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- Herausgeber: John Wiley & Sons
- Kategorie: Wissenschaft und neue Technologien
- Sprache: Englisch
In the era of cost cutting and lack of adequate health insurance for many patients, clinical skills and time spent with patients are not adequately compensated. Yet, these dwindling and underpaid skills – good history taking, observation of and listening to patients, and physical examination of patients – remain very essential to making and reaching a complete and accurate diagnosis. Expensive laboratory and imaging diagnostics while very relevant, should not replace these age-old skills that have served to enhance and maintain the doctor-patient relationship and human connection, a connection that is often necessary for healing.
Cases in Clinical Infectious Disease Practice uses case studies to illustrate how the infectious disease clinician processes and integrates data to arrive at a diagnosis. This type of hands-on approach, invaluable in training programs, is utilized to take the reader through initial patient encounter, through the history and physical examination, to simple laboratory findings and stains, to a final diagnosis, in a way that is easily accessible to clinicians, students, and laboratory personnel working with clinical specimens.
- Appeals to practitioners of all levels, with focus on patients with common problems or complications of common infections without heavy technical language
- Emphasizes basic clinical skills including history taking, observation, epidemiology, and physical exam, as well as simple laboratory tests, explaining how they lead to a reasonable diagnosis
- Presents cases seen first-hand within the community setting, reflective of cases or situations a resident or student is likely to encounter in the real world after training
Cases in Clinical Infectious Disease Practice is an essential resource for clinicians, graduate and medical school students, and others conducting medical and clinical microbiology or infectious disease research on real patients.
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Veröffentlichungsjahr: 2016
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Table of Contents
Cover
Title Page
Copyright
Table of Normal Laboratory Values*
About the Author
Dedication
Acknowledgments
Preface
Introduction
How the book should be used and understood
Chapter 1: Skin and Soft Tissue Infections
Case 1.1 Soft tissue infection following traumatic aquatic exposure
References
Case 1.2 Soft tissue infection of the hand and wrist in an 81-year-old man
References
Case 1.3 A 41-year-old Caucasian female with right arm swelling
Case 1.4 A 24-year-old female with fever and arm swelling
Case 1.5 A 72-year-old male with necrotic soft tissue elbow infection
Case 1.6 A 37-year-old man with severe body aches and fever
Case discussion of the four beta-hemolytic
Streptococcus
infections
Lessons learned from these cases
References
Further reading
Chapter 2: Fever of Unknown Origin and Drug-Induced Fever
Case 2.1 Hypersensitivity masquerading as sepsis
Reference
Further reading
Case 2.2 A psychiatric patient with HIV infection and fever
Case 2.3 A hypertensive patient with 2 months of fever and chills
Brief review and discussion of drug-induced fever
Lessons learned from these two cases
References
Further reading
Chapter 3: Dermatologic Manifestations of Infectious and Non-infectious Diseases
Case 3.1 A 45-year-old patient referred for “persistent shingles”
Reference
Further reading
Case 3.2 A 39-year-old female with fever and acute rash illness
Reference
Case 3.3 A 45-year-old female with subacute rash illness for 2 weeks
Case discussion of the two patients with secondary syphilis (cases 3.2 and 3.3)
References
Further reading
Case 3.4 An 82-year-old man with a chronic non-healing elbow wound
Further reading
Chapter 4: Diseases Acquired Through Close Contact with Animals
Case 4.1 A 10-month-old child with “worms”
Reference
Further reading
Case 4.2 Infectious complication of cat scratch
References
Further reading
Case 4.3 A young man with acute left arm lymphadenopathy
Further reading
Chapter 5: Travel-associated Blood-borne Parasitic Infection
Case 5.1 A 15-year-old adolescent male with fever and thrombocytopenia
Case 5.2 A 23-year-old Caucasian male with fever and chills
Case 5.3 A 57-year-old male with acute-onset fever and chills
Comparison of the characteristics of five patients with malaria seen between 1998 and 2015
References
Further reading
Chapter 6: Gulf Coast Tick Rash Illness*
Case 6.1 Woman with rash and prolonged eschar following a tick bite
Case 6.2 A 58-year-old male with generalized body aches and fever
Case discussion
Lessons learned from these cases
References
Chapter 7: Infectious Diseases Associated with Trauma and Outdoor Activities
Introduction
Case 7.1 A 30-year-old man with thumb infection and forearm nodules
Reference
Further reading
Case 7.2 Severe infection and sepsis following recreational fishing
Further reading
Classification and characteristics of infectious diseases associated with trauma and outdoor activities
References
Further reading
Chapter 8: Acute and Chronic Subcutaneous Fungal Infections
Case 8.1 Exophytic skin lesion masquerading as cancer
Case 8.2 Chronic persistent subcutaneous fungal infection of the leg
Further reading
Case 8.3 A young man with a laceration injury contaminated with soil
References
Chapter 9: Endocarditis with Unusual Organisms or Characteristics
Case 9.1 Man with dyspnea, cough, fever, and weight loss
References
Further reading
Case 9.2 Confusing staining characteristics and false identification of a pathogen by automated system in a seriously ill patient
References
Further reading
Chapter 10: Severe Systemic Fungal and Other Infections in AIDS Patients
Case 10.1 HIV patient with progressive shortness of breath
Reference
Further reading
Case 10.2 Recurrent multiorgan infection in an immunocompromised patient
Reference
Further reading
Chapter 11: Toxic Manifestations of Infectious and Non-infectious Diseases
Case 11.1 An odd presentation for toxic shock syndrome
References
Case 11.2 A peculiar and dramatic presentation of septic shock
References
Case 11.3 A 45-year-old woman with rash, hepatitis, and lymphadenopathy
References
Chapter 12: Skin and Soft Tissue Infections Seen Post Hurricane Katrina in 2005
Introduction
Case 12.1 A 76-year-old Caucasian female with leg laceration
Case 12.2 A 76-year-old man with rapid-onset cellulitis
Case 12.3 A 61-year-old man with diabetic neuropathy
Case 12.4 A 45-year-old man from a refugee camp with calf laceration
General comments on soft tissue infections in relation to Hurricane Katrina
References
Chapter 13: Other Miscellaneous Infections
Case 13.1 A 17-month-old child with facial swelling and adenopathy
References
Further reading
Case 13.2 Persistent headache in a 50 year old with known migraine
References
Case 13.3 A 54-year-old man with skin lesions with central numbness
References
Further reading
Case 13.4 Delayed diagnosis in a young woman with migratory joint pain
References
Index
End User License Agreement
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Guide
Cover
Table of Contents
Preface
Introduction
Begin Reading
List of Illustrations
Chapter 1: Skin and Soft Tissue Infections
Figure 1.1a Left calf wound on day 4 post surgery (reproduced with permission). (
See insert for color information
)
Figure 1.1b Luxuriant growth of gram-negative rod on blood agar medium in 24 hours, and comparative growth of the same organism on BA, chocolate BA, and MacConkey agar. (
See insert for color information
)
Figure 1.1c Photo taken in March 2011, 6 months after the injury: healed left calf post skin grafting (reproduced with permission).
