Case 1

During track practice, a 15-year-old female high school student tripped over a barrier and heard a “pop” in her
right knee cap. She experienced pain in her right knee and shin and was not able to walk on that leg. She was
seen at an emergency clinic, where it was determined that she may have torn her anterior cruciate ligament
(ACL) and she was referred to an orthopedic surgeon. The damaged ACL was removed and replaced with an
ACL graft, which was secured in place with screws. She was given a brace to wear for several weeks, given
broad-spectrum therapy, and was to be followed up by her primary care physician within a few weeks.
During the second week of recovery, increased pain was noted in the injured knee and a clear exudate was noted
at the incision site. The site was drained, and primary cultures and antimicrobial susceptibility tests were
performed at a large metropolitan laboratory.
Gram-stained results showed many gram-positive cocci in pairs and clusters with few polymorphonuclear
neutrophils (PMNs). Heavy growth of coagulase-positive Staphylococcus species grew at 18 hours. The
laboratory was validating a matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) procedure,
and an analysis was performed. The laboratory scientist reviewing the MALDI-TOF report was surprised that S.
aureus had not been identified and consulted with infectious disease staff. A review of the patient’s history
showed this student, and her sister were frequent volunteers at a local animal shelter, and a preliminary report
based on the MALDI-TOF identification was released with susceptibility results using the latest reference
ranges for minimum inhibitory concentration (MIC) interpretation for this species of staphylococci. The isolate
was referred to the state health department, which confirmed the MALDI-TOF identification as S.
pseudintermedius.

Questions:
1. What are the risk factors associated with acquiring this organism?
2. Based on the given data, what is the possible diagnosis of the patient?
3. Explain the methods that were used to identify this isolate?
4. Describe the coagulase methods for staphylococci (slide, tube, and rapid) and their limitations
5. What is the role of mass spectrometry in identifying common and uncommon species?
6. Discuss the importance of correct identification and using the latest susceptibility guidelines.
Case 2
A 76-year-old woman who was receiving corticosteroid therapy for a malignant tumor complained to her
physician of fever and headache of 7 days’ duration. Her headache had become progressively worse, and her
temperature was elevated. A complete blood count was performed and showed a slightly elevated white blood
cell (WBC) count with normal distribution. A lumbar puncture was performed, and the following laboratory
results were obtained:

250 WBC/mL
Glucose 30 mg/dL (serum glucose was 105 mg/dL)
Protein 180 mg/dL

No bacteria were observed on a gram-stained smear of the cerebrospinal fluid (CSF). The CSF was inoculated
onto sheep blood and chocolate agars. β-Hemolytic colonies grew on the sheep blood agar (SBA) 2 days later.
Similar colony growth was present on the chocolate agar. Gram stain morphology revealed a pleomorphic,
gram-positive, non–spore-forming bacillus.

The isolate had the following biochemical characteristics:

Questions:
1. What is the diagnosis of the patient based on the laboratory result?
2. What key tests differentiate non–spore-forming gram-positive bacilli?
3. What factors increase an individual’s risk for infection by non–spore-forming gram-positive bacilli?
4. Explain the distribution in nature of non–spore-forming gram-positive bacilli and the species that
constitute the normal bacterial biota of humans.
Case 3
An 18-year-old, sexually active college student on the women’s gymnastics team visited student health services
complaining of pain, redness, and swelling of both wrist joints and the left elbow. She gave a history of casual,
unprotected sexual intercourse with “three or four” men during the past 4 months. She denied any vaginal
discharge or abdominal pain but recalled having had a rash recently on both her arms. An aspirate from the left
wrist was sent to the laboratory for culture and Gram stain. Direct Gram stain of the aspirate showed the
following: “Many polymorphonuclear white blood cells, rare intracellular and extracellular gram-negative
diplococci seen.” At 24 hours, many small, tan colonies were visible on chocolate agar (CHOC), but there was
no growth on sheep blood agar, the U.S. Centers for Disease Control and Prevention (CDC) anaerobic blood
agar, or MacConkey agar. The organism was identified according to routine laboratory protocol.

