The patient is a 23-year-old male who works as a baker\'s assistant. He presente

Question

The patient is a 23-year-old male who works as a baker's assistant. He presented to the local emergency room with low-grade fever, malaise, and headache. He was sent home with a diagnosis of influenza. He presented 7 days later with a 1-day history of worsened headache, photophobia, and stiff neck. On physical examination he appeared to be in mild distress with a temperature of 102.2 oF. He had mild nuchal rigidity and a maculopapular rash on his trunk, arms, palms, and soles. Areas on his palms and soles had some papulosquamous lesions. There were no mucous membrane lesions. No focal deficits were seen on neurologic examination. He had a white blood cell count of 11,200/mm3 with an increased number of PMN. A computed tomogram (CT scan) of the head was normal, and a lumbar puncture revealed 120 white blood cells/mm3 with 80% lymphocytes and 20% PMN, a glucose level of 40 mg/dl (normal), and a protein level of 82 mg/dl (elevated). Blood cultures were obtained, and antimicrobial therapy was begun. The next day a serologic test of his CSF and blood revealed the diagnosis. Further questioning of the patient when the serology results were known revealed that 1 month previously, he had a painless ulcer on his penis which healed spontaneously. His condition improved greatly over the next 3 days and his rash cleared within 10 days. 1. Which bacterial infections can cause a maculopapular rash? What is the most likely agent of his infection?
2. In what stage of this infection is this patient? What is the significance of his CSF findings? Describe the disease course as it occurs in infected patients who go untreated.
3. How can the diagnosis of this infection be made? What is the difference between the screening test for the organism infecting this patient and the confirmatory test? How are these two tests used?
4. If this patient had been found to have a T-helper cell count of <200 and was HIV seropositive, what adjustment to his antimicrobial therapy would be necessary to treat the infection causing his skin rash? The patient is a 23-year-old male who works as a baker's assistant. He presented to the local emergency room with low-grade fever, malaise, and headache. He was sent home with a diagnosis of influenza. He presented 7 days later with a 1-day history of worsened headache, photophobia, and stiff neck. On physical examination he appeared to be in mild distress with a temperature of 102.2 oF. He had mild nuchal rigidity and a maculopapular rash on his trunk, arms, palms, and soles. Areas on his palms and soles had some papulosquamous lesions. There were no mucous membrane lesions. No focal deficits were seen on neurologic examination. He had a white blood cell count of 11,200/mm3 with an increased number of PMN. A computed tomogram (CT scan) of the head was normal, and a lumbar puncture revealed 120 white blood cells/mm3 with 80% lymphocytes and 20% PMN, a glucose level of 40 mg/dl (normal), and a protein level of 82 mg/dl (elevated). Blood cultures were obtained, and antimicrobial therapy was begun. The next day a serologic test of his CSF and blood revealed the diagnosis. Further questioning of the patient when the serology results were known revealed that 1 month previously, he had a painless ulcer on his penis which healed spontaneously. His condition improved greatly over the next 3 days and his rash cleared within 10 days. 1. Which bacterial infections can cause a maculopapular rash? What is the most likely agent of his infection?
2. In what stage of this infection is this patient? What is the significance of his CSF findings? Describe the disease course as it occurs in infected patients who go untreated.
3. How can the diagnosis of this infection be made? What is the difference between the screening test for the organism infecting this patient and the confirmatory test? How are these two tests used?
4. If this patient had been found to have a T-helper cell count of <200 and was HIV seropositive, what adjustment to his antimicrobial therapy would be necessary to treat the infection causing his skin rash? The patient is a 23-year-old male who works as a baker's assistant. He presented to the local emergency room with low-grade fever, malaise, and headache. He was sent home with a diagnosis of influenza. He presented 7 days later with a 1-day history of worsened headache, photophobia, and stiff neck. On physical examination he appeared to be in mild distress with a temperature of 102.2 oF. He had mild nuchal rigidity and a maculopapular rash on his trunk, arms, palms, and soles. Areas on his palms and soles had some papulosquamous lesions. There were no mucous membrane lesions. No focal deficits were seen on neurologic examination. He had a white blood cell count of 11,200/mm3 with an increased number of PMN. A computed tomogram (CT scan) of the head was normal, and a lumbar puncture revealed 120 white blood cells/mm3 with 80% lymphocytes and 20% PMN, a glucose level of 40 mg/dl (normal), and a protein level of 82 mg/dl (elevated). Blood cultures were obtained, and antimicrobial therapy was begun. The next day a serologic test of his CSF and blood revealed the diagnosis. Further questioning of the patient when the serology results were known revealed that 1 month previously, he had a painless ulcer on his penis which healed spontaneously. His condition improved greatly over the next 3 days and his rash cleared within 10 days. 1. Which bacterial infections can cause a maculopapular rash? What is the most likely agent of his infection?
2. In what stage of this infection is this patient? What is the significance of his CSF findings? Describe the disease course as it occurs in infected patients who go untreated.
3. How can the diagnosis of this infection be made? What is the difference between the screening test for the organism infecting this patient and the confirmatory test? How are these two tests used?
4. If this patient had been found to have a T-helper cell count of <200 and was HIV seropositive, what adjustment to his antimicrobial therapy would be necessary to treat the infection causing his skin rash?

