputum. She was previously in good health. Her 19 year old brother had had similar symptoms 2 weeks earlier. T = 39.3 C, P = 105/min, R = 28/min, BP = 105/66 mmHg. On exam, the patient appeared slightly pale. Mild pharyngeal erythema was noted with minimal cervical adenopathy but no exudates. Chest exam was completely normal. A chest X-ray revealed bilateral patchy infiltrates consistent with atypical pneumonia.

Mycoplasma pneumoniae. - tx tetracycline, erythromycin

A 20 year old white male college student was brought to an emergency department in early January with a 12-hour history of high fever, chills, and severe headache. Soon after arriving at the ED, he vomited twice. He looked confused and was highly agitated. He was admitted to the hospital, and within two hours he developed purpuric skin lesions. He had recieved all appropriate immunizations and was otherwise healthy. T = 39.9 C, P = 124/min, R = 38/min, BP = 71/54 mmHg. On exam, the patient was unable to answer questions or follow commands. Neck stiffness was present, and a purpuric rash mainly on his extremities was noted. Head CT was normal.

Neiserria meningitidis - tx ceftriaxone and rifampin prophylaxis

A 41 year old white man was brought to the emergency department with a 3 day history of shaking chills, high fever, headache, abdominal pain, and generalized weakness. Mild diarrhea had started 2 days earlier and had been improving when the fever began. The patient had returned to the United States 10 days earlier, after a 3 week visit to India. He recalls eating a variety of local foods, particularly from street vendors. He had not received any travel-related vaccines. Past medical history was unremarkable. T, P, R elevated. BP low. On examination, the patient appeared ill and confused. His abdomen was diffusely tender, and his liver and spleen were enlarged, although there was no evident jaundice. Erythematous maculopapular lesion ("rose spots") were noted on his chest. Abdominal CT scan was remarkable for enlarged liver and spleen with no focal lesions.

Salmonella typhi (typhoid fever). Treatment standard has been chloramphenicol, ampicillin, or trmethoprim sulfamethoxazole (TMP/SMX), but multidrug resistance has lead to use of ceprofloxacin.

Six individuals from a single family presented over the course of 2 days with low-grade fever, abdominal cramp, vomiting, and diarrhea. All six individuals had eaten Thanksgiving dinner together in a private home, and they had all eaten the turkey and stuffing approximately 24 hours before the onset of first symptoms. Elevated T, R, P, normal BP. On exam, an ill-appearing patient with dry mucous membranes; abdominal exam revealed mild, diffuse, tenderness. Abdominal x-ray was normal.

Salmonella typhimurium (salmonella enteritis). No treatment for non-typhoidal Salmonella enteritis.

A 62 year old white man was admitted to the hospital in the month of January with fever, shortness of breath, productive cough, and chest pain. He also complained of a thick, yellowish discharge in his eyes that prevented him from opening his eyes in the morning. He was a chain smoker (three packs a day), did not drink alcohol, and had no chronic underlying diseases. The patient had not received the current flu vaccine, and 10 days prior to admission, the patient experienced sudden onset of fever, chills, sore throat, and arthralgias. His symptoms had gradually resolved over the following week, before the development of his current symptoms. T = 39.4 C, 120/min, R = 30/min, BP = 140/80 mmHg. The ill-appearing man was mild respiratory distress. On chest examination, decreased breath sounds and rales were heard at the left base. Unilateral erythematous palpebral conjunctiva, watery eye, and purulent exudate were also noted. A chest x-ray revealed an alveolar infiltrate in the posterior segment of the left lower lobe.

Staphylococcus aureus (secondary bacterial pneumonia and concurrent acute conjuctivitis) - naficillin, vancomycin

Twenty-four people became ill within 3 hours after eating a meal at an office party. All had nausea, most had vomiting, and several had crampy abdominal pain. Three of the individuals sought medical care at the emergency department of a local hospital. All 24 individuals had been in good health. The day before the office party, a food preparer had purchased a 17 pound precooked packaged ham, baked it at home at 400 F for 1.5 hours, and transported it to her work place, a large institutional kitchen, where she sliced the hot ham on a commercial slicer. The ham was served cold at the party the next day. T = 37 C, P = 84/min, R = 14/min, BP = 136/80 mmHg. Patient X appeared in mild distress due to abdominal pain. Abdomen was soft and nontender, with normal bowel sounds.

Staphylococcus aureus - naficillin, vancomycin

A 3 week old baby boy was brought to the emergency department with a 24 hour history of fever, poor feeding, irritability, and a seizure that occured just before arriving at the ED. He was born preterm (32 weeks' gestation) with very low birth weight (1490 g) after a normal vaginal delivery. T = 38.2 C, P = 142/min, R = 32/min, BP = 90/42 mmHg. On exam, male infant who was irritable, with nuchal rigidity. Neurologic exam was otherwise nonfocal.

Streptococcus agalactiae (group B streptococcus [GBS]) type 2 meningitis - tx ampicillin

A 67 year old white man was rbought by his wife to the ED for the abrupt onset of shaking chills, high fever, and pain on the right side of this chest that began the prior evening. His wife reported that in the last 24 hours, he had experienced shortness of breath and a cough that was productive of rust-colored sputum. The patient was diabetic and smoked two packs of cigarettes per day. he had been a chain smoker for the last 20 years. he had not sought medical care in the past and had not received any vaccinations in the last 20 years. T = 39.6 C, P = 130/min, R = 32/min, BP = 159/77 mmHg. Examination revealed an ill-appearing, confused man in moderate respiratory distress. Dullness to percussion over the right uppoer thorax, assocaited with increased fremitus, was noted. Auscultation revealed bronchial breath sounds and crackles over this area. A chest x-ray revealed consolidation of the right upper lobe. Bands on the CBC was elevated.

Streptococcus pneumoniae (pneumococcal pneumonia) - tx macrolides, ceftriaxone, amoxicillin

A 6 year old girl came home from school feeling miserable on a cold day in January. She had a high fever and complained of an itchy throat. She had difficultly swallowing any food, refused to eat, and cried almost all evening. the next day her grandpa took her to their family physician's clinic. It was noted that several children from her school had reported sore throats recently. The patient had received all standard childhood immunizations at the appropriate times. T = 39.4 C, P = 120/min, R = 16/min, BP = 110/60 mmHg. Red throat (pharyngeal erythema) with petechiae on the soft palate and patchy grayish-whitish tonsillar exudates were seen. Enlarged and tender anterior cervical lymph nodes were also noted. The patient did not have any cough.

Streptococcus pyogenes - tx beta lactams

A 76 year old man was seen in his family physicians's office for complaints of low-grade fevers, night sweats, and fatigue for 3 weeks. The patient had a history of a heart murmur but had never undergone extensive evaluation. He had been in generally excellent health with normal exercise tolerance. Approximately 6 weeks ago he underwent an uncomplicated extraction of an impacted wisdom tooth but received no antibiotics prior to the procedure. T = 38 C, P = 104/min, R = 14/min, BP = 130/82 mmHg. On exam, the patient was alert; a rough, diamond-shaped systolic murmur, heard loudest in the upper left sternal border, was noted. A "splinter hemorrhage" in the nail of this right finger and conjunctival petechiae were also noted. His spleen was palpable as well.

Viridans streptococci - penicillin G

On a summer day in August, an 18 year old man was taken to the emergency department of a local hospital because of a 2 day history of fever, weakness, pain in his left groin, and diarrhea. The groin pain was so severe that he walked with a limp, with his left leg abducted. He also had small rashes on his leg. The patient lived in Flagstaff, Arizona. He had maintained good health before the current event. Elevated T,R,P, low BP. On exam, the patient was alert but restless and was in moderate distress due to pain. A left groin mass (~6cm), which was firm and exquisitely tender, was noted, with mild erythema, and there were small hemorrhages on the skin of his right leg.

Yersinia pestis. Southwest is important geographic location. Treat with streptomycin and chemoprophylaxis with tetracycline.