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Case Study and Questions

A 65-year-old man entered the emergency department of St. Pauls

Hospital . He appeared to be acutely ill, with abdominal tenderness and a
temperature of 40 C. The patient was taken to surgery because
appendicitis was suspected. A ruptured appendix surrounded by
approximately 20 ml of foul-smelling pus was found at laparotomy. The
pus was drained and submitted for aerobic and anaerobic bacterial culture
analysis of Microbiology laboratory. Postoperatively, the patient was
started on antibiotic therapy. Gram stain of the specimen revealed a
polymicrobial mixture of organisms, and the culture was positive for B.
fragilis, Escherichia coli, and Enterococcus faecalis.
1. Which organism or organisms are responsible for causing the abscess
formation? What virulence factors are responsible for causing abscess
2. B. fragilis causes infections at what other body sites?
3. What antibiotics should be selected to manage this polymicrobial
4. What other anaerobic gram-negative rods are important causes of
human disease

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1. This urinary pathogen "swarms" across agar surfaces
and may cause bladder and renal calculi (stones).
A. Citrobacter freundii B. Enterobacter aerogenes
C. Serratia marcescens D. Klebsiella oxytoca
E. Proteus mirabilis
2. Which of the following virulence factors of E. coli is
important for attachment to host epithelial cells in the
pathogenesis of urinary tract infections?
A. Aerobactin B. Alpha hemolysin
C. Urease D. K1 antigen E. Pili

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3.Which of the following statements regarding Enterotoxigenic E.
coli are CORRECT?
A. They are important causes of traveler's diarrhea.
B. Transmission occurs from ingestion of contaminated food
and water.
C. Disease is caused by production of one or both of two types
of enterotoxins.

D. All of the above are correct.

e. . None of the above are correct.

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4. All Enterobacteriaceae share all of the following
characteristics EXCEPT:
A. Ferment glucose B. Reduce nitrates to nitrites
C. Oxidase positive D. Gram negative
E. Rod-shaped (bacilli)
5.Which of the following bacteria is rarely associated with
Urinary Tract Infections?
A. E.coli B. Enterobacter spp
c. Proteus spp D. Shigella spp

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6. Which of the following is not an opportunistic enteric bacterium?
A)E. coli B)Klebsiella C)Proteus D)Shigella
7. In the laboratory, the screening procedure used to discriminate
Salmonella and Shigella from other Enterobacteriaceae includes
testing for their inability to:
(A) Ferment glucose (B) Ferment lactose
(C) Produce cytochrome oxidase (D) Reduce nitrates
8.A test for urease production is useful to differentiate between:
(A) Proteus spp. andSalmonella spp.
(B) Escherichia coli and Klebsiella spp.
(C) Candida albicans and other yeasts
(D) Actinomyces and Nocardia

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9. the bubo of bubonic plague is a/an
A)ulcer where the flea biteoccurred
B)granuloma in the skin
C)enlarged lymph node
D)infected sebaceous gland
10. Which of the following represents a major difference between
Salmonella and Shigella infections?
a.mode of transmission
B. likelihood of septicemia
c. the portal of entry
d. presence/absence of fever and diarrhea

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1. Name four genera of Enterobacteriaceae that can cause
gastrointestinal disease. Name two genera that can cause
hemorrhagic colitis.

2. What virulence factor mediates this disease?

3. Name the five groups of E. coli that can cause gastroenteritis.

What is characteristic of each group of organisms?

4. What are the four forms of Salmonella infection? Only 3

5. Differentiate between disease caused by Salmonella Typhi and

that caused by S. sonnei. systemic vs GI

6. Describe the epidemiology of the two forms of disease caused

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A 57-year-old man was hospitalized in New York with a 2-day

history of severe, watery diarrhea. The illness had begun 1 day
after his return from Ecuador. The patient was dehydrated and
suffering from an electrolyte imbalance (acidosis,hypokalemia).
The patient made an uneventful recovery after fluid, and
electrolyte replacement was instituted to compensate for the
losses resulting from the watery diarrhea. Stool cultures were
positive for V. cholerae.

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1. What are the characteristic clinical symptoms of cholera?

2. What is the most important virulence factor in this disease? What

other virulence factors have been described? What are the modes of
their action?

3. How did this patient acquire this infection? How does this situation
differ from the acquisition of infections caused by V.
parahaemolyticus or V. vulnificus?

