Patient Case Study

By: Pau

l, Jen, C

hris, &

Ben

Case & Social H

istory

A 65 year o

ld w

om

an w

ith p

resum

ed au

toim

mu

ne h

epatitis w

as transferred

to

a secon

d h

osp

ital for a p

ossib

le liver transp

lantatio

n.

●H

eavy drin

ker: 3-5 half gallo

ns o

f distilled

spirits p

er week

●M

ino

r histo

ry of sm

okin

g

●Lived

alon

e

●In

do

or cat, n

o o

ther an

imals

●N

o recen

t travel

●W

orked

in h

ealthcare field

●Fam

ily histo

ry states no

liver pro

blem

s

6 years before admission to

Massachusetts G

eneral Hospital

Patient receives ab

no

rmal liver-fu

nctio

n test

-A

dd

ition

al testing reveals:

-Elevated

antin

uclear an

tibo

dy titer

-N

egative for viral h

epatitis

Do

ctors p

resum

e auto

imm

un

e hep

atitis and

cirrho

sis from

her h

eavy alcoh

ol

con

sum

ptio

n:

-Patien

t is prescrib

ed glu

coco

rticoid

s and

stop

s drin

king h

eavily

7 weeks before adm

ission

Patient exp

eriences m

alaise, jaun

dice, fatigu

e and

seeks treatmen

t at ano

ther

ho

spital. V

ariou

s tests were p

erform

ed, ch

ecking fo

r...

Antinuclear A

ntibody Titer

●A

uto

imm

un

e respo

nses resem

ble n

orm

al imm

un

e respo

nses b

ecause th

ey are specifically activated

by an

tigens (like th

ose b

y path

ogen

s), except th

at in th

is case, the an

tigens are fro

m th

e ho

st, or self.

●Th

ese are called self-an

tigens, o

r auto

antigen

s. ○

Give rise to

auto

reactive effector cells an

d an

tibo

dies

■Term

ed: au

toan

tibo

dies

●Th

e antin

uclear an

tibo

dy is a su

btyp

e of au

toan

tibo

dy w

hich

attacks pro

teins in

, and

the n

ucleu

s of, th

e (ho

st) cell.

●Th

erefore, elevated

levels of an

tinu

clear antib

od

y titer reveals a po

tential au

toim

mu

ne d

isease ○

This w

ou

ld exp

lain th

e presu

mp

tive auto

imm

un

e label fo

r her au

toim

mu

ne h

epatitis

An

ultraso

un

d revealed

a no

du

lar liver

In resp

on

se, the p

atient w

as treated w

ith P

redn

ison

e (imm

un

osu

pp

ressive):

●U

sed to

treat her au

toim

mu

ne h

epatitis

○Th

erapy lasted

4 weeks, p

atient w

as prescrib

ed A

zathio

prin

e

■D

ifferent co

rticostero

id

No

du

lar Liver: liver dam

age (from

cirrho

sis) yields fib

rou

s collectio

ns in

the

liver wh

ich accu

mu

late to fo

rm n

od

es distin

guish

ed b

y increased

den

sity on

an

ultraso

un

d

Question: W

hat process most directly

causes the phenotype seen in nodular livers?A

)In

flamm

ation

B)

Fibro

sis

C)

Necro

sis

D)

Fatty accum

ulatio

n

E)A

uto

imm

un

e respo

nse

Question: W

hat process most directly

causes the phenotype seen in nodular livers?A

)In

flamm

ation

B)

Fibro

sis

C)

Necro

sis

D)

Fatty accum

ulatio

n

E)A

uto

imm

un

e respo

nse

3 weeks prior to adm

ission

Instead

of tran

sition

ing to

azathio

prin

e, the p

atient o

pted

to take h

erbal

sup

plem

ents o

n h

er ow

n d

iscretion

●M

ilk thistle is b

elieved to

treat liver diseases

○C

on

tains silym

arin

●B

uckth

orn

may also

alleviate symp

tom

s of cirrh

osis

1 week before adm

ission

●Patien

t’s dau

ghter n

oted

mo

ther h

ad jau

nd

ice

Question: W

hat is most likely the cause

of this patient’s jaundice?A

.Excessive leu

kocyto

sis

B.

