Post on 17-Jun-2020
Patient Case Study
By: Pau
l, Jen, C
hris, &
Ben
Case & Social H
istory
A 65 year o
ld w
om
an w
ith p
resum
ed au
toim
mu
ne h
epatitis w
as transferred
to
a secon
d h
osp
ital for a p
ossib
le liver transp
lantatio
n.
●H
eavy drin
ker: 3-5 half gallo
ns o
f distilled
spirits p
er week
●M
ino
r histo
ry of sm
okin
g
●Lived
alon
e
●In
do
or cat, n
o o
ther an
imals
●N
o recen
t travel
●W
orked
in h
ealthcare field
●Fam
ily histo
ry states no
liver pro
blem
s
6 years before admission to
Massachusetts G
eneral Hospital
Patient receives ab
no
rmal liver-fu
nctio
n test
-A
dd
ition
al testing reveals:
-Elevated
antin
uclear an
tibo
dy titer
-N
egative for viral h
epatitis
Do
ctors p
resum
e auto
imm
un
e hep
atitis and
cirrho
sis from
her h
eavy alcoh
ol
con
sum
ptio
n:
-Patien
t is prescrib
ed glu
coco
rticoid
s and
stop
s drin
king h
eavily
7 weeks before adm
ission
Patient exp
eriences m
alaise, jaun
dice, fatigu
e and
seeks treatmen
t at ano
ther
ho
spital. V
ariou
s tests were p
erform
ed, ch
ecking fo
r...
Antinuclear A
ntibody Titer
●A
uto
imm
un
e respo
nses resem
ble n
orm
al imm
un
e respo
nses b
ecause th
ey are specifically activated
by an
tigens (like th
ose b
y path
ogen
s), except th
at in th
is case, the an
tigens are fro
m th
e ho
st, or self.
●Th
ese are called self-an
tigens, o
r auto
antigen
s. ○
Give rise to
auto
reactive effector cells an
d an
tibo
dies
■Term
ed: au
toan
tibo
dies
●Th
e antin
uclear an
tibo
dy is a su
btyp
e of au
toan
tibo
dy w
hich
attacks pro
teins in
, and
the n
ucleu
s of, th
e (ho
st) cell.
●Th
erefore, elevated
levels of an
tinu
clear antib
od
y titer reveals a po
tential au
toim
mu
ne d
isease ○
This w
ou
ld exp
lain th
e presu
mp
tive auto
imm
un
e label fo
r her au
toim
mu
ne h
epatitis
An
ultraso
un
d revealed
a no
du
lar liver
In resp
on
se, the p
atient w
as treated w
ith P
redn
ison
e (imm
un
osu
pp
ressive):
●U
sed to
treat her au
toim
mu
ne h
epatitis
○Th
erapy lasted
4 weeks, p
atient w
as prescrib
ed A
zathio
prin
e
■D
ifferent co
rticostero
id
No
du
lar Liver: liver dam
age (from
cirrho
sis) yields fib
rou
s collectio
ns in
the
liver wh
ich accu
mu
late to fo
rm n
od
es distin
guish
ed b
y increased
den
sity on
an
ultraso
un
d
Question: W
hat process most directly
causes the phenotype seen in nodular livers?A
)In
flamm
ation
B)
Fibro
sis
C)
Necro
sis
D)
Fatty accum
ulatio
n
E)A
uto
imm
un
e respo
nse
Question: W
hat process most directly
causes the phenotype seen in nodular livers?A
)In
flamm
ation
B)
Fibro
sis
C)
Necro
sis
D)
Fatty accum
ulatio
n
E)A
uto
imm
un
e respo
nse
3 weeks prior to adm
ission
Instead
of tran
sition
ing to
azathio
prin
e, the p
atient o
pted
to take h
erbal
sup
plem
ents o
n h
er ow
n d
iscretion
●M
ilk thistle is b
elieved to
treat liver diseases
○C
on
tains silym
arin
●B
uckth
orn
may also
alleviate symp
tom
s of cirrh
osis
1 week before adm
ission
●Patien
t’s dau
ghter n
oted
mo
ther h
ad jau
nd
ice
Question: W
hat is most likely the cause
of this patient’s jaundice?A
.Excessive leu
kocyto
sis
B.
