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WLRN 2006 Case Study

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Boys are playmates. 3 _WSLH. Case Study: Day 1. Rapid Strep antigen test negative on two boys with pharyngitis. Routine stool cultures ordered on all 3 boys ... – PowerPoint PPT presentation

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Title: WLRN 2006 Case Study


1
WLRN 2006 Case Study
Tim Monson Laboratory Program Coordinator, Food
Water-Borne Diseases Phone
608-262-3302 Email mony_at_mail.slh.wisc.edu
Julie Tans-Kersten Laboratory Program
Coordinator, TB Phone 608-263-5364 Email
tanskejl_at_mail.slh.wisc.edu
Wisconsin State Laboratory of Hygiene
2
Case Study Day 1
  • Three boys, ages 8-9, show up in the ER of
    Hospital A December 14 15.
  • Symptoms
  • Abrupt onset of pharyngitis(2)
  • Fever
  • Chills
  • Nausea
  • Vomiting
  • Diarrhea
  • Myalgia
  • Malaise
  • Boys are playmates.

3
Case Study Day 1
  • Rapid Strep antigen test negative on two boys
    with pharyngitis
  • Routine stool cultures ordered on all 3 boys
  • Strep A culture ordered for the 2 boys with
    pharyngitis
  • Treatment Amoxacillin/clavulanate sent home
  • Parent of one boy comments to intake nurse
    regarding the oddity of all three boys ill.
  • Rapid Flu test(s) negative.

4
Case Study Day 3
  • The 3 boys seen in follow-up by personal
    physicians - symptoms persisting.
  • Have developed cervical lymphadenopathy
  • Stool cultures Strep A cultures are negative.
  • Blood cultures collected.
  • Elevated WBC noted (24,500/mm)
  • No response to Amox/clavulanate
  • Doxycyline treatment initiated

5
Case Study Day 5
  • Father of one of the boys arrives at ER.
  • Symptoms
  • Ulcerative lesion on finger thumb
  • History of painful papules at site of lesions
  • Enlarged regional lymph nodes
  • Fever
  • Chills
  • Myalgia
  • Malaise
  • Mild GI symptoms
  • Started about a week ago

6
Case Study Day 5
  • Father (continued)
  • Elevated WBC counts
  • Blood cultures initiated
  • Wound culture collected
  • Serum collected for possible serology studies
    later
  • Treatment Ciprofloxacin
  • No growth in blood cultures of the 3 ill boys

7
Case Study Day 5Fathers Hand Lesion
8
Case Study Day 5Fathers 2nd Hand Lesion
9
Case Study Day 7
  • Fathers wound culture showed normal skin flora
    pin-point colonies at 48 hour on chocolate agar,
    normal flora on sheep blood agar.

10
Case Study Day 8
  • Your machine flags one blood culture positive
    from one of the boys.
  • No organisms seen on gram stain.
  • Blood culture subcultured onto chocolate agar
    sheep blood agar.
  • Cultures remain negative for the remaining 2
    boys.
  • The father is responding to cipro therapy.
  • The 3 boys are responding to doxycycline.

11
Case Study Day 11
  • Microbiologist who worked on the blood cultures
    calls in sick with
  • Abrupt onset of fever
  • Chills
  • Myalgia
  • Malaise
  • Nausea

12
Case Study Day 11
  • Blood subcultures
  • SBA shows possible pinpoint colonies
  • Chocolate agar shows some small colonies.
  • Want to see the cultures?

13
Case Study Growth at 48 hours
Chocolate Agar
Sheep Blood Agar
14
Case Study Day 11
  • Want to see the gram stain?

15
Case Study Gram Stain
16
Case Study Day 11
  • What would you do next?

17
Case Study Day 11
  • Which rule out tests would you perform?
  • Oxidase
  • Oxidase - Negative
  • Catalase
  • Catalase Weak Positive
  • Beta-Lactamase
  • Beta-Lactamase - Positive
  • Urease
  • Urease - Negative

18
Case Study Additional Information
  • ID doctor provides some additional case
    information.
  • No history of travel outside the U.S.
  • No common meals to all four initial cases
  • The father had butchered several rabbits 1 week
    prior to his onset of illness
  • The 3 boys had played extensively with the hides
    of the butchered rabbits while they were drying
  • Treatment changed to Streptomycin for 10 days
    for all 4.

