Lippincott Clinical Cases

Question 1

An African American girl with sickle cell anemia visits the doctor after developing weakness, fatigue, and pallor. She tells
her physician that several days before, she felt a fever, headache, and muscle aching. She also began to feel joint pain and developed a rash that had a “slapped-face” appearance on her face. A blood test reveals severe anemia, as well as a decline in neutrophils and lymphocytes. The myeloid lineage seems normal. Serology confirms the diagnosis, and the doctor orders a transfusion of erythrocytes to prevent life-threatening anemia.


Answer 1

Parvovirus B19

Question 2

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.

Answer 2

HPV

Question 3

A middle-aged man, diagnosed with AIDS, presents to the EW complaining of “seeing double.” Physicians perform a complete neurological examination and further discover problems in talking, coordinating movements, and remembering things. Imaging of the brain reveals deep densities localized to the white matter that span the frontal, parietal, and temporal lobes. The doctors make an infectious disease diagnosis and discuss how to best tell the patient about his very grave prognosis.

Answer 3

JC Polyomavirus- PML

Question 4

A mother brings her 4-year-old child to the doctor because of a swollen, red right eye. She is frustrated, complaining that the symptoms appeared after she had taken her child to a local ophthalmologist. The doctor diagnoses conjunctivitis. Later that evening, the doctor learns that many other children have presented with similar symptoms after appointments with the same ophthalmologist.

Answer 4

Adenovirus

Question 5

A teenager complains of pain during sexual intercourse and irregular intermenstrual bleeding. She has also begun to experi- ence 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.

Answer 5

Gonorrhea

Question 6

A sexually active young woman develops dysuria, pyuria, and fever suggestive of urinary tract infection. Urine cultures show Gram 􏰀+ bacteria in clusters that are catalase +, coagulase -.

Answer 6

Staph saprophyticus- UTI

Question 7

An adolescent presents to the clinic complaining of brownish urine that started the day before. Two weeks earlier, he had a sore throat that resolved. Physical exam reveals high BP and slight swelling around his eyes. Serum studies are significant for elevated BUN and Cr, ASO 􏰀, and diminished levels of C3 (complement protein). In addition, urinalysis indicates protein and RBC casts. Although a kidney biopsy was not performed, if it were, EM studies would likely reveal subepithelial humps (“lumpy-bumpy pattern”) in the glomerulus.

Answer 7

Group A Strep- Delayed Antibody-Mediated response

Acute post-streptococcal glomerulonephritis

Question 8

An elderly woman presents with a cough producing rusty-colored sputum. She complains of sharp right-sided chest pains, chills, and fevers. Physical exam reveals increased fremitus, dullness to percussion, and bronchial breath sounds on the lower right side. CXR shows right lower lobe consolidation, and Gram stain of sputum shows Gram 􏰀 diplococci

Answer 8

Strep pneumoniae

Question 9

A 33-year-old woman presents with an ulcerous lesion on the neck. The ulcer has a blackened necrotic eschar surrounded by edema. The woman first noticed the lesion 2 weeks ago as a painful, small red macule that gradually developed into an ulcer and, over the last few days, became painless. On the occupational history, the patient reveals that she works in the imported wool and hides industry

Answer 9

Bacillus anthracis- Cutaneous anthrax

Question 10

A teenage girl enters the emergency room suffering from painful muscle spasms. Throughout her examination, she sustains a facial sneer, a stiff arched back, and clamped palms. Her father is anxious about the fact that she has also experienced difficulty eating, probably due to a stiff jaw. The father affirms that his daughter is usually quite active and boasts how, a week ago, she continued a soccer game even after falling on a nail in the field.

Answer 10

Clostridium tetani- Tetanus

Question 11

A woman straggles into the emergency room with a marked paralysis of her upper body. She describes the paralysis as a weakness that began in her neck and spread to her arms. She also complains of blurred double vision and requests water to soothe her dry throat. Although she has no fever, she appears quite dizzy and her eyelids are drooping. The day before, she returned from a camping trip where she insists she maintained good hygiene, limiting her diet to canned foods only.

