University of Babylon
Case-study in Microbiology
Dept. of microbiology
College of Medicine
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Case-study in Bacteriology (Prof. Dr. Alaa Al-Charrakh):
1- Five children from the same school presented with abdominal pain and diarrhoea (streaked with
blood) over a period of 3 days. Upon investigation it was found that one of the children had recently
been abroad with his family. Fecal specimen was collected and sent to microbiology lab. Many pus
cells on direct microscopy and non-lactose fermenting colonies were found on MacConkey’s agar.
On motility test it was non-motile
a. What is the identity of the organism?
b. What is the mode of spread?
2- A 30 years old man presented to out-patient gastroenterology clinic with the complaints of:
-Changed taste & bad breath
-Recurrent epigastric pain & heart burn
On gastroscopy he was diagnosed as having gastric ulcer. A biopsy was taken and sent to
microbiology lab:
a) What tests will be performed on the biopsy specimen?
b) What is the likely organism causing the disease?
c) What other lab tests will help to confirm the identity of the organism?
3- A previously normal, full-term infant developed bilateral conjunctivitis at 2 weeks of age. The
conjunctivitis was followed by severe coughing, but the infant remained afebrile. When the infant
was 4 weeks old, a chest X-ray showed bilateral symmetrical interstitial infiltrates. The white blood
cell (WBC) count was 14,000/mm3 with 32% segmented neutrophils, 58% lymphocytes, 2%
monocytes, and 4% eosinophils. Which of the following is the most probable infectious agent?
A. Chlamydia trachomatis
B. Streptococcus agalactiae
C. Haemophilus influenza
D. N. meningococcus
4. A 16-year-old girl was admitted to a Merjan teaching hospital because of hypotension, cyanosis,
high fever (39.9°C), and bilateral, non-fluctuant, inguinal, and axillary lymphadenopathy. The
patient died the same day. Blood cultures obtained on admission were positive for bipolar-staining,
short, gram-negative bacilli. What is the most probable etiologic agent?
A. Yersinia pestis
B. K. rhinoscleromatis
C. Francisella tularensis D. Brucella abortus
5- A woman brings her 2 ½-year-old child to the physician with complaints that the child is
suffering ear pain and drainage, fever, lethargy and irritability. After examining the child, the
doctor explains to the mother that the child has an ear infection. The physician prescribes a 7-day
course of amoxicillin for the child. After 5 days, the mother and the child return to the physician’s
office. The child’s condition has not improved and she still has pain and fever. The physician
switches the infant to a 7-day prescription of amoxicillin/clavulanate (Augmentin) and the
symptoms clear. What are possible explanations for this child’s initial lack of response to therapy
and subsequent recovery?
Case-study in Immunology:
Q1/ An 18-year-old student with end-stage renal failure due to chronic glomerulonephritis was
given a cadaveric kidney transplant. He had been on maintenance haemodialysis for 2 months, and
on antihypertensive therapy for several years. His major blood group was A and his tissue type
was HLA-A1, -A9, -B8, -B40, -Cw1, -Cw3, -DR3, -DR7. The donor kidney was also blood group
A and was matched for one DR antigen and four of six ABC antigens. He was given triple
immunosuppressive therapy with cyclosporin A, azathioprine and prednisolone.
He passed 5 litres of urine on the second postoperative day and his urea and creatinine fell
appreciably. However, on the seventh postoperative day, his graft became slightly tender, his
serum creatinine increased and he had mild pyrexia (37.8°C).
What is your diagnosis? How can you confirm it?
Q2/A 48-year-old man was admitted for investigation of weight loss associated with intermittent
diarrhoea. He had a history of pneumonia as a child and again as a young man working abroad. At
the age of 33 he had developed chronic sinusitis, with persistent headaches. On examination he
was thin but had no signs of malignancy. He had no clubbing and his chest was clear on
auscultation. There was no lymphadenopathy and no hepatosplenomegaly. He was not anaemic,
had a normal serum albumin and normal liver function tests. Immunological tests are shown in
Table C3.3. No infective cause of the intermittent diarrhoea was found; barium enema was normal.
Endoscopic examination of his maxillary sinuses showed considerable inflammation and
hypertrophy of the mucosa.