Accu
mu
lation
of u
nco
nju
gated b
ilirub
in
C.
Accu
mu
lation
of h
emo
siderin
D.
Failure o
f bile to
drain
into
GI
E.N
on
e of th
e abo
ve
A.
Excessive leuko
cytosis
B.
Accu
mu
lation
of u
nco
nju
gated b
ilirub
in
C.
Accu
mu
lation
of h
emo
siderin
D.
Failure o
f bile to
drain
into
GI
E.N
on
e of th
e abo
ve
Question: W
hat is most likely the
cause of this patient’s jaundice?
4 days prior to admission
●Patien
t fou
nd
delirio
us an
d in
sho
ck on
the
floo
r of h
er
ho
me. M
ore
tests were
perfo
rmed
:
●H
ydro
nep
hro
sis
absen
t
Anaplerotic M
etabolism
Implications in
elevated lactate levels
Question: W
hen Ala- and A
sp-AT levels
increase, what im
plication for metabolism
does that carry?A
)D
ecrease in p
rotein
metab
olism
B)
Decrease in
amm
on
ium
pro
du
ction
C)
Low
er pH
than
no
rmal
D)
Increased
Krebs C
ycle activity
E)D
ecreased o
xygen n
eed
Question: W
hen Ala- and A
sp-AT levels
increase, what im
plication for metabolism
does that carry?A
)D
ecrease in p
rotein
metab
olism
B)
Decrease in
amm
on
ium
pro
du
ction
C)
Low
er pH
than
no
rmal
D)
Increased
Kreb
s Cycle activity
E)D
ecreased o
xygen n
eed
Adm
inistered Medications
●o
ral meth
ylpred
niso
ne (given
prio
r to in
traveno
us in
fusio
ns)
●in
traveno
us vitam
in K
to red
uce IN
R
●lactu
lose an
d rifaxim
in to
redu
ce her h
epatic en
ceph
alop
athy
Coagulopathy
INR
did
no
t no
rmalize after vitam
in K
adm
inistratio
n:
●IN
R m
ade to
stand
ardize
pro
thro
mb
in tim
e
●C
on
firms th
e presen
ce of h
epatic
synth
etic dysfu
nctio
n (a co
nd
ition
con
sistent w
ith acu
te liver failure
becau
se synth
esis of p
roth
rom
bin
occu
rs in th
e liver cells)
Question: if a patient has a problem
with
fibrogen production, this could mean...
A)
Vitam
in K u
tilization
is po
or
B)
This co
uld
lead to
pro
lon
ged in
flamm
ation
states
C)
Clo
t form
ation
do
es no
t occu
r, or o
ccurs very slo
wly
D)
All o
f the ab
ove
E)N
on
e of th
e abo
ve
Question: if a patient has a problem
with
fibrogen production, this could mean...
A)
Vitam
in K u
tilization
is po
or
B)
This co
uld
lead to
pro
lon
ged in
flamm
ation
states
C)
Clo
t form
ation
do
es no
t occu
r, or o
ccurs very slo
wly
D)
All o
f the ab
ove
E)N
on
e of th
e abo
ve
Urinanalysis:
Creatinine LevelH
er level:
-3.6 m
g/dL, very little u
rine
ou
tpu
t
-Stage 3
-C
linical h
allmark o
f acute
kidn
ey inju
ry
Question: w
here does creatinine originate from
in the body?A
)M
uscles as creatin
e ph
osp
hate
B)
Mu
scles as creatinin
e
C)
Liver as creatine p
ho
sph
ate
D)
Liver as creatinin
e
E)M
ainly circu
lates in b
loo
d as creatin
ine
Question: w
here does creatinine originate from
in the body?A
)M
uscles as creatin
e ph
osp
hate
B)
Mu
scles as creatinin
e
C)
Liver as creatine p
ho
sph
ate
D)
Liver as creatinin
e
E)M
ainly circu
lates in b
loo
d as creatin
ine
●So
on
after, oligu
ric acute kid
ney in
jury d
evelop
ed w
ith h
er high
creatinin
e level becau
se of h
epato
renal syn
dro
me (H
RS).
