Legaspi, Kimberly M. Mr.

Dayle Daniel Sorveto

BS Medical Technology Y3 SA Bacteriology Laboratory

CASE STUDY

 Answers:
Case 1:
1.) All of us has white blood cell and red blood cell in the urine but the normal white blood cell in the urine is
less than 5-10 per high power fields while the red blood cell is less than less than 0-3 per high power fields.
In this case, the urinalysis findings indicate that the patient is suffering from Pyuria which means that the
patient has increased of white blood cell or commonly referred to pus and Hematuria which means that she
has increased or presence of red blood cell in the urine. It is also said that the patient has a bacteria in the
urine that support the diagnosis because normally, individuals does not have bacteria in their urine. Lastly
they used clean catch specimen which is less traumatic for obtaining bacterial culture and it is infrequently
sterile because the bacteria is colonized in the urethra. Urine is extremely good as growth medium, so in
accordance for the organism not to be separated it must be analyzed within 1 hour, it may be plant on the
culture media or refrigerated immediately.

2.) Urine in the bladder is sterile in a normal individual, it is frequently contaminated with small amount of
microorganism when it passes to the urethra which has inhabitant microflora. Clean catch samples are
essentially contaminated by the urethra which contain small amount of organism, so it does not allow
differentiation between colonization of urethra and infection of the bladder when culturing the urine
nonquantitatively. In this case the patient’s bladder is infected with UTI because it has a very large number
or amount of bacteria in her urine. The patients bacterial count is >10 raise to 5 CFU/ml which indicate that
she has a consistent high amount of bacterial infection and it is highly specific, but normally the bacterial
count of women that also indicate a consistent urinary tract infection is as low as 10 raise 2 CFU/ml of a
uropathogens and it is highly sensitive for diagnosis UTIs but it has a low specificity. Uropathogen bacteria
includes Escherichia coli, Klebsiella pneumoniae. Enterobacter spp and Staphylococcus saprophyticus that
markedly she has UTI.

3.) There are only three gram negative bacilli that is lactose fermenter this is the KEE. This stands for Klebsiella
species, Escherichia coli and Enterobacter species which produces pink colonies on MacConkey Agar and
this lactose fermenter organism are commonly isolated in urine culture. Among this three bacteria the most
common cause and the number 1 cause of UTI is Escherichia coli. Pseudomonas aeruginosa is another gram
negative bacteria that is frequently beta-hemolytic that is doubtful cause to be the cause of community
acquired cystitis or pyelonephritis in healthy woman. Pseudomonas aeruginosa should not be confused with
lactose-fermenting isolates of E. coli because it does not capable of fermenting carbohydrates and A spot
Indole test was done on the patient’s isolate and was positive, confirming the identity of this organism as E.
coli.
4.) The most dangerous effects associated with the use of antimicrobial agents is the selection of antibiotic-
resistant bacteria. This happens when plasmids coding for resistance may mobilized in response to
antimicrobial pressure, leading to the transfer of resistance to previously susceptible organisms, such as in
this E. coli isolate. The plasmid may contain genes that code for resistance to other antimicrobial agents that
a result of being multidrug-resistant organism. In the past years the emergence of multidrug-resistant E. coli
has made the selection of empiric antimicrobial therapy which more difficult and which causing both
community-acquired as well as health care-associated UTIs. Extended-spectrum β-lactamases (ESBLs) is
the strain produces by E. coli that causes UTI. ESBL are carried on plasmids that frequently encode resistance
to trimethoprim-sulfamethoxazole, fluoroquinolones, and aminoglycosides. The fluoroquinolones and
trimethoprim-sulfamethoxazole are widely used as empiric therapy for cystitis in women. ESBL-producing
strains has greatly limits the choice of oral agents to treat uncomplicated cases of UTI because of the
increasing resistance being seen in E. coli. ESBL-producing E. coli isolates remain susceptible to the oral
agent’s fosfomycin which is poorly absorbed and should not be used to treat patients with pyelonephritis,
such as the patient in this case or urosepsis and carbapenems such as ertapenem and imipenem has a lesser
degree nitrofurantoin and fosfomycin has some degree of activity and may be useful in treating cystitis. These
carbapenemase-encoding plasmids found in E. coli and is also emerged and can be encoded on plasmids that
carry resistance genes similar to those found on ESBL-encoding plasmids. ESBL-producing organisms is
parenterally administered antimicrobials are widely used to treat systemic infections such as pyelonephritis.

