Clinical Cases

Case 1: Acute Osteomyelitis

This case concerns a ten year old boy presenting with pain and stiffness in his left knee. Previously well, he did
suffer from 'septic spots' that usually disappeared after prescription of amoxycillin. On Friday 22 March he became
ill with fever (39oC), a raised pulse (120 beats per minute) and muscle aches and pains. His General Practitioner
diagnosed influenza, and prescribed paracetamol for the boy.

The patient's condition deteriorated during the next 24 hours and by 6 p.m. on Saturday 23 March, he had a
temperature of 40.2oC and a pulse of 140 beats per minute. In addition to general aches and pains, he complained of
pain in his left leg, just below the knee joint. Flexing the left knee caused severe pain.

His mother was unhappy with the diagnosis of influenza and rang the doctor's deputising service, who reassured her
that the infection was self-limiting, and that it might be wise to persist with the paracetamol.

During the next 24 hours he showed no improvement, and the symptoms were aggravated by nausea and vomiting.
The boy became flushed and delirious. His temperature was 41.0oC by Sunday afternoon. The child was taken to the
casualty department of St. James' University Hospital. He was seen at 7 p.m. and was diagnosed as suffering from
meningitis because of his toxaemia, headache, and reduced level of consciousness. He was given intravenous
cefotaxime. A lumbar puncture was performed.

Two hours later, the CSF was reported as normal, but his blood sample showed 3.5x 109 leukocytes per litre, of
which 92% were polymorphs. The diagnosis was changed to pyogenic sepsis of unknown aetiology. An emergency
brain scan was performed to exclude a cerebral abscess. At midnight this was reported as normal.

The Consultant noted that despite a general restlessness, the patient did not move his left leg spontaneously. Careful
examination of the upper part of the left tibia revealed an area where any local pressure caused extreme pain. The
limb was swollen and red, and the mother said it had been like this for the past three days.

A diagnosis of acute osteomyelitis was now made, and the patient was referred to the orthopaedic department. Two
boreholes were drilled in the upper part of the left tibia where inflammation was most marked. Each aspirate yielded
5 ml of bloodstained pus. The left knee joint was aspirated and its fluid was cloudy. The following results were
reported by the laboratory:

Both bone aspirates yielded a pure growth of Staphylococcus

aureus resistant to penicillin, ampicillin and amoxycillin, but
sensitive to erythromycin, fusidic acid, flucloxacillin and
gentamicin. The knee aspirate contained 300 polymorphs/cu.mm
but was sterile.

The osteomyelitis had not invaded the knee joint - the effusion was sympathetic. The pus aspirate confirmed the
diagnosis of osteomyelitis. The patient was treated with flucloxacillin and fusidic acid, begun after surgery was
complete.

Case 1 Comments:
The patient was probably a nasal carrier of Staphylococcus aureus, the source of the bacterium causing
osteomyelitis.
The probable delay in diagnosis and treatment was because:
a) The diagnosis was not considered because the condition is rare.
b) Cefotaxime was considered to be the correct therapy.
The use of two antibiotics initially in undiagnosed osteomyelitis is reasonable because the probable causative
bacterium, Staphylococcus aureus, has an unpredictable sensitivity and because flucloxacillin and fusidic acid are
synergistic against this bacterium.
In suspected cases of osteomyelitis, why are
holes drilled into the bone?
To relieve the pain, to debride the wound,
and to obtain a sample for laboratory
analysis.
How long does it take for the laboratory to be
fairly confident that Staphylococcus aureus is
present?
Given the aetiology of the condition, about
ten minutes - a Gram stain will show Gram-
positive cocci in the pus.
How long does it take for the laboratory to be
certain that Staphylococcus aureus is present?
Up to 48 hours, if the slide test for clumping
factor is negative, and a DNase test and tube
coagulase must be carried out.
If Staphylococcus aureus resists penicillin,
why is it also resistant to ampicillin and
amoxycillin, but sensitive to flucloxacillin?
Flucloxacillin is an anti-staphylococcal
penicillin that can resist the action of
staphylococcal penicillinase. The other
penicillins listed are sensitive to
staphylococcal penicillinase.
How would you have managed this case had
the patient been allergic to penicillins?
Because of the patient's allergy to penicillins,
an alternative antimicrobial regime must be
sought. Due to the poor penetration of many
antibiotics into bone, the choice of therapy in
such cases is not easy. Clindamycin as a
single agent is a reasonable choice, reserving
vancomycin as a first-line agent for the
treatment of resistant staphylococcal
infections.
Case 2: Lobar Pneumonia
A 23 year old male, a known asthmatic, developed a 'cold' a week before a referral letter was written in March. He
complained of malaise, generalised dull headache, a mild sore throat and non-productive cough. After four days he
suffered a severe shaking chill lasting 15 minutes, his cough worsened and the patient produced a rusty coloured
sputum. The patient was pyrexial when examined and was admitted to hospital. His notes are given:

Presenting complaint
Cold - one week
Cough - one week
Headache - one week
Shaking chill three days ago.

History of presenting complaint

Known asthmatic, cold week ago, tired, headache, sore
throat, general aches, chestiness. Just before tea-break
three days ago suffered a chill. Cough worsened. Started
coughing up sputum, wheezing got worse, pain on breathing
in.

Past history
Known asthmatic, tonsillectomy aged 7, LGI.

Current Medication
Sodium chromoglycate 20 mg qds (for asthma)
No recent antibiotics

Family History
Mother and Father - well. One sister - well.

Social History
Non-smoker, Social drinker

Temperature: 40oC
Blood Pressure: 112/70
Physical Examination
23 year old male, respiratory distress and an obvious
herpetic lesion on his top lip. No signs of anaemia.

Respiratory System
Rapid, shallow breathing, rate 36/min.
Reduced expansion on right side.
Dullness to percussion over right middle lobe.
Fine crepitations over right middle lobe.

Rest of physical examination

No abnormalities detected.
 Laboratory reports
Blood chemistry: normal
Haematology: normal, except total wbc 15,000/cu
mm
Differential leukocyte count:
neutrophils 11,000 - shift to left
eosinophils 1,000
basophils 30
lymphocytes 2,500
monocytes 470

You are provided with a Gram film and culture plate from the specimen of sputum, and cultures from three sets of
blood cultures subcultured after overnight incubation at 37oC. An anterior chest X-ray is also provided.

What bacteria are present in the Gram film?

A mixed flora, both cocci and bacilli, that
are either Gram-positive or Gram-negative.
Notably, however, the film will cntain
lanceolate Gram-positive diplococci.
What bacterium has grown from the blood
culture?
Streptococcus pneumoniae
Is the same isolate present in the sputum?
Yes, but amongst many other bacteria,
derived from the patient's commensal flora.
What tests would you use to confirm the
identity of the blood culture isolate?
Catalase (negative),
Optochin sensitivity (sensitive),
Bile solubility (soluble).
What treatment is generally used in such
cases?
Penicillin, unless the patient is allergic, or
the isolate is penicillin tolerant.
Erythromycin is an alternative.
Case 3: Food Poisoning in a Psycho-Geriatric Unit
This incident occurred in a psychogeriatric hospital, where many inpatients experienced a sudden episode of
diarrhoea and vomiting. The first patients became ill on the morning of 21 August.

What information and samples will you

require to investigate and control this
problem?
Menus, and information on who had eaten
what.