●alb
um
in in
fusio
n w
as adm
inistered
○p
atient h
ad n
o im
pro
vemen
t in creatin
ine level o
r urin
e ou
tpu
t
●m
ido
drin
e and
octreo
tide w
ere given in
com
bin
ation
to treat H
RS
○O
ctreotid
e and
mid
od
rine m
ainly reverse p
eriph
eral vasod
ilation
in
HR
S by in
creasing system
ic vascular resistan
ce, these d
rugs red
uce
shu
ntin
g and
imp
rove ren
al perfu
sion
■p
rolo
ngin
g survival u
ntil liver tran
splan
t
Fever and LeukocytosisA
fter mid
od
rine an
d o
ctreotid
e were p
rescribed
, patien
t develo
ped
fever and
leuko
cytosis, w
hich
pro
mp
ted a b
loo
d cu
lture:
-56 h
ou
r incu
batio
n p
eriod
yielded
detectab
le micro
bial gro
wth
in an
aerob
ic blo
od
cultu
re
Gram
’s stain:
-C
orkscrew
-shap
ed, gram
-negative ro
d b
acterial cells
Prescribed Medication and Leave
Emp
irical vanco
mycin
and
ceftriaxon
e were ad
min
istered;
ceftriaxon
e therap
y was d
iscon
tinu
ed after o
ne d
ose, an
d
pip
eracillin–tazo
bactam
therap
y was in
itiated
Patient is tran
sferred...
ON
AD
MISSIO
N
Massachusetts G
eneral Hospital
●Th
e patien
t app
eared fatigu
ed, b
ut w
as orien
ted to
perso
n, p
lace, and
time. A
dd
ition
ally, she
cou
ld still recite th
e days o
f the w
eek backw
ards.
●H
er vitals were m
ostly w
ithin
a no
rmal ran
ge; ho
wever h
er temp
erature w
as slightly elevated
for h
er age grou
p, an
d h
er oxygen
saturatio
n w
as belo
w n
orm
al range o
f her age gro
up
○Tem
peratu
re: 37.1 to <37°C
○H
eart Rate: 65 b
eats per m
inu
te
○B
loo
d P
ressure: 126/60 to
<120/<80 mm
Hg
○B
reathin
g rate at >65 years old
: 18 to 12-28 b
reaths p
er min
ute
○O
xygen Satu
ration
: 94% to
96%-98%
Checked for viral origins of Hepatitis A
, B and C●
All tests cam
e back n
egative
●Fu
rtherly co
nsisten
t with
auto
imm
un
e hep
atitis
Adm
ission Lab R
esults
Physical Examination Findings
●Th
e patien
t’s sclerae were icteric w
ith
her skin
havin
g jaun
dice.
●Jau
nd
ice = The ap
pearan
ce of yello
wish
skin (an
d/o
r eyes) caused
by h
igh
biliru
bin
levels in th
e blo
od
.
Referen
ce Ph
oto
:
http
s://library.m
ed.u
tah.ed
u/W
ebP
ath/C
INJH
TML/C
INJ049.h
tml#
Physical Examination Findings Cont.
●Th
e patien
t’s skin also
had
scattered sp
ider
angio
mata, th
e app
earance o
f swo
llen b
loo
d
vessels caused
by d
ilation
of b
loo
d vessels
○C
aused
by in
creased estro
gen levels
●Sh
e also sh
ow
ed sign
s of ecch
ymo
sis, wh
ich is
the ap
pearan
ce of b
ruisin
g un
der th
e skin d
ue
to su
bcu
taneo
us b
leedin
g.
○C
an b
e linked
to h
er high
INR
Ph
oto
:
http
s://med
icalbite.co
m/sp
ider-an
giom
a.htm
l
Ou
r patien
t sho
ws sign
s of ecch
ymo
sis, this d
iscolo
ration
of skin
caused
by
sub
cutan
eou
s bleed
ing w
as said to
be lin
ked to
her h
igh IN
R (In
ternatio
nal
No
rmalised
Ratio
). In sh
ort, th
e INR
uses yo
ur p
roth
rom
bin
time, th
e time it
takes for yo
ur b
loo
d to
clot, an
d co
mp
ares it a stand
ard. W
hich
cho
ice cou
ld
NO
T be a reaso
n a p
atient p
resents a h
igh IN
R (lo
nger clo
t times)? (H
int: U
se yo
ur kn
ow
ledge o
f coagu
lation
)
A.