5.) UTI are most frequently in women than men simply because women has a shorter urethra that results in a
greater likelihood that organisms will ascend the urethra and enter the bladder than men. The other reason is
that the specific uropathogens bind to vaginal and perurethral epithelial cells that is often seen in women
prior to the development of UTI.

6.) In this case the patient is constantly suffering from acute pyelonephritis. As we all know Pyelonephritis is an
infection of the kidney while cystitis is an infection of the bladder. The case said that the patient is suffering
from fever, chills, and left flank pain, with corresponding cost vertebral angle tenderness which constant
symptoms with pyelonephritis. The reason why it is important to distinguish between pyelonephritis and
cystitis is that they have different antimicrobial treatment. Cystitis therapy is typically give 3-day course of
trimethoprim-sulfame-thoxazole unless there is a high rate of resistance to this agent in the community, while
pyelonephritis therapy may be more prolonged, typically lasting 7 days to 2 weeks.

7.) The evolution of causing infection of UTI is start when the large segments of DNA that encode virulence
factors that have been inserted by recombination into chromosomal regions that appear to more readily allow
“foreign” DNA. The organism E. coli can quickly evolve from harmless gastrointestinal tract commensals
to agents capable of causing UTI by incorporating DNA that encodes virulence factors, the strain can also
cause diarrheal disease. There are two most important virulence factor of E. coli first is the P fimbriae which
are the major means of adhesion of uropathogenic E. coli allowing them to bind to the various types of
epithelial cells that line the urinary tract and it is also designated because they agglutinate red blood cells
possessing the P blood group antigen. They also bind to uroepithelial cells and are resistant to phagocytosis.
The Type 1 fimbriae are distinct from the P fimbriae strains are and said to be mannose sensitive. Type 1
fimbriae are found more frequently in patients with cystitis and less frequently in patients with pyelonephritis.
Our patient likely had a P-fimbriated E. coli strain because she had pyelonephritis. The second one is the
Hemolysins because it detected E. coli form from patients with pyelonephritis. The last virulence factor is
the aerobactin which is found causing pyelonephritis, it is a siderophores meaning this are a molecules that
is an essential nutrient and scavenge iron produce by the bacteria.
Case 2:
1.) The organism that is seen in the patient is Neisseria gonorrhoeae which is gram negative intracellular
diplococci. Gram stain is highly valid and dependable when examining urethral discharge for the diagnosis
of Neisseria gonorrhoeae urethral infection in males with has a symptoms of urethritis. It will be highly be
positive around 95 to 100 percent for Gram negative diplococci of infected male patients while with vaginal
specimen the result will also be positive but around 50 to 60 percent only because of the presence of
saprophytic Neisseria spp in the vaginal microbiota, making direct Gram stain an unreliable test for women
suspected of having a gonococcal infection. The other direct detection technique that is available for
laboratory diagnosis of N. gonorrhoeae is nucleic acid amplification test (NAATs), including ones that use
PCR and transcription-mediated amplification and this method are more sensitive than culture in part due to
the fastidious nature of the organism. These assays can be performed on either urine or urethral swabs of
men while on endocervical swabs, vaginal swabs, or urine of women. False-positive results have been
reported in some NAATs for closely related but saprophytic Neisseria spp and are now in use have a greater
specificity than did the earlier NAATs. The Clinical laboratories become more centralized in the era of
managed care, the NAATs are replacing N. gonorrhoeae culture because for this changing diagnostic
approach is that maintaining the viability of this fastidious organism for culture is difficult when specimens
have to travel significant distances to a central laboratory.

2.) Yes because in this case it has sad that the patient is positive to leukocyte esterase which is an enzyme
produce by leukocyte which indicates the patient is suffering from gonococcal urethritis, negative in urine
culture because N. gonorrhoeae are not recovered on urine culture because of tis media and incubation
condition and has a multiple white cells. N. gonorrhoeae grows on enriched medium such as chocolate agar
and elective media such as Thayer martin and modified Thayer martin and incubation times of at least 36 to
48 hours in 5% CO2 for growth to be detected visibly. The patient in this case has a positive urinalysis for
leukocytes who does not have an organism recovered on urine culture is said to have “sterile Pyuria.” N.
gonorrhoeae is a common cause of sterile Pyuria that’s why the patient has Pyuria.

3.) The partners have a negative history for sexually transmitted infections may because the incubation time of
N. gonorrhoeae is approximately 2 to 5 days for and an acute symptomatic history of 24 hours, it is most
likely that this patient was recently infected. In this case may be the patient was “serially monogamous” it is
likely that he was infected by one of his recent partners and that his previous partners had not been infected
and it is possible that his sexual partner who infected him was asymptomatic. In term of complication it is
more common in women because of enlarged and increase rate of asymptomatic infections which is tend to
be severe. The PID ( pelvic inflammatory disease was the major complication seen in women infected with
N. gonorrhoeae which cause fallopian tube scarring and obstruction, which may result in infertility and
ectopic pregnancy. Lastly rash and septic arthritis are present with disseminated gonococcal infection for
both men and women.

4.) The intense inflammatory response is manifested clinically in males as exudate from the urethra by N.
gonorrhoeae. There are two most important virulence factors N. gonorrhoeae have, first is pili which is
mediate attachment and stimulate nonspecific phagocytosis by epithelial cells in the urethra and the second
one is the Lipo-oligosaccharide which can stimulate an inflammatory reaction to these phagocytized
organisms.
5.) The patient is at risk with different sexually transmitted disease such as C. trachomatis which has a common
symptoms due to PID, Treponema palladium causing syphilis, herpes simplex virus, human papillomavirus,
and HIV and because of his history of multiple sexual partners and the diagnosis of a sexually transmitted
infection, this individual is at increased risk for becoming infected with HIV. HIV is one of the most popular
sexually transmitted on active teenagers. I think the patient was asked to return for follow up visit to make
sure there is appropriate counseling and HIV testing could be done if the patient is also suffering from HIV
infection.

6.) I think the anti-microbial agents given to the patient for treating uncomplicated gonococcal urethritis are to
administer a single dose of an oral cephalosporin or an intramuscular injection of ceftriaxone, plus
doxycycline or azithromycin to treat a presumed coinfection with C. trachomatis. The intramuscular
administration of antimicrobial agents for treatment of gonococcal disease have been abandoned because of
the high risk infection among health professionals over needle stick injuries after injection of patients who
are HIV positive that why oral therapy is favorable. In addition to resistance to the tetracycline’s, gonococcal
resistance to penicillin therapy has become so widespread in the past 25 years that penicillin is no longer a
reasonable therapeutic option for treating infections with this organism. Penicillin resistance was due to a
plasmid-encoded β-lactamase; β-lactamase is an enzyme that degrades the β-lactam ring in penicillin,
inactivating the drug which making the binding of penicillin to the gonococci much less efficient and This
decreased binding resulted in resistance to penicillin. There are Molecular methods that are increasingly used
for diagnosis of gonococcal infections do not determine the antimicrobial resistance pattern of these
organisms. Therefore, the CDC surveillance studies of gonococcal resistance are critical for the recognition
of when increased resistance to cefixime and ceftriaxone emerges.

7.) There is no vaccine applicable in treating Gonococcal infection because it does not produce a conventional
exotoxin and the surface components of gonococci such as pili can undergo rapid antigenic variation because
of frequent rearrangement of the pili genes, making it impossible to produce a reliably protective vaccine
antigen. It conserved and phenotypically stable determinants on the surface of the gonococcus have not yet
been used in vaccine development.
Case 4:
1.) The diagnosis of differential of ulcerative genital lesions is by swabbing the base of the lesion and performing
either viral culture or NAAT and using a shell vial culture technique, the virus can usually be detected within
24 hours. The detection of HSV antigen by immunofluorescence or DNA from the lesion by NAAT is more
rapid than culture, HSV was detected in this patient by an HSV NAAT performed on a swab of her genital
lesion, which was positive for HSV-2. NAAT testing of lesions may be more sensitive than culture, though
it is critical to monitor for laboratory contamination since these specimens contain high viral titers. There is
only one FDA-cleared NAAT for HSV, which is only approved for vaginal lesion swabs which is the Tzanck
preparations, in which smears taken from the edge of the lesion are examined for the presence of cells
showing pathologic changes consistent with HSV infection, can also be used in the diagnosis of genital
lesions. This techniques is lack both the sensitivity and specificity of culture, immunofluorescence, or NAAT
and it is inexpensive.

2.) The complication she underlying develop was pleocytosis with a lymphocytic predominance and an elevated
protein level, as was seen in this case. A NAAT was positive from the lesion as well as from her CSF while
HSV NAAT testing on lesions performs similarly to culture, NAAT testing on CSF is much more sensitive
than culture. When CSF cultures were standard laboratory practice, the rate of isolation of HSV-2 was 0.5 to
3.0% in patients with aseptic meningitis. Now that NAAT testing of CSF is the reference method, the rate of
detection of HSV-2 has increased to 5 to 17%.

3.) If the patient I pregnant in the time of her infection the fetus is at risk for neonatal herpes. Neonatal herpes
is a relatively infrequent infection, it is estimated that 25 to 50% of women who have acquired HSV during
pregnancy and have vaginal deliveries will transmit the disease to their child. Other factors that increase the
likelihood of infection are prolonged rupture of membranes, a mother who is seronegative for HSV-2
suggesting acute infection, and the use of fetal scalp monitors of neonates with herpes infections, around
80% are infected during passage through an infected birth canal, while 6 to 14% are infected in utero and the
remaining are infected postpartum. Most neonatal HSV infections occur in the second to third week of life.
There are three forms of neonatal HSV infection: skin, eyes, and mouth disease, central nervous system
(CNS) disease; and disseminated disease. The most benign form causes infection localized to the skin, eyes,
and mouth if it recognized easily, it can be effectively treated with antiviral agents such as acyclovir. The
most severe manifestation of disease is disseminated infection this infection, multiple organs, including the
brain, may be infected. These individuals typically have a viral exanthem in the setting of CNS infection
and/or multi organ failure.

4.) Herpes viruses causes a lifelong, latent infection. The virus enters a latent state in the sacral nerve ganglia in
the genital tract infections and recurrences occur when the virus replicates in the neuron and is carried along
the peripheral nerves to the epithelium. Adults with HSV-2 have a clinical history of genital herpes lesions.
HSV-infected individuals can intermittently shed HSV in the absence of symptoms and therefore contribute
to the transmission of HSV. Symptomatic recurrences may occur as frequently as 8 to 10 times per year,
although the majority of individuals have significantly fewer episodes and it is milder than the previous
episode.
5.) The epidemiology of HSV-2 infects around 16% of individuals. Infections are more common in females than
in males and are more common in black individuals (39%, versus 12% for whites). Other risk factors for
HSV-2 infection include early age of first sexual encounter, a high number of sexual partners, history of other
sexually transmitted infections, and lower socioeconomic status. Infection rates among commercial sex
workers may approach 100%. Although HSV-2 infection rates increased significantly from the increasing
years with the highest rate of increase in individuals <30 years old, this trend has reversed in recent years.

6.) There are two distinct serotypes of HSV—HSV-1 and HSV-2. HSV-1 is an infection primarily of the
oropharyngeal mucosa, with latent infection occurring in the trigeminal ganglion and typically acquired in
early childhood, while HSV-2 primarily infects the genital mucosa, though either serotype can be seen in
these anatomic sites and occur after the individual becomes sexually active. There both serotypes are
neurotropic but HSV-1 appears to cause more severe CNS infection affecting the temporal and frontal lobes.
In contrast to aseptic meningitis associated with primary genital HSV-2 infection and neonatal CNS
infection, herpes encephalitis in adults and older children is most often due to HSV-1 infection. The diagnosis
can be confirmed by detecting HSV directly using fluorescent antibody staining of tissue obtained by brain
biopsy. Because brain biopsy is dangerous, alternative means of making this diagnosis have been sought.
Two studies have carefully evaluated the sensitivity of HSV PCR compared with histopathological
evaluation of brain tissue for PCR. Therefore, HSV PCR of CSF has become the standard method for
diagnosing HSV CNS infection

REFERENCE:
http://www.academia.edu/13758006/Cases_in_Medical_Microbiology_and_Infectious_Diseases
https://emedicine.medscape.com/article/2074001-overview
http://www.imop.gr/en/urotools-normal-values