| Clinical History A 72- year old woman had a history of recurrent urinary tract infections over the past several months, for which she had received different regimens of antibiotics including ampicillin, trimethoprim-sulfasoxazole, and ciprofloxacin.Relapses often occurred 10 days to two weeks after cessation of therapy.The current flare up, manifest by dysuria, lower abdominal pain and cloudy urine was accompanied by shaking chills and spiking fever.A sterile mid-stream urine specimen was sent to the laboratory for culture.
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| Case History A 63 year old man was seen in the emergency room with the complaints of sudden onset of fever, chills, and abdominal pain, accompanied by mild diarrhea. The blood pressure was 140/84, the pulse rate 82/minute, and the body temperature 39.8C. A blood sample was drawn for a complete blood count, and a blood culture.A second blood culture was drawn from the opposite arm, with 10 ml of blood being placed into each an aerobic and an anaerobic bottle, following customary practice.The complete blood count revealed a hemoglobin of 15.8 mg/dl, a hematocrit of 45%, and a white blood count of 4.2/L. The neutrophils were 39%, lymphocytes 45%, monocytes 10%, eosinophils 4% and basophils 2%. The platelet count was 255/L. The patient was admitted to the hospital for further work-up and empiric antibiotic therapy.Within 24 hours after admission, the body temperature had decreased to 38.2C, although the mild diarrhea persisted.A stool toxin test for Clostridium difficile was negative and neither enteric pathogens nor Campylobacter species were recovered in stool culture after 24 hours incubation. Fecal neutrophils were not seen on direct examination.
The anaerobic blood culture became positive 36 hours after inoculation. | View Page |
| Review 3 Kornbluth AA. Danzig JB. Bernstein LH.:
Clostridium septicum infection and associated malignancy. Report of 2 cases and review of the literature.
Medicine. 68(1):30-7, 1989We report 2 patients with myonecrosis due to Clostridium septicum and associated colon carcinoma and have reviewed the English language literature for all reported cases of atraumatic C. septicum infection. A total of 162 cases of C. septicum infection have been reported.Eighty-one percent of these patients had an associated malignancy. Thirty-four percent of all patients had associated colon carcinoma, while 40% had a hematologic malignancy. Thirty-seven percent of reported patients had an occult malignancy at the time of their infection with C. septicum. In many patients, the portal of entry was found in the large intestine.In a particularly lethal form (79% mortality) of C. septicum infection, known as "distant myonecrosis," infection metastatic from the initial site of infection causes severe myonecrosis, gangrene, and often death within hours of clinical detection. Overall, survival of patients with C. septicum infection is only 35%.Review of all cases of C. septicum infection suggests several conclusions. 1) Patients with malignancy, particularly colonic or hematologic, and patients with cyclic neutropenia who develop signs and symptoms of sepsis, especially with associated findings of abdominal pain or pain in an extremity, should be treated for possible clostridial infection. 2) C. septicum infection does not appear to be a result of a single specific defect in either humoral or cell-mediated immunity. Rather, it may occur in patients who are granulocytopenic and therefore prone to an enterocolitis. 3) Patients in whom an infection with C. septicum is found must undergo a vigorous search for malignancy following ac | View Page |
| A clinical condition often associated with Streptococcus milleri (anginosus) is: | View Page |
| The epidural and subdural abscesses in the two patients reported by Gelfand, et al, are clinical manifestations uncommon for S. milleri. | View Page |
| A 20 year-old female was admitted into the hospital complaining of 10 to 15 bloody mucous stools per day, fever, gastrointestinal disturbances, abdominal pain, and nausea. The preliminary O & P report went out as "Probable Entamoeba histolytica trophozoites and cysts, confirmation pending." This patient is most likely suffering from: | View Page |
| A 32 year old male was seen in the emergency room with gastrointestinal discomfort. Upon questioning the patient it was learned that he first began feeling ill after spending a day at the park where he swam and played volleyball barefooted. He first noticed a lesion on his foot. Later, he developed vague respiratory symptoms. Now his largest complaint is severe abdominal pain along with occasional vomiting. This patient is most likely suffering from: | View Page |