A severe d
eficiency in
vitamin
K
B.
Occu
rrence o
f acute liver failu
re
C.
Use o
f blo
od
-thin
nin
g med
ication
(Warfarin
)
D.
Havin
g the b
leed d
isord
er Hem
op
hilia
E.N
on
e of th
e abo
ve
Physical Examination Findings Cont.
●U
po
n au
scultatio
n o
f the p
atient’s lu
ngs, sh
e was revealed
to h
ave
bib
asilar crackles, wh
ich su
ggests fluid
in h
er air spaces.
● H
er abd
om
en w
as fou
nd
to so
ft, no
nten
der, an
d d
istend
ed w
ith p
ossib
le
fluid
wave.
○D
ue to
abd
om
en co
nd
ition
s, liver and
spleen
were n
ot p
alpab
le
●C
linically sign
ificant ed
ema w
as seen in
the p
atient’s lo
wer legs to
the
sacrum
.
Frontal View
Chest Radiograph
●M
ultifo
cal patch
y air-space o
pacities
●B
ilateral Pleu
ral Effusio
ns = b
uild
up
of flu
id in
the p
leural sp
ace wh
ich is
the tissu
e betw
een th
e lun
gs and
chest cavity
●Flu
id alo
ng th
e min
or fissu
re of th
e
right lu
ng w
hich
is a find
ing
con
sistent w
ith p
ulm
on
ary edem
a
○R
adio
graph
con
sistent w
ith th
e
bib
asilar crackles
Health
y Lun
g Rad
iograp
h vs P
atient Lu
ng
Referen
ce Ph
oto
:http
://ww
w.ch
estx-ray.com
/images/igallery/re
sized/1-100/69-78-500-500-100.jp
g
CT Image of Chest
●Perfo
rmed
with
ou
t any
adm
inistratio
n o
f con
trast
material
●C
on
firms th
e presen
ce of th
e
grou
nd
-glass op
acities
pred
om
inan
t in th
e up
per lo
bes
of th
e patien
t’s lun
g as well as
mild
interlo
bu
lar septal
thicken
ing
Axial CT Im
age of the Abdom
en
●W
itho
ut an
y con
trast material,
this im
age sho
ws a n
od
ular
hep
atic con
tou
r of th
e liver wh
ich
is a sign o
f liver dam
age or d
isease
●Th
e patien
t also is seen
to h
ave
small vo
lum
e ascites wh
ich
con
firms o
bservatio
ns d
urin
g the
ph
ysical examin
ation
.
Ascites is the accum
ulation of fluid in the peritoneal cavity. O
ur patient appears to be experiencing ascites show
n by both the CT and her distended abdomen.
What could N
OT be a possible cause of this?
A.
A red
uctio
n o
f albu
min
du
e to a cirrh
otic liver
B.
An
increase in
vascular resistan
ce du
e to a cirrh
otic liver
C.
Activatio
n o
f the ren
in-an
gioten
sin system
D.
An
increase in
blo
od
collo
id o
smo
tic pressu
re
E.A
n in
crease in cap
illary perm
eability
Wh
ile the p
atient’s p
reviou
s diagn
osis o
f auto
imm
un
e hep
atitis may b
e
presu
mp
tive, rather th
an revisitin
g this d
iagno
sis, it is imp
erative to fo
cus o
n
urgen
tly iden
tifying th
e trigger for h
er sho
ck and
acute liver failu
re du
e to h
er
rapid
ly deterio
rating h
ealth. Th
ere are man
y po
ssible cau
ses of su
dd
en
deterio
ration
in a p
atient w
ith cirrh
osis w
ho
recently received
imm
un
osu
pp
ressive therap
y. In th
e presen
ce of fever an
d sh
ock, in
fection
mu
st be stro
ngly co
nsid
ered.
