Case 1

History of Present Illness: A 36-year-old mother and her 8-year-old daughter sought medical care in a
hospital emergency room 2 days after arriving in Colorado for vacation. One day prior to presentation,
both mother and daughter developed sudden onset of fever, chills, cough, fatigue, and muscle
soreness. The daughter also suffered from nausea, vomiting, stomach cramps, and diarrhea. Their
symptoms had severely worsened overnight.

Physical Exam Findings: Temperature, 102.7°F (mother); 103.9°F (daughter). Physical examination
of the daughter revealed stridor and lower extremity cyanosis.

The daughter’s chest xray showed bilateral infiltrates and consolidation consistent with pneumonia.
Additionally, sputum samples were collected from both patients and sent to the laboratory for
microscopic examination and culture.

Principal Laboratory Findings:

Daughter Mother Reference Range notes

Hematology

WBC count 21.6 10.2 0.36-1.1E+4/µ/

Neutrophils 92a 73 43-73% a With left shift

Hemoglobin 13.2 12.8 12.0-16.0g/dL

Hematocrit 39 39 36-48%

Platelet count 79 181 165-353 x 103/µL

Microbiology

Sputum Bloody with Not done. Sputum specimen was Many small, plump, ovoid
gram- Negative unsuitable for analysis due to >10 gram-negative rods
negative bacilli epithelial cells/low power field. exhibiting bi-polar
staining with a
characteristic “closed
safety pin” appearance.
QUESTION: What are these patients’ most striking clinical and laboratory findings?

Sudden onset and rapid progression of symptoms consistent with pneumonia in previously healthy
individuals. The most striking laboratory findings were leukocytosis with neutrophilia and a left shift and
the presence of gram-negative bacilli in a bloody sputum from the daughter consisting of many small,
plump, ovoid gram-negative rods exhibiting bipolar staining with a characteristic “closed safety pin”
appearance.
QUESTION: What is the most likely diagnosis for both patients?

The serious symptoms and characteristic staining of the organism found in the daughter’s sputum
should alert the medical technologist that they may be dealing with Yersinia pestis.

QUESTION: The patients contracted the illness in Colorado. What important history should be
investigated.

Investigate potential contact with wildlife: fleas of ground squirrels, prairie dogs, chipmunks can carry Y.
pestis in the western states.

QUESTION: If the patients had the same symptoms from a visit to Washington D.C. would that
change the investigation as to the source of the infection?

The eastern seaboard does not have endemic Y. pestis. The suspicion would be “deliberate infection.”
(?)

QUESTION: Contrast the symptoms of disease caused by this organism as it pertains to

infectious route?

The plague bacteria can be transmitted to humans in the following ways:

Flea bites. Plague bacteria are most often transmitted by the bite of an infected flea. During plague
epizootics, many rodents die, causing hungry fleas to seek other sources of blood. People and animals
that visit places where rodents have recently died from plague are at risk of being infected from flea
bites. Dogs and cats may also bring plague-infected fleas into the home. Flea bite exposure may result
in primary bubonic plague or septicemic plague.
Contact with contaminated fluid or tissue. Humans can become infected when handling tissue or
body fluids of a plague-infected animal. For example, a hunter skinning a rabbit or other infected animal
without using proper precautions could become infected with plague bacteria. This form of exposure
most commonly results in bubonic plague or septicemic plague.
Infectious droplets. When a person has plague pneumonia, they may cough droplets containing the
plague bacteria into air. If these bacteria-containing droplets are breathed in by another person they
can cause pneumonic plague. Typically this requires direct and close contact with the person with
pneumonic plague. Transmission of these droplets is the only way that plague can spread between
people. This type of spread has not been documented in the United States since 1924, but still occurs
with some frequency in developing countries. Other risk factors might include proximity to a lawn
mower that accidentally encountered a dead rodent. Additionally, a bioterrorism event should be
suspected if the infection occurs in an area of the country that is not endemic of plague or if a large
number of previously healthy individuals become critically ill with severe pneumonia and hemoptysis.
Symptoms of pneumonic plague and bubonic plague are similar with the exception of lymphadenitis
(bubo formation) which typically accompanies bubonic plague.
Cats are particularly susceptible to plague, and can be infected by eating infected rodents. Sick cats
pose a risk of transmitting infectious plague droplets to their owners or too veterinarians. Several cases
of human plague have occurred in the United States in recent decades as a result of contact with
infected cats.
Case 2:

History of Present Illness: A 23-year-old man recently from Sierra Leone was seen at an emergency
department because of abdominal pain for three days and a fever of 40°C. He reports fevers that are
irregular with night sweats.