Serum immunoglobulins (g/l)
IgG
IgA
IgM
IgG1
IgG2
IgG3
IgG4
Antibody activity - post immunization
IgG: tetanus toxoid
diphtheria toxoid
7.2
<0.1
1.2
2.7
3.2
0.1
2.2
Negative [>0.85iu/ml]
Negative [>0.2iu/ml]
[6.5-12.0]
[0.8-5.0]
[0.5-2.0]
[3.6-7.3]
[1.4-4.5]
[0.3-1.1]
[0.1-1.0]
pneumococcal polysaccharide
Antibody activity - post exposure
IgG: Rubella
Measles
Varicella zoster
Blood lymphocyte subpopulations (x109/l)
Total lymphocyte count
T lymphocytes
CD3
CD4
CD8
B lymphocytes
CD19
Inadequate [>80U/ml]
Not detectable
Not detectable
Not detectable
2.8
[1.5-3.5]
2.2
1.6
0.6
[0.9-2.8]
[0.6-1.2]
[0.4-1.0]
0.3
[0.2-0.4]
*Normal adult ranges shown in brackets.
What is your diagnosis?
Q3/ A 25-year-old joiner presented with a 12-month history of an intensely itchy 'nettle rash' on
his chest and back. The lesions appeared suddenly and lasted from 6 to 12h, to be replaced by new
lesions at other sites. The lesions varied in size from a few millimetres to several centimetres.
Attacks occurred two to three times each week. In addition, he had experienced four episodes of
sudden swelling of lips which took 48h to subside. He said he looked as though he had been
punched. He was unaware of any triggering factors and there was no personal or family history of
atopy. His general health was excellent and he was not taking any medications. On examination,
the lesions consisted of raised, red, irregular patches, some with white centres, and were typically
urticarial. General examination was entirely normal. Laboratory investigations showed a normal
haemoglobin and white cell count, with no eosinophilia.
What type of immunological reaction is this case?
Q4/ A 26-year-old West Indian man presented with a 24-h history of occipital headache and
vomiting. He was pyrexial (temperature 38.3°C), confused, irritable and had marked neck stiffness
with a positive Kernig's sign. There was no other history of serious infections. His immediate
family were healthy.
Lumbar puncture produced turbid cerebrospinal fluid (CSF) with a protein concentration of 4.5g/l
(NR 0.1-0.4), glucose content of less than 0.1mmol/l (NR 2.5-4.0) and a leucocyte count of
8000/mm3 (97% neutrophils). Neisseria meningitidis was cultured from the CSF. A search was
made for an underlying cause of his meningitis. X-rays of the skull and sinuses showed no
abnormal communication with the CSF. The possibility of an underlying immune defect was then
considered.
What are you expect to find as an immunological abnormality in this case? Could it be a heritable
disease?
Q5/ A 77-year-old woman was referred from the Accident and Emergency Department, having
been admitted overnight because of sudden onset of massive angioedema of her tongue associated
with laryngeal stridor. She was treated with intravenous hydrocortisone only. This was her fifth
such episode: an anaphylactoid attack 2 months earlier was severe enough for her to be intubated
and ventilated on the Intensive Care Unit.
She had no history of previous allergy and no family history of atopy. A drug history revealed that,
in addition to oral prednisolone prescribed in the Accident and Emergency Department, she was
taking oral frusemide and captopril.
What is the cause of this case symptoms? How can you prevent it?
Q6/ A 38-year-old woman was referred for investigation following an anaphylactic reaction whilst
visiting a relative in hospital. She gave a 5-year history of recurrent conjunctival oedema and
rhinitis when blowing up balloons for her children's birthday parties. In the year prior to
admission, three successive visits to her dentist triggered marked angioedema of her face on the
side opposite to that requiring dental treatment. The swellings took 48h to subside.
On the day of admission, she visited a critically ill relative in hospital. The patient was being
reverse barrier nursed and visitors were required to wear gown and gloves. About 20min after
putting on the gloves her face and eyes became swollen, she felt wheezy and developed a
pounding heart beat and light-headedness. Her tongue started to swell and she was taken to the
Emergency Department where she was given intramuscular epinephrine (adrenaline) and
intravenous hydrocortisone. She recovered rapidly but was kept under observation overnight.
What is the diagnosis? What would you advise this patient?
Case-study in Virology
Dr.Jawad Kadhim Tarrad
Case-1
Complaint (ID/CC):
A 67- year-old man has right- sided chest pain and a rash on his chest. His pain began one
week ago. The rash, which didn’t begin until 3 nights ago, is in the same distribution as the pain.
History (HPI):
The patient is usually healthy and takes no regular medications. He does not smoke or drink
alcohol. Family history is unremarkable.
Physical exam (PE):
Exam reveals a rash on the left side of back and chest in a dermatomal distribution, which
consists of many vesicles, many of which have crusted over. The patient is tender in the region of
the rash. The rest of the exam is unremarkable.