Explanation / Answer

Answer 1:- The bacteria related to the disease according to the given symptoms is most probably Streptococcus. The agent of the infection is most likely is air, as the infection is transferred from skin of the infected individual.

Answer 2:- The stage of this patient is initial as the symptoms given in the questions are the onset symptoms of the infection.

The CSF findings are important because it is useful in the determination of the gram stain and through which it is easy to determine is it bacterial infection or viral infection or some other infection.

Disease Course :-

When scarlet fever occurs because of a throat infection, the fever typically subsides within 3 to 5 days, and the sore throat passes soon afterward. The scarlet fever rash usually fades on the sixth day after sore throat symptoms started, and begins to peel. The infection itself is usually cured with a 10-day course of antibiotics, but it may take a few weeks for tonsils and swollen glands to return to normal.

Answer 3:- Scarlet fever can be diagnosed by clinical signs and symptoms. Complete blood countfindings characteristic of scarlet fever show a marked increase in white blood cell countwith neutrophilia and conserved or increasedeosinophils, high erythrocyte sedimentation rate and C-reactive protein, and elevation ofantistreptolysin O titer. Blood culture is rarely positive, but the streptococci can usually be demonstrated in throat culture.

Screening Test :-

The rash has typical features that the physician uses to diagnose the condition. It begins at the neck and spreads to the arms, legs, chest and groin.

The rash appears like a fine pink layer over the skin usually sparing the face. It is punctuate - pin-point dark red spots over a reddish discoloration of skin.

The face appears red and flushed with a pale area around the mouth called “circumoral pallor”. This effect is more prominent than in other fevers.

The rash remains for several days but after a few days it gains prominence in the skin folds due to breakage of the capillary or small skin blood vessels. This is seen in the armpits and groin and is called Pastia's sign and the lines known as “Pastia's lines”.

The skin begins to peel after the fever reduces and this may last for several weeks. This commonly affects the soles and palms and tips of fingers, toes, ears etc.

Throat examination

The physician examines the throat of the patient. There may be small red blotchy spots over the roof of the mouth (palate). These are usually bleeding spots rather than rash.

The tonsils along with neck lymph nodes are swollen. The tonsils appear red and may be covered with a pale whitish discharge or layer. The neck glands are usually swollen and may be painful to touch.

Confirmatory Test:-

For confirmation of diagnosis a sample of saliva or a throat swab is taken from the back of the throat. The secretions on the cotton tipped swab is then wiped onto a sterile, dry glass slide. The slide is stained with appropriate dyes and stains and examined under the microscope.

Sometimes the sample is incubated at favourable temperatures, humidity and nutrient medium in a petri dish. This allows selective growth of the infecting bacteria. This is called a culture study.

The bacteria grows selectively as colonies on the nutrient media. They are then stained on glass slides and examined under the microscope. These bacteria are also tested with a wide range of antibiotics to see which ones they are susceptible too. This is called a culture and sensitivity test.

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