Blood Culturing
Patient d
isplayed
signs o
f fever and
sho
ck. Blo
od
cultu
ring w
as used
to
determ
ine w
heth
er these sym
pto
ms w
ere caused
by b
acteremia.
The results of the blood culture established that the patient w
as suffering from bacterem
ia. The following
drugs were adm
inistered to the patient prior to this diagnosis. W
hich drug was m
ost likely responsible for prom
oting infection of the patient?A
.Pred
niso
ne
B.
Lactulo
se
C.
Rifaxim
in
D.
Van
com
ycin
E.N
on
e of th
e abo
ve
The patient's condition is rapidly deteriorating, so the physicians require diagnostic tests that can quickly narrow
down the bacterial species responsible for the
bacteremia. G
iven this limited tim
eframe, w
hat diagnostic test should be used?
A.
Ad
ditio
nal b
loo
d cu
lturin
g usin
g differen
t med
ia and
enviro
nm
ental
con
ditio
ns
B.
Gram
's stainin
g
C.
An
timicro
bial su
sceptib
ility tests
D.
Toxico
logy testin
g
E.N
on
e of th
e abo
ve
Gram
’s StainingR
esults aid
in d
esignin
g targeted treatm
ents
against p
atho
gen.
Figure 1: Ph
oto
of th
e Gram
stain
perfo
rmed
at the o
ther h
osp
ital. The
left arrow
ind
icates the cu
rved ro
ds,
wh
ile the b
otto
m arro
w sh
ow
s the
extend
ed sp
irals.
Gram
’s Staining Results
Massach
usetts G
eneral w
anted
to reco
nfirm
the b
loo
d
cultu
re results, th
erefore th
ey con
du
cted th
eir ow
n set o
f
Gram
’s stains; resu
lts yielded
:
●G
ram-n
egative
●A
pp
earance
○C
urved
rod
s
○Exten
ded
spirals
○“G
ull-w
ing” arran
gemen
t
Very sp
ecific characteristics; n
ot m
any b
acterial species
shared
these traits.
Figure 3: Ph
oto
of th
e Gram
Stain
perfo
rmed
at Massach
usetts G
eneral.
Plan of Action
Becau
se it takes time to
do
no
n-stan
dard
blo
od
cultu
re tests, ph
ysicians o
n
this case relied
on
a com
bin
ation
of b
road
antib
iotic ad
min
istration
and
ph
eno
typic an
alysis of p
oten
tially path
ogen
ic bacteria
Requirem
ents of Pathogen
1.Th
e path
ogen
mu
st be ab
le to ad
op
t a spiral fo
rm
2.Th
e path
ogen
mu
st be ab
le to gro
w in
a stand
ard b
loo
d cu
lture
3.Th
e path
ogen
mu
st be ab
le to cau
se rapid
deco
mp
ensatio
n in
patien
ts p
resentin
g with
cirrho
sis
Identification of the Bacteria
Based
on
these resu
lts, the p
atient’s b
acteremia co
uld
have b
een cau
sed b
y a cou
ple o
f path
ogen
s:
Treponema pallidum
●Sp
iral-shap
ed b
acteria
●C
auses syp
hilis
○Patien
t’s symp
tom
s similar to
secon
dary stage syp
hilis sym
pto
ms
■Fever, sw
ollen
lymp
h glan
ds, m
uscle ach
es, fatigue, h
eadach
es, hair lo
ss, and
sore
thro
at
○A
cute d
ecom
pen
sation
of cirrh
osis is n
ot ch
aracteristic of syp
hilis
●Treponem
a too
thin
to b
e visualized
usin
g Gram
stainin
g
Borrelia
●Sp
iral-shap
ed b
acteria
●Stain
as Gram
-negative, b
ut cell w
all con
tent u
nch
aracteristic of m
ost G
ram-n
egative bacteria
●C
ause recu
rring fevers an
d Lym
e disease
○Early sym
pto
ms (<1 m
on
th) in
clud
e fever, chills, h
eadach
e, fatigue, m
uscle/jo
int ach
es,
Erythem
a migran
s rashes (th
e characteristic “b
ulls-eye” rash
), swo
llen lym
ph
no
des
●R
equ
ires specialized
med
ia and
enviro
nm
ental co
nd
ition
s wh
en cu
ltured
from
blo
od
Spirillum m
inus
●Sp
iral-shap
ed
●G
ram-n
egative bacteria
●R
espo
nsib
le for So
do
ku, a varian
t of rat-b
ite fever
○Sym
pto
ms in
clud
e fever, ulcer/sw
elling at th
e bite w
ou
nd
, swo
llen lym
ph
no
des, rash
●S. m
inu
s is rarely fou
nd
ou
tside o
f Asia
●R
equ
ires specialized
blo
od
cultu
ring co
nd
ition
s
Streptobacillus moniliform
is
●R
od
-shap
ed
●G
ram-n
egative bacteria
●C
auses b
acillary rat-bite fever
○Sym
pto
ms in
clud
e fever, vom
iting, h
eadach
e, mu
scle pain
, join
t pain
, rash
●Fo
un
d w
ithin
the n
orth
eastern U
nited
States
●A
ble to
grow
with
in th
e stand
ard b
loo
d cu
lture m
edia
Leptospira
●Sp
iral bacteria
●In
fection
associated
with
liver and
kidn
ey failure, alo
ng w
ith p
ulm
on
ary hem
orrh
aging
●Leptospira to
o th
in to
be visu
alized u
sing G
ram stain
ing
●R
equ
ires specialized
blo
od
cultu
ring co
nd
ition
s, will n
ot gro
w in
stand
ard b
loo
d cu
lture
●Fo
un
d w
ithin
temp
erate/trop
ical climates
Vibrio vulnificus
●G
ram-n
egative
●Sym
pto
ms:
○R
apid
declin
e in h
ealth, w
atery diarrh
ea with
stom
ach cram
pin
g, nau
sea, vom
iting,
fever, skin in
fection
, blo
od
stream in
fection
, fever, chills, d
angero
usly lo
w b
loo
d
pressu
re, blisterin
g skin lesio
n, an
d so
metim
es death
●Targets h
osts alread
y afflicted w
ith liver d
isease
○Liver d
isease often
associated
with
iron
overlo
ad
■V
. vulnificus utilizes iro
n, aid
s their gro
wth
●O
ften ap
pears as cu
rved ro
ds, rarely as sp
iral-shap
ed
●C
an b
e transm
itted th
rou
gh raw
seafoo
d
Anaerobiospirillum
succiniciproducens
●G
ram-n
egative
●Sp
iral bacteria
●In
fection
associated
with
fever, leuko
cytosis, an
d gastro
intestin
al distress
●Targets p
atients w
ith a h
istory o
f liver disease, d
iabetes, o
r con
sum
ptio
n o
f alcoh
ol
●N
orm
ally grow
s un
der an
aerob
ic con
ditio
ns
Cam
pylobacter
●G
ram-n
egative bacteria
●A
pp
ear as bo
th cu
rved ro
ds an
d exten
ded
spirals
●C
auses self-lim
iting gastro
enteritis
○C
an fu
rther d
evelop
into
bacterem
ia
in im
mu
no
com
pro
mised
ind
ividu
als
●Fo
un
d w
orld
wid
e
○O
ften w
ithin
raw p
ou
ltry
con
tamin
ated b
y feces
●G
row
s in stan
dard
blo
od
cultu
re med
ium
●C
ampylobacter jejuni is th
e mo
st com
mo
n
○C
. fetus may also
be resp
on
sible,
ho
wever is less co
mm
on
ly seen.
Helicobacter
●G
ram-n
egative
●C
urved
rod
and
spiral sh
aped
bacteria
●C
an gro
w in
stand
ard b
loo
d cu
lturin
g
con
ditio
ns
●C
ause gastro
enteritis
○C
an cau
se bacterem
ia in
ind
ividu
als with
com
pro
mised
imm
un
e systems.
●H
elicobacter is no
t as prevalen
t as
Cam
pylobacter
Phenotypic Tests●
In o
rder to
furth
er iden
tify the gu
ll-win
g–shap
ed gram
-negative ro
ds p
hen
otyp
ic testing w
as
perfo
rmed
. They p
erform
ed tw
o tests: C
atalase Test & O
xidase Test
○C
atalase Test: If the b
acteria po
ssess catalase (catalase-po
sitive), wh
en a sm
all amo
un
t of
bacterial iso
late is add
ed to
hyd
rogen
pero
xide, b
ub
bles o
f oxygen
are ob
served. Th
e
catalase test is do
ne b
y placin
g a dro
p o
f hyd
rogen
pero
xide o
n a m
icrosco
pe slid
e.
○O
xidase Test:Th
e oxid
ase test is used
to id
entify b
acteria that p
rod
uce cyto
chro
me c
oxid
ase, an en
zyme o
f the b
acterial electron
transp
ort ch
ain. R
eagent tu
rns d
ark blu
e wh
en
oxid
ized an
d co
lorless w
hen
redu
ced.
Results of Phenotypic Tests
●The tests w
ere both positive for catalase production and oxidase activity. This suggested the identity of this bacteria could be a cam
pylobacter species but it is important to note these
phenotypes are not specific to them.
Mass Spectrom
etry ●
The u
ltimate m
icrob
iolo
gic diagn
osis w
as con
firmed
by th
e results o
f MA
LDI-TO
F
(matrix-assisted
laser deso
rptio
n io
nizatio
n–tim
e-of-fligh
t) mass sp
ectrom
etry and
sup
po
rted b
y the resu
lts of stan
dard
bio
chem
ical assays
Based on the given inform
ation, what is
the bacteria responsible for the patient’s final diagnosis?A
.Streptobacillus m
oniliformis
B.
Vibrio vulnificus
C.
Anaerobiospirillum
succiniciproducens
D.
Cam
pylobacter
E.H
elicobacter
Final Diagnosis
Cam
pylobacter bacterem
ia in a p
atient w
ith p
resum
ed
auto
imm
un
e hep
atitis.
What are possible w
ays Campylobacter
could be acquired? A
.R
aw p
ou
ltry
B.
Co
ntact w
ith in
fected p
eop
le
C.
Infected
feces
D.
Co
ntact w
ith an
imal o
r insect carryin
g bacteria
E.A
ll of th
e abo
ve
Follow-up
●A
fter it was d
iscovered
that th
e patien
t had
bacterem
ia caused
by C
ampylobacter, p
hysician
s
treated h
er with
azithro
mycin
and
mero
pen
em. H
ow
ever, these d
rugs d
id n
ot alleviate h
er
symp
tom
s.
●Th
e ho
spital co
ntin
ued
to ad
min
ister vasop
ressors, b
ut sh
e con
tinu
ed to
deterio
rate.
●Sh
e develo
ped
respirato
ry failure. A
t this p
oin
t, she req
uired
a mech
anical ven
tilator to
survive. Sh
e was kep
t on
the ven
tilator fo
r 9 days. A
fterward
, her h
ealth sh
ow
ed so
me
imp
rovem
ent, so
she w
as extub
ated.
●H
ow
ever, her co
nd
ition
wo
rsened
2 days later. Sh
e had
symp
tom
s of p
rogressive h
ypo
xemia;
as a result, sh
e was rein
tub
ated. Sh
e was n
ot ab
le to reco
ver, and
she d
ied o
ne d
ay later.
What part of Cam
pylobacter causes it to be pathogenic?
-R
eleases toxin
called cyto
lethal d
istend
ing to
xin, C
DT, w
hich
causes D
NA
dam
age and
the arrest o
f cell cycle divisio
n
-Triggers ap
op
tosis in
affected cell
Patient
diagnosed w
/autoimm
une hepatitis
6 Years PriorTim
e Relative to A
dmission to M
ass. Gen.
7 Weeks
Prior
Patient develops m
alaise, fatigue, jaundice. S
he begins a prednisone treatm
ent.
Patient sw
itches from
prednisone to herbal supplem
ents.
3 Weeks
Prior
Summ
ary
Jaundice returns
1 Week
PriorTime R
elative to Adm
ission to Mass. G
en.
Everything goes
wrong: A
dmitted
to other hospital.
4 Days
Prior
Transferred from
unknown hospital
to Massachusetts
General H
ospital
Adm
itted
Patient condition
deteriorates, she dies
12 Days
After