Figure 1.2a A large bulge of purplish bruised area is noted in the right wrist, along with the surgical incision in the hand. Photo was taken on 3/4/09 (reproduced with permission). (
See insert for color information
)
Figure 1.2b A. Photo taken on 3/14/09, 9 days after the second surgery. B. 10 weeks later, on 5/21/09 (reproduced with permission).
Figure 1.2c Healed right hand and wrist wound. Photo was taken on 12/18/09, 4 months after completion of antimicrobial therapy. The healing occurred without plastic surgery (reproduced with permission).
Figure 1.3a Swelling of the right arm, elbow, and hand, reflecting cellulitis. Compare the left hand without swelling. Photos taken on 1/6/10 (reproduced with permission). (
See insert for color information
)
Figure 1.3b Photographs taken on 1/10/10, 2 days after the second surgery: markedly improved arm swelling (reproduced with permission).
Figure 1.5a A. Photo taken at surgery on 1/28/10. B. Right elbow on 2/16/10, 19 days after the initial surgery (reproduced with permission).
Figure 1.6a Right forearm: A. Day 15 post admission, after several debridements (note necrotic tendon). B. Day 21 of hospitalization: initial plastic surgery. Photos were taken on 6/26 (A) and 7/2/01 (B) (reproduced with permission). (
See insert for color information
)
Figure 1.6b Photos taken on 8/23/01. Office visit 10 weeks after hospital admission. A. Healed right leg. B. Healed right arm wounds following skin grafts (reproduced with permission).
Chapter 2: Fever of Unknown Origin and Drug-Induced Fever
Figure 2.1a Vital signs and other comments recorded on the day of drug challenge, 6/1/05.
Figure 2.1b Sample of EKG tracing noted during drug challenge on 6/1/05 (the maximum rate noted on the top tracing was about 150 beats per minute).
Figure 2.1c Graphic display of temperature, respiration rate, pulse rate, and blood pressure during drug challenge with trimethoprim/sulfamethoxazole over a period of 6 hours.
Figure 2.1d Three basic mechanisms postulated for the explanation of drug-induced fever in humans. PMN, polymorphonuclear leukocyte.
Figure 2.2a Temperature recordings from 4/8 to 4/12/98, with heart and respiratory rate notations.
Figure 2.2b Temperature recordings from 4/13 to 4/22/98, with heart and respiratory rate notations.
Figure 2.3a Graph of temperature and other vital sign recordings: 4/28–5/2/98.
Chapter 3: Dermatologic Manifestations of Infectious and Non-infectious Diseases
Figure 3.1a Eczematous skin changes in the right buttock-perineal area. Photo taken on 4/8/10, 9 days after treatment was started. The indurated area above is the site of a skin biopsy on 3/31/10 (reproduced with permission).
Figure 3.1b Lactophenol cotton blue prep of aerial growth of dermatophyte culture of skin scraping at 5 weeks. Septate hyphae and microconidia are seen on the slides.
Figure 3.2a Maculopapular rash on the abdomen and back: photo taken on 2/9/02.
Figure 3.2b Graphic display of temperatures before and after penicillin treatment.
Figure 3.3a A. Right upper arm and shoulder: maculonodular lesions, some scaling noted. B. Anterior chest lesions: maculonodular, only partially blanching. Photos taken on 1/13/11 (reproduced with permission). (
See insert for color information
)
Figure 3.3b Right foot: plantar desquamative erythematous lesions; pustular right palmar lesions, with surrounding erythema; and ulcerative lesions on the tongue. Photos taken 1/13/11 (reproduced with permission).
Figure 3.4a Left arm and elbow edema with inflammatory abscess: note the bluish area of the wound with abscess at the edge. Office photo taken on 3/18/09 (reproduced with permission). (
See insert for color information
)
Chapter 4: Diseases Acquired Through Close Contact with Animals
Figure 4.1a Proglottid of tapeworm obtained from the 13-month-old Caucasian male (March, 2006). (
See insert for color information
)
Figure 4.1b These digital images depict tapeworm proglottids from our patient: the mature proglottid on the right shows lateral genital pores and “rice-grain” shape, while the immature proglottids are broader in appearance. Courtesy of Henry S. Bishop, CDC, Atlanta. (
See insert for color information
)
Figure 4.1c Eggs in a cluster: image captured by use of digital image correlation (DIC). Individual eggs are about 35–40 µm (31–50 × 27–48 µm), with an onchosphere that has six hooklets visible. Courtesy of Henry S. Bishop, CDC, Atlanta.
Figure 4.1d Life cycle of
Dipylidium caninum
(the double-pored dog tapeworm) which mainly infects dogs and cats, but is occasionally found in humans. (The expanded legend can be accessed at www.cdc.gov/dpdx/dipylidium/index.html.)
Figure 4.2a Right shoulder/neck and left lateral flank areas with tiny tunneling abscesses (reproduced with permission). (
See insert for color information
)
Figure 4.2b Right upper arm and abdomen (above and right of the umbilicus): tiny tunneling abscesses (reproduced with permission).
Figure 4.2c Brain heart infusion (BHI) agar (with blood), 4-week growth of yeast-like colony.
Figure 4.2d Sabouraud dextrose agar (SDA), 3–4-week culture. Left, bottom of agar; right: aerial mold growth.
