A 22-year-old college senior is brought to the emergency department by a roommate.  Patient was found on the floor of his room “convulsing.”  He was reportedly well the previous morning.  He has no prior health problems.  Uses some alcohol, one pack per day smoker, no illicit drugs.  Vaccination status unknown.
Temp: 39.5º oral
Pulse: 108
Respirations: 20
BP: 96/50
Intermittently combative and somnolent, disoriented
Neck: Nuchal rigidity
Cranial nerves: 3-12 grossly normal
Moves all extremities with good power
Responds to noxious stimuli – unable to cooperate for more detailed exam
No rash, no lymphadenopathy
Funduscopic exam – sharp disc margins
Remainder of exam (including cardiovascular, respiratory and abdominal) is normal

1. The first step in the evaluation and management of this patient would be t
   a. Administer dexamethasone
   b. Perform lumbar puncture
   c. Obtain head CT scan
   d. Obtain MRI (magnetic resonance imaging)
   e. Administer parenteral antibiotic
2. What organisms are the most common etiologic agents of acute meningitis in young adults?
3. What antibiotics should be chosen empirically to treat this patient while awaiting a diagnosis?
4. A gram stain of the CSF is shown (figure 1).  Should these results lead you to modify his treatment?
5. This organism is known to colonize respiratory epithelium.  What are the implications for his classmates? Family? Health care providers?  Should anything further be done?
6. Was this disease vaccine preventable?

A 22 yo woman presents with a 1 day history of urinary frequency and severe burning on urination.  She has had similar episodes in the past that always respond to “an antibiotic.”  She denies prior STD and denies vaginal discharge.  She is sexually active, uses diaphragm “always”, and last intercourse was 2 nights ago.

Exam is only remarkable for oral temp of 37.8º and suprapubic tenderness.

1. What evaluation should be undertaken for this patient?
2. What are the likely pathogens?
3. What are your options for treatment?
4. Can this be prevented?

A 17-year-old woman, 32 weeks estimated gestational age (EGA), has a urine culture positive for > 10⁵ group B strep.  She has no urinary tract symptoms.

1. What is the most appropriate course of action?

A 96 yo woman, residing in a nursing home, is noted to be increasingly incontinent of urine and now requires a diaper.  Physical exam is normal for age.  Urinalysis is positive for bacterial nitrite and leucocyte esterase with 22 wbc/hpf.  A urine culture is positive for > 10⁵ enterococcus.

1. What is the most appropriate course of action?

A 41-year-old male with paraplegia following a T6 spinal cord injury 12 years ago presents with 5 days of fever, feeling cold, vague back discomfort and nausea.

Oral temperature: 38.4º
A suprapubic catheter is in place
Urinalysis shows pH 8.0, 60 rbc, 55 wbc, bacterial nitrite positive
Culture of the urine grows 25000 cfu of a Proteus species.

1. Does this patient have a urinary tract infection?

After 14 days of ciprofloxacin the patient feels better but still has some back discomfort.

Urinalysis shows pH 8.0, 40 rbc, 3 wbc, bacterial nitrite negative
Moderate yeast are noted by microscopy.

1. What could explain the current symptoms and findings?
2. What is the best course of action to follow?

A 42-year-old woman sustains a laceration to her lower leg, just above the medial malleolus, while wading off of Folly Beach.  The wound is immediately cleaned and sutured.  Two days later she presents with rapid (< 24 hour) onset of erythema at the laceration site, extending proximally 20 cm over the anterior and medial lower leg.  The area is swollen and is a little warmer than the opposite ankle.  There is exquisite tenderness to light pressure over the ankle and distal leg.  She denies fever.

Past history:  hepatitis C
Social:  1 ppd tobacco, 12 pack of beer on weekends, no illicit drugs
PE:  T 99º    leg as decribed above
Remainder of exam normal
Some bloody discharge is noted when the sutures are cut but no pus
WBC is 8200 cells/µl.

