Case 1-A

A 2 year old child was brought to you because of diarrhea of 3 days duration. Stools were described to be bloodstreaked occurring 3-4x per day. Accompanying symptoms were moderate grade fever, tenesmus and abdominal
pain. PE showed a conscious child, slightly febrile. No signs of dehydration.
Questions:
1. What is your diagnosis for the case and give the basis for diagnosis
Hemorrhagic colitis is a type of gastroenteritis in which certain strains of the bacterium Escherichia coli (EHEC)
infect the large intestine and produce a toxin (Shiga toxin) that causes bloody diarrhea and other serious
complications.
Other symptoms accompanying hemorrhagic colitis:
Severe abdominal cramps begin suddenly along with watery diarrhea, which may become bloody within 24 hours.
The diarrhea usually lasts 1 to 8 days. Fever is usually absent or mild but occasionally can exceed 102 F (39
C).
2.

What would be the probable etiologic agents?

Enterohemorrhagic Escherichia coli (EHEC)

Escherichia coli O157:H7

Gram negative rod, a facultative anaerobe motile by means of peritrichous flagella, and found in the
GI tract of mammals

E. coli pathotypes that cause diarrhea are transmitted via contaminated food or water, or through
contact with infected animals or people

EHEC cause disease by producing a toxin called Shiga toxin, Shiga toxin causes bloody diarrhea
and in approximately 5-10% of cases hemolytic uremic syndrome (HUS), which can lead to complete kidney
failure

Patients with bloody diarrhea usually recover within ten days and those who develop HUS usually
recover within a few weeks, but in cases of kidney failure the patient may die
3. What laboratory test would you request?
EIA (detection of both shiga toxins), clear colonies on sorbitol Mac, (-) MUG, PCR, cytotoxic activity on Vera cells.
4.

Outline the management for each case

The disease usually is self-limiting and most patients recover without specific treatment within five to 10 days.
Antibiotics are counter-indicated for treatment of E. coli 0157:H7 infections as studies have shown that antibiotic
treatment may increase the risk of HUS. Non-specific supportive therapy, including hydration, is essential.
E. coli 0157:H7 is transmitted by the fecal-oral route. It is most frequently associated with hamburger or other
ground beef products, unpasteurized milk and fruit juices, and leafy green vegetables. Hence it is important to
avoid consuming undercooked meats and unwashed vegetables. E. coli 0157:H7 can also be transmitted via
person-to-person contact. Sanitization and hand washing are important after using the bathroom or changing
diapers, before preparing or eating food and after contact with animals or their environments.

Source:
http://www.merckmanuals.com/home/digestive-disorders/gastroenteritis/hemorrhagic-colitis
https://microbewiki.kenyon.edu/index.php/EHEC
Jawetz, Medical Mircobiology

Case 2
A 20 year old female nursing student was admitted because of fever of 2 weeks duration. History revealed that she
developed fever 2 weeks prior to admission which was initially low grade becoming high grade after a week.
Accompanying symptoms were severe headache, vomiting and loose to watery stools. A consultation was done and
she was prescribed Chloramphenicol which she discontinued after 3 days because there was slight improvement.
Personal history revealed that she always would have meals in the food stalls around the school. Two classmates of
her also had the same complaints. Her companion at her house also noted her to be talking incoherently.
PE: conscious, incoherent, not in respiratory distress, toxic looking
Vital signs: T 40 C, RR 20/min, PR 70/min
HEENT: slightly pale palpebral conjuctivae, slightly icteric sclerae throat not congested
Heart: bradycardia, no murmur
Lungs: unremarkable
Abdomen: slightly distended, liver palpable, 3cm below (R) subcostal margin with slight tenderness, spleen palpable 4 cm
below (L) subcostal margin.
Extremities: unremarkable
Questions:
1. What is your diagnosis?
Typhoid fever, also known as enteric fever, is a potentially fatal multisystemic illness caused primarily by
Salmonella enterica, subspecies enterica serovar typhi and, to a lesser extent, related serovars paratyphi A, B,
and C.
The classic presentation includes fever, malaise, diffuse abdominal pain, and constipation. Untreated, typhoid fever
is a grueling illness that may progress to delirium, obtundation, intestinal hemorrhage, bowel perforation, and
death within 1 month of onset. Survivors may be left with long-term or permanent neuropsychiatric
complications.
The clinical syndromes associated with S typhi and paratyphi are indistinguishable. Typhoid fever begins 7-14 days
after ingestion of the organism . The fever pattern is stepwise, characterized by a rising temperature over the
course of each day that drops by the subsequent morning. The peaks and troughs rise progressively over time.

2.

What is the probable etiologic agent?

Salmonella Typhi

Salmonella typhi is a rod-shaped, gram negative bacteria that contain features that
separates itself from other types of bacteria which include: having 2 membranes ( and outer and an inner),
periplasm, and a Lipopollysaccharide chain that consists of -d-galactosyl-(1 2)--d-mannosyl-(1 4)-lrhamnosyl-(1 3)-repeating units, and has short branches of single 3,6-dideoxyhexose residues

Gram negative bacterium that causes systemic infections and typhoid fever in humans.