Figure 4.2e Tease mount of culture grown on potato flake agar showing septate hyphae bearing unicellular conidia on denticles, typical for
Sporothrix schenkii
(lactophenol cotton blue stain).
Figure 4.3a Photograph of the left arm showing bulging mass above the medial elbow, 1/23/09 (reproduced with permission).
Figure 4.3b Resolved lymphadenopathy of the medial left elbow. Photo taken on 2/6/09, 22 days after doxycycline was started (reproduced with permission).
Chapter 5: Travel-associated Blood-borne Parasitic Infection
Figure 5.1a Recorded temperature and other vital signs between 10/28 and 11/1/98.
Figure 5.1b Thin smear of blood (Giemsa stain) for malaria, showing the “banana-shaped” gametocyte, typical for
P. falciparum
, on the left slide and “ring” forms noted on both smears. Smear was made on 10/31/98.
Figure 5.2a Peripheral blood smear (Wright's stain) done on 5/15/99 showing intracellular trophozoites.
Figure 5.3a A. Peripheral blood malaria stain (Giemsa, thin smear) done on 6/9/15 showing intracellular ring forms in normal-sized red cells. B. Segmented PMN noted for size comparison. (
See insert for color information
)
Figure 5.3b Peripheral blood malaria stain (Giemsa, thin smear), 6/9/15, showing intracellular ring forms in normal-sized red cells. One RBC had two ring forms, suggesting
P. falciparum
.
Figure 5.4a Nineteen cases of malaria, including four among travelers, were reported as acquired on the island of Great Exuma in the Bahamas in May–June 2006. Source: www.cdc.gov/mmwr/preview/mmwrhtml/mm5537a1.htm, accessed February 26, 2016.
Figure 5.4b
Chapter 6: Gulf Coast Tick Rash Illness*
Figure 6.1a Tick bite eschar in anterior right ankle, and macular papular rash on abdominal torso and upper back (reproduced with permission of the Mississippi State Medical Association). (
See insert for color information
)
Figure 6.2a Tick bite eschar right groin and papular nodular rash on abdomen and foot dorsum (reproduced with permission of the Mississippi State Medical Association).
Figure 6.2b Histopathology and immunohistochemical staining for spotted fever group rickettsiae (SFGR) of right groin eschar of case #5. A. Hematoxylin and eosin stain showing diffuse lymphocytic perivascular inflammation: original magnification ×100. B. Immunohistochemical stain for SFGR (red). Original magnification ×258 (reproduced with permission of the Mississippi State Medical Association). (
See insert for color information
)
Chapter 7: Infectious Diseases Associated with Trauma and Outdoor Activities
Figure 7.1a A. Right thumb: scabbed pustular area with skin peeling. B. Inflammation involving both the thumb and radial dorsal ball of the hand. (
See insert for color information
)
Figure 7.1b Growth of mold on potato flake (PFA), Sabouraud (SDA), and brain heart infusion (BHI) agars on day 10 of subculture of isolated mold from the right arm biopsy: front view of agar plates.
Figure 7.2a Photo taken on the day of admission, 6/16/14, 1 day post laceration of right medial mid-distal shin. Size of blister bruise was noted the next day to be 12.5 × 15 × 0.2 cm (reproduced with permission). (
See insert for color information
)
Figure 7.2b Progressive changes in the right leg over time and following initial surgical debridement. Photo taken on 6/22/14, 3 days after initial debridement on 6/19/14 (reproduced with permission).
Figure 7.2c Severe necrosis of skin, subcutaneous tissue and down to fascia noted at right leg debridement on 6/25/14. Size of wound post debridement: 10 × 15 × 2 cm. Photo taken on 6/26/14 (reproduced with permission).
Figure 7.2d Severe necrosis of skin, subcutaneous tissue and down to fascia noted on right leg post second debridement on 6/25/14. Photo taken on 6/30/14, 5 days post second debridement (reproduced with permission).
Figure 7.3a Schematic diagram of skin depicting skin structures, including the location of transient and resident bacteria. Source: From Talbot [1].
Chapter 8: Acute and Chronic Subcutaneous Fungal Infections
Figure 8.1a Left-hand photo taken on 10/12/04; photo on the right taken on 11/3/04 (after excision of hand dorsum lesion) (reproduced with permission).
Figure 8.1b New keratotic lesion on third left finger (photo taken 2/28/05), and histopathology of the biopsy (H&E stain) done on 3/3/05. Note the giant cells and the large brown, thick-walled, septate hyphae (reproduced with permission). (
See insert for color information
)
Figure 8.2a Right ankle and foot: photo taken on 6/27/01 (reproduced with permission).
Figure 8.2b A 33-day-old culture on SDA (top). Velvety, powdery black mold culture (middle) is a close-up of the powdery mold on the left; right shows bottom of agar with growth progression of mold from days 9, 12, and 33. Photo taken on 8/13/01.
Figure 8.2c Progressive chromomycosis of the right leg, 16 years after onset. Photo taken on 5/29/09 (reproduced with permission). (
See insert for color information
)
Figure 8.2d Progressive chromomycosis of the right leg, 20 years after onset. Photo taken on 6/28/13 (reproduced with permission).
Figure 8.3a Photo taken by the patient's family on 7/3/97, 3 days before readmission on 7/6/97.
Figure 8.3b Progressive healing of right calf wound. Photos were taken on 8/6/97, 11/25/97, and 7/7/98.
Chapter 9: Endocarditis with Unusual Organisms or Characteristics
Figure 9.1a CT scan of the brain, with and without contrast, done 6 days after admission showing right superior cerebral (parietal lobe) hemorrhage.
Figure 9.2a Graphic display of temperature recordings from 6/21 to 6/30/99.
Figure 9.2b
Abiotrophia
spp (formerly known as nutritionally deficient streptococci) showing satellite growth with
Staphylococcus aureus
. Reproduced from Brouqui and Raoult [1], with permission from the American Society for Microbiology.
Chapter 10: Severe Systemic Fungal and Other Infections in AIDS Patients
Figure 10.1a Chest x-ray taken on 1/5/07 during the initial ER visit, 3 days before admission.
Figure 10.1b GMS stain of RLL transbronchial biopsy done on 1/11/07. Magnification ×40: yeast forms, average size 2.5 microns. (
See insert for color information
)
Figure 10.1c Purplish violaceous lesion in the hard palate noted on 4/5/07 (reproduced with permission).