Physical Examination: He did not appear acutely ill. HR 84, BP 108/55, temperature was 40 °C. He
had abdominal tenderness. There were no other abnormalities.

Laboratory: Hemoglobin level of 8.3 g/dL, platelet count of 56 X 103/ µL, a leukocyte count of 4.5 ×
103 cells/ µL and a normal differential.

Given his travel history, symptoms and lab findings a blood smear was done and showed the following:
QUESTION: What is your diagnosis? What are the species of this organism which cause
human disease? Which is suggested by the slide?

Plasmodium malariae, Plasmodium ovale, Plasmodium vivax, Plasmodium falciparum and recent
emergence of Plasmodium knowlesi in Asia. Plasmodium falciparum causes the most severe disease.
The slide shows only ring (early trophozoite) forms, a double infected erythrocyte, and normal sized
erythrocytes infected, all suggesting P. falciparum infection which is hyperendemic in Sierra Leone.

QUESTION: Describe the life cycle of this organism?

The malaria parasite life cycle involves two hosts. During a blood meal, a malaria-infected female
Anopheles mosquito inoculates sporozoites into the human host. Sporozoites infect liver cells and
mature into schizonts, which rupture and release merozoites. (Of note, in P. vivax and P. ovale a
dormant stage [hypnozoites] can persist in the liver and cause relapses by invading the bloodstream
weeks, or even years later.) After this initial replication in the liver, the parasites undergo asexual
multiplication in the erythrocytes. Merozoites infect red blood cells. The ring stage trophozoites mature
into schizonts, which rupture releasing merozoites. Some parasites differentiate into sexual erythrocytic
stages (gametocytes).

Blood stage parasites are responsible for the clinical manifestations of the disease.
The gametocytes are ingested by an Anopheles mosquito during a blood meal. The parasites’
multiplication in the mosquito is known as the sporogonic cycle. While in the mosquito's stomach, the
microgametes penetrate the macrogametes generating zygotes. The zygotes in turn become motile
and elongated (ookinetes) which invade the midgut wall of the mosquito where they develop into
oocysts. The oocysts grow, rupture, and release sporozoites, which make their way to the mosquito's
salivary glands. Inoculation of the sporozoites into a new human host perpetuates the malaria life cycle.
Reference: Cdc.gov

QUESTION: Which species have a dormant liver cycle, why is this important?
in P. vivax and P. ovale a dormant stage [hypnozoites] can persist in the liver and cause relapses by
invading the bloodstream weeks, or even years later. Therefore, treatment of these Plasmodium
species involves primaquine as this can kill hypnozoites in the liver and prevent relapses. Those treated
with primaquine should be screened for glucose-6-phosphate dehydrogenase deficiency, which can
lead to life-threatening hemolysis in severe G-6-PD deficiency. Unfortunately, G-6-PD deficiency is
enriched in populations from malaria endemic areas.

QUESTION: What are some of the major complications of this infection?

Plasmodium falciparum causes the most severe disease. Complications can include severe anemia,
cerebral malaria where patients can have neurological symptoms and present in a coma, and less
commonly, renal and liver failure, shock, and hypoglycemia. It can cause very severe disease in
pregnancy leading to fetal loss, maternal death, and underweight children upon birth.
Case 3:

A 31 year old man who grew up in rural Brazil presents with dyspnea on exertion, fatigue, palpitations
and bilateral lower extremity edema. He reports sometimes getting chest pain that he thought was
reflux disease. Given his edema and dyspnea on exertion, an echocardiogram was done and shows
new biventricular heart failure. Blood tests confirm an exposure to an infectious disease that he has
likely had for many years.

QUESTION: What is his most likely diagnosis and how is this disease transmitted?

This is most likely Trypanosoma cruzi which causes Chagas disease. It is transmitted by the Reduviid
bug or “kissing bug” and is often a painless bite. The vector defecates during its blood meal and fecal
material containing the parasite is inoculated into a bite sound or mucous membranes through
scratching. Transmission can also occur congenitally from mother to infant, through blood transfusion
as well as in organ transplantation.

QUESTION: What are some other clinical manifestations of this disease?

There can be both acute and chronic type of symptoms associated with this disease. Most patients are
asymptomatic when infected but some patients in the acute period can have generalized symptoms
such as fever, petechial rash, and myalgias. Often, in the acute phase, the level of parasitemia is high.
In a small number of patients, there might be inflammation and swelling at the site of inoculation.
Romaña’s sign is swelling of the eyelid when bug feces get rubbed into the eye. The chronic phase can
occur 10-20 years later in which patients can get megacolon, dilated cardiomyopathy and a mega-
esophagus.

QUESTION: What are some tests that would help in making a diagnosis?

The organism is diagnosed by blood smear if in the acute phase and one can see motile trypanosomes
during active infection. In chronic disease, both clinical symptoms and history, along with serology can
help to make the diagnosis. Multiple blood draws may reveal T. cruzi DNA by sensitive PCR or lab-
reared reduviid bugs can be fed on infected persons and 30 days later T. cruzi infection of the bugs can
be demonstrated (Xenodiagnosis). Serologic methods detect IgG antibodies to T. cruzi. On cardiac
biopsy, trypanosomes might be seen.
Case 4

History of Present Illness: In the month of August, a 7 year old boy is brought to the pediatric clinic
with the chief complaint of a large, red circular rash on his left thigh. The rash has been present for 2
weeks and has been enlarging. His father states that 3 weeks ago, the family was visiting relatives at a
rural farm in Connecticut, and one day after playing outside in the woods, the boy was found to have a
tick attached to his thigh. His father had removed the tick with tweezers; however a red macule
remained at the site where the tick had been attached. One week after the tick was removed, a red ring
developed around the macule, and then the ring appeared to grow larger by expanding outward,
leaving an area of central clearing. The boy has had a mild headache and myalgia, but has been
afebrile.

Physical Exam: VS T37.1, P90, RR 20, BP 100/70. He is alert, active, in no distress, and is non-toxic.
Over the anterior surface of his left thigh, there is a red ring, 20 cm in diameter, with central clearing,
and a central brownish-red macule that is 3 mm in diameter. The thigh is non-tender. No joint redness,
swelling or pain. His neck is supple without lymphadenopathy. The remainder of his exam is
unremarkable.

QUESTION: What is the likely culprit? If the patient was from the south east region of the US
what other illness would you consider?

Lyme, STARI. Lyme disease caused by Borrelia burgdorferi is transmitted by ticks, specifically the
Ixodes tick.

QUESTION: What other tick borne diseases can be transmitted by this tick vector?

The Ixodes tick is involved in the transmission of three diseases and can sometimes be seen together
in the same patient: Lyme disease, Anaplasmosis and Babesiosis. These ticks can also carry Ehrlichia
spp. but the range overlap is not as pronounced.

QUESTION: What are the clinical manifestations of this disease?

Stage 1: Localized infection

incubation period 3 – 30 days
Erythema chronicum migrans (or Erythema migrans): characteristic rash which can resemble a
target or bull’s eye appearance. It is an expanding annular lesion at site of tick bite

Stage 2: Disseminated infection

Skin: Secondary EM lesions (target lesions away from site of bite)
MSK: Migratory arthralgias, myalgias
Cardiac: Acute cardiac involvement (5%): atrioventricular or heart block, myopericarditis

Stage 3: Persistent (Late) infection

Months after onset
Recurring arthritis (prolonged) (60%) migratory polyarthritis
Occasional chronic neurologic disorders: cognitive slowing, memory difficulty
QUESTION: How would you definitively diagnose this disease.

