Clinical case 1

History
A 45 y male presented with:
high-grade fever, intermittent,
moderately severe headache lasting 6 days associated with multiple
episodes of vomiting,
and altered sensorium for 2 days

Patient was not a known case of TB, Diabetes, HTN, no surgery performed in
the past.
He was diagnosed with HIV -1 infection 2 yrs ago and was started on ARVs.

History & Examination

Relatives informed that the patient would NOT take his Anti-Retroviral Therapy
medication regularly. Patient was not on any other drugs.

On examination:
Glasgow coma scale of E1M5V1.
fever of 100C,
pallor, cachexic
Systemic:
-CNS: Patient had altered sensorium,
showing signs of meningitis (Kernigs sign,
Brudzinskis sign positive)
-RS, CVS, P/A normal

Investigations

CBC, S. electrolytes, Renal function tests, Liver function tests

A lumbar puncture was done & CSF collected
CSF Routine, microscopy, biochemical parameters
CSF for bacterial and fungal cultures

Labs
Laboratory investigations revealed:
Total leukocyte count = 12,900/cumm with 86% neutrophils.
Serum electrolytes, renal function tests, and liver function
tests were within normal limits.

The cerebrospinal fluid (CSF) examination revealed 80 WBCs,

predominantly lymphocytes (90%)
with protein of 54.7 mg/dl
Glucose of 38 mg/dl (corresponding blood glucose was 136 mg/dl).
A computerized tomography (CT) scan of the head and a chest X ray
were both normal

Microbiology

Bacterial cultures: negative

India Ink examination of the CSF

Culture on SDA after 72h incubation at 30C.

Urease positive

Colonies on Sabouraud dextrose agar are cream to

beige and mucoid due to the capsule surrounding
the yeast cells. This was also confirmed with the
Vitek 2 yeast identification system.

Diagnosis: cryptococcal meningitis

Appearance

Protein
( mg/dl)

Glucose
(mg/dl)

WBC /
cumm

Clear, colorless

10- 45

45 - 80

0-5

Purulent,
Acute
pyogenic slightly yellow,
meningitis delicate clot

50 1500
(100- 500
common)

0 - 45

25- 10,000
most PMNs
( 80 %)

Grams -60-90 % sens.

Culture 80% sens & 100
% specific.
Direct Ag up to 70 %
sens, 99 % specific.

Opalescent,
TB
meningitis clot /cobweb

45 - 500

10 -45

10 -100
most
Lymphocytes

AFB 25 % sens Culture

-75 % sens PCR is 100%
specific.

500
usually; first
PMN, later
mono

All bact. cultures ve

Seroconversion Specific
IgM
Direct Antigen/
PCR Cultures - viral

Normal LP

Clear, turbid or 20 - >200

Aseptic
Meningitis xantho-chromic

Normal
Fungal
meningitis

50- 300

Moderate 800
in 55 %
(lympho >
PMN)

Micro/Sero/Other

India ink 50 % sens

Crypto Ag 90 %
Culture 90 % sens.

Clinical Case 2

History
A 25 year old female came with history of
fever since 4 days (continuous and high grade)
headache since 4 days
abdominal discomfort & constipation since 3 days

Patient was not a known case of TB, Diabetes, HTN,

no surgery performed in the past. Not on any
medication.

On examination
On examination:
Fever of 102C
Pulse rate of 90/min
No other significant findings in general or systemic
examination.
USG abdomen showed mild splenomegaly

Investigations

CBC with ESR

PS for MP
Widal test
Dengue serology
Blood for C/S

Labs
The CBC showed WBC count per 6800/ mm3 (N =57%, L= 36%,
M=04%, E= 03%)
platelet count 220000/L
Hemoglobin 10.2 g/dl.
ESR 60 mm at 1h.
Serum urea and creatinine normal
Urinalysis normal.
Dengue IgM, IgG, NS1 Ag Negative
PS for Malaria- Negative
Widal : O/neg; H/1:20, AH & BH neg.

Cultures
The next day the bottle
flashed positive in the
automated Blood culture
system
Grams stained smear was
prepared. Showed Gram
negative bacilli. Subcultured
on to Blood agar,
MacConkey agar plates
Sensitivity and identification
performed

MacConkey Agar
Blood Agar

Biochemical Reactions

Indole
TSI: K/A with H2S
Glucose fermented, Gas
Urease
Citrate
Lysine decarboxylase +
Arginine dehydrolase
Ornithine decarboxylase

Oxidase
Motility +
Methyl Red +
Voges proskauer

Widal test
Significant titer of 1: 160 or more for O and H or either is
accepatable in India (in some countries 1:80 and
greater).
It is important to demonstrate a rising titer after 5-7
days. Single Widal may not be useful in endemic areas
Widal may be negative in 1st week of fever.
Accuracy of widal test has been shown to range form
50% to 85% approx. It is a non specific test
Inferior to Blood cultures for specific diagnosis. Blood
cultures usually positive in 1st week of fever
Still popular because of cost factor & quick results

Management
Salmonella Typhi was reported after confirmation with antisera.
Antimicrobial susceptibility testing was done for

ampicillin,
ceftriaxone,
ciprofloxacin,
co-trimoxazole,
chloramphenicol,
cefixime,
azithromycin.

Found to be Susceptible to cotrimoxazole, ceftriaxone, ampicillin and

azithromycin, intermediate to ciprofloxacin. Patient started on
Ceftriaxone.

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