Figure 10.1d Deterioration of chest x-ray compared to January, 2007: micronodular/miliary pattern, 3/5/07.
Figure 10.1e CT scan of abdomen and pelvis showing splenomegaly and enlarged lymph nodes in the pelvic region, 3/6/07.
Figure 10.1f 21-day-old mold culture on brain heart infusion (BHI) and Sabouraud dextrose agar (SDA). (
See insert for color information
)
Figure 10.1g Slide/tease mount of 21-day-old culture with the larger macroconidia and the smaller microconidia evident in this mycelial phase
Histoplasma
; the macroconidium or tuberculate form with protrusions is also shown in the next picture. The macroconidia are usually 8–15 microns in size, while the microconidia are about 2–5 microns. (
See insert for color information
)
Figure 10.2a Aerobic BA plate: chalky white, crumbly or sticky colonies, more than 1 week old. (
See insert for color information
)
Chapter 11: Toxic Manifestations of Infectious and Non-infectious Diseases
Figure 11.1a Erythema and tiny blisters in between the thighs, and erythema with Nikolski sign in the right arm (photos taken 2 days after ID consult, 4 days after admission) (reproduced with permission).
Figure 11.1b Intravaginal tampon that fell out during showering 10 days after admission (reproduced with permission).
Figure 11.2a Sketch of the feet on day 13 of admission (the day of ID consultation). Exfoliation of feet. The shaded areas reflect a thick, peeling, horny layer while the unshaded areas reflect exfoliated areas with exposed erythematous skin (sketch adapted from a photograph taken on 6/22/10).
Figure 11.3a Temperature and vital signs recorded between 5/12/00 and 5/26/00.
Figure 11.3b Fever pattern noted during the second admission: 6/28–7/12/00.
Chapter 12: Skin and Soft Tissue Infections Seen Post Hurricane Katrina in 2005
Figure 12.1a Hemorrhagic blisters noted at the medial and lateral left foot, ankle and heel. Photos taken on 9/2/05 (reproduced with permission). (
See insert for color information
)
Figure 12.1b Debridement of left leg: one of several done on this patient. Photo taken on 9/6/05, 4 days after the initial debridement (reproduced with permission).
Figure 12.2a Edema and blisters noted in the left foot and ankle. Photo taken on 9/7/05, 7 days after admission (reproduced with permission).
Figure 12.2b Necrotizing fasciitis left shin and foot, 6 days after initial debridement. Photo taken 9/13/05 (reproduced with permission). (
See insert for color information
)
Figure 12.2c Slowly healing leg wounds 6 weeks after initial debridement of necrotizing fasciitis. Photo taken on 10/19/05. A. Lateral view. B. Medial view of left leg and foot (reproduced with permission).
Figure 12.3a Multiple skin erosions caused by nail and other lacerations inside wet boots in a diabetic with peripheral neuropathy. Photo taken on 9/2/05, 2 days after admission.
Figure 12.4a Posterior calf non-hemorrhagic blisters following leg laceration. Photo taken on 9/9/05.
Figure 12.5a Cases of post-Hurricane Katrine
Vibrio
illness among residents of Louisiana and Mississippi, by date of hospital admission – United States, 8/29–9/11/05. Source: www.cdc.gov/mmwr/preview/mmwrhtml/mm5437a5.htm.
Chapter 13: Other Miscellaneous Infections
Figure 13.1a Right cervical lymphadenitis. Photo taken on 5/13/09, 1 day before the second surgery (reproduced with permission).
Figure 13.1b Graphic display of vital signs (hospital admission) between 5/13 and 5/17/09.
Figure 13.2a Blood agar plate cultures: A. Day 1. B. Day 9. C. Broth culture of CSF on day 9. (
See insert for color information
)
Figure 13.2b A. Gram stain of cerebrospinal fluid showing inflammatory cells and small, gram-positive rods and coccobacilli. B. Clear areas around each colony of
L. monocytogenes
are characteristic small zones of beta-hemolysis on blood agar [1]. Reproduced with permission from: Waltzman M. Initial evaluation of shock in children. Available at: www.uptodate.com/contents/initial-evaluation-of-shock-in-children, accessed on March 4, 2016. Copyright © 2015 UpToDate, Inc. For more information visit www.uptodate.com. (
See insert for color information
)
Figure 13.3a Sketch of left proximal extensor forearm skin lesion. The 5–6 cm lesion showed an anesthetic flat center, with surrounding raised borders (adapted from a photograph taken in the office on 9/29/10).
Figure 13.3b The different clinical classifications of leprosy using both the World Health Organization and the Ridley–Joplin systems. The increase in number of acid-fast bacilli and defects in cell-mediated immunity are represented in the continuum from paucibacillary (PB) to multibacillary (MB) disease. Adapted with permission from Elsevier from Jacobson and Krahenbuhl [4].
Figure 13.4a Left foot and big toe showing evolving inflammation of the MTP joint. The photo on the left was taken on 8/24/15 by the patient; the photo on the right was taken 16 days later, on 9/9/15, at the hospital (reproduced with permission).
Figure 13.4b Two-day-old culture of the left hip aspirate on CBA: growth on 9/9/15. The plate shows typical colony morphology (form) of this organism: small (0.5–1.0 mm in diameter), raised, and glistening.
Figure 13.4c Gram stain of 2-day-old growth on CBA on 9/9/15: gram-negative diplococci and coccobacillary forms. (
See insert for color information
)
Figure 13.4d Oxidase test on filter paper done on the CBA positive culture isolate on 9/9/15: the test was positive (dark purplish color).
Figure 13.4e Biochemical reactions of the CBA culture of the left hip, as noted on 9/9/15.