This rod-shaped, flagellated organisms sole reservoir is humans.

Salmonella typhi has undergone evolutionary change and has become resistant to
antibiotics.

In order to survive in the intestinal organs of its hosts where there are low levels of oxygen,
Salmonella typhi has to be able to learn to use other sources other than oxygen as an electron acceptor.
Therefore, Salmonella has adapted to grow under both an aerobic and anaerobic conditions. (Obligate aerobe
or Obligate anaerobe)

3.

Give the pathogenesis of the disease

The ingested salmonellae reach the small intestine, enter the lymphatics and then the bloodstream,
are carried by the blood to many organs, including the intestine. The organisms multiply in intestinal lymphoid
tissue and are excreted in stools.

After an incubation period of 1014 days, fever, malaise, headache, constipation, bradycardia, and
myalgia occur. The fever rises to a high plateau, and the spleen and liver become enlarged. Rose spots, usually
on the skin of the abdomen or chest, are seen briefly in rare cases.

4.

Give the laboratory test which will support your diagnosis

Culture in differential mediums like EMB, MacConkey, or deoxycholate medium (NLF)

Culture in selective mediums like salmonella-shigella (SS) agar, Hektoen enteric agar, xylose-lysine decarboxylase (XLD)
agar, or deoxycholate citrate agar
Identified by biochemical reaction patterns and slide agglutination tests with specific sera
Widal test detect antibodies against the O and H antigens, at least two serum specimens, obtained at intervals of 710 days,
are needed to prove a rise in antibody titer. Serial dilutions of unknown sera are tested against antigens from representative
salmonellae. False-positive and false-negative results occur. The interpretive criteria when single serum specimens are
tested vary, but a titer against the O antigen of greater than 1:320 and against the H antigen of greater than 1:640 is
considered positive.
Radiography: Radiography of the kidneys, ureters, and bladder (KUB) is useful if bowel perforation (symptomatic or
asymptomatic) is suspected.
CT scanning and MRI: These studies may be warranted to investigate for abscesses in the liver or bones, among other sites.

5.

Which of these tests is confirmatory?

Biochemical tests and agglutination with specific sera

6.

What are the possible complications that could arise from this infection?
Hyperplasia and necrosis of lymphoid tissue (eg, Peyers patches); hepatitis; focal necrosis of the liver; and
inflammation of the gallbladder, periosteum, lungs, and other organs

7.

What would be the preventive measures?

Eat safe foods:

Bushmeat (monkeys, bats, or

other wild game)

Eat

Drink safe beverages:

Food that is cooked and served

hot

Drink

Hard-cooked eggs

Fruits and vegetables you have

washed in clean water or peeled yourself

Pasteurized dairy products

Bottled water that is sealed

(carbonated is safer)

Water that has been disinfected

(boiled, filtered, treated)

Ice made with bottled or

disinfected water

Bottled and sealed carbonated

and sports drinks

Hot coffee or tea

Pasteurized milk

Don't Eat

Food served at room temperature

Food from street vendors

Raw or soft-cooked (runny) eggs

Raw or undercooked (rare) meat

or fish

Unwashed or unpeeled raw fruits

and vegetables

Peelings from fruit or vegetables

Condiments (such as salsa) made

with fresh ingredients

Salads

Unpasteurized dairy products

Don't Drink

Tap or well water

Ice made with tap or well water

Drinks made with tap or well

water (such as reconstituted juice)

Flavored ice and popsicles

Unpasteurized milk

Fountain drinks

Practice hygiene and cleanliness:

Wash your hands often.

If soap and water arent available, clean your hands with hand sanitizer (containing at least 60%
alcohol).

Dont touch your eyes, nose, or mouth. If you need to touch your face, make sure your hands are
clean.

Try to avoid close contact, such as kissing, hugging, or sharing eating utensils or cups with people
who are sick.
8.

How effective are the vaccines that are available?

Typhoid vaccine is only 50%-80% effective, so you should still be careful about what you eat and drink.

9.

How will you treat the patient?

Chloramphenicol was used universally to treat typhoid fever from 1948 until the 1970s, when widespread resistance
occurred. Ampicillin and trimethoprim-sulfamethoxazole (TMP-SMZ) then became treatments of choice. However,
in the late 1980s, some S typhi and S paratyphi strains (multidrug resistant [MDR] S typhior S paratyphi)
developed simultaneous plasmid-mediated resistance to all three of these agents.
Fluoroquinolones are highly effective against susceptible organisms, yielding a better cure rate than cephalosporins.
Unfortunately, resistance to first-generation fluoroquinolones is widespread in many parts of Asia.
In recent years, third-generation cephalosporins have been used in regions with high fluoroquinolone resistance
rates, particularly in south Asia and Vietnam. Unfortunately, sporadic resistance has been reported, so it is
expected that these will become less useful over time
Third generation cephalosphorin:
Chloramphenicol (Chloromycetin)
Binds to 50S bacterial-ribosomal subunits and inhibits bacterial growth by inhibiting protein synthesis.
Effective against gram-negative and gram-positive bacteria.
Amoxicillin (Trimox, Amoxil, Biomox)
Interferes with synthesis of cell wall mucopeptides during active multiplication, resulting in bactericidal
activity against susceptible bacteria.
Cefotaxime (Claforan)
Arrests bacterial cell wall synthesis, which inhibits bacterial growth.
Corticosteroids:
Dexamethasone may decrease the likelihood of mortality in severe typhoid fever cases complicated by delirium,
obtundation, stupor, coma, or shock if bacterial meningitis has been definitively ruled out by cerebrospinal fluid
studies.

