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Cases in infectious diseases.pptx

  1. Cases in infectious diseases
  2. Clinical Presentation: A Man With MRSA The patient is a 48-year-old man with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. He was on dialysis and had rigors, fever, and hypotension. Blood cultures were obtained and he was admitted to the hospital after a dose of vancomycin and ceftazidime. Within 18 hours his blood cultures were positive for what would be identified as MRSA.
  3. History and Physical Examination History. The patient has had insulin-dependent diabetes since he was a teenager, and currently his A1c is approximately 10 mmol/mol. He has neuropathy, retinopathy, and nephropathy. He has a dilated cardiomyopathy after myocardial infarctions and an ejection fraction of 22%. Physical examination. On physical examination, the following were noted: •The patient was febrile and tachycardic •HEENT: no emboli; he is legally blind •Heart: 3/6 systolic murmur •Lungs: basilar crackles •Abdomen: nontender •Extremities: 2+ edema, no emboli
  4. Labs and imaging. As expected, the patient's lab studies indicated that he was diabetic, had an infection, and was in renal failure. Hospital course. The patient's fever gradually resolved over 7 days. His blood cultures were positive on day 3 (but not day 5) for MRSA with a minimum inhibitory concentration (MIC) to vancomycin of 1.0 µg/mL. The organism was resistant to all other antibiotics except linezolid and daptomycin. The dialysis catheter was removed, and a tip culture was negative. A transthoracic echocardiogram showed vegetation on the mitral valve. He was sent home on a 6-week course of vancomycin and he completed the course, the vancomycin trough levels never falling below 18 µg/mL.
  5. One week after completion of antibiotics, the patient was again febrile and hypotensive on dialysis and his blood cultures grew the same MRSA, with a MIC of 1.0 µg/mL to vancomycin. His evaluation in the hospital was identical to that of his last admission. Neither the thoracic surgeon nor the patient wished to proceed with valve replacement, the former because of worries about infecting the prosthetic valve, and the latter simply not wanting the intervention
  6. Clinical Presentation A 19-year-old girl who has just returned to the United States from West Africa presents with fever and jaundice. History and Physical Examination History. This 19-year-old has returned to the United States after spending a year in West Africa, where she taught in a rural village. While she was in Africa, she experienced 2 episodes of undiagnosed fever that were treated as malaria. One month before leaving, she experienced 3 days of severe diarrhea that resolved without therapy. For the last 3 days she has had fevers to 104°F with shaking, chills, and drenching sweats that began at the airport when she was waiting to leave Africa. Upon arrival in the United States, she noticed that her eyes were yellow and she came to the emergency department (ED). While she was in Africa, she took no prophylactic medications.
  7. Medical history: None Medications: None Allergies: None Habits: None Animal exposure: Exposed to multiple animals in rural Africa including cattle and goats Diet: In Africa, she ate and drank the local food and water Travel: West Africa, mostly Ghana Immunizations: Had the standard immunizations for travel to West Africa Sports/water exposure: Swam in the local river in West Africa Infectious disease exposure: Bug bites too numerous to count
  8. Physical examination. On physical examination, the following were noted. Vital signs: Temperature was afebrile in the ED, but subsequently became febrile to 104°F; pulse, 110 beats/minute; respirations, 16 breaths/min; blood pressure, 120/90 mm Hg General: Tired and ill-appearing young woman HEENT: Yellow sclera Lungs: Clear Heart: No pathology Abdomen: Mild to moderate right upper quadrant tenderness with palpable liver Extremities: Normal Skin: Jaundiced Genitourinary: Normal Neurologic: Normal
  9. Diagnostic Evaluation Lab results. The following results were obtained. White blood cell count: 2.1 x 109/L Hemoglobin: 9.8 g/dL Differential: 15% Platelets: 95,000/mL Bilirubin: 4.5 mg/dL Transaminases: Lactate dehydrogenase, 600 U/L; alanine aminotransferase, 434 U/L Urinalysis: Negative except bilirubin Imaging. Chest radiograph is normal.
  10. What is the diagnosis? (One or more may be correct.) Amoebic liver abscess Malaria Yellow fever Meningococcal serotype X Hepatitis E