List of Tables
Chapter 1: Skin and Soft Tissue Infections
Table 1.1a Organisms associated with soft tissue infection following water exposure
Table 1.6a Characterization of patients with severe beta-hemolytic streptococcal soft tissue infections
Chapter 2: Fever of Unknown Origin and Drug-Induced Fever
Table 2.3a Temporal relationship between administration of drug and onset of fever
Chapter 3: Dermatologic Manifestations of Infectious and Non-infectious Diseases
Table 3.2a Results of serial liver panel tests
Chapter 5: Travel-associated Blood-borne Parasitic Infection
Table 5.2a Serial complete blood count (CBC) parameters recorded over several days
Table 5.3a Comparison of five cases of malaria seen between 1998 and 2015
Chapter 6: Gulf Coast Tick Rash Illness*
Table 6.1a Characterization of patients with suspected
Rickettsia parkeri
infection
Chapter 7: Infectious Diseases Associated with Trauma and Outdoor Activities
Table 7.2a General chemistry data noted on the day of admission – June 16, 2014 at 8.25am
Table 7.2b Complete blood count with differentials noted on the day of admission – June 16, 2014 at 8.25am
Table 7.2c Antimicrobial susceptibility of gram-negative organism from blood on June 16, 2014
Table 7.3a Characterization and classification of infectious diseases associated with trauma and outdoor activities
Chapter 8: Acute and Chronic Subcutaneous Fungal Infections
Table 8.2a The subcutaneous mycoses
Chapter 11: Toxic Manifestations of Infectious and Non-infectious Diseases
Table 11.2a Clinical characteristics of toxic shock-like syndrome caused by group A streptococcus [2, 4]
Table 11.3a Serial liver panel recorded in May, 2000
Table 11.3b Serial liver function tests measured after the May, 2000 admission
Chapter 12: Skin and Soft Tissue Infections Seen Post Hurricane Katrina in 2005
Table 12.1a Characteristics of serious soft tissue infections seen before Hurricane Katrina (July and August, 2005)
Table 12.1b Characteristics of serious soft tissue infections seen post Hurricane Katrina (after August 29, 2005)
Table 12.1c Number of cases of selected diseases and conditions reported in evacuees and rescue workers during the 3 weeks immediately after Hurricane Katrina made landfall – multiple states, August–September 2005
Chapter 13: Other Miscellaneous Infections
Table 13.4a Cell count and differential of the left hip aspirate on 9/7/15
Table 13.4b Serial C-reactive protein (CRP) values measured over time
Table 13.4c Serial erythrocyte sedimentation rate (ESR) values measured in the patient
Cases in Clinical Infectious Disease Practice
Obtaining a good history from the patient remains the cornerstone of an accurate clinical diagnosis: Lessons learned in many years of clinical practice
Okechukwu Ekenna
Copyright © 2016 by John Wiley & Sons, Inc. All rights reserved
Published by John Wiley & Sons, Inc., Hoboken, New Jersey
Published simultaneously in Canada
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Library of Congress Cataloging-in-Publication Data:
Names: Ekenna, Okechukwu, author.
Title: Cases in clinical infectious disease practice / Okechukwu Ekenna.
Description: Hoboken, New Jersey : John Wiley & Sons, Inc., [2016] | Includes bibliographical references and index.
Identifiers: LCCN 2016023166 (print) | LCCN 2016023807 (ebook) | ISBN 9781119044161 (cloth) | ISBN 9781119044185 (pdf) | ISBN 9781119044062 (epub)
Subjects: | MESH: Communicable Diseases-diagnosis | Communicable Diseases-therapy | Clinical Medicine-methods | Case Reports
Classification: LCC RC112 (print) | LCC RC112 (ebook) | NLM WC 100 | DDC
616.9-dc23
LC record available at https://lccn.loc.gov/2016023166
Table of Normal Laboratory Values*
Component
Unit
Reference range
White blood cell
K/UL
4.4–10.1 (4400–10,100/μL)
Hemoglobin
g/dL
10.0–18.0
Hematocrit
%
37–50
Platelets
K/UL
117–369
MCV
fL
82–99
Neutrophils (polymorphonuclear leukocytes)
%
43.7–84.9
Eosinophils
%
0.6–6.0
Lymphocytes
%
8.4–40.7
Erythrocyte sedimentation rate
mm/hour
0–20
C-reactive protein
mg/dL
0.00–0.30
O
2
saturation
%
95–99 (arterial/capillary); >74 (venous)
Glucose (fasting)
mg/dL
65–99
Blood urea nitrogen
mg/dL
7–18
Creatinine
mg/dL
0.6–1.3
Sodium
mmol/L
135–148
Potassium
mmol/L
3.5–5.3
Alanine aminotransferase (serum glutamic pyruvic transaminase)
IU/L
12–78
Aspartate aminotransferase (serum glutamic oxalo-acetic transaminase)
IU/L
15–37
Albumin
g/dL
3.4–5.0
Alkaline phosphatase
IU/L
45–117
Total bilirubin
mg/dL
0.2–1.0
Lactate dehydrogenase
IU/L
84–246
* Adapted from the 2015 Singing River Health System Adult Normal Laboratory Values. Variations with age and sex are not reflected here. These values are to be used only as a general guide.
Okechukwu Ekenna, MD, MPH, D(ABMM), FACP
Dr Ekenna was born in Aba, Nigeria, where he had his primary school and most of his secondary school education (Dennis Memorial Grammar School in Onitsha). He spent a year as an exchange student at Loughborough Grammar School in Leicestershire, England, and another year in Germany, at Neusprachliches Gymnasium Aue, in Wuppertal-Elberfeld. General Certificate of Education (GCE, Advanced Level) was acquired following attendance at the Modern Tutorial College in London.
He attended medical school at Philipps-Universitaet Marburg/Lahn, Germany, graduating in April, 1979 (Aerztliche Pruefung). He successfully defended his doctoral thesis in June, 1979 (magna cum laude) and spent a year of medical internship in Germany before moving to the United States for Residency and Fellowship trainings in Internal Medicine, Infectious Diseases,and Post-Doctoral Fellowship in Medical Microbiology.
Through the course of his clinical and teaching experiences, he has served as consultant physician and lecturer to several institutions in Nigeria (University of Maiduguri Teaching Hospital) and in the USA. He is presently Adjunct Associate Professor of Medicine (since 1998)at the University of South Alabama, in Mobile, AL. He is in private practice in Pascagoula, MS,and is Consultant in Infectious Diseases to the Singing River Health System (SRHS). He is the Chairman of the Infection Prevention/Control Committee for SRHS. He has active consulting privileges at Ocean Springs Hospital and Singing River Hospital in Pascagoula, MS.