| A 21 year old male presented in the emergency room with symptoms resembling a liver infection. The patient complained of abdominal pain, fever, cough, nausea, vomiting and constipation alternating with diarrhea. Further examination revealed the presence of a hepatic abscess. This suspicious form was recovered following parasitic examination of a sample from the abscess and measures 20 µm. What condition is the patient most likely suffering from? | View Page |
| A 35 year old male presented to the local clinic complaining of abdominal cramps, severe diarrhea, and intestinal gas discomfort. A stool was collected for parasite examination. It was foul-smelling and light colored in nature. This suspicious form was recovered and measured 10 µm by 12 µm. The patient is infected with: | View Page |
| A 55 year old female, who recently returned from an extensive trip to China, presented to her physician complaining of diarrhea and abdominal cramps. The doctor ordered a complete blood count (CBC), chem 21 panel, and stool for culture and parasite examination (O & P). The CBC revealed pronounced eosinophilia. The chem 21 and stool culture were unremarkable. The O & P revealed suspicious forms like the one below that each measured approximately 140 µm by 80 µm. This patient is most likely infected with: | View Page |
| A 31 year old male missionary worker recently returned from Africa where he helped a small rural community update their sanitation practices. He presented to his physician weak and complained of recent weight loss, abdominal pain, and diarrhea that was often bloody. The doctor ordered a battery of tests including a complete blood count (CBC) and stool for parasite examination. The CBC revealed eosinophilia and anemia. This suspicious form was seen on the wet preparations. It measured 52 µm by 27 µm. What parasite is mostly likely present? | View Page |
| A 65 year old Asian female presented to the emergency room exhibiting severe abdominal pain, fever and diarrhea. Examination revealed an enlarged liver that was tender to the touch. Patient history revealed that the woman worked in a fish processing plant for years prior to moving to the United States. Her diet was heavy in raw fish. Stool and duodenal contents were collected and sent to the laboratory for cultures and parasite examination. The cultures were unremarkable. This suspicious form was seen in both specimen types. It measures 27 µm by 14 µm. This patient is most likely suffering from: | View Page |
| A 7 year old male presented to the local clinic experiencing mild, yet annoying, abdominal pain, diarrhea and nausea. Patient history revealed that the child lives in a shack where sanitation practices are marginal, at best. The dwelling is infested with rats and multiple insects. Stool was collected and submitted for parasitic study. Numerous suspicious forms, measuring 60 µm by 75 µm were seen. This child is most likely infected with: | View Page |
| A 10 year old male presented to the local Appalachian Mountain clinic complaining of vomiting, fever and severe abdominal pain. Patient history revealed that the child lives in the area in substandard conditions and receives only one balanced meal per day. A stool was collected and submitted for parasite study. This suspicious form, measuring 50 µm by 35 µm was found. This patient is most likely infected with: | View Page |
| A 40 year old male recently completed a two-week hiking expedition in Russia. Upon his return to the United States, the man presented to his physician complaining of severe foul-smelling diarrhea and abdominal discomfort. The doctor immediately suspected a parasitic infection and ordered stool for examination. The sample was loaded with this suspicious form that averaged 13 µm in length. This patient is most likely suffering from: | View Page |
| A 4 year old female from South Carolina was rushed to the emergency room who was suffering from malaise, bloody diarrhea and abdominal pain. Examination revealed rectal prolapse. Stool was submitted for parasitic examination and this suspicious form was seen. It measures 45 µm by 20 µm. Which of the following is the correct identity of this suspicious form? | View Page |
| A 54 year old Finnish male presented at the local clinic with abdominal pain, weight loss, overall weakness and digestive discomfort. Patient history revealed that the man's diet was rich in raw fish. A complete blood count (CBC) was performed and revealed macrocytic anemia. A stool for parasitic examination was ordered. This suspicious form was seen upon initial screening of the sample. It measures 77 µm by 48 µm. This patient is most likely suffering from an infection with: | View Page |