Two-step serologic test

The first step uses a testing procedure called “EIA” (enzyme immunoassay) or rarely, an “IFA” (indirect
immunofluorescence assay). If this first step is negative, no further testing of the specimen is
recommended. If the first step is positive or indeterminate (sometimes called "equivocal"), the second
step should be performed. The second step uses a test called an immunoblot test, commonly, a
“Western blot” test. Results are considered positive only if the EIA/IFA and the immunoblot are both
positive.
The two steps of Lyme disease testing are designed to be done together. CDC does not
recommend skipping the first test and just doing the Western blot. Doing so will increase the frequency
of false positive results and may lead to misdiagnosis and improper treatment.

The Two-tier Testing Decision Tree describes the steps required to properly test for Lyme disease. The
first required test is the Enzyme Immunoassay (EIA) or Immunofluorescence Assay (IFA). If this test
yields negative results, the provider should consider an alternative diagnosis. Or in cases where the
patient has had symptoms for less than or equal to 30 days, the provider may treat the patient and
follow up with a convalescent serum. If the first test yields positive or equivocal results, two options are
available: 1) if the patient has had symptoms for less than or equal to 30 days, an IgM Western Blot is
performed; 2) if the patient has had symptoms for more than 30 days, the IgG Western Blot is
performed. The IgM should not be used if the patient has been ill for more than 30 days.
If the blood smear appeared as follows what additional disease does the patient have?

Babesiosis. The presence of the “Maltese Cross” formations are pathognomonic of babesiosis. The
Ixodes tick can be infected with and transmit both Borrelia burgdorferi and Babesia microti
simultaneously.
Case 5

A 62 y.o. white female was seen in clinic for a several week history of episodic fevers, malaise,
myalgias, and prostration. Episodes lasted several days with intervening periods of relative well being
lasting approximately one week. She had had three such cycles of illness at the time of her evaluation.
The patient had previously been in good health. Ten days prior to her first episode of illness she had
spent several days at her family cabin on Lake Roosevelt. Lake Roosevelt, in north central Washington,
is a reservoir formed by the damming of the Columbia River by Grand Coulee Dam. The patient had
swam in the reservoir and gone for lengthy hikes about the property. She could recall no specific insect
exposure.
Laboratory evaluation was notable for mild anemia and thrombocytopenia (plts 76). Liver function tests
were normal.
She was feeling well when seen in the office. Had she been seen during one of her episodic periods of

illness, her peripheral blood smear might have appeared as above.

Likely culprit? Differential diagnosis?

Tick Borne relapsing fever (TBRF) caused by B. hermsii or B. turicatae

How did she get infected?

Sleeping in the cabin. The cabin likely harbors rodent nests and infected soft ticks.

Why does she not recall any insect exposure?

Ornithodoros (soft) ticks feed for less than one hour, typically at night, and the bites are painless and
usually unnoticed.
Describe why the fever is relapsing from both the bacterial and host point of view.

Infection results in a febrile illness due spirochetes in the blood stream activating DAMPs and PAMPs.
The host mounts an immune response including antibodies. The antibodies neutralize the organism.
Some of the spirochetes have undergone antigenic variation mediated by homologous DNA
recombination between pseudogenes and expressed surface protein genes resulting in new antigens
on the surface. The host is naive to these antigens and the immune response wanes allowing
replication of these mutated spirochetes and new round of fever. The host adapts by producing new
antibodies that recognize the new epitopes. The cycle repeats itself.
Case 6
History of Present Illness: A 5-year-old female presented to an emergency department in Missouri
with a 1-week history of intermittent fever as high as 40°C. She also complained of frontal headache
and stomachache. Three days after the onset of fever, she developed a maculopapular erythematous
rash on her extremities, including her palms and soles, that moved centripetally to involve her trunk.
The diagnosis of Coxsackie hand-foot-mouth disease was made despite no oral lesions.
Her parents reported tick exposure around their rural residence, but no definite antecedent tick bite.
Physical Examination: T 40.6 degrees C, P 104, RR 22, BP 120/85. She is lying in a hospital gurney,
awake and responsive, but tired and ill appearing. Her skin has a blanching, maculopapular rash on the
upper and lower extremities as well as palms and soles (see photos below). There are several sites of
scattered petechiae located on her back. Abdomen is soft, mildly tender to palpation in all four
quadrants, with normal bowel sounds. Remainder of exam is unremarkable.
Laboratory studies: white blood cell count of 8800 × 103/µL, with 5% band cells, 70% neutrophils,
17% lymphocytes, and 8% monocytes. The platelet count was 92 × 103/µL. Serum sodium is 130
mEq/L. AST and ALT levels are also mildly elevated.