He is a naturalized citizen of the United States.
Dr Ekenna is a member of the American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, and Emerging Infections Network of the Infectious Diseases Society of America. He is a Fellow of the American College of Physicians and Fellow of the Royal Society of Tropical Medicine and Hygiene, London. He is also a member of the Organizing Committee of the African Initiative Group of the American Society for Microbiology.
Dr Ekenna is Board certified in Internal Medicine, Infectious Diseases, and in Medical and Public Health Microbiology. He is also certified in Clinical Tropical Medicine and Travelers' Health. He has a Master's degree in Public Health (MPH). He has authored multiple papers in peer-reviewed journals.
Dr Ekenna is fluent in Igbo (Nigerian), English, German, moderately so in French, and speaks a little Hausa. He is still trying to learn Spanish. His wife thinks of him as a history buff.
Dedication
To my parents: Eze Raymond Onuoha Ekenna and Ugo-eze (Mrs) Gabraeline Urasi Ekenna (née Ezurike), and their recognition of the value of a good education.
Acknowledgments
First, I would like to thank the many patients presented here (who will remain anonymous), who have allowed me to tell their story and use their image to illustrate the clinical points made in this book. We are reminded every day that it is a privilege to care for patients who entrust their lives and well-being to our judgments, often working with incomplete or conflicting data. Many of the presented images have made it easier to tell the stories in this book.
I am grateful to the colleagues who asked me to see their patients and render an opinion. I thank them for their trust, and the confidence reposed in me. It is clear that sometimes there are no clear answers to the complex questions posed by these physicians and their patients.
I also thank the many journal and book publishers who gave us permission to use data and figures from their publications and resources. We have acknowledged them wherever indicated. Those illustrations have served to improve the presentation of the cases in this book.
The Singing River Health System gave permission and approval to use laboratory and demographic data, as well as radiologic images where applicable, without patient identifiers or infringing on patient confidentiality. I am grateful for their support.
Ms Cyndi Aycock, MLT (senior microbiologist), was particularly helpful in working with me to process and preserve many microbiological cultures and specimens over the years, many of which are depicted in this book. She did this with such enthusiasm. Thank you, Cyndi.
Dr Sid Eudy, pathologist, was gracious enough to prepare some of the micrographs used in this book.
Several of my friends and colleagues reviewed this manuscript and offered useful suggestions: John O. Chikwem, PhD, Professor of Microbiology and Immunology, Lincoln University, Lincoln, Pennsylvania; Keith Ramsey, MD, Professor of Medicine, East Carolina University, Greenville, NC, formerly Head of Infectious Diseases at the University of South Alabama (USA) in Mobile, AL, who first recruited me as adjunct faculty at USA; and Abraham Verghese, MD, Professor of Medicine and Vice Chair for the Theory and Practice of Medicine, Stanford University, CA.
Dr Christopher Paddock, of the Centers for Disease Control and Prevention, was kind enough to write a generous preface for me. I thank him immensely.
Ms Cynthia Davis, my office nurse, was very helpful in tracking down some of the patients, so that I could obtain their formal permissions to use their photographs in the book.
I am grateful to John Wiley & Sons, Inc., my publishers, and especially to Ms Mindy Okura-Marszycki and Ms Stephanie Dollan, for trusting me initially with this opportunity; to my project editor, Divya Narayanan, and Anandhavalli Namachivayam, production editor, for working with me intensely to get this book readied for publication on time.
The copy editor, Holly Regan-Jones did a wonderful job to help clear up ambiguities.
Finally, I would like to thank my wife, Chiazo, for her support and encouragement over the several years it took to put this book together. She encouraged me as I worked over the holidays to add small sections to the book, in between other clinical and family responsibilities.
Preface
In the spring of 2007, I received a call from a colleague at the Mississippi State Department of Health who informed me of a patient recently evaluated by an infectious diseases physician from the Gulf Coast. The patient had presented with fever, rash, and an eschar following the bite of a tick. At the time of the call, the patient was no longer symptomatic, for the physician had presumptively and correctly diagnosed the illness as rickettsial infection and prescribed the appropriate antibiotic; however, he was curious to know if there was a way to determine if this illness represented a recently recognized disease known as Rickettsia parkeri rickettsiosis. Remarkably, he had retained the tick removed by the patient. Working with the state health department, the tick was sent to our laboratory at the Centers for Disease Control and Prevention, where we determined that it was in fact infected by R. parkeri, closing the loop and establishing this little-known agent as the cause of the patient's illness.
This episode was my first interaction with Dr Ekenna, the astute infectious disease physician and author of this book. To place Dr Ekenna's diagnostic acumen in greater perspective, he diagnosed four more patients with R. parkeri rickettsiosis over the next several years, which is particularly remarkable when one considers that our laboratory at CDC has identified only about 40 patients with this disease in the entire United States since its discovery in 2002.
The case studies provided in this book are salient examples of Dr Ekenna's keen ability of medical detection, whereby the diagnosis and care of each patient are based on a careful history and physical examination. These fundamental processes represent the pillars of clinical diagnosis and are emphasized considerably during the training of medical students and residents; nonetheless, years of practice and experience are characteristically needed to hone and channel these skills to a level where they can be applied effectively and consistently. The cases described herein illuminate Dr Ekenna's deceptively simple and logical approach to each medical mystery in which he gathers pertinent data relating to person, place, and time and assembles a diagnosis and careful plan of treatment tailored to the complete circumstances of the individual patient. This truly is the art of medicine. In this context, we follow the diagnosis and successful treatment of a financially challenged patient with sporotrichosis, learn of the removal of carious teeth from a patient with Actinomyces israelii endocarditis, and observe the confirmation of a sulfa drug-induced hypersensitivity masquerading as sepsis in a long-suffering patient.
The breadth and scope of cases portrayed in this collection are fascinating. These include a wide spectrum of infectious conditions caused by various common and not so common infectious agents that include mycobacteria, fungi, helminths, spirochetes, and, of course, rickettsiae. Many of the infections are presented as syndromic or uniquely situational processes, such as a section on serious soft tissue infections caused by various Vibrio, Staphylococcus, and Alcaligenes species bacteria identified in patients along the Gulf Coast in the aftermath of Hurricane Katrina. Remarkably, these clinical vignettes originate not from the collective encounters by a large group of specialists at a tertiary care facility in a large metropolitan center, but rather from the professional experience of one doctor working at a small community hospital along the Mississippi Gulf Coast, and reflect the immeasurable good that a thorough and thoughtful physician can provide to the health and well-being of an entire region.
Christopher D. Paddock, MD, MPHTM Centers for Disease Control and Prevention, Atlanta, Georgia
Introduction
In the era of cost cutting and lack of adequate health insurance for many patients, clinical skills and time spent with patients are not adequately compensated. Yet these dwindling and underpaid skills – good history taking, observation of and listening to patients, and physical examination – remain essential to making and reaching a complete and accurate diagnosis. Expensive laboratory and imaging diagnostics, while very relevant, should not replace these age-old skills that have served to enhance and maintain the doctor–patient relationship and human connection, a connection that is often necessary for healing.
The process of differential diagnosis is particularly relevant in infectious diseases, and still involves what we typically label as “the art and science of medicine.” This process requires a skill that usually improves with clinical experience, and is not achieved by textbook reading alone.
I have had the privilege and requirement to present on a regular basis real cases seen in my private practice over the last 18 years to medical students, residents, fellows, and faculty as part of my teaching responsibilities with the University of South Alabama in Mobile, Alabama, as well as presenting to the local medical staff on the Gulf Coast of Mississippi. The positive feedback I have received from students, medical staff, and faculty has encouraged me to present some of these cases in this publication. The format chosen is similar to the way I have usually presented them at the teaching conferences, except that they will not be in PowerPoint and will be somewhat abbreviated because of space constraints.
These cases will provide an illustration of how the infectious disease clinician processes and integrates data to arrive at a diagnosis. This type of hands-on approach is not given adequate emphasis these days in our training programs.
The cases presented in this book will take the reader from the initial patient encounter, through the history and physical examination, to simple laboratory findings and stains, to a final diagnosis, in a way that is simple to follow and without the need to cram up a lot of other data.
The book is intended for the practicing clinician or student in clinical training. It should be useful to teaching hospitals involved in the training of medical residents and students of allied health institutions involved in clinical practice. An additional advantage is that the cases presented here do not reflect patients seen at tertiary institutions, but rather in the community setting. They reflect the type of cases or situations the resident or student is likely to encounter in the real world after training.
The cases presented in this book should be within the reach of the average practicing physician and medical resident in training. They should also help practitioners and students in allied health, who may work up clinical specimens referred by clinicians, in their understanding of the thinking of the consultant. The cases will include photographs, illustrations, and microbiological slides as applicable and available. I have added schematic diagrams on the few occasions where it was not possible to obtain permits for patient photographs.
It is hoped that reviewing these cases will enhance the integrated skills and critical thinking of the reader.
Finally, at the end of each case, I will discuss diagnostic aids or clues in the case and practical lessons learned.
How the book should be used and understood
The cases presented were seen between 1997 and 2015, an 18-year period, and include inpatients and outpatients.
The presentations reflect the time and period during which the patients (cases) were encountered. Diagnostic and treatment modalities, therefore, reflect those available at the time and place of care.
All of these cases were consultations provided to physicians practicing in the community setting (whether hospital based or in office practice).
All personal identifiers have been removed (including names of institutions where care was provided), in order to protect the identity of the patients.
However, the dates of patient encounters (consults) have been included for context, as well as the season of the year, as these may provide important epidemiologic clues to making a correct diagnosis.
My suggestion is that you first review the case history and then hazard a diagnosis before turning to the answer and discussion section.
At the end of each case presentation, we will address simple diagnostic clues and any lessons learned from the case.
Chapter 1Skin and Soft Tissue Infections
Case 1.1 Soft tissue infection following traumatic aquatic exposure
In early September 2010, a 7-year-old boy suffered a laceration injury to the left calf during a recreational boat ride on a coastal river. He was brought to the emergency room (ER) within 2 hours of this accident, after initial cleansing first aid with saline in the field.
The wound was noted to be severe and deep, and was described as “partial degloving” by the ER physician. The boy's vital signs were stable. Due to the nature of the wound, an orthopedic surgeon was consulted and the patient was taken to surgery within 2 hours for wound washout and closure. X-rays of the leg showed no fractures.
Cefazolin and gentamicin were given preoperatively. The patient received 34 stitches to close the large (>10 cm) complex left calf laceration injury after extensive washout. No cultures were done.
One day later, infectious diseases consult was sought for outpatient oral antibiotic recommendations, in anticipation of discharge home later that day.
The boy's past medical history was unremarkable, except for hospital admission for symptoms of nausea and vomiting 1 year earlier, and ear tubes placed 1.5 years earlier.
His examination was unremarkable except for superficial abrasions on the lower abdomen and right upper arm, and the deep (now sutured) left calf laceration. Temperature was 100.5 °F, but other vital signs were stable.
A combination of trimethoprim/sulfamethoxazole and cefuroxime was recommended as oral antibiotics, and the patient was then discharged to outpatient follow-up.
Six days after discharge from the hospital, he was readmitted because of wound infection. He had failed to take the prescribed antibiotics because of severe nausea.
At surgery, no frank pus was found but serous old blood and drainage were noted. A swab of this drainage was stained and cultured.
The infectious diseases consultant was called (after surgery) to help with additional recommendations. He added ceftriaxone to the vancomycin already prescribed. Examination of the patient the next day found him to be comfortable, afebrile, and eating breakfast. His temperature was normal (97.8 °F). The abdominal skin abrasions were healing, but the left calf was wrapped up following the surgical incision and debridement (I&D) the day before.
Basic laboratory findings were normal (white blood cell [WBC] count was 7300/μL, platelet count 401,000/μL, and creatinine 0.5 mg/dL).
The gram stain of the serous fluid from the wound showed rare WBCs and no organisms. Twenty-four hours later, the culture was reported positive for a gram-negative rod (GNR).
The left calf wound was clean when inspected on day 4 post surgery (Fig. 1.1a).
What are the likely organisms in this patient (differential diagnoses) and why?