1. Which of the following should be considered as possible etiologies of this cellulitis? What is the rank order of your choices?
   a. Streptococcus pyogenes
   b. Staphylococcus aureus
   c. Bacillus cereus
   d. Vibrio vulnificus
2. How would you manage this patient?

An 82-year-old woman is bitten on the leg by her cat after she inadvertently stepped on its tail.  Evaluation in the ED showed 4 small puncture wounds consistent with a cat bite.  The wound was scrubbed, and the patient received a tetanus booster and 5 days of oral cephalexin.  She presents to you 4 days later complaining of pain at the bite site.

Temperature: 37.6º
12 cm oval patch of erythema with warmth, swelling and tenderness over the left  leg just above the lateral malleolus

1. What organism(s) are the most likely etiology of this cat bite cellulitis?
2. Why did she fail therapy?

A 67-year-old diabetic man with left hemiparesis from a stroke is transferred to your service from the nursing home for “pneumonia.”  He has a stage 3 sacral decubitus, 4 cm in diameter, 4 mm deep that is filled with “pus.”  The margins of the ulcer are sharp, without undermining.  There is no erythema surrounding the ulcer.

A gram stain taken from the wound exudate reveal mixed organisms (greater than 3) and no white cells.  Culture is positive for Pseudomonas.

1. The antibiotic of choice for this situation is:
   a. Piperacillin-tazobactam
   b. Ciprofloxacin
   c. Amikacin
   d. Cefepime
   e. None of the above

An 18-year-old surfer presents with a nonhealing ulcer on his hand.  He relates sustaining an injury six weeks ago when he was thrown onto some rocks while surfing, resulting in several abrasions to his right hand and forearm.  While most of these areaas healed, one area on the back of the hand has persisted and over the past two weeks has been slowly enlarging.  He has also noticed a new ulceration on the back of his arm about 8 cm proximal to this and some lumps under the skin further up the arm.

Temperature: 37.7º
1 cm ulcer over the dorsum of the right hand, 4 mm deep
No erythema or swelling, nontender
A similar ulcer, 6 mm in diameter and 3 mm deep, is present on the dorsal forearm
Proximal to this, on the dorsal forearm, are 2 nodules, each 5 mm and nontender.

1. What infections may present in this manner? 
2. Which one is the likely etiology here?
3. How would you establish the diagnosis?
4. What antibiotic should you send him home on?

A 58 year-old man with a 17-year history of CAD underwent CABG for unstable angina symptoms. Postoperatively, antihypertensive and antianginal medications were continued, and docusate sodium was started.

PMH is significant for hypercholesterolemia and HTN. He is a social drinker and has been a heavy smoker for 30 years. His family history is positive for CAD.

Preoperative PE: temp 37.2, pulse 82, RR 14, BP 220/110
General: obese, NAD
HEENT grade II hypertensive changes, carotid bruits present, no JVD
Cardiac soft S1 murmur, presystolic gallop, L renal bruit
Abdomen: soft, mild RUQ tenderness, no organomegaly, no hepatojugular reflux
Extremities: stasis dermatitis of lower legs
Hospital course: CABG uneventful; postoperative period uneventful until fever developed on day 7
Patient continued to be febrile for 72 hours
Multiple blood cultures were drawn: negative
Temperature was 40.5 C, pulse 90
General exam: not acutely ill, physical exam unrevealing except for slight serosanguinous discharge from vein graft site on the leg
CXR : questionable LL opacity with definite small, L sided pleural effusion
Labs: WBC 19,800/uL diff 62% PMN, 4% bands, 6% eosinophils, 18% lymphocytes; platelets normal; ESR 110 mm/Hr; UA: 5 RBC/hpf, 4WBC/hpf
LFTs and renal function tests  : WNL with the exception of AST= 56 ALT 45, Alk Phos 220
Leg wound cultures Citrobacter freundii; UC: Stenotrophomonas maltophiliaSputum culture: few WBC
Gram stain: gram negative bacilli
cx:  Stenotrophomonas maltophilia.