Case 3
A 26 year old female presents to her primary care physician stating that she is having severe hypogastric pain
whenever she urinates and seems to be urinating more frequently than normal. She reports that her symptoms
started after she began having unprotected sexual intercourse with 1 partner earlier this week. The physician
obtains a urinalysis which demonstrates the following: SG 1.010, leukocyte esterase (+), nitrites (+), protein: trace,
pH 5.0, rbc (-), a urease test is performed which is negative.
Questions:
1. This patient has most likely been infected with what organism?
Uropathogenic E. coli (UPEC) cause 90% of the urinary tract infections (UTI) in anatomically-normal, unobstructed
urinary tracts. The bacteria colonize from the feces or perineal region and ascend the urinary tract to the bladder.
Bladder infections are 14-times more common in females than males by virtue of the shortened urethra. The typical
patient with uncomplicated cystitis is a sexually-active female who was first colonized in the intestine with a
uropathogenic E. coli strain. The organisms are propelled into the bladder from the periurethral region during sexual
intercourse. With the aid of specific adhesins they are able to colonize the bladder.
Source: http://textbookofbacteriology.net/e.coli_3.html
Symptoms:

Burning feeling during urination

Intense urges to urinate
Passing frequent but small amounts of urine
Unusual-smelling, cloudy, or bloody urine
Fever or chills
Pain in the lower back, hips, or flanks
Pelvic pain in women, rectal pain in men
Source: http://www.everydayhealth.com/e-coli/guide/symptoms/
2. What is the principle of urease test? What organisms are positive for this test?
Urease broth is a differential medium that tests the ability of an organism to produce an exoenzyme, called urease, that
hydrolyzes urea to ammonia and carbon dioxide. The broth contains two pH buffers, urea, a very small amount of
nutrients for the bacteria, and the pH indicator phenol red. Phenol red turns yellow in an acidic environment and
fuchsia in an alkaline environment. If the urea in the broth is degraded and ammonia is produced, an alkaline
environment is created, and the media turns pink.
Source: http://www.austincc.edu/microbugz/urease_test.php
Urea is a diamide of carbonic acid. It is hydrolyzed with the release of ammonia and carbon dioxide.
Many organisms especially those that infect the urinary tract, have an urease enzyme which is able to split urea in the
presence of water to release ammonia and carbon dioxide. The ammonia combines with carbon dioxide and water to
form ammonium carbonate which turns the medium alkaline, turning the indicator phenol red from its original orange
yellow color to bright pink.
Source: http://microbeonline.com/urease-test-principle-procedure-interpretation-and-urease-positive-organsims/
Organisms with urease (+)
Proteus
Providencia
Morganella
Cryptococcus spp
Corynebacterium spp
Helicobacter pylori

Yersinia spp
Brucella spp
Klebsiella
3.

What is your diagnosis? What are your basis for such diagnosis?

UTI caused by UPEC E. coli, since the patient had been experiencing severe hypogastric pain whenever she urinates
and seems to be urinating more frequently than normal. Also, symptoms started after she began having unprotected
sexual intercourse with 1 partner earlier this week. The urinalysis demonstrates the following: SG 1.010, leukocyte
esterase (+), nitrites (+), protein: trace, pH 5.0, rbc (-), a urease test is performed which is negative.
The + LE and nitrite is a proof that there is an infection happening.
The (-) urease test shows that it might be E. coli since it is urease (-)
The symptoms mentioned by the patient is compatible with UTI.
The sexual intercourse is one of the transmission of UPEC E. coli, which is the most common cause of UTI.
4.

What clinical laboratory examinations would you request to arrive at a definitive diagnosis?

Gram stain of urine sample

Urine Culture and Sensitivity
Biochemical Tests
Source: http://www.mayoclinic.org/diseases-conditions/urinary-tract-infection/basics/tests-diagnosis/con-20037892
5.

What antibiotic therapy should be given for infection with this organism?

Usual treatment to the uropathogenic E. coli are trimethoprim/sulfamethoxazole or ciprofloxacin but there is
documentation of increase in antibiotic resistance, allergic reaction to certain pharmaceuticals, alteration of normal gut
flora, and failure to prevent recurrent infections. Also, some strains of E. coli had extended-spectrum beta-lactamase
(ESBL) that causes antibiotic resistance. There are now only a few classes of oral antibiotics that remain effective at
treating UTIs from ESBL E. coli, such as fosfomycin (Monural) and nitrofurantoin (Macrobid)
Sources: http://www.everydayhealth.com/e-coli/guide/treatment/
http://aac.asm.org/content/54/9/4006.full
http://www.umich.edu/~hltmlab/research/coli/