Figure 1.1a Left calf wound on day 4 post surgery (reproduced with permission). (See insert for color information)
The GNR was found to be oxidase positive, beta-hemolytic on sheep blood agar (BA), and the subculture showed luxuriant growth on all three agar media (BA, chocolate BA, and MacConkey agar) within 24 hours (Fig. 1.1b). It was noted later to be resistant to penicillin/ampicillin-like agents, including carbapenems, but sensitive to second- and third-generation cephalosporins, quinolones, and trimethoprim/sulfamethoxazole, as well as tetracyclines and aminoglycosides.
What is your new diagnosis?
Figure 1.1b Luxuriant growth of gram-negative rod on blood agar medium in 24 hours, and comparative growth of the same organism on BA, chocolate BA, and MacConkey agar. (See insert for color information)
The patient was discharged 6 days later to outpatient follow-up on intravenous ceftriaxone after a peripherally inserted central catheter (PICC line) was placed.
Two months later he was doing very well, and underwent plastic surgical repair of the calf laceration (Fig. 1.1c).
What were the clues to the diagnosis?
Figure 1.1c Photo taken in March 2011, 6 months after the injury: healed left calf post skin grafting (reproduced with permission).
Case discussion
First, the injury occurred while boating on a river, in possibly brackish water (coastal river). Gram-negative organisms are common and likely to contaminate the wound with such a severe laceration injury. The organism grew rapidly on all three culture media used (BA, Choc BA, and MAC). It was oxidase positive, non-lactose fermenting, mucoid, and beta-hemolytic on sheep BA. It did not require high salt concentration to grow, making certain Vibrio organisms (those that need high, 6.5% salt concentration) unlikely. The sensitivity pattern is also useful (see earlier). The organism turned out to be sensitive to the two agents originally recommended (trimethoprim/sulfamethoxazole and cefuroxime). The child was unable to take the antibiotics because of persistent nausea.
Differential diagnosis
Our differential diagnoses at the onset were Aeromonas or Pleisiomonas, more likely than Vibrio, because of the fresh water or brackish water environment where the injury occurred. The luxuriant growth in all three media was in keeping with the differential diagnoses chosen.
Final diagnosis: Aeromonas hydrophila
Some data from the literature on Aeromonas are shown in Table 1.1a and given below.
Table 1.1a Organisms associated with soft tissue infection following water exposure
Organisms
Exposure
Clinical syndromes
Aeromonas
spp
*
Fresh water
Rapidly developing infection associated with fever; sepsis
Edwardsiella tarda
*
Fresh water
Cellulitis, occasionally fulminant infection with bacteremia
Erysipelothrix rhusiopathiae
Puncture wounds from shrimp, crabs, and fish
Indolent localized cutaneous eruption; erysipeloid
Vibrio vulnificus
*
Salt or brackish water
Rapidly progressive necrotizing infection; bullous cellulitis; sepsis
Mycobacterium marinum
Salt or fresh water including fish tanks
Indolent infection; papules progressing to shallow ulcers; ascending lesions may resemble sporotrichosis
* Infection associated with patients with underlying liver disease, iron overload syndromes, and cancer; infections in these high-risk groups are particularly fulminant [1].
Reproduced with permission of UpToDate from Baddour [1].
Sites of isolation of Aeromonas (environmental reservoirs) [2]
Fresh water
Estuarine (brackish) water
Surface water, especially recreational
Drinking water, including treated, well, and bottled
Polluted waters
Waste water effluent sludge
The organism grows at a range of temperatures from 0 °C to 42 °C.
Characterization and classification of Aeromonas [2]
Aeromonads are ubiquitous inhabitants of fresh and brackish water.
They have also been recovered from chlorinated tap water, including hospital water supplies.
They occasionally cause soft tissue infections and sepsis in immunocompromised hosts and increasingly have been associated with diarrheal disease.
Because of recent phylogenetic studies,
Aeromonas
species have been moved from the family Vibrionaceae to a new family, the Aeromonadaceae.
Microbiologic identification of Aeromonas [2, 3]
Oxidase-positive, polar flagella, glucose fermenter, facultative anaerobic GNR.
Resistant to the vibriostatic agent O/129, and unable to grow in 6.5% NaCl.
Hemolysis is variable but most are beta-hemolytic on BA media.
There are a few useful standard biochemical tests (
A. hydrophila
is catalase positive and motile, converts nitrate to nitrite, and is urease negative).
Antimicrobial susceptibility tests of motile Aeromonas spp [2]
Most strains are resistant to penicillin, ampicillin, carbenicillin, and ticarcillin.
Most are susceptible to second- and third-generation cephalosporins, aminoglycosides, (carbapenems), chloramphenicol, tetracyclines, trimethoprim/sulfamethoxazole (TMP-SMX), and fluoroquinolones. In the case presented here, the
Aeromonas
was resistant to carbapenems, ampicillin, and first-generation cephalosporins.
Higher resistance patterns (to TMP-SMX, tetracycline, and some extended-spectrum cephalosporins) have been found in Taiwan and Spain.
Therapy with ampicillin or first-generation cephalosporins is not appropriate.
Lessons learned from this case
Think of wound contamination with any complex laceration injury.
Culture of the wound is critical before antibiotics are prescribed.
No complete closure of wound, especially when environmental contamination is known or anticipated, as in this case.
The patient should be advised to take the antibiotics or report if there are problems, so adjustments may be made. The patient in this case did not take the prescribed antibiotics because of nausea.
Inspect wounds regularly for signs of inflammation or infection (pus, redness, pain, swelling, induration, or drainage).
Think of the epidemiology (type of injury, environment, place, and season of the year) of the injury, and likely organisms expected in the given circumstances
References
1 Baddour LM.Soft tissue infections following water exposure. Available at:
www.uptodate.com/contents/soft-tissue-infections-following-water-exposure?view=print#
, accessed February 24, 2016.
2 Morris JG, Horneman A. Aeromonas infections. Available at:
www.uptodate.com/contents/aeromonas-infections?topicKey=ID%2F3138&elapsedTimeMs=5&source=search_result&searchTerm=Aeromonas+infections&selectedTitle=1%7E28&view=print&displayedView=full
, accessed February 24, 2016.
3 Steinberg JP, Burd EM. Other gram-negative and gram-variable bacilli. In: Mandell GL, Bennett JE, Dolin R (eds)
Principles and Practice of Infectious Diseases