What do you think about the original diagnosis? What is the differential?
A viral infection such as Coxsackie may have initially been reasonable, however the differential for a
rash involving the palms and soles also includes some serious bacterial infections:
meningococcemia, secondary syphilis, Rocky Mountain spotted fever are some examples.

Continued…
Two days later she returned because she continued to worsen and she was now refusing to walk.
Laboratory tests again showed thrombocytopenia (42,000 [normal 150000-450000]), leukopenia (3300
[normal 4500-11000]), and anemia (hemoglobin 10.4 g/dL [normal range: 13.8--17.2 g/dL]), and
hyponatremia (130 mmol sodium/L [normal range: 135--145 mmol sodium/L]).
She was admitted and treated with IV ceftriaxone and doxycycline.

What do you think now? What is in your differential diagnosis? What about the treatment?

Much sicker, evidence of vascular stress and evidence of a possible bacterial infection. Any of the
vector borne rickettsiae would come to mind as well as meningococcus and syphilis.

Combination antibiotic therapy is useful when considering empiric coverage of several possible
diagnoses (e.g.,rickettsioses, meningococcemia, syphilis).

Continued…
Her condition continued to deteriorate; 8 days after initial treatment, she died from multiple system
failure. A serum specimen collected 2 days earlier tested positive by enzyme immunoassay for IgM
antibodies reactive with the infectious agent.

What is the likely agent here?

R. rickettsii. Very serious infections, difficult to diagnosis (need to have high index of suspicion).
Continued…
The child's mother, aged 40 years, was hospitalized 2 days before her daughter's death with 2 days of
diplopia, dizziness, headache, and fever. IV ceftriaxone and doxycycline were administered; she was
discharged after 5 days. IgG antibodies reactive with the infectious agent were demonstrated in acute
and convalescent phase serum specimens obtained during illness and 2 weeks later.

Why did they need both acute and convalescent serum for diagnosis?

IgG can is a relatively long lived antibody. The presence of IgG in the convalescent serum cannot tell
you when the infection had occurred, only that she had at some point been infected with R. Rickettsii.
The paired serum shows a rise in titer and that can tell you when the exposure occurred.

Why was the mother’s outcome so different? What do you think about the treatment?

Early treatment with doxycycline.

Combination drug therapy offers no advantage for etiologically diagnosed Rocky Mountain spotted
fever, and thus there are no relevant susceptibility data. However,

How was this disease transmitted?

Rocky Mountain spotted fever is a serious tickborne illness which can be deadly if not treated early. It is
spread by several species of ticks in the United States, including the American dog tick (Dermacentor
variabilis), Rocky Mountain wood tick (Dermacentor andersoni) and, in parts of the southwestern United
States and Mexico, the brown dog tick (Rhipicephalus sanguineus) . RMSF cases occur throughout the
United States, but are most commonly reported from North Carolina, Tennessee, Missouri, Arkansas,
and Oklahoma.

What genetic disorder protects you from malaria, but makes this infection much more severe?

G6PD (glu-6-phosphate dehydrogenase) deficiency

What are some of the virulence strategies used by this organism? What arms of the immune
system can help control this organism.

R. rickettsii is an obligate intracellular pathogen this allows it avoid interactions with the complement
system and antibodies. In addition to living inside cells R rickettsii, along with multiple other intracellular
parasites, avoid immune detection by invading neighboring cells without exiting to the extracellular
space. Shigella, Listeria, Burkholdaria and R. rickettsii polymerize actin at one pole and ride a wave of
F-actin pushing into neighboring cells. The most effective immune response to this organisms is the cell
autonomous arm of the innate immune response and CD8 T cells generated from the adaptive immune
response.