Exam 3 Clinical Cases (lots of organisms) Flashcards
A Boy Scouts troop master calls the doctor asking about symptoms that have developed in 7/20 of his scouts shortly after a camping trip. The ill boys complain of nausea, loss of appetite, and vomiting. The Scout master also notes a yellow hue in some of the boys, especially visible in their eyes. Two of the affected boys are brought to the hospital where their urine is noted to be dark and their feces pale. Liver enzyme assays reveal and elevated ALT and AST level. The physician confirms the diagnosis with an assay of serum IgM and then assures the master and his Scouts that the illness will completely go away in several weeks
Hepatitis A (Picornaviridae Enterovirus)
BUZZ WORDS
Hepatitis- elevated ALT, AST, and jaundice
A- epidemic among children (summer camps, school) via oral-fecal transmission
A middle-aged immigrant from China presents with RUQ pain and a “full stomach” despite a recent history of weight loss. He remembers having bouts of “turning yellow” since childhood and recalls many in his family–including his mother–having similar experiences. Immunization records are unavailable and lab values show elevated ALT levels and alpha-fetoprotein levels. Further imaging reveals the presence of hepatocellular carcinoma
Hepatitis B (Hepadnaviridae Orthohepadnavirus)
BUZZWORDS
Hepatitis- elevated ALT and jaundice
Chronic presentation with hepatocellular carcinoma- Hep B, C, and D
not sure how we are able to narrow it down to B :(
Feeling fatigued, a man visits his doctor. On physical examination, the patient has reduced liver size. After a thorough history, the doctor learns that the patient had jaundice 5 years ago following a car accident for which he was hospitalized and received a blood transfusion. The doctor is not surprised to see an elevated serum level of ALT in his blood workup and awaits an ELISA to differentiate the cause of his illness
Hepatitis C (Flaviviridae)
BUZZWORDS
Hepatitis- elevated ALT and jaundice
Chronic presentation and blood transmission- Hep B, C, and D
Not sure how we are able to narrow it down to C :(
A chronic drug user previously diagnosed with hepatitis B presents with a recurrence of symptoms, most notably yellow sclerae. Typical signs of chronic hepatitis– serum AST and ALT elevation, jaundice, hepatomegaly, splenomegaly–seem more severe in this patient. The physician suspects the hepatitis B is only part of his clinical picture and recommends treatment with alpha-interferon to reduce the symptoms. The patient is informed that he is at risk for liver failure
Hepatitis D (genus TBD)
BUZZWORDS
- Hepatitis- elevated AST, ALT, jaundice, hepatomegaly, splenomegaly (Question Stem also mentioned he has it)
- Hep D because it is often presented as an superinfection in addition to Hep B. Alpha-interferon is only administered for HBV and HDV infections
A man goes to India on a hiking trip in the Himalayas. Upon returning, he develops nausea, vomiting, malaise, and headache. His doctor notices jaundice and hepatomegaly on PE, and labs detect increased AST, ALT, and direct serum bilirubin levels. Immunization records show that the man had received HAV and HBV vaccines before leaving. The Sx are traced back to a shared water supply along the hiking route
Hepatitis E (Hepeviridae Hepevirus)
BUZZWORDS
- Hepatitis- elevated AST, ALT, jaundice, hepatomegaly
- Acute presentation & oral transmission = Hep A and Hep E only
- Since patient is vaccinated for HAV, the answer has to be Hep E
A child presents with altered mental status and seizures. During the exam, the doctor notes epistaxis, gum bleeding, and right lower quadrant pain. Further questioning reveals that 3 weeks ago, the child had general weakness, myalgias, fever, and a cough. His mother had similar flu-like symptoms a week before and treated both herself and her child with aspirin. The doctor suspects that the child’s serious symptoms would have been prevented had the mother given Tylenol instead of aspirin to her child. Liver function and blood tests are ordered immediately
Influenza Virus (The Flu) Specifically: Rey's Syndrome
BUZZ WORDS
- Rey’s syndrome is categorized by liver damage and encephalomyelitis associated with aspirin treatment for influenza in children
A woman presents with a runny nose, sneezing, an irritable throat, and a slight fever. She suffers similar symptoms every year, often at the same time as other members of her family. Her symptoms go away within a week, except for the nasal discharge that persists for a few more days
Rhinovirus (Picornaviridae)
BUZZ WORDS
Seasonal illness that is self-limiting
A woman in India complains of fever, muscle pains, and weakness of her trunk, abdomen, and legs. This morning she notes difficulty in swallowing and neck pain, which prompts her to come to the hospital. Physical exam reveals fasciculations and flaccid paralysis of the lower limbs and trunk. Breathing seems to be troubled. A CSF analysis reveals lymphocytosis, PMNs, and normal glucose and protein levels. The physician confirms the Dx by checking the woman’s vaccination history and prepares respiratory support in case her breathing difficulties worsen
Poliovirus (Picornaviridae Enterovirus)
BUZZ WORDS
Distal muscles weakness, proximal muscles weakness (respiratory insufficiency), increased lymphocytes + normal glucose and protein levels consistent with aseptic meningitis. Vaccination history (implied).
A young man presents with chest pain, dyspnea, and early signs of heart failure. His history shows he had an upper respiratory infection 3 weeks ago. Examination reveals tachycardia and gallop rhythm, while ECG shows evidence of a conduction defect with nonspecific ST-T changes. ECC is ordered and shows cardiomegaly with contractile dysfunction. The doctor makes a viral diagnosis by serology and admits the patient for monitoring, assuring the patient that he will likely recover completely.
Coxsackieviruses A&B (Picornaviridae Enterovirus)
A 55 year old man is hospitalized for a recent onset of high fever, headaches, and sporadic sensations of smelling sausages. PE reveals neck stiffness, prompting the physician to perform a lumbar puncture. CSF values indicate elevated lymphocytes, elevated protein, and normal glucose. A CT image confirms encephalitis localized to the temporal lobes. A diagnosis is confirmed by PCR of the CSF. The physician begins treatment with acyclovir and informs the patient that he may suffer permanent neurological abnormalities from the infection
HSV-1
This is a rare presentation of HSV1 infection– infection of the brain via cranial nerves.
BUZZ WORDS
Acyclovir indicates this is a viral infection
Elevated lymphcyte, protein, and normal glucose in CSF also indicates viral infection
Temporal lobe encephalitis is a rare presentation of HSV1
Permanent neurologic damage is also indicative of this infection
ADDITIONAL INFO
HSV-1 lies latent in trigeminal dorsal root ganglion
HSV-2 lies latent in S2-S6 dorsal root ganglia→ encephalitis
Lifelong infection
At a preterm evaluation, a 31 year old pregnant mother reports pain on urination and a burning, itching sensation in the genital area. A careful exam of her vagina reveals a vesicular rash. The physician confirms a diagnosis with a Tzanck smear of the lesions showing multinucleate giant cells with intranuclear inclusion bodies. The mother is administered acyclovir with assurances that the infection will likely resolve, but she is informed that should the infection persist, her child will have to be delivered by cesarean section
HSV-2
Genital Herpes
BUZZ WORDS
Genital itching, burning, with a vesicular rash
Multinucleate giant cells on Tzanck smear of skin lesions is indicative of a HSV infection
“Below the neck” presentation = HSV-2
ADDITIONAL INFO
HSV-1 lies latent in trigeminal dorsal root ganglion
HSV-2 lies latent in S2-S6 dorsal root ganglia→ encephalitis
Lifelong infection
A 72 year old woman complains to her doctor of a burning, painful rash on her chest. A physical exam reveals fever and a vesicular, erythematous rash limited to the right side of her chest and overlapping the dermatomal area of T7-T8. The physician confirms a diagnosis by a Tzanck smear of the lesions showing multinucleate giant cells with intranuclear inclusion bodies. The physician administers acyclovir and explains that thought the rash will likely ameliorate, the regional pain might persist longer
Varicella Zoster Virus
Shingles
BUZZ WORDS
Elderly patient with vesicular erythematous rash following dermatomal pattern– hallmark of Shingles
Eosinophilic Cowdry intranuclear inclusion bodies on skin biopsy is also indicative of a VZV infection
A 20 year old female college student reports to the medical center complaining of “the flu”. She reports fever, night sweats, a very painful sore throat, and headaches. She thought she could endure the illness, but she became frustrated after feeling “so sleepy all the time.” PE reveals enlarged lymph nodes and a slight splenomegaly. Results from a blood smear later that day reveal lymphocytosis with about 20% lymphocytes having an abnormally large nucleus and vacuolated cytoplasm. The student is assured that the illness will spontaneously resolve within 2-3 weeks, but that she should avoid contact sports during that time. She is also told not to share drinks to prevent spread o the illness.
Epstein-Barr Virus
Mononucleosis
BUZZ WORDS "So sleepy all the time" Enlarged lymph nodes Sight splenomegaly and advice to avoid contact sport Advice to not share drinks
A 34 year old kidney transplant patient currently on immunosuppressants complains of SOB and coughing. PE reveals fever and abnormal lung sounds while CXR indicates interstitial infiltrates in the lungs. No cysts are detected on silver stain of bronchoalveolar lavage fluid, ruling out Pneumocystis jirovecii infection. The doctor makes a diagnosis after viewing a sample of the patient’s lung tissue, which shows abnormal giant cells with “owl’s eye” intranuclear inclusions
Cytomegalovirus (CMV/Herpesvirus 5)
Pneumonia in immunocompromised
BUZZ WORDS
Giant cells with “owl’s eye” intranuclear inclusion bodies
A 22 year old sexually active man complains of warts on his penis. He does not report pain, but he is concerned that he might be spreading them to his female sexual partner. The doctor, diagnosing the warts as condyloma acuminata, treats the patient by ablating the warts. He also decides to test the sexual partner, fearing that if she contracted the patient’s illness, she would be at increased risk for cervical cancer
Human Papilloma Viruses (HPV)
Warts
BUZZ WORDS
Genital warts (aka condyloma acuminata)
Risk of cervical cancer
Can be sexually transmitted
ADDITIONAL INFO
HPV 16 and 18 cause genital warts
A sexually active man seeks medical attention for a wart-like lesion developing on his genitals. He recalls a painless ulcer on his genitals over a month ago, but now is concerned because papules are appearing in his armpits and palms as well. Recently he has also suffered fever and chills, and the doctor notices a nontender, generalized lymphadenopathy. The doctor questions the man about the health of his sexual partners. A dark-field analysis confirms the doctor’s suspicion of the etiology and the patient is prescribed penicillin G.
Treponema pallidum
Secondary Syphilis
BUZZ WORDS
Painless genital lesion narrows it down to Herpes and syphilis
STI with papules appearing on palms = syphilis
Dark-field analysis is used to visualize T Pallidum (a spirochete)
ADDITIONAL INFO
Primary syphilis- painless chancres that go away
Tertiary Syphilis- gummas on skin and bones
Neurosyphilis- possible at any stage
A woman is brought to the EW complaining o vaginal discharge and RUQ abdominal pain. On history, the patient reports having many sexual partners. Pelvic exam reveals cervical motion tenderness, and labs of vaginal discharge detected numerous PMNs but no organisms on Gram stain. The doctor makes a diagnosis based on these findings and administers doxycycline and ceftriaxone. Later, surgeons, concerned about the patient’s abdominal pain, rule out cholecystitis by imaging, but laparoscopy reveals adhesions around the patient’s liver capsule.
Chlamydia trachomatis
Complication of chlamydia infection –> Pelvic Inflammatory Disease (PID)
BUZZ WORDS
Complex sexual history with vaginal discharge = STI
Organism not visible on gram stain rules out gonorrhea
Cervical motion tenderness and infected liver capsule = Fitz-Hugh-Curtis syndrome (symptom of PID)
Doxy = for chlamydia infections (ceftriaxone administered for probable gonorrhea infection
A teenager complains of pain during sexual intercourse and irregular intermenstrual bleeding. She has also begun to experience lower abdominal pain. A pelvic exam reveals a yellow mucopurulent discharge; during the exam, the cervix begins to bleed. Gram stain of discharge reveals gram - intracellular diplococci. The teenager reports that she has been sexually active with several partners over the last year. One of her partners, a male, comes to the same clinic complaining of dysuria and profuse yellow urethral discharge
Neisseria gonorrhea
Gonorrhea
BUZZ WORDS
Gram - diploccoci = Neisseria specie
STI that causes urethritis in male and cervicitis in female = gonorrhea
Several months ago, a patient presented to a free clinic with a thick, white membrane covering the roof of his mouth. After a thorough social history, the doctor suspected a possible HIV infection. However, at this time, the patient refused testing and never returned for follow-ups. Now, the patient revisits the clinic complaining of painful swallowing and severe chest pains. The doctor immediately places the patient on fluconazole and makes arrangements for future treatments and tests.
Candida albicans
Candidiasis
BUZZ WORDS
Thick, white membrane covering the roof of his mouth = oral thrush = candida albicans
Immunocompromised = ALWAYS CONSIDER FUNGUS
Subsequent painful swallowing = esophagitis, hallmark of immunocompromised patients with a candida infection
Rx fluconazole = validates suspicion of a fungal infection
A teenage girl complains of vaginal itching and burning. Sexual history reveals numerous sexual partners. Her gynecologist performs a pelvic exam and finds a greenish, foul-smelling thin discharge from the vagina. A wet mount of the discharge reveals motile amoeba, each with 1 nucleus and 5 flagella. The patient is started on metronidazole
Trichomonas vaginalis
Trichomoniasis
BUZZ WORDS
Complex sexual history = STI
Greenish, foul-smelling thin discharge = trichomonas
Wet mount showing motile amoeba is indicative
ADDITIONAL INFO
Trichomonas can be distinguished from other flagellate protozoa in that it lacks a cyst form (sexual transmission)
A student reports to his college clinic complaining of “the flu.” He explains that he has been suffering from intermittent headaches, fever, and muscle aches. Assuming the flu, the physician sends the student home with acetaminophen. Now, days later, the student returns with chills, extreme fever, and debilitating fatigue. PE also reveals yellow sclera and severe splenomegaly. CBC reveals low hematocrit, UA shows hemoglobinuria. Alarmed, the doctor questions the student about recent travels and learns that he has just returned from a visit to India. A blood smear showing ring shapes confirms the diagnosis, and the patient is begun on mefloquine.
Plasmodia malariae
Malaria
BUZZ WORDS
Recent travel to India
Blood smear showing rings = indicative of P. falciparum
Hemoglobinuria = blackwater fever = hallmark of P. falciparum malaria
Mefloquine is prescribed to treat chloroquine-resistant P. falciparum
ADDITIONAL INFO
3 species of Plasmodium =
P. malariae (regular fever cycle of 3 days)
P. ovale/vivax (dormant liver infections)
P. falciparum (irregular fever cycle)
RX
chloroquine is most commonly used
Mefloquine is used for resistant species like P. falciparum
Primaquine for P. vivax/ovale; G6PD deficiency must be checked prior to prescribing primaquine (can lead to hemolytic anemia)
An elderly New England man presents to his physician with high fevers, chills, and weakness. On exam, he appears icteric, and laboratory results showed severe anemia, low haptoglobin, and high unconjugated bilirubin. His physician, who had graduated from medical school in south Asia, initially suspected malaria. However, the physician made the correct diagnosis after eliciting a more detailed history, in which the patient recalled removing a tick form his skin approximately 5 weeks earlier.
Babesia divergens
Babesiosis
BUZZ WORDS
Almost misdiagnosed as malaria
Tick involvement (Babesia is a tick-borne illness, Ixodes tick)
ADDITIONAL INFO
Ixodes tick also transmit Lyme Disease
After a camping trip to Mexico, a patient visits her doctor complaining of loose stools and abdominal cramps. The patient describes the stools as having flecks of blood and lots of mucus. The doctor orders a stool specimen in which she finds motile amoeba with ingested RBCs. She starts the patient on metronidazole and considers a CT scan to detect any liver abscesses
Entamoeba histolytica
Amebiasis
BUZZ WORDS
Bloody diarrhea
Motile amoeba with ingested RBCs
Liver abscess
ADDITIONAL INFO
- Diarrhea caused by protozoa
1. Bloody = Entamoeba histolytica
2. Fatty = Giardia lamblia
3. Watery = Cryptosporidium parvum