4. How can cholera be controlled in areas where infection is endemic?

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1. Which of the following is true of Haemophilus influenzae?
A. Invasive infections are most commonly associated with encapsulated strains.
B. Most invasive infections occur in infants during the neonatal period.
C. Most human infections are acquired from domestic pets.
D. The organism can be readily cultured on sheep blood agar in an environment
of elevated CO2.
E. Older adults are rarely at risk for infection with this organism because they
typically have a high level of immunity.

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2.Which one of the following best describes the components of vaccines
against Haemophilus influenzae disease?
A. Live, attenuated Haemophilus influenzae
B. Killed Haemophilus influenzae
C. Toxoid derived from Haemophilus influenzae
D. Polysaccharide derived from Haemophilus influenzae
E. Polysaccharide derived from Haemophilus influenzae conjugated
to a protein antigen
3.A Gram-stain smear of spinal fluid from a 2- year-old child reveals
short gram-negative rods or cocco bacilli . It grows on enriched
chocolate agar, but does not grow on blood agar, except adjacent to a
streak of staphylococci. The organism most probably is which of the
(A) H. influenzae (B) N. gonorrhoeae
(C) N. meningitidis (D) L. monocytogenes (E) S. pneumoniae

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4.An inhibitor was designed to block a biologic function in H.

influenzae. If the goal of the experiment was to reduce the virulence of
H. influenzae, the most likely target would be
a. Exotoxin liberator b. Endotoxin assembly
c. Flagella synthesis D. Capsule formation
e. IgA protease synthesis

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A 78-year-old man confined to a nursing home awoke with a severe
headache and stiff neck. Because he had a high fever and signs of
meningitis, the nursing home staff took him to a local emergency
department. The cerebrospinal fluid (CSF) specimen was cloudy.
Analysis revealed 400 white blood cells per mm3 (95%
polymorphonuclear neutrophils), a protein concentration of 75mg/dl,
and a glucose concentration of 20mg/dl. Small gram-negative rods
were seen on Gram stain of the CSF, and cultures of CSF and blood were
positive for Haemophilus influenzae.

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1. Discuss the epidemiology of H. influenzae meningitis,
and compare it with the epidemiology of meningitis
caused by S. pneumoniae and by Neisseria meningitidis.
2. Compare the biology of the H. influenzae strain that is
likely to be the cause of this patients disease with that of
the strains that historically caused pediatric diseases
(before vaccination).
3. What other diseases does this organism cause? What
other Haemophilus species cause disease, and what are
the diseases?
4. Why is chocolate agar needed for the isolation of
Haemophilus organisms?

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A 5-year-old girl was brought to the local public health clinic
because of a severe, intractable cough. During the previous 10
days, she had a persistent cold that had worsened. The cough
developed the previous day and was so severe that vomiting
frequently followed it. The child appeared exhausted from the
coughing episodes. A blood cell count showed a marked
leukocytosis with a predominance of lymphocytes. The
examining physician suspected that the child had pertussis.

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1. What laboratory tests can be performed to confirm the physicians
clinical diagnosis? What specimens should be collected, and how
should they be submitted to the laboratory?

2. What virulence factors are produced by B. pertussis, and what are

their biologic effects?

3. What is the natural progression and prognosis for this disease?

How can it be prevented?

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A 27-year-old man was mowing his field when he ran over two
young rabbits. When he stopped his mower, he realized that two
other rabbits were dead in the unmowed part of the lawn. He
removed all the rabbits and buried them. Three days later he
developed a fever, muscle aches, and a dry, nonproductive cough.
Over the next 12 hours he became progressively sicker and was
transported by his wife to the area hospital. Results of a chest
radiograph showed infiltrates in both lung fields. Blood cultures
and respiratory secretions were collected, and antibiotics were
initiated. Blood cultures became positive, with small gram-
negative rods after 3 days of incubation, and the same organism
grew from the respiratory specimen that was inoculated onto
BCYE agar.

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1. What test should be performed to confirm the tentative
diagnosis of Francisella tularensis?

2. This infection was presumably acquired by inhalation of

aerosolized contaminated blood. What are the most
common sources of F. tularensis infections and the most
common routes of exposure?