The most likely cause of this patient`s fever is:

1. Nosocomial urinary tract infection
2. Hospital acquired pneumonia complicated by pleural effusion
3. Wound infection at the harvest site
4. Mediastinitis
5. none of the above

You will suggest the following plan of management:

1. repeat blood cultures, since you suspect that patient may still be bacteremic
2. start trimethoprim-sulfamethoxazole for nosocomial UTI
3. call surgical team to assess the leg wound for possible debridement and start Cefepime pending deep wound cultures
4. order  abdominal ultrasound and HIDA scan to look for possible cholecystitis
5. Discontinue a medication

A 52-year-old HIV-infected man presents with vague headache, slow speech and some drooping of the left side of his face.  He denies fever or head trauma.  He takes no medications currently.  Last known CD4 count is 92 cells/µl.
Temperature: 36.5º
Pulse: 72
Respirations: 12
BP: 136/86
Awake, oriented x 3 but verbal responses are slow.
Pupils 2 mm, fundi not visible
Multiple dental caries with severe periodontal disease
Neck supple
Cranial nerves 2-6 and 8-12 normal, left facial weakness noted. 
Peripheral motor, sensory and cerebellar exams are normal.

1. What is the differential diagnosis?
2. Which of the following should be done next?
   a. Serum RPR and cryptococcal antigen
   b. MRI of the brain
   c. Head CT with and without contrast
   d. Lumbar puncture

MRI reveals multiple nodular lesions with surrounding edema and mild mass effect (figure 2). 

1. What is the most likely diagnosis?  What should you do to confirm this?
2. What is the best treatment for this disease?

The patient returns to the office 2 weeks later for follow up.  His total white blood count is 800 cells/µl, down from 3200 from admission.

1. What could this be due to?
2. What other important complications are associated with drug therapy for this disease?

A 32-year-old Haitian woman with HIV infection presents with three weeks of cough, fevers, sweats and poor appetite.  Cough is minimally productive of white sputum with occasional flecks of blood.  She thinks she has lost some weight.  She has never been on antiretroviral therapy and has had no know complications of her HIV.  She is a single mother of two children, ages two and five.

Temperature: 38.2°
HR: 104
RR: 14
BP: 102/50
Height: 170 cm
Weight: 52 kg
HEENT: Poor dentition, no exudates
Shotty cervical lymphadenopathy, no palpable supraclavicular or axillary nodesChest: No crackles or wheezes on auscultation
Skin: No rash or lesions noted
Remainder of physical exam is normal
LAB:   WBC 3300 (67 neutrophils/22 lymphs/11 monocytes)
CD4: 210 cells/µl (13%) HIV viral load 66,000 copies/ml
CXR: (figure 3) left upper lobe infiltrate

1. What is the differential diagnosis for this patient?
2. Outline the diagnostic and management steps you would take for this family.

A 76-year-old male is transferred to your service from the ICU where he has been managed for hospital acquired pneumonia with piperacillin-tazobactam.  After 24 hours on the floor he spikes a fever to 39.1°.  Blood cultures are drawn peripherally and through his internal jugular line that was placed in the ICU eight days previously.  A grade 1/6 systolic crescendo-decrescendo murmur is noted in the left upper sternal border and is unchanged from prior exam. No other new physical findings are noted.  The on call intern adds tobramycin and fluconazole to the pip-tazo.  The next morning you receive a phone call that the blood is growing gram positive cocci in clusters in all 4 bottles.  A gram positive organism is growing in the urine as well.

1. What organism is likely responsible for the fever?
2. What is the likely source?
3. Should the antibiotic management be changed?
4. Should the internal jugular catheter be removed?
5. Should anything else be done to evaluate the patient at this point?

Blood cultures repeated 2 and 4 days later remain positive for gram positive cocci and the patient continues to have intermittent fever and some blurring of vision in the left eye.  You are unable to visualize the fundus in either eye.  A short 1/6 decrescendo diastolic murmur is noted.  Three small (2-4 mm) dark purple spots are noted on the toes of the left foot and are asymptomatic.