Answer 11

Clostridium botulinum

Question 12

An old woman comes to the doctor with a fever and loose bowels. Her diarrhea occurs in tremendous volumes, she complains, although she does not remember ever seeing blood. She has an unremarkable recent past medical history, except for an infection a few weeks earlier that was treated with clindamycin. Sigmoidoscopy of her colon reveals yellow-white plaques, which the doctor predicted after analyzing her stools for toxins.

Answer 12

Clostridium difficile- Pseudomembranous colitis

Question 13

A man enters the emergency room claiming to have been stabbed 2 days earlier. Muscles in his arm hurt, and on palpation, small air bubbles are felt below the skin. The wound area exudes a blackish, ill-smelling fluid and generates a crackling sound when touched. The patient has a fever, a low blood pressure, marked tachycardia, and has urinated very little since his injury. The doctors decide to amputate the arm, as well as monitor the patient for shock and renal failure.

Answer 13

Clostridium perfringens- Gas gangrene

Question 14

A young immigrant girl goes to the doctor complaining of a sore throat and difficulties in breathing and swallowing. Her voice is unusually nasal and a large gray mucous film is noticed on the oropharynx. The patient also exhibits ST-T wave changes on an electrocardiogram and a slight paralysis of her tongue. Her blood pressure is low, her lungs edematous, and her neurologi- cal examination shows cranial nerve problems. Her physician begins immediate treatment and orders a potassium tellurite culture to confirm his worst suspicions.

Answer 14

Corynebacterium dyptheriae- Dyptheria

Question 15

A 45-year-old man presents with multiple sinuses on the left side of his face. The sinuses discharge pus and are painless. His past medical history is insignificant except for a dental surgery done a few weeks ago for a dental infection. His doctor examines the pus under the microscope and finds filamentous organisms. The doctor rules out Nocardia by lack of acid-fast staining and makes the diagnosis by noting sulfur granules.

Answer 15

Actinomyces

Question 16

Early one evening, a young soldier in an army base enters the emergency room with a petechial rash, fever, and headache. Physical exam reveals 􏰀 Kernig’s sign, nuchal rigidity, and impaired mental status. An LP is performed showing ↑ PMNs, ↑ protein, ↓ glucose, as well as intracellular kidney bean-shaped diplococci.

Answer 16

Neisseria meningitidis

Question 17

An alcoholic presents with a fever, pleuritic chest pain, dyspnea, and cyanosis. His cough produces a bloody “currant-jelly” sputum. CXR shows inflammation involving the right upper lobe with possible cavities.

Answer 17

Klebsiella pneumoniae

Question 18

A man and his two sons just returned from a vacation on their relative’s farm. All three arrive complaining of bloody diarrhea. The youngest son becomes well spontaneously. The older son complains of right flank pain, while the father starts to notice tenderness in his joints. One surgeon, worried about appendicitis in the older son, performs the initial incisions and discovers a normal appendix but an inflamed colon. After also observing swollen mesenteric lymph nodes during surgery, he makes a diagnosis explaining the symptoms in all three patients.

Answer 18

Yersinia enterocolitica

Question 19

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.

Answer 19

Treponema pallidum- syphilis

Question 20

A man comes to the doctor with a fever of 40°C. He assures the doctor that he would not ordinarily seek medical attention simply for a fever, but that he has had two previous episodes of fever over the past 3 weeks. In these episodes, he suffers from a high fever, rash, myalgias, and nausea. The fever worsens over 2 days and abruptly spikes on the third day, but then just as abruptly drops to normal temperature with a drenching sweat. On history, the patient reports no recent mosquito bites. After noting spirochetes on blood culture, the doctor prescribes penicillin and assures the patient he will be fine.