Accu

mu

lation

of u

nco

nju

gated b

ilirub

in

C.

Accu

mu

lation

of h

emo

siderin

D.

Failure o

f bile to

drain

into

GI

E.N

on

e of th

e abo

ve

A.

Excessive leuko

cytosis

B.

Accu

mu

lation

of u

nco

nju

gated b

ilirub

in

C.

Accu

mu

lation

of h

emo

siderin

D.

Failure o

f bile to

drain

into

GI

E.N

on

e of th

e abo

ve

Question: W

hat is most likely the

cause of this patient’s jaundice?

4 days prior to admission

●Patien

t fou

nd

delirio

us an

d in

sho

ck on

the

floo

r of h

er

ho

me. M

ore

tests were

perfo

rmed

:

●H

ydro

nep

hro

sis

absen

t

Anaplerotic M

etabolism

Implications in

elevated lactate levels

Question: W

hen Ala- and A

sp-AT levels

increase, what im

plication for metabolism

does that carry?A

)D

ecrease in p

rotein

metab

olism

B)

Decrease in

amm

on

ium

pro

du

ction

C)

Low

er pH

than

no

rmal

D)

Increased

Krebs C

ycle activity

E)D

ecreased o

xygen n

eed

Question: W

hen Ala- and A

sp-AT levels

increase, what im

plication for metabolism

does that carry?A

)D

ecrease in p

rotein

metab

olism

B)

Decrease in

amm

on

ium

pro

du

ction

C)

Low

er pH

than

no

rmal

D)

Increased

Kreb

s Cycle activity

E)D

ecreased o

xygen n

eed

Adm

inistered Medications

●o

ral meth

ylpred

niso

ne (given

prio

r to in

traveno

us in

fusio

ns)

●in

traveno

us vitam

in K

to red

uce IN

R

●lactu

lose an

d rifaxim

in to

redu

ce her h

epatic en

ceph

alop

athy

Coagulopathy

INR

did

no

t no

rmalize after vitam

in K

adm

inistratio

n:

●IN

R m

ade to

stand

ardize

pro

thro

mb

in tim

e

●C

on

firms th

e presen

ce of h

epatic

synth

etic dysfu

nctio

n (a co

nd

ition

con

sistent w

ith acu

te liver failure

becau

se synth

esis of p

roth

rom

bin

occu

rs in th

e liver cells)

Question: if a patient has a problem

with

fibrogen production, this could mean...

A)

Vitam

in K u

tilization

is po

or

B)

This co

uld

lead to

pro

lon

ged in

flamm

ation

states

C)

Clo

t form

ation

do

es no

t occu

r, or o

ccurs very slo

wly

D)

All o

f the ab

ove

E)N

on

e of th

e abo

ve

Question: if a patient has a problem

with

fibrogen production, this could mean...

A)

Vitam

in K u

tilization

is po

or

B)

This co

uld

lead to

pro

lon

ged in

flamm

ation

states

C)

Clo

t form

ation

do

es no

t occu

r, or o

ccurs very slo

wly

D)

All o

f the ab

ove

E)N

on

e of th

e abo

ve

Urinanalysis:

Creatinine LevelH

er level:

-3.6 m

g/dL, very little u

rine

ou

tpu

t

-Stage 3

-C

linical h

allmark o

f acute

kidn

ey inju

ry

Question: w

here does creatinine originate from

in the body?A

)M

uscles as creatin

e ph

osp

hate

B)

Mu

scles as creatinin

e

C)

Liver as creatine p

ho

sph

ate

D)

Liver as creatinin

e

E)M

ainly circu

lates in b

loo

d as creatin

ine

Question: w

here does creatinine originate from

in the body?A

)M

uscles as creatin

e ph

osp

hate

B)

Mu

scles as creatinin

e

C)

Liver as creatine p

ho

sph

ate

D)

Liver as creatinin

e

E)M

ainly circu

lates in b

loo

d as creatin

ine

●So

on

after, oligu

ric acute kid

ney in

jury d

evelop

ed w

ith h

er high

creatinin

e level becau

se of h

epato

renal syn

dro

me (H

RS).