| A 29 year old male steak house owner from Arizona presented to his doctor complaining of weight loss, abdominal pain and diarrhea. Patient history revealed that the man eats all of his meals at his restaurant and his favorite meat is rare sirloin steak. The man also noted that he had recently been on anti-parasitic medication. The doctor ordered a stool for parasitic examination. These two suspicious forms were seen. The patient is most likely suffering from an infection with: | View Page |
| A 35 year old man presented to his doctor with fever, diarrhea, abdominal pain and epigastric discomfort. Upon questioning the patient, it was learned that he travels extensively on business and loves to try new kinds of raw fish. The patient is most likely suffering from: | View Page |
| Considering the predominance of microspherocytes on the blood smear, and the patient's jaundiced condition, what is the most likely diagnosis? | View Page |
| Atypical smear: Case follow-up The patient whose blood smear is shown in the photograph was a 32-year-old female from Virginia who came to the high country of Colorado to ski. The day after arrival, she experienced shortness of breath, fatigue, and upper abdominal pain. She was seen in a medical center in the mountains where a working diagnosis of altitude sickness was made. A CBC revealed RBCs 5.1 x 1012/L, hemoglobin 12.8g/dL, MCV 60fL, hematocrit 40.9%, and normal total WBC, differential, and platelet count. The RDW was normal. Further questioning revealed a previous diagnosis of heterozygous beta-chain thalassemia. No other abnormal hemoglobins were found on hemoglobin electrophoresis, but HbA-2 was elevated to 5%, supporting the diagnosis of beta thalassemia. The patient's poikylocytosis and anisocytosis may be a clue to an underlying erythrocyte abnormality. Persons with iron deficiency anemia may experience various degrees of hypoxia upon arriving at high altitudes. Those with sickle cell disease and thalassemia minor (as in this case) may experience bone pain or other symptoms of "crisis" and/or alteration in the appearance of their erythrocytes upon sudden high altitude exposure. The classic teaching is that in differentiating iron deficiency anemia from thalassemia, increased RDW would favor iron deficiency; normal RDW favors thalassemia. | View Page |
| Case History A 17-year-old young woman was admitted to the hospital with abdominal pain and a tentative diagnosis of appendicitis.The total white blood count was 14,500 cells/cumm with a left shift and neutrophils with changes tagged by the arrow in the photographs (see blue arrow).The bluish-staining, blurred accumulations in the cytoplasm (Doehle bodies), are located at the cell periphery in neutrophils with toxic changes.Doehle bodies are remnants of endocytoplasmic reticulum and are products of cytokine activity in the induction and shortened activity of neutrophil activation.They are often present in conditions with increased neutrophil lysosomal activity, manifest as toxic granulation.In this case, the presence of Doehle bodies serves as markers for infection-induced leukocytosis and supports the diagnosis of acute appendicitis. | View Page |
| Case Follow-up Illustrated in the upper and lower photographs are two-lobed, eye glass ("pince nez") nuclei of neutrophils typical for patients with Pelger-Huet anomaly. In addition to the characteristic two lobes connected by a delicate bridge, the dense, homogeneous nuclear chromatin helps to define Pelger-Huet anomaly. Since the peripheral blood smear did not support the diagnosis of appendicitis in this patient, and since abdominal pain localized to the right lower quadrant never developed, the boy was hydrated with intravenous fluid and observed. After hydration, his constitutional symptoms improved and the abdominal pain subsided. In fact, the lad was back on the ski slopes the next afternoon. People entering high altitude where the humidity may be very low are susceptible to dehydration and may experience symptoms related to mountain sickness. Therefore, close observation and hydration may be the best practice in monitoring patients with stories and findings similar to this one. A further lesson here is that technologists must be alert to the possibility of Pelger-Huet anomaly if a high white blood cell count with a high percentage of band neutrophils with strikingly uniform morphology and without toxic granulation are found. Inappropriate therapy or an invasive procedure as was contemplated here may be avoided by a proper smear assessment and clinical corroboration. | View Page |