Skin Infections

Mark is an active student leader; he organized a 2-day farewell party for their
graduating batch at a local resort. After the fun-filled party, he noticed an area of
erythema that is raised and painful in his lower extremities. After a day, there is a
presence of pus-filled vesicle that ruptures and form crust in his face accompanied
by swollen lymph node. He worriedly consulted a physician at a local hospital, the
doctor suspected a bacterial skin infection and order a laboratory test for
confirmation. A medium is used to culture a specific suspected causative agent.
Mark was given a penicillin but after administration he manifested a rash, a sign for
an allergic reaction.

1. What is the most probable causative agent? Describe.

- Streptococcus pyogenes, a gram positive cocci arranged in pairs or chains,
encapsulated. Also known as beta-hemolytic group A streptococcus, most
pathogenic bacterium in the genus of streptococcus.

2. What is the major virulence factor of the causative agent?

- M-protein encapsulate S. pyogenes that is antiphagocytic by preventing
opsonization by C3b.

3. In what ways it can be transmitted?

- This can be transmitted through direct contact with infected person and
through fomites (soiled lines and clothing).

4. What is the medium used and what is the indication that it is positive?
- Bacitracin test is used to distinguish Beta-hemolytic streptococci, S.
agalactiae and S. pyogenes. In this test S. pyogenes is positive because it is
resistant to bacitracin, a zone of inhibition is formed in the medium.

5. What is the alternative drug for Penicillin?

- Macrolides (Azithromycin, Erythromycin) is the alternative drug in cases of
Penicillin allergy. It stop bacterial growth by inhibiting protein synthesis by
binding to bacterial 50s ribosomal unit.

Infection of the Respiratory Tract:

A 20-year-old patient was brought to the emergency room and complained
about difficulty in breathing. The case also presented inflammation in the respiratory
tract that leads to sore throat and fever. Upon inspection of the client’s throat, you
had observed a thick, gray, adherent pseudomembrane over the tonsils and throat
that had probably cause the airway obstruction.

1. What is the most probable diagnosis and causative agent? -The patient is
suffering from diphtheria that is causes by Corynebacterium diphtheriae.

2. How can this be transmitted? - It can be transmitted by airborne droplets of a

carrier or prolonged direct contact to the discharge from a cutaneous lesion of an
infected person.
3. What are the possible laboratory diagnosis to confirm the diagnosis of the patient?
- We can perform a swab from the throat of the patient and perform gram-staining
and microscopic examination. We should also culture the specimen using Loeffler's
medium. The colonies of C. diphtheriae must also be tested for toxin production to
know its pathogenicity.

4. What will be the appearance of the causative agent under the microscope?

- C. diphtheriae is a gram-positive, which means it is purple in color and is known for

its club-shaped arranged in V- or L-shape forms that is similar to a "Chinese
character" appearance.

5. What can be the possible treatment and prevention for this?

- The recommended antibiotics for diphtheria are penicillin G or erythromycin, as
well as diphtheria antitoxin to neutralize the toxins produced by C. diphtheriae. A
vaccine for active immunization is also a way to prevent acquiring diptheria.

GI tract infections
A 37-year-old man likes to travel. He visited Japan and before going home, he
decided to eat Japanese cuisines. He picked a seafood restaurant where he
specifically ordered raw oyster. After eating, he took his flight back to USA. A few
hours after his arrival, he experienced an increase in his body temperature and
nausea followed by vomiting. He also experienced abdominal cramps and mild
watery diarrhea. He then decided to go to the doctor the following day. During the
consultation, he told the doctor that he recently came from Japan and the last food
he ate before going home was raw oyster. After knowing those important details, the
doctor requested a stool sample to determine the causative agent. In the laboratory
diagnosis, a culture media with 8% sodium chloride solution (NaCl) is used since the
causative agent is halophilic.

1. What is the causative agent? Where can this be found? - Vibrio parahaemolyticus
that can be found in the bodies of water.
2. What is the probable diagnosis? - Bacterial Enterocolitis (Food poisoning)
3. Is oyster associated with the causative agent? Why?- Yes, Since the causative
agent is a marine organism and oyster is considered as a filter-feeder which feed by
filtering water wherein the causative agent may be present.
4. What culture media is used to determine the causative agent? - Thiosulfate-
Citrate-Bile-Salts-Sucrose Agar
5. What are the treatment and prevention? - Supportive care, proper refrigeration
and cooking of seafood
Sexually transmitted Infections
Mitch is an18 year old girl who loves to party as her stress reliever. One day
she observed a greenish and purulent vaginal discharge accompanied by painful
urination (dysuria) and abdominal pain. Months later, she consulted a physician
because she experienced an inflammation of her fallopian tube, an indication that
there is progressive ascending infection. In laboratory diagnosis, a selective medium
is used to confirm the presence of the microorganism.

1. What is the most probable diagnosis? Gonorrhea

1. Describe the most probable etiologic agent?

- Neisseria gonorrhea, is a gram (-) diplococci, that is bean shaped if
single and coffee bean-shaped if in pairs. Has pili for attachment to host
cell, motility, transfer of genetic material, and important in its pathogenesis.

3.What selective medium is used?

- Thayer-Martin medium is used.

4.Why it is considered as selective medium?

- Thayer- Martin medium inhibit the overgrowth of other microorganisms because it
incorporates antimicrobials (VPN). Vancomycin kills gram (+) bacteria, Polymyxin kill
most gram (-) bacteria except for Neisseria, and Nystatin that kills most fungi.

5. What are the treatment/s and mechanism of action?

- For uncomplicated gonorrhea, Ceftriaxone, Ciproflaxacin,Cefixime, and Oxfloxacin
are used for treatment. Both Ceftriazone and Cefixime target cell wall synthesis of
the bacteria as it binds with PBPs, inhibit transpeptidation, and peptidoglycan
synthesis that cause loss of bacterial integrity, change shape, burst that lead to
death of the cell. Ciprofloxacin and Oxfloxacin both target DNA gyrase and
topoisomerase IV.

Infections of the Urinary Tract

A 30-year-old female patient had complaint of pain in the lower back and
blood in the urine. She also has fever and chills and feels pain when urinating and
had the urgent need to urinate every now and then. You decided to perform a kidney
punch to the patient and she tested positive. Upon conducting a urinalysis and urine
culture to the patient's urine, you had observed a bright-red pigment on the culture
medium and a high white cell casts count of 8/hpf in the urine sediment.

1. What is the most probable diagnosis and the causative agent of this
infection? - The patient may be suffering from acute pyelonephritis that is caused by
a Serratia species, most possibly by Serratia marcescens.

2. What are the possible routes by which bacteria can cause this infection? -
Pyelonephritis is an upper urinary tract infection which can be caused by bacteria
through ascending infection from the lower urinary tract or though the bloodstream.
 3. . Can the patient's gender play a role in her contracting a UTI? Why? - Yes.
It is because females are more prone to UTI because their urethral orifice is closer to
their anus and their urethra are much shorter compared to male which makes the
bacteria reach the bladder faster.

4. What is the normal white cell cast present in the urine under the
microscope? What does elevation of white cell casts indicates? - The normal value
of white cell casts is 0-2/hpf and an elevation on this value is highly suggestive of an
upper urinary tract infection such as acute pyelonephritis.

5. What can be the possible treatment? - For acute pyelonephritis,

fluoroquinolones or third generation cephalosporins may be given 3-10 days.
We should also increase the water intake of the patient to avoid dehydration.

Infections of the Eyes and Central Nervous System

In a hot Saturday morning, a 12-year-old girl living beside a lake decided to
swim. She is living in a crowded community where they do not practice proper waste
disposal. During her swim, she saw someone throwing wastes but she ignored it and
continued what she was doing. She also noticed that a fly landed in between her
eyes, so she used her hand to swat the fly away. She then scratched her eyes
unconsciously and decided to stop swimming to go home. After how many days, she
experienced itching and irritation of the eyes with mucopurulent discharge. She also
experienced swelling of the upper eyelids. As days pass by, her mother decided to
bring her to the doctor because they observed that there is a presence of in-turned
eyelids.