●alb

um

in in

fusio

n w

as adm

inistered

○p

atient h

ad n

o im

pro

vemen

t in creatin

ine level o

r urin

e ou

tpu

t

●m

ido

drin

e and

octreo

tide w

ere given in

com

bin

ation

to treat H

RS

○O

ctreotid

e and

mid

od

rine m

ainly reverse p

eriph

eral vasod

ilation

in

HR

S by in

creasing system

ic vascular resistan

ce, these d

rugs red

uce

shu

ntin

g and

imp

rove ren

al perfu

sion

■p

rolo

ngin

g survival u

ntil liver tran

splan

t

Fever and LeukocytosisA

fter mid

od

rine an

d o

ctreotid

e were p

rescribed

, patien

t develo

ped

fever and

leuko

cytosis, w

hich

pro

mp

ted a b

loo

d cu

lture:

-56 h

ou

r incu

batio

n p

eriod

yielded

detectab

le micro

bial gro

wth

in an

aerob

ic blo

od

cultu

re

Gram

’s stain:

-C

orkscrew

-shap

ed, gram

-negative ro

d b

acterial cells

Prescribed Medication and Leave

Emp

irical vanco

mycin

and

ceftriaxon

e were ad

min

istered;

ceftriaxon

e therap

y was d

iscon

tinu

ed after o

ne d

ose, an

d

pip

eracillin–tazo

bactam

therap

y was in

itiated

Patient is tran

sferred...

ON

AD

MISSIO

N

Massachusetts G

eneral Hospital

●Th

e patien

t app

eared fatigu

ed, b

ut w

as orien

ted to

perso

n, p

lace, and

time. A

dd

ition

ally, she

cou

ld still recite th

e days o

f the w

eek backw

ards.

●H

er vitals were m

ostly w

ithin

a no

rmal ran

ge; ho

wever h

er temp

erature w

as slightly elevated

for h

er age grou

p, an

d h

er oxygen

saturatio

n w

as belo

w n

orm

al range o

f her age gro

up

○Tem

peratu

re: 37.1 to <37°C

○H

eart Rate: 65 b

eats per m

inu

te

○B

loo

d P

ressure: 126/60 to

<120/<80 mm

Hg

○B

reathin

g rate at >65 years old

: 18 to 12-28 b

reaths p

er min

ute

○O

xygen Satu

ration

: 94% to

96%-98%

Checked for viral origins of Hepatitis A

, B and C●

All tests cam

e back n

egative

●Fu

rtherly co

nsisten

t with

auto

imm

un

e hep

atitis

Adm

ission Lab R

esults

Physical Examination Findings

●Th

e patien

t’s sclerae were icteric w

ith

her skin

havin

g jaun

dice.

●Jau

nd

ice = The ap

pearan

ce of yello

wish

skin (an

d/o

r eyes) caused

by h

igh

biliru

bin

levels in th

e blo

od

.

Referen

ce Ph

oto

:

http

s://library.m

ed.u

tah.ed

u/W

ebP

ath/C

INJH

TML/C

INJ049.h

tml#

Physical Examination Findings Cont.

●Th

e patien

t’s skin also

had

scattered sp

ider

angio

mata, th

e app

earance o

f swo

llen b

loo

d

vessels caused

by d

ilation

of b

loo

d vessels

○C

aused

by in

creased estro

gen levels

●Sh

e also sh

ow

ed sign

s of ecch

ymo

sis, wh

ich is

the ap

pearan

ce of b

ruisin

g un

der th

e skin d

ue

to su

bcu

taneo

us b

leedin

g.

○C

an b

e linked

to h

er high

INR

Ph

oto

:

http

s://med

icalbite.co

m/sp

ider-an

giom

a.htm

l

Ou

r patien

t sho

ws sign

s of ecch

ymo

sis, this d

iscolo

ration

of skin

caused

by

sub

cutan

eou

s bleed

ing w

as said to

be lin

ked to

her h

igh IN

R (In

ternatio

nal

No

rmalised

Ratio

). In sh

ort, th

e INR

uses yo

ur p

roth

rom

bin

time, th

e time it

takes for yo

ur b

loo

d to

clot, an

d co

mp

ares it a stand

ard. W

hich

cho

ice cou

ld

NO

T be a reaso

n a p

atient p

resents a h

igh IN

R (lo

nger clo

t times)? (H

int: U

se yo

ur kn

ow

ledge o

f coagu

lation

)

A.