19
Case Study
  • What would you do next?
  • Send subculture of isolates to WSLH for F.
    tularensis PCR DFA confirmatory testing.
  • PCR DFA both positive at WSLH for F.
    tularensis.

20
Case Study Serology Test Results
  • F. tularensis serology ? 1160
  • Is this confirmatory or presumptive?
  • What happens next?
  • Follow up with convalescent serum to look for
    4- fold rise in titer.

21
Case Study Infection Control
  • What is the response by Infection Control?
  • Isolation of patients?
  • Prophylaxis of contacts?
  • What is the lab response regarding biosafety and
    potential exposures?

22
Case Study Reporting
  • When would this be reported to
  • Local Public Health Agency?
  • Wisconsin Division of Public Health?
  • WSLH?
  • Tularemia is a Category II reportable disease in
    Wisconsin
  • The following diseases shall be reported to the
    local health officer on an Acute and Communicable
    Disease Case Report (DPH 4151) or by other means
    within 72 hours of the identification of a case
    or suspected case. See s. HFS 145.04 (3) (b).

23
Case Study Definitions
  • Presumptive Laboratory Positive Single elevated
    serum antibody level to F. tularensis antigen in
    a patient without history of vaccination or a
    positive fluorescent assay result
  • Confirmatory Laboratory Positive Isolation of
    F. tularensis from a clinical sample or a
    four-fold or greater rise in antibody titer to
    F. tularensis antigen
  • Presumptive Case Clinically compatible case with
    lab results indicative of presumptive infection
  • Confirmed Case Clinically compatible case with
    confirmatory lab results

24
Case Study Select Agent Issues
  • Sentinel Laboratory Responsibilities
  • Call, Fax, or Email CDC Select Agent Program
    IMMEDIATELY after you receive confirmatory report
    from WSLH.
  • Secure the Select Agent from theft or loss
  • Within 7 days of confirmation
  • Submit Form 4 to CDC destroy specimens/
    isolates by recognized method
  • OR submit Form 2 4 to CDC and transfer to
    registered facility (may require prior approval)
  • Please fax a copy of the form(s) to WSLH

25
Case Study Select Agent Issues
  • WSLH Responsibilities
  • Report results to you with guidance on Select
    Agent requirements
  • Report to CDC Select Agent Program by Phone, Fax
    or Email immediately after confirmation
  • Report results to WDPH ASAP (presumptive
    confirmatory results)

26
Case Study F. tularensis Review
  • Agent of Tularemia
  • Category A Select Agent
  • Clinical Presentation ulceroglandular,
    glandular, oculoglandular, oropharyngeal,
    intestinal, pneumonic and typhoidal presentations
    possible
  • Treatment Streptomycin or Gentamicin
    Doxycycline, Cipro or Chloramphenicol alternates

27
Case Study F. tularensis Review
  • Small, gram negative coccobacillus
  • Culture
  • May not grow or may grow very slowly in the
    laboratory (extended blood culture necessary)
    generally grows very poorly on standard blood
    agar plates.
  • May be enhanced by enriched plating media, e.g.,
    chocolate agar with isovitalex or similar, rabbit
    blood agar, or cysteine-enriched media (cysteine
    heart agar or BCYE agar)
  • Highly infectious well-known cause of laboratory
    acquired infections

28
Case Study F. tularensis Review
  • May be acquired via tick bite (after a blood meal
    on an infected animal)
  • May be aerosolized by lawn mowers and brush
    cutters
  • May persist in the environment (cold soil
    water)
  • Generally rural occurrences rarely seen in urban
    populations
  • U.S. averaged 124 cases per year during 1990-2000
  • WI has had 5 reported cases since 1999

29
U.S. Cases of Tularemia Reported to CDC, 1990-2000
  • 1,368 cases from 44 states
  • Average of 124 cases per year

30
Case Study Growth on Cysteine Heart Agar after
72 hours
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