The affected patients all ate food on the menus below:

19 August

Lunch
Fried Cod Chips and Peas
Apple Crumble and Custard

Supper
Shepherds Pie Brussels Sprouts Boiled Potatoes
Lemon Meringue Pie

20 August

Lunch
Ham Salad
Rhubarb Crumble

Supper
Chicken Kiev
Fresh Fruit Salad with Condensed Milk.
What foods may be implicated and what food
poisoning organisms are associated with that
food?
Given that this is NHS catering, some foods
that may be prepared fresh in some
establishments will be prepared in bulk, and
form previously pasteurised constituents.
This will actually reduce the risk posed by,
for example, lemon meringue pie. Had this
been freshly prepared, it is a potential source
of Salmonella enterica var. Enteritidis, but
given the catering limitations this is unlikely
in this case. There are a number of sources
of food poisoning on the menu from the
previous two days. These include:

Shepherd's pie - Clostridium perfringens.

Lemon meringue pie - see above

Ham salad - Staphylococcus aureus in the

ham, but incubation is too long.

Chicken Kiev - a salmonella.

Given the symptoms, and the timing of the

incident, the Chicken Kiev is the most likely
cause of the incident.
Primary culture of faeces from affected patients on MacConkey agar yielded motile, non-swarming Gram-negative
bacilli that did not ferment lactose.

What organism is likely to be the causative

agent?
A salmonella
What further laboratory tests might be used to
identify the isolate?
Biochemical reactions and its antigenic
structure, as determined by serological
agglutinations. Since a large number of
isolates ill be generated, strain sub-typing
will greatly help in investigating the incident.
Plasmid profiles can be rapidly determined.
If the serovar is common, then the reference
laboratory will also perform bacteriophage
typing.

You have now been interviewed on local television because patients have died, and there is a call for a Government
enquiry.

What steps have you taken to control this

episode of food poisoning?
This will fall into two categories; patient
management and environmental measures.
Screen for carriage, and cohort infected
patients, whether or not they are
symptomatic, and close the hospital to
further admissions. This will prevent
secondary spread, and will also alleviate the
burden of the over-worked staff. On the
environmental front, make sure that the
kitchen practices are adequate, and that the
physical state of the food preparation and
consumption areas are satisfactory. Full
environmental sampling is necessary to
identify the source of the incident.
Case 4: Osteomyelitis Following Major Trauma
Mr AS sustained a compound fracture of the tibia in a motor car accident, and was admitted to the LGI. A swab was
taken before cleaning the wound prior to suturing. Mr S was placed on traction to allow the fracture to heal. A
culture is provided.

What has been isolated?

A coliform and a Staphylococcus aureus
Which of the isolates are likely to lead to a
wound infection?
Staphylococcus aureus
Is it helpful to use prophylactic antibiotics in
casualty?
Given the severity of the injury in this case,
yes, if only to prevent anaerobic infection of
the wound.

Four days after his accident, Mr. S became pyrexial (39.6oC) and he had a raised white blood cell count. Whilst in
hospital his fracture was immobilised. A sample of pus was aspirated from his wound. The isolate from the pus is
provided.

What is the bacterium likely to be?

Staphylococcus aureus
How would you confirm this? List the tests
you would perform and the results you would
expect to obtain.
Gram reaction (Gram-positive cocci)
Catalase (positive)
Coagulase (positive)
[DNase (positive)]
After 70 days the original wound had healed, but the bone did not. Mr. S required a bone graft and fixation with pins
attached to an external frame. Post-operatively there was a serosanguinous discharge from the wound. A swab was
taken and the culture is provided for you.

What is the isolate?

A coliform.
How should this be treated?
Pins should be removed, if possible, and the
wound treated with an antiseptic.

Two days later Mr. Simmons was pyrexial (37.5oC). He was started on gentamicin (120mg tds).

Is this a suitable treatment?

No. Gentamicin has poor penetration into
bone.
What precautions are necessary when
gentamicin is used?
Serum levels must be monitored to ensure
that toxic accumulation does not occur, and
that therapeutic levels are maintained.

By day 90 Mr. S is progressing well, his wound has now healed, but he has a purulent discharge from the base of
one of his pins. A staphylococcus was isolated.

Is this likely to be significant?

Yes
Does it have any importance for any other
patients and, if so, how may its spread be
prevented?
Yes. The most important control is thorough
hand washing by staff on the unit.