A severe d

eficiency in

vitamin

K

B.

Occu

rrence o

f acute liver failu

re

C.

Use o

f blo

od

-thin

nin

g med

ication

(Warfarin

)

D.

Havin

g the b

leed d

isord

er Hem

op

hilia

E.N

on

e of th

e abo

ve

Physical Examination Findings Cont.

●U

po

n au

scultatio

n o

f the p

atient’s lu

ngs, sh

e was revealed

to h

ave

bib

asilar crackles, wh

ich su

ggests fluid

in h

er air spaces.

● H

er abd

om

en w

as fou

nd

to so

ft, no

nten

der, an

d d

istend

ed w

ith p

ossib

le

fluid

wave.

○D

ue to

abd

om

en co

nd

ition

s, liver and

spleen

were n

ot p

alpab

le

●C

linically sign

ificant ed

ema w

as seen in

the p

atient’s lo

wer legs to

the

sacrum

.

Frontal View

Chest Radiograph

●M

ultifo

cal patch

y air-space o

pacities

●B

ilateral Pleu

ral Effusio

ns = b

uild

up

of flu

id in

the p

leural sp

ace wh

ich is

the tissu

e betw

een th

e lun

gs and

chest cavity

●Flu

id alo

ng th

e min

or fissu

re of th

e

right lu

ng w

hich

is a find

ing

con

sistent w

ith p

ulm

on

ary edem

a

○R

adio

graph

con

sistent w

ith th

e

bib

asilar crackles

Health

y Lun

g Rad

iograp

h vs P

atient Lu

ng

Referen

ce Ph

oto

:http

://ww

w.ch

estx-ray.com

/images/igallery/re

sized/1-100/69-78-500-500-100.jp

g

CT Image of Chest

●Perfo

rmed

with

ou

t any

adm

inistratio

n o

f con

trast

material

●C

on

firms th

e presen

ce of th

e

grou

nd

-glass op

acities

pred

om

inan

t in th

e up

per lo

bes

of th

e patien

t’s lun

g as well as

mild

interlo

bu

lar septal

thicken

ing

Axial CT Im

age of the Abdom

en

●W

itho

ut an

y con

trast material,

this im

age sho

ws a n

od

ular

hep

atic con

tou

r of th

e liver wh

ich

is a sign o

f liver dam

age or d

isease

●Th

e patien

t also is seen

to h

ave

small vo

lum

e ascites wh

ich

con

firms o

bservatio

ns d

urin

g the

ph

ysical examin

ation

.

Ascites is the accum

ulation of fluid in the peritoneal cavity. O

ur patient appears to be experiencing ascites show

n by both the CT and her distended abdomen.

What could N

OT be a possible cause of this?

A.

A red

uctio

n o

f albu

min

du

e to a cirrh

otic liver

B.

An

increase in

vascular resistan

ce du

e to a cirrh

otic liver

C.

Activatio

n o

f the ren

in-an

gioten

sin system

D.

An

increase in

blo

od

collo

id o

smo

tic pressu

re

E.A

n in

crease in cap

illary perm

eability

Wh

ile the p

atient’s p

reviou

s diagn

osis o

f auto

imm

un

e hep

atitis may b

e

presu

mp

tive, rather th

an revisitin

g this d

iagno

sis, it is imp

erative to fo

cus o

n

urgen

tly iden

tifying th

e trigger for h

er sho

ck and

acute liver failu

re du

e to h

er

rapid

ly deterio

rating h

ealth. Th

ere are man

y po

ssible cau

ses of su

dd

en

deterio

ration

in a p

atient w

ith cirrh

osis w

ho

recently received

imm

un

osu

pp

ressive therap

y. In th

e presen

ce of fever an

d sh

ock, in

fection

mu

st be stro

ngly co

nsid

ered.

Blood Culturing

Patient d

isplayed

signs o

f fever and

sho

ck. Blo

od

cultu

ring w

as used

to

determ

ine w

heth

er these sym

pto

ms w

ere caused

by b

acteremia.

The results of the blood culture established that the patient w

as suffering from bacterem

ia. The following

drugs were adm

inistered to the patient prior to this diagnosis. W

hich drug was m

ost likely responsible for prom

oting infection of the patient?A

.Pred

niso

ne

B.

Lactulo

se

C.

Rifaxim

in

D.

Van

com

ycin

E.N

on

e of th

e abo

ve

The patient's condition is rapidly deteriorating, so the physicians require diagnostic tests that can quickly narrow

down the bacterial species responsible for the

bacteremia. G

iven this limited tim

eframe, w

hat diagnostic test should be used?

A.

Ad

ditio

nal b

loo

d cu

lturin

g usin

g differen

t med

ia and

enviro

nm

ental

con

ditio

ns

B.

Gram

's stainin

g

C.

An

timicro

bial su

sceptib

ility tests

D.

Toxico

logy testin

g

E.N

on

e of th

e abo

ve

Gram

’s StainingR

esults aid

in d

esignin

g targeted treatm

ents

against p

atho

gen.

Figure 1: Ph

oto

of th

e Gram

stain

perfo

rmed

at the o

ther h

osp

ital. The

left arrow

ind

icates the cu

rved ro

ds,

wh

ile the b

otto

m arro

w sh

ow

s the

extend

ed sp

irals.

Gram

’s Staining Results

Massach

usetts G

eneral w

anted

to reco

nfirm

the b

loo

d

cultu

re results, th

erefore th

ey con

du

cted th

eir ow

n set o

f

Gram

’s stains; resu

lts yielded

:

●G

ram-n

egative

●A

pp

earance

○C

urved

rod

s

○Exten

ded

spirals

○“G

ull-w

ing” arran

gemen

t

Very sp

ecific characteristics; n

ot m

any b

acterial species

shared

these traits.

Figure 3: Ph

oto

of th

e Gram

Stain

perfo

rmed

at Massach

usetts G

eneral.

Plan of Action

Becau

se it takes time to

do

no

n-stan

dard

blo

od

cultu

re tests, ph

ysicians o

n

this case relied

on

a com

bin

ation

of b

road

antib

iotic ad

min

istration

and

ph

eno

typic an

alysis of p

oten

tially path

ogen

ic bacteria

Requirem

ents of Pathogen

1.Th

e path

ogen

mu

st be ab

le to ad

op

t a spiral fo

rm

2.Th

e path

ogen

mu

st be ab

le to gro

w in

a stand

ard b

loo

d cu

lture

3.Th

e path

ogen

mu

st be ab

le to cau

se rapid

deco

mp

ensatio

n in

patien

ts p

resentin

g with

cirrho

sis

Identification of the Bacteria

Based

on

these resu

lts, the p

atient’s b

acteremia co

uld

have b

een cau

sed b

y a cou

ple o

f path

ogen

s:

Treponema pallidum

●Sp

iral-shap

ed b

acteria

●C

auses syp

hilis

○Patien

t’s symp

tom

s similar to

secon

dary stage syp

hilis sym

pto

ms

■Fever, sw

ollen

lymp

h glan

ds, m

uscle ach

es, fatigue, h

eadach

es, hair lo

ss, and

sore

thro

at

○A

cute d

ecom

pen

sation

of cirrh

osis is n

ot ch

aracteristic of syp

hilis

●Treponem

a too

thin

to b

e visualized

usin

g Gram

stainin

g

Borrelia

●Sp

iral-shap

ed b

acteria

●Stain

as Gram

-negative, b

ut cell w

all con

tent u

nch

aracteristic of m

ost G

ram-n

egative bacteria

●C

ause recu

rring fevers an

d Lym

e disease

○Early sym

pto

ms (<1 m

on

th) in

clud

e fever, chills, h

eadach

e, fatigue, m

uscle/jo

int ach

es,

Erythem

a migran

s rashes (th

e characteristic “b

ulls-eye” rash

), swo

llen lym

ph

no

des

●R

equ

ires specialized

med

ia and

enviro

nm

ental co

nd

ition

s wh

en cu

ltured

from

blo

od

Spirillum m

inus

●Sp

iral-shap

ed

●G

ram-n

egative bacteria

●R

espo

nsib

le for So

do

ku, a varian

t of rat-b

ite fever

○Sym

pto

ms in

clud

e fever, ulcer/sw

elling at th

e bite w

ou

nd

, swo

llen lym

ph

no

des, rash

●S. m

inu

s is rarely fou

nd

ou

tside o

f Asia

●R

equ

ires specialized

blo

od

cultu

ring co

nd

ition

s

Streptobacillus moniliform

is

●R

od

-shap

ed

●G

ram-n

egative bacteria

●C

auses b

acillary rat-bite fever

○Sym

pto

ms in

clud

e fever, vom

iting, h

eadach

e, mu

scle pain

, join

t pain

, rash

●Fo

un

d w

ithin

the n

orth

eastern U

nited

States

●A

ble to

grow

with

in th

e stand

ard b

loo

d cu

lture m

edia

Leptospira

●Sp

iral bacteria

●In

fection

associated

with

liver and

kidn

ey failure, alo

ng w

ith p

ulm

on

ary hem

orrh

aging

●Leptospira to

o th

in to

be visu

alized u

sing G

ram stain

ing

●R

equ

ires specialized

blo

od

cultu

ring co

nd

ition

s, will n

ot gro

w in

stand

ard b

loo

d cu

lture

●Fo

un

d w

ithin

temp

erate/trop

ical climates

Vibrio vulnificus

●G

ram-n

egative

●Sym

pto

ms:

○R

apid

declin

e in h

ealth, w

atery diarrh

ea with

stom

ach cram

pin

g, nau

sea, vom

iting,

fever, skin in

fection

, blo

od

stream in

fection

, fever, chills, d

angero

usly lo

w b

loo

d

pressu

re, blisterin

g skin lesio

n, an

d so

metim

es death

●Targets h

osts alread

y afflicted w

ith liver d

isease

○Liver d

isease often

associated

with

iron

overlo

ad

■V

. vulnificus utilizes iro

n, aid

s their gro

wth

●O

ften ap

pears as cu

rved ro

ds, rarely as sp

iral-shap

ed

●C

an b

e transm

itted th

rou

gh raw

seafoo

d

Anaerobiospirillum

succiniciproducens

●G

ram-n

egative

●Sp

iral bacteria

●In

fection

associated

with

fever, leuko

cytosis, an

d gastro

intestin

al distress

●Targets p

atients w

ith a h

istory o

f liver disease, d

iabetes, o

r con

sum

ptio

n o

f alcoh

ol

●N

orm

ally grow

s un

der an

aerob

ic con

ditio

ns

Cam

pylobacter

●G

ram-n

egative bacteria

●A

pp

ear as bo

th cu

rved ro

ds an

d exten

ded

spirals

●C

auses self-lim

iting gastro

enteritis

○C

an fu

rther d

evelop

into

bacterem

ia

in im

mu

no

com

pro

mised

ind

ividu

als

●Fo

un

d w

orld

wid

e

○O

ften w

ithin

raw p

ou

ltry

con

tamin

ated b

y feces

●G

row

s in stan

dard

blo

od

cultu

re med

ium

●C

ampylobacter jejuni is th

e mo

st com

mo

n

○C

. fetus may also

be resp

on

sible,

ho

wever is less co

mm

on

ly seen.

Helicobacter

●G

ram-n

egative

●C

urved

rod

and

spiral sh

aped

bacteria

●C

an gro

w in

stand

ard b

loo

d cu

lturin

g

con

ditio

ns

●C

ause gastro

enteritis

○C

an cau

se bacterem

ia in

ind

ividu

als with

com

pro

mised

imm

un

e systems.

