Question

1.       A 58-year old lawyer presents in the emergency room with headache, irritability, generalized muscle pain and uncontrollable back spasms. He has become very restless and worried because he has had the back spasms all through his court case that afternoon and they became extremely painful. In his history, the lawyer states that he has a very busy practice. He is on medication for high blood pressure (beta blocker) and has mild asthma. He injured himself about 10 days earlier, puncturing his left arm with a nail from an old barn he is in the process of tearing down. The wound has produced moderate quantities of pus, but he has been keeping it clean. When asked, he did not remember having a tetanus shot since he was a kid. The wound was sampled for microscopic examination and culture. The patient's back appears to have very tight contractions and spasms. He is in obvious agonizing pain. Subsequent microscopic examination has shown a Gram-positive endospore-forming bacillus. The culture would not grow aerobically, but upon culture in a Gaspak anaerobic system bacterial colonies developed.

·      What is your diagnosis here?

·      What is the proper treatment of this problem?

·      How could this have been prevented?

2.      A white male, 17 years of age presented at the emergency room with a severe headache, vomiting, and a stiff neck with pain running up his back. On admission, his temperature was 101°F. The young man appeared to have trouble hearing during the nurse's interview and also seemed to have trouble concentrating. The history revealed that the young man is a wrestler for the local high school team. He had felt as though he were getting a cold the past few days, since his last meet in Hicksville. He did not smoke or drink, but he had attended a party two days earlier thrown by his girlfriend and the other cheerleaders to celebrate his victory in the sectionals. He had been holding his weight at 162lbs for the season, so he ate little and did not drink on the day of meets (today is a day of the meet). On physical exam, the physician noticed several areas of small purplish spots on the skin of the back, thigh and arm. The boy thought those were from wrestling.

For each of the following questions, mark the box at the left of your answer:

·      Which of the following is the most likely diagnosis?

□  Neisseria gonorrhoae induced meningitis

□  E. coli induced meningitis

□  Neisseria meningitidis induced meningitis

□  Streptococcus pneumonae induced meningitis

□  Arboviral encephalitis

Which of the following was a critical factor in your choice of diagnosis?

□  The fact the he is a wrestler and he does not eat or drink much.

□  The headache, vomiting, stiff neck, fever and purplish spots.

□  The party he went to with the cheerleaders.

□  His trouble hearing.

□  The cold symptoms.

Which of the following will likely happen if he is not treated?

□  He will continue to have a fever and stiff neck for a few days and recover.

□  His symptoms will progressively worsen until he develops shock and dies.

□  He may get better in a few days, but will likely have permanent hearing loss.

□  It is impossible to tell, because not enough data is available for an assessment of his condition.

□  He will likely recover from the acute illness, but develop chronic arthritis later.

3.      A 24-year old female automotive technician presents herself at the doctor's office. She complains of fever and of pain in her left hand. On physical examination, the patient had a deep wound on her left palm that was oozing pus. She had purplish, red streaks running up her left arm. She had enlarged lymph nodes at the elbow and under her arm. The patient's skin was warm and dry. In her history, the patient had punctured her left palm with sharp metal from the undercarriage of a "real cherry" 1977 Malibu about a week earlier. She said the wound had bled for a few minutes and she thought that she had washed it "real good" with soap and water. She had covered the wound with a large "band-aid" and gone back to work. She developed a fever about three days later. For the past couple of days, she "did not feel so good" and had vomiting and diarrhea.

For each of the following questions, mark the box at the left of your answer:

What type of infection do you believe she has in this hand?

□  Streptococcus pyogenes                     □   Bordetella pertussis

□  Staphylococcus aureus                      □   Treponema pallidum

□  Clostridium botulinum

From complaint and physical examination, which of the symptoms lead you to your choice of agent?

□  the fever and pain in the hand

□  the fever, wound with oozing pus and enlarged lymph nodes

□  the lymph nodes and red streaks

□  the warm dry skin

□  the pain, red streaks and enlarged lymph nodes

From the history, which of the information confirmed your choice?

□  The wound had bled for a while.

□  The wound was cleaned with soap and water.

□  The wound had been covered and had perhaps become anaerobic.

□  She had diarrhea and vomiting.

□  The cut was from a rusting car frame.

Which of the following is most likely to follow this infection?

□  gangrene and amputation                   □   neurological dysfunction of the hand

□  toxic shock syndrome                        □   arthritis

□  muscle spasms

Answer 1

1. 58 year old male who is a lawyer by profession is suffering from headache, muscle pain, irritability and severe back spasms. He has a history of back spasms but they were never this worse. He has medications for his high blood pressure. He also suffers from mild asthma. However, 10 days prior to the symptoms he had a punctured injury which he self treated. He is unsure of his tetanus shot. His back spasms are getting serious.

-There is a chance that he has been infected by the bacteria Clostridium tetani which is responsible for causing tetanus. Tetanus causes muscle spasms and in severe cases it can affect the nervous system and cause death.

-Tetanus could be treated by having antibiotics and supportive health care

-The situation could have been prevented by having a tetanus shot.
2. 17 year old male who does wrestling is showing symptoms of headache, stiff neck and vomitting. He also had mild fever. He is unable to hear things properly. He has purplish spots on his back and thigh area.

-Neisseria meningitidis which resulted in meningitis.

-Headache, vomit, stiff neck and purplish spots.

-His symptoms will progressively worsen until he gets a shock and dies.