Questions:
1. What microorganism is isolated from the patient sample?
2. What is the diagnosis of the patient based on the laboratory result?
3. What are the risk factors for acquisition of the organism?
4. Explain the types and consequences of sequelae of untreated primary infection in female and male
patients.
5. Discuss the importance of definitive identification of the microorganism.
Case 4
A 71-year-old man with diabetes who was hospitalized for diabetic ketoacidosis complained of flank pain and
painful urination. A urine sample was plated and after 18 hours of incubation, a MacConkey (MAC) agar plate
showed moderate growth of oxidase-negative, lactose-fermenting organisms. A sheep blood agar (SBA) plate
showed isolated colonies. Biochemical tests to identify the isolate were performed with the following results:
H2S negative, indole, methyl red, Voges-Proskauer, citrate (IMViC) reactions were + + − +; urea was
hydrolyzed; arginine and ornithine were decarboxylated; malonate was utilized; the organism was motile and
resistant to cefotaxime, norfloxacin, ciprofloxacin, and the aminoglycosides.

Questions:
1. What is the diagnosis of the patient based on the laboratory results?
2. Identify the microorganism which was isolated from the patient’s urine.
3. What is the significance of this patient’s health status and medical history?
4. Explain colony morphology feature that provides clues about the identity of the organism.
5. Which biochemical tests that are the most specific for identification of this organism?
Case 5
A 65-year-old Chinese man, in obvious shock, was examined in the emergency department for a painful
swelling of the left hand. His medical history revealed bilateral knee joint pain and posthepatic cirrhosis. The
day before admission, he had pricked his left index finger while selecting shrimp at a fish market. Initially, he
noticed only a local reaction in his finger, but after 12 hours the left hand began to swell. He later experienced
nausea, vomiting, and diarrhea. The patient was now clammy with a weak pulse, marked swelling, and bullous
formation with gangrenous changes apparent on the left hand. A diagnosis of septic shock was made, and
antimicrobial therapy was initiated. Blood and wound cultures subsequently grew an oxidase-positive, gram-
negative rod that produced pink colonies on MacConkey agar and green colonies on thiosulfate citrate bile salt
sucrose agar and required 3% to 6% NaCl for growth. No acceptable identification could be made with a rapid
identification system for gram-negative bacilli, and final identification was made with conventional
biochemicals supplemented with 1% NaCl. The patient suffered a cardiac arrest and died 11 hours after
admission.

Questions:
1. Enumerate various pathogenic organisms associated with aquatic life that cause human infections.
2. Referring to number 1, explain the disease spectrum and states associated with these organisms.
3. Explain the diagnosis, clinical signs, and symptoms of the patient.
4. Which culture media of choice should be used for rapid diagnosis of the patient’s condition?
5. Which key biochemical reactions is essential to presumptively and definitively identify the organism
responsible for this infection?
6. What is the treatment of choice for this infectious agent?
Case 6
A 56-year-old man came to the emergency department complaining of fatigue and weight loss (10 lb) over the
past 12 months. The patient also complained of a cough for 3 months that produced red-tinged sputum. He
indicated a history of night fever and chills but reported not having dyspnea or chest pain. The patient, who
moved to the US from Mexico, had a family history of pulmonary tuberculosis. He reported that his last purified
protein derivative (PPD) skin test, performed approximately 5 years ago, was nonreactive.

Vital signs included temperature of 36.5° C (97.7° F), pulse of 63 beats per minute, 15 respirations per minute,
and blood pressure of 96/56 mm Hg. Chest radiography revealed an infiltrate in the upper lobe of the right lung.
Computed tomography of the chest showed a nodular patchy opacity in the upper lobe of the right lung. The
patient was admitted for further evaluation. A PPD skin test showed a 10 × 7 mm induration.

Three sputum samples were obtained over a 3-day period for acid-fast bacilli (AFB) smears and culture. Direct
smears on all three samples were reported as no organisms seen. Processed samples were inoculated onto
Löwenstein-Jensen (LJ) medium and into BACTEC 12B bottles. After 12 to 14 days of incubation, the
BACTEC bottles from all three specimens showed a positive result. Stained smears of the bottles revealed AFB
with Kinyoun staining. Polymerase chain reaction (PCR) DNA amplification for Mycobacterium tuberculosis of
the BACTEC medium showed a positive result. A four-drug antituberculosis regimen comprising isoniazid,
rifampin, pyrazinamide (PZA), and ethambutol was recommended.

Questions:
1. What is the patient’s diagnosis based on the laboratory results?
2. Explain the significant aspects of this patient’s family history.
3. Discuss the characteristic symptoms of tuberculosis.
4. What is the typical length of time for a culture to yield pathogenic Mycobacterium?