●H

elicobacter is no

t as prevalen

t as

Cam

pylobacter

Phenotypic Tests●

In o

rder to

furth

er iden

tify the gu

ll-win

g–shap

ed gram

-negative ro

ds p

hen

otyp

ic testing w

as

perfo

rmed

. They p

erform

ed tw

o tests: C

atalase Test & O

xidase Test

○C

atalase Test: If the b

acteria po

ssess catalase (catalase-po

sitive), wh

en a sm

all amo

un

t of

bacterial iso

late is add

ed to

hyd

rogen

pero

xide, b

ub

bles o

f oxygen

are ob

served. Th

e

catalase test is do

ne b

y placin

g a dro

p o

f hyd

rogen

pero

xide o

n a m

icrosco

pe slid

e.

○O

xidase Test:Th

e oxid

ase test is used

to id

entify b

acteria that p

rod

uce cyto

chro

me c

oxid

ase, an en

zyme o

f the b

acterial electron

transp

ort ch

ain. R

eagent tu

rns d

ark blu

e wh

en

oxid

ized an

d co

lorless w

hen

redu

ced.

Results of Phenotypic Tests

●The tests w

ere both positive for catalase production and oxidase activity. This suggested the identity of this bacteria could be a cam

pylobacter species but it is important to note these

phenotypes are not specific to them.

Mass Spectrom

etry ●

The u

ltimate m

icrob

iolo

gic diagn

osis w

as con

firmed

by th

e results o

f MA

LDI-TO

F

(matrix-assisted

laser deso

rptio

n io

nizatio

n–tim

e-of-fligh

t) mass sp

ectrom

etry and

sup

po

rted b

y the resu

lts of stan

dard

bio

chem

ical assays

Based on the given inform

ation, what is

the bacteria responsible for the patient’s final diagnosis?A

.Streptobacillus m

oniliformis

B.

Vibrio vulnificus

C.

Anaerobiospirillum

succiniciproducens

D.

Cam

pylobacter

E.H

elicobacter

Final Diagnosis

Cam

pylobacter bacterem

ia in a p

atient w

ith p

resum

ed

auto

imm

un

e hep

atitis.

What are possible w

ays Campylobacter

could be acquired? A

.R

aw p

ou

ltry

B.

Co

ntact w

ith in

fected p

eop

le

C.

Infected

feces

D.

Co

ntact w

ith an

imal o

r insect carryin

g bacteria

E.A

ll of th

e abo

ve

Follow-up

●A

fter it was d

iscovered

that th

e patien

t had

bacterem

ia caused

by C

ampylobacter, p

hysician

s

treated h

er with

azithro

mycin

and

mero

pen

em. H

ow

ever, these d

rugs d

id n

ot alleviate h

er

symp

tom

s.

●Th

e ho

spital co

ntin

ued

to ad

min

ister vasop

ressors, b

ut sh

e con

tinu

ed to

deterio

rate.

●Sh

e develo

ped

respirato

ry failure. A

t this p

oin

t, she req

uired

a mech

anical ven

tilator to

survive. Sh

e was kep

t on

the ven

tilator fo

r 9 days. A

fterward

, her h

ealth sh

ow

ed so

me

imp

rovem

ent, so

she w

as extub

ated.

●H

ow

ever, her co

nd

ition

wo

rsened

2 days later. Sh

e had

symp

tom

s of p

rogressive h

ypo

xemia;

as a result, sh

e was rein

tub

ated. Sh

e was n

ot ab

le to reco

ver, and

she d

ied o

ne d

ay later.

What part of Cam

pylobacter causes it to be pathogenic?

-R

eleases toxin

called cyto

lethal d

istend

ing to

xin, C

DT, w

hich

causes D

NA

dam

age and

the arrest o

f cell cycle divisio

n

-Triggers ap

op

tosis in

affected cell

Patient

diagnosed w

/autoimm

une hepatitis

6 Years PriorTim

e Relative to A

dmission to M

ass. Gen.

7 Weeks

Prior

Patient develops m

alaise, fatigue, jaundice. S

he begins a prednisone treatm

ent.

Patient sw

itches from

prednisone to herbal supplem

ents.

3 Weeks

Prior

Summ

ary

Jaundice returns

1 Week

PriorTime R

elative to Adm

ission to Mass. G

en.

Everything goes

wrong: A

dmitted

to other hospital.

4 Days

Prior

Transferred from

unknown hospital

to Massachusetts

General H

ospital

Adm

itted

Patient condition

deteriorates, she dies

12 Days

After