1. What is the probable diagnosis? - Trachoma

2. What is the causative agent? - Chlamydia trachomatis
3. Based on the situation given, how did the girl acquire the infection? - Through eye-
seeking fly(mechanical vector) that carries the causative agent which was
transferred from her face to her eyes when she swatted it and scratched her eyes
using her hand.
4. In what type of infection can this probable diagnosis be classified? - Bacterial
infection
5. What type of discharge is present in this infection? And why? - Mucopurulent
discharge consist of pus and mucus. It contains pus because of the dead white blood
cells resulted from the immune response to a bacterial infection.

Nervous system infections

Norma is a vendor in Divisoria, every day she encountered different sets of
people. One day, she manifested a throat infection and presence of petechiae (skin
lesion due to bleeding in the skin) over her trunk and lower extremities. She
consulted a doctor due to muscle and bone weakness, high blood pressure, and
weight loss. The doctor told her that she experienced Waterhouse-Friderichsen
syndrome, a group of symptoms caused by adrenal gland failure.

1. Describe the most probable causative agent?

- Neisseria meningitidis (meningococcus), is encapsulated gram negative coffee
bean shape (kidney bean-shaped) diplococcus and transient flora of nasopharynx.

2. In what possible ways did Norma acquire it?

-She acquired it by inhalation of respiratory droplets among contacts or through
respiratory aerosols from infected person she encountered in Divisoria.

3. What laboratory test/s can be used to confirm the diagnosis?

- The specimens are blood and CSF. Gram staining and Counter-
immunoelectrophoresis, agglutination, latex particle coated with specific antibiotics to
detect polysaccharide antigen.

4. If CSF is collected, what is the possible result?

- In bacterial meningitis, CSF is thicker (clear, cloudy or purulent). CSF glucose level
is low with increased WBC count, and protein due to increased number of replicating
bacteria and body cells are fighting the infections.

5. What treatment should be given to Norma?

-Penicillin is the drug use while Cephalosporins and chloramphenicol are alternative
drugs. Minocycline and Rifampicin are recommended for treatment of carriers. And
for contacts, prophylaxis includes sulfonamides and rifampicin for sulfonamide-
resistant strains

Viral Exanthem
A 7-year-old patient has a high grade fever accompanied by cough, common
cold, conjunctivitis with photophobia. A pathognomonic enanthem also developed
after two days. There were also maculopapular rashes noted over the face and the
trunk of the patient which later spread to the extremeties.

1. What is the most probable diagnosis and causative agent? - The most probable
diagnosis is measles (rubeola) that is caused by the rubeola virus or the measles
virus.

2. How does the causative agent bind to its target cell? - The measles virus (rubeola
virus) will attach to host cell receptor mediated by the Hemagglutinin antigen (H-
antigen) then will trigger membrane fusion between the virus and host cell mediated
by the Fusion protein (F-protein) that leads to formation of a multinucleated giant
cells.

3. How can it br transmitted? - It can be transmitted through inhalation of the

respiratory droplets.
4. What is the pathognomonic enanthem of the complaint of the patient is called?
What is its appearance? - It is Koplik's spots that is described as "grains of salts"
over the inner cheek that is grayish to white in color.

5. What are the treatment and prevention? - Treatment is done through symptomatic
and supportive, and administration of the vaccine (MMR vaccine) as well as
administration of immune globulin given to exposed susceptible individuals like those
who are immunocompromised.

Other Systemic Infections

A 30 year old man went home to their province to visit his mother. Near their house,
there is a pond filled with water. One late afternoon, he decided to take a nap near
the pond and when he woke up, he noticed mosquito bites on his lower extremities.
After 3 days of visiting, he went back to the city where he works. A day after, he
experienced fever and severe muscle and joint pain to the point that he is unable to
go to work. There is also presence of rash and mild headache without pain behind
his eyes. Due to his absence, his friend visited him and brought him to the hospital.

1. What is the probable diagnosis? - Chikungunya

2. What is the probable vector of this infection? - Aedes agypti since he got the
infection in a rural area.
3. What is the etiologic agent of this infection? - Alphavirus
4. How can you differentiate this diagnosis from dengue fever? - There is no
presence of retroorbital pain, muscle and joint pain is more severe than dengue
fever, and headache is mild.
5. What can be the supportive care for this infection? - analgesics, fluid replacement,
and bed rest.