Microbiology Case Studies (Anaerobes mostly) Name: __________________________________ The patient was an 85 year old female with advanced

ed squamous cell carcinoma of the bladder, who was admitted for treatment of a presumed cellulitis of her right lower leg. On examination, the patient appeared chronically ill. The right heel had a bluish hematoma and blister with approximately 6 by 6 cm of erythema medially. Laboratory studies on admission were notable for an elevated white blood cell count of 33,200/mm 3 with a left shift. The patient was treated with intravenous antibiotics for 2 days but her condition did not improve. She underwent an x-ray of the right ankle and foot, which demonstrated extensive gas in the soft tissues. She was taken for surgical debridement and ultimately a below the knee amputation. A Gram stain of the wound aspirate revealed rare polymorphonuclear leukocytes and many boxcar-shaped gram positive rods. No growth was seen on aerobic cultures. The patients condition worsened and she died. 1. Which genus of bacteria can cause the type of infection described in this case? Several species of this genus are commonly associated with this infection. List three of them.

2. Explain the finding of gas in the soft tissues.

3. Which virulence factors play an important role in the spread of these organisms through tissues?

4. Why was it necessary to amputate her leg below the knee?

5. Explain the possible ways in which this woman could have become infected.

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Microbiology Case Studies (Anaerobes mostly) This 21 year old man presented to the emergency room with 3 days of abdominal pain, which began as a diffuse, dull, continuous pain. The pain became crampy in the midgastric and lower abdomen. He noted a decrease in appetite but no nausea, vomiting or diarrhea. On examination, the patient was febrile to 39.2C, tachycardic with a heart rate of 150 beats/min and tachypneic with a respiratory rate of 52/min and had a blood pressure of 108/60 mmHg. His physical examination was notable for midgastric and right lower quadrant abdominal tenderness. The white blood cell count was normal. Blood cultures were obtained on admission and were subsequently positive for an anaerobic, gram negative rod, at which time the patient was taken to the operating room for an exploratory laparotomy. 1. To which genus do you think this organism belongs and why?

2. Upon learning of the positive blood culture, the surgical team opted for abdominal surgery. What type of lesion would you suspect they would find in the abdomen?

3. How is this intra-abdominal lesion treated?

4. What would surgical samples of this lesion be likely to grow on culture?

5. What other types of infections does this organism cause?

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Microbiology Case Studies (Anaerobes mostly) This 63 year old alcoholic was taken to the emergency room of a hospital with obvious gangrene of both feet. He was stuporous. During that evening, he had a seizure and was treated with phenytoin and barbiturates. By the night of transfer he was noted to have opisthotonic posturing and to have developed increasing rigor, respiratory distress, and unresponsiveness. On examination, he had a temperature of 41.7C rectally, a blood pressure of 70/30 mmHg, a heart rate of 110 beats/min, and a respiratory rate of 40/min. Examinations were notable for marked trismus. The neck was stiff and hyperextended. Necrotic, blackened areas were present over both feet and several draining ulcers were noted on the heels and toes. Neurologically, the patient responded to deep pain with a grimace. On the basis of these findings, specific therapy, in addition to supportive care was initiated and the patient ultimately recovered. 1. What is the etiology of his infection? What virulence factor produced by the etiological agent of his infection was responsible for his trismus?

2. How did this patient become infected with this organism? What was the role of his gangrenous feet in the development of this infection?

3. What was the specific therapy used to treat this infection?

4. How might this infection have been prevented?

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Microbiology Case Studies (Anaerobes mostly) A 24-year old female automotive technician presents herself at the doctors office. She complains of fever and of pain in her left hand. On physical examination, the patient had a deep wound on her left palm that was oozing pus. She had purplish, red streaks running up her left arm. She had enlarged lymph nodes at the elbow and under her arm. The patients skin was warm and dry. In her history, the patient had punctured her left palm with sharp metal from the undercarriage of a "real cherry" 1977 Malibu about a week earlier. She said the wound had bled for a few minutes and she thought that she had washed it "real good" with soap and water. She had covered the wound with a large "band-aid" and gone back to work. She developed a fever about three days later. For the past couple of days, she "did not feel so good" and had vomiting and diarrhea. 1. What type of infection do you believe she has in this hand? a. Streptococcus pyogenes b. Staphylococcus aureus c. Clostridium d. Pseudomonas e. Pasteurella multocida 2. From complaint and physical examination, which of the symptoms lead you to your choice of agent? a. the fever and pain in the hand b. the fever, wound with oozing pus and enlarged lymph nodes c. the lymph nodes and red streaks d. the warm dry skin e. the pain, red streaks and enlarged lymph nodes 3. From the history, which of the information confirmed your choice? a. The wound had bled for a while. b. The wound was cleaned with soap and water. c. The wound had been covered and had perhaps become anaerobic. d. She had diarrhea and vomiting. e. The cut was from a rusting car frame. 4. Which of the following is most likely to follow this infection? a. gangrene and amputation b. toxic shock syndrome c. muscle spasms d. neurological dysfunction of the hand e. arthritis

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