Case Study Pathogenic Bacteriology 2009 Case #41 Angela Augustus.
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Transcript of Case Study Pathogenic Bacteriology 2009 Case #41 Angela Augustus.
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Case StudyPathogenic Bacteriology 2009
Case #41
Angela Augustus
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Case Summary
13 month old – HIV negative– Up to date on immunizations
Initial symptoms: runny nose, low grade fever– Treated with Tylenol
Later in the day: – Seizures– Lethargic, limp, unresponsive, post ictal– Temperature 39oC – Supple neck
Blood and urine cultures were taken Intravenous ceftriaxone
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Case Summary (cont)
Next Day: – No improved mental status– CSF with:
WBC count of 4650 cells/μl (95% neutrophils) Low glucose level Elevated protein level
– Peripheral WBC count increased from 6,600 to 14,600 cells/ μl
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Case Summary (cont)
Transferred to University Hospital:– Irritable, stiff neck– Blood culture: positive – CSF culture: negative
Bacterial antigen test is consistent with blood culture
– Normal: Antibodies for Hib and pneumococci Complement Immunoglobulin class and subclass levels Lymphocyte function
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Case Study (cont)
Gram Stain Choc CBA
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Key Information Pointing to Diagnosis
DISEASE: – Fever– Decreased mental status– Stiff neck– Positive blood culture and bacterial antigen test
ORGANISM:– Gram Stain
Eliminated S. aureus and S. agalactiae (Micrococcaceae and Streptococcaceae)
– Lack of growth on CBA, growth on Choc Eliminated E. coli
– Normal complement and lack of petechial rash Eliminated N. meningitidis
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Diagnosis
Meningitis caused by Haemophilus influenzae– Serotype b (vaccine failure)
“32% of children aged 6-59 months with confirmed type b disease had received 3 or more doses of the Hib vaccine” (Atkinson, 2008)
– Serotype a “No cross protection is afforded to type a by immunization with
Hib conjugate vaccines” (Jin, et al, 2007) As “the incidence of Hib meningitis decreased by 69% during
the first year following initiation of Hib conjugate immunization…the incidence of Hia meningitis increased eightfold” (Jin, et al, 2007)
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H. influenzae
Classification: Pasteurellaceae Gram Stain: Gram negative coccobacilli Requires both X and V
– Grows on Choc – Grows poorly on CBA
Ferments xylose – H. aegyptius is -
"The Normal Flora of Humans." The Microbial World . 11 Jan 2009. Kenneth Todar University of Wisconsin-Madison Department of Bacteriology . 2 Mar 2009 <http://bioinfo.bact.wisc.edu/themicrobialworld/NormalFlora.html>.
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Pathogenesis and Disease
H. influenzae: – Colonizes the nasopharynx– Invades local tissues and bloodstream to spread– Human carrier, possibly transmitted by respiratory droplets– Causes:
Meningitis 2mo – 3 years – Fever, decreased mental status, stiff neck
Epiglottitis 2-4 year old boys Pneumonia Septic arthritis Cellulitis Pericarditis
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Change in Epidemiology
(Atkinson, 2008)
An increase in vaccine use has led to a 99% decrease in Hib disease
CDC hopes to eliminate Hib disease by 2010
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Diagnosis of H. influenzae
Diagnosis requires: – Isolation and culturing of MO from sterile body sites:
Blood, CSF, joint, pericardial, or pleural fluid
– Detection of Hib specific antigen in sterile site especially after intravenous antibiotic treatment
Latex agglutination Counterimmunoelectrophoresis
Serotyping should also be done to identify specific type causing the disease
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Therapy, Prevention, and Prognosis
Treatment: Hospitalization and 10 days of:– Effective 3rd generation cephalosporin
Cefotaxime Ceftriaxone
– Chloramphenicol with ampicillin Ampicillin resistant strains have now emerged
Prognosis: 2-5% mortality rate even with appropriate antimicrobial therapy
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Treatment, Prevention, and Prognosis
Prevention: Hib vaccine– 2, 4, and 6 mo old with booster at 12-15 months– Safe for HIV patients (but immunogenicity varies) and
premature infants– Conjugate vaccines: poorly antigenic polysaccharide binds
to effective protein carrier PRP-T (ActHib) PRP-OMP (Pedvax HIB)
– Combination vaccines: combine two vaccines DTaP-Hib (TriHIBit) Hepatitis B-Hib (COMVAX)
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Childhood Immunizations
http://www.cdc.gov/vaccines/recs/schedules/child-schedule.htm#printable
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Primary Research Article
Ellen Hyun-Ju Lee, et al, 2008, Haemophilus influenzae type b conjugate vaccine is highly effective in the Ugandan routine immunization program: a case-control study, Tropical Medicine and International Health, 13:495-502.
Test Hib vaccine effectiveness in Uganda– Case patients – 12 weeks to 59 mo w/ confirmed Hib disease– Control groups – 3/case patient, age matched from:
Neighborhood Hospital
Data regarding immunizations and environment were collected using:
– Structured questionnaires– Written documentation and logbooks
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Primary Research Article
TABLE 2 FROM ARTICLE
Vaccine effectiveness increases with # of doses (as high as 98.7%)
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Take Home Message
Meningitis involves symptoms of fever, decreased mental status and stiff neck
Though it is caused by a variety of agents, H. influenzae is a common cause in young children (~2 mo to 3 years)
Potentially transmitted through aerosols, the organism colonizes the nasopharynx and infects the bloodstream
Diagnosis involves culturing/ isolating the organism from sterile body sites or a positive bacterial antigen test
Therapy includes a 10 day cycle of a 3rd generation cephalosporin or a combination of chloramphenicol and ampicillin.
Preventative measures with the Hib vaccine have led to a decreased threat. In the future, this threat may be nonexistant.
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References
Atkinson, William , Jennifer Hamborsky, Lynne McIntyre, and Charles Wolfe.Epidemiology and Prevention of Vaccine-Preventable Diseases. 10th ed. Washington DC: Public Health Foundation, 2008.
Jin, Zhigang, Sandra Romero-Steiner, George M. Carlone, John B. Robbins, and Rachel Schneerson. "Haemophilus influenzae Type a Infection and Its Prevention." Infection and Immunity. 75(2007): 2650-2654.
Lee, Ellen Hyun-Ju, Rosamund F. Lewis, Issa Makumbi, Adeodata Kekitiinwa, Tom D. Ediamu, monic Bazibu, Fiona Braka, Brendan Flanery, Patrick L. Zuber, and Daniel R. Feikin. "Haemophilus influenzae type b conjugate vaccine is highly effective in Ugandan routine immunization program: a case-control study." Tropical Medicine and International Health 13(2008): 495-502.
"Recommended Immunization Schedule for Persons Aged 0 Through 6 Years." Centers for Disease Control and Prevention . 26 Feb 2009. Centers for Disease Control and Prevention . 2 Mar 2009 <http://www.cdc.gov/vaccines/recs/schedules/downloads/child/2009/09_0-6yrs_schedule_pr.pdf>.
Roush, Sandra W. , Lynne McIntyre, and Linda M. Baldy. Manual for the Surveillance of Vaccine-Preventable Diseases. 4th ed. Atlanta, GA: Centers for Disease Control and Prevention, 2008.
Seehusen, M.D., Dean, Mark M. Reeves, M.D., and Demitria A. Fomin, M.D. . "Cerebrospinal Fluid Analysis." American Family Physician 68(2003): 1103-1108.