1. What has happened?
2. Does this change his management?

A 37-year-old male is referred to you from the Hampton Emergency Room one fine May evening with a 24 hour history of fever and confusion.  His partner tells you he has no previously diagnosed health problems and that he runs a small farm and spends much of his time hunting, fishing, or in the woods tending his still. His partner is unaware of any complaints such as headache prior to illness onset and doesn’t think he had any tick bites, although his dogs have soft ticks and fleas all summer.

Temperature: 39º
HR: 100
RR: 16
BP: 148/90
Arousable with noxious stimuli
Not oriented
No focal neurologic abnormalities noted.
Neck: Supple
Respiratory, cardiovascular and abdominal exams normal
No lymphadenopathy
Skin: A few petechiae noted on the distal arms (figure 4)
WBC: 4200
Hemoglobin 14.2 mg/dl
Platelet count: 123000
BUN: 16 creatinine 1.6
AST: 77
ALT: 87
Total bilirubin: .5
UA 100 mg/dl protein, otherwise normal
Head CT scan with and without contrast is normal
Lumbar puncture: Protein 120 mg/dl, Glucose 60 mg/dl, 3 rbc, 120 wbc (33% neutrophils, 67% lymphocytes)

1. Which of the following diagnoses are possible explanations for this clinical scenario?
   a.      Neisseria gonorrhea
   b.      Herpes simplex type 1
   c.      Neisseria meningitidis
   d.      Rickettsia rickettsiae
   e.      Ehrlichia chaffeensis
   f.        Borrelia burgorferi
2. Which of the above is the most likely diagnosis?
3. How should you confirm the diagnosis?
4. What antibiotics/antivirals would you start this patient on?

A healthy 27-year-old day care worker presents with three days of fever (temps at home to 102°) and explosive diarrhea with cramps, tenesmus and watery, blood streaked stools 10 times/day.

1. What is your differential diagnosis for the etiology of this diarrhea?
2. What cultures should be done?
3. Which antibiotic(s) should you give this patient?
   a. Ciprofloxacin
   b. Rifaximin
   c. Trimethoprim-sulfamethoxazole
   d. Azithromycin
   e. None
4. What is the role of antimotility agents in this disease?
5. Are there any public health issues to address?

A 27-year-old engineer presents with two weeks of abdominal bloating, intermittent bouts of diarrhea described as loose to watery stools without blood three to five times daily, and poor appetite.  He returned from three weeks in Nepal five days ago.  Three days of ciprofloxacin did not improve symptoms.  His past medical history is only significant for IgA deficiency.  Physical examination is normal.

Stool cultures and an ova and parasite exam are normal.

1. Which of the following studies should be obtained?
   a. Stool leukocyte examination
   b. More ova and parasite exams
   c. Giardia stool ELISA
   d. Immunoflorescent exam for giardia and cryptosporidia
   e. Acid fast stain of the stool
   f. Duodenal aspirate or biopsy (by upper endoscopy)
   g. Colonoscopy
2. Empiric therapy should be started with:
   a. 14 days of ciprofloxacin
   b. Metronidazole
   c. Trimethoprim-sulfamethoxazole
   d. Empiric antibiotics are not indicated
3. Does IgA deficiency put him at risk for any specific gastrointestinal pathogen?

A 44-year-old male in the surgical intensive care unit develops ileus, fever with temperature to 40° and escalation of the WBC count from 12000 to 32000.  He has been on ciprofloxacin and cefepime for 3 weeks for treatment of a pseudomonas empyema which has been responding to therapy.

1. Is this presentation (no diarrhea) consistent with Clostridium difficile colitis?
2. What testing could be used to confirm a diagnosis of Clostridium difficile colitis?  Does a negative test refute the diagnosis?
3. Describe the principles of management of this disease.
4. Why is soap and water handwashing for providers encouraged with C. difficile infected patients?