Answer 20

Borriela recurrentis- Relapsing fever

Question 21

A Kosovo refugee sees a volunteer camp doctor complaining of a rash spreading outward from his trunk but sparing his palms and soles. Two days ago, he experienced abrupt onset of fever, headaches, and confusion. On physical exam, the doctor discovers lice in the man’s hair

Answer 21

Rickettsia prowazekii- Epidemic typhus

Question 22

A Boy Scouts troop master calls the doctor asking about symptoms that have developed in 7 of his 20 Scouts shortly after a camping trip. The ill boys complain of fever, 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 an 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.

Answer 22

Picornavirus- Hepatitis A

Question 23

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.

Answer 23

Rhinovirus- Common cold

Question 24

A young man enters the emergency room dehydrated, afebrile, and complaining of nausea and vomiting. Since he began vomiting 1 hour ago, he has been “hugging the toilet” nearly every 10 minutes. He remembers eating a dish with fried rice at an Asian restaurant several hours ago.

Answer 24

Bacillus cereus food poisoning

Question 25

A heart transplant patient on immunosuppressants develops slight fever, weight loss, and a cough, producing a viscous, purulent sputum. The patient explains that these symptoms come and go over weeks and generally do not bother him enough for a checkup. The doctor decides to take a CXR, which reveals small abscesses with sinus tracts in the lung. A biopsy of the lung tissue reveals a filamentous, acid-fast, Gram 􏰀+ microorganism.

Answer 25

Nocardia

TB is not filamentous

Question 26

A 2-year-old girl returns to her pediatrician with fevers, recurrent ear pain, and new onset yellow discharge from the right ear. She had been diagnosed earlier in the week with right otitis media and treated with amoxicillin. The pediatrician correctly suspects that a beta-lactamase–producing organism is causing the infection, and had he gram stained the ear discharge, he would have found gram-negative diplococci.

Answer 26

Moraxella catarrhalis- Otitis media

Question 27

A series of patients in a small town visit the hospital complaining of bloody diarrhea, fatigue, and confusion. Physical exams reveal neurological deficits, and laboratory tests show anemia, thrombocytopenia, and uremia. Peripheral blood smears show fragmented RBCs, but subsequent Coombs tests are negative. After careful questioning, the doctors discover that each patient frequents the same fast-food burger joint. The physicians identify the causative agent with serological testing and stool cultures appearing metallic green.

Answer 27

E. coli (EHEC) and possible HUS

Question 28

A patient whose appendix was removed is put on gentamicin to suppress Gram 􏰁 aerobes causing the initial infection. The patient’s fever declines, only to spike some hours later. Imaging of the patient’s abdomen detects an abscess that has formed. The area near the abscess is also noted to have a reduced blood supply. The patient is given an additional antibiotic to combat anaerobic bacteria, and, as a result, her abscess rescinds and her fever disappears.

Answer 28

Bacteroides fragilis

Question 29

An elderly diabetic woman, who recently began swimming to control her weight, complains of painful discharge from her left ear. Physical exam shows extreme tenderness of the left tragus. A swab culture of the ear reveals blue-green colonies emitting a fruity odor. Fearing that the infection could eventually spread to the mastoid bone, her doctor prescribes antibiotic therapy.

Answer 29

Pseudomonas aeruginosa (Otitis media especially in diabetics)

Question 30

A farmer comes to the EW with a 1-week history of flu-like symptoms with photophobia. His severe headache, cough, and myalgias suggest to the physician some kind of respiratory infection. However, more careful physical exam reveals conjunctival suffusion and macular rash. Lab findings include elevated serum bilirubin, alkaline phosphatase, aminotransferases, and creatine phosphokinase. With this clinical picture and lab results, the physician prescribes penicillin G immediately. His suspicions are confirmed later when a spirochete is isolated from the patient’s blood.

Answer 30

Leptospirosis- Weil’s disease