3. What are the different clinicamanifestations of F.

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1.For which of the following organisms is there no known animal
A. Francisella tularensis B. Pasteurella multocida
C. Bordetella pertussis D. Brucella melitensis
E. Yersinia pestis
2. Which of the following is transmitted to humans via an
arthropod vector?
A. Pseudomonas aeruginosa B. Legionella pneumophila
C. Yersinia pests, francis& ricketssiae D. Brucella abortus
E. Pasteurella multocida

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3. Which of the following statements about Bordetella pertussis
infection is true?
A. Infection causes a leukocytosis characterized primarily by a
marked elevation in polymorphonuclear leukocytes.
B. Isolation of the organism from clinical specimens is greatest
during the early stages of illness.
C. Clinical diagnosis of whooping cough can usually be made
within a few days of onset of initial symptoms.
D. Children who receive a full series of immunizations with the
pertussis vaccine generally develop solid, lifelong immunity to
E. The organism can be cultured on standard laboratory
media such as sheep blood agar

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1. Listeria monocytogenes shows which of the following
A. It can grow at refrigerator temperatures (4C).
B. It is an extracellular pathogen.
C. It is catalase negative.
D. It is a gram-negative coccus.
E. It is strictly a human pathogen.
2. Microbiologic analysis revealed no growth in the baked beans,
ham, or coffee; many Gram-positive beta-hemolytic, short, rod-
shaped bacteria in the coleslaw; and rare Gram-positive cocci in
the eclairs. The most likely cause of this outbreak is
a. Staphylococcus aureus b. Listeria
c. Clostridium perfringens d. Clostridium botulinum
. e. Nonmicrobiologic

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A 2-year-old child was admitted to the hospital with acute meningitis. The Gram
stain revealed Gram-positive short rods, and the mother indicated that the child
had received all of the meningitis vaccinations. What is the most likely cause of
the disease?
a. N. meningitidis, group A b. N. meningitidis, group C
c. Listeria d. S. pneumoniae e. H. influenzae

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A 35-year-old man was hospitalized because of headache, fever,
and confusion. He had received a kidney transplant 7 months
earlier, after which he had been given immunosuppressive drugs to
prevent organ rejection. CSF was collected, which revealed a
white blood cell count of 36 cells/mm3, with 96%
polymorphonuclear leukocytes; a glucose concentration of
40mg/dl; and a protein concentration of 172mg/dl. A Gram
stain preparation of CSF was negative for organisms, but gram-
positive cocco bacilli grew in cultures of the blood and CSF.
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1. What is the most likely cause of this patients

2. What are the potential sources of this organism?

3. What virulence factors are associated with this


4. How would this disease be treated? Which antibiotics

are effective in vitro? Which antibiotics are

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1. A patient complained to his dentist about a draining lesion in his
mouth. A Grams stain of the pus showed a few Gram-positive cocci,
leukocytes, and many branched Gram-postive rod. The most likely
cause of the disease is:
A. Actinomyces israelii B. Actinomyces viscosus
C. C. diphtheriae D.Propionibacterium acnes E. S. aureus
2. A. viscosus, another ubiquitous actinomycete, can best be
described as:
A. A facultative anaerobe that often inhabits the buccal mucosa early in a
neonates life and can cause endocarditis.
B. -hemolytic organism that causes a diffuse, rapidly spreading cellulitis
C. An anaerobic, filamentous bacterium that often causes cervicofacial
D. A facultative anaerobe that is highly cariogenic and sticks to teeth by
A 47-year-old renal transplant recipient who had been receiving
prednisone and azathioprine for 2 years was admitted to the
university medical center. Two weeks earlier, the patient had noticed
the development of a dry, persistent cough. Five days before
admission, the cough became productive and pleuritic chest pain
developed. On the day of admission, the patient was in mild
respiratory arrest, and chest radiographs revealed a patchy right
upper lobe infiltrate. Sputum specimens were initially sent for
bacterial culture; results were reported as negative for organisms
after 2 days of incubation. Antibiotic therapy with cephalothin was
ineffective, so additional specimens were collected for the culture of
bacteria, mycobacteria, Legionella species, and fungi. After 4 days of
incubation, Nocardia was isolated on the media inoculated for
mycobacteria, Legionella species, and fungi.

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1. Why did the organism fail to grow initially? What can
be done to correct this problem?

2. If this organism disseminates, what two target tissues

are most likely to be involved?

3. What is the most common presentation of disease

caused by N. brasiliensis?

4. Which bacteria cause mycetoma?

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