Tests (Labs):
Complete blood count: normal
Tzanck smear from the base of one of the vesicles on the patient chest: multinucleated giant cells.
Questions (Qs):
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What is name of the condition affecting this patient? Which virus causes it?
Where does this virus live in its human host?
How can this infection be prevented and treated?
What clinical infection does this virus typically cause in children?
Case-2:
Complaint (ID/CC):
A 41-years-old woman complains of nausea and vomiting. She also reports that her eyes have
turned yellow, her abdomen is sore, and her urine has turned dark. The patient first felt ill 3 to 4
days ago. She mentions that she went to a seafood restaurant 3 week ago. Apparently, all her
dinner partners from that night also are experiencing fatigue and nausea and vomiting.
History (HPI):
The woman is usually health. She takes no regular medications; is monogamous, and does not
smoke, drink alcohol, or use illicit drugs.
Physical exam.(PE):
A low-grade fever is present, and the patient is jaundiced. Abdominal exam reveals right upper
quadrant tenderness and mild hepatomegaly.
Tests (labs):
Hemoglobin: 14 g/dL(normal 12-1 6g/dL)
Alanine aminotransferase(ALT): 100 IU/L(normal 1-21 IU/L)
Aspirate aminotransferase(AST): 98 IU/L(normal 7-27 IU/L)
Bilirubin, total 3-2 mg/dL(normal : 0.1-1 mg/dL)
Bilirubin, direct 1.6mg/dL( normal 0.1-0.4mg/dL)
Alkaline phosphatase 42 IU/L(normal 13-39IU/L)
Urinalysis : elevated urobilinogen ; negative for glucose, protein, and bacteria.
Hepatitis A IgM : positive
Hepatitis B panel: negative
Hepatitis C IgM antibody: negative
Hepatitis D IgM antibody: negative
Questions (Qs):
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Given her history and lifestyle, how many of the four hepatitis viruses listed would the
woman be unlikely to contact?
What is the route of spread of HAV? Is there a chronic state for this virus?
How is HEV transmitted? What is the link between hepatitis E and pregnancy? Is there a
chronic carrier state this virus?
Case-3
ID/CC
A 30-year-old male presents with a high fever and chills, headache , nausea, vomiting, and muscle
aches.
HPI
Yesterday he had an episode involving abnormal movements of his right hand and face (focal
seizure). He also has difficulty comprehending speech and has olfactory hallucinations. He has no
history of psychiatric illness.
PE
VS(Viral signs): tachycardia, mild tachypnea, normotention. PE: confused and disoriented,
papilledema; mild nuchal rigidity, Kernigʼs sign positive, paraphasic error in speech , deep tendon
reflexes normal and bilaterally symmetric.
Labs
Cytology by LP(lumbar puncture): cells 400/µl which mononuclear pleocytosis. Biochemistry:
mildly elevated proteins, and normal glucose. Bacteriology exam. Negative.
CSF-PCR reveals herpes simplex virus type-1. Serology: serum complement-fixing antibody
titer more than 1:1000. EEG(electroencephalography):spiked and show waves localized to
temporal lobes.
Imaging:
CT: characteristic changes of encephalitis seen over temporal lobes.
Gross pathology:
Hemorrhagic , necrotizing encephalitis most severe along inferior and medial regions of temporal
lobes and orbitofrontal gyri.
Micro pathology
Brain biopsy reveals Cowdry intranuclear viral inclusion bodies in both neurons and glial cells
with perivascular inflammatory infiltrates.
Treatment
Intravenous acyclovir.
Discussion:-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Case-4
Mr.Fadhil left his place of employment at 3:00 P.M complaining of headache ,fatigue, general
achiness,runny nose, cough and distinct chill. Headache and severe muscular aches ensued , and a
temperature rise to 120F was noted by early morning of following day. Laryngitis with hoarseness
and cough and substernal soreness were noted. Epistaxis was also noted. Physical examination
revealed slight tachycardia and somewhat lower than normal blood pressure. The lymphoid
follicles of the soft palate were enlarged and dewy in appearance. The nasal mucous membrane
appeared bright red and there were areas of hemorrhage. The patient complained of loss of appetite
and experienced a sense of fatigue and weakness. Nausea, vomiting or diarrhea were not observed.
1.
2.
3.
4.
5.
The disease is diagnosed as ------------- which similar in C/F of--------The most common complication is------------------------------------------A specific therapy for the disease is-----------------------------------------The most effective disseminators occur in age group--------------------The control measures against the disease include--------------------------
Case-5
Complaint
A 32-year-old woman comes in for a routine Pap smear. She has no complaints, but has not had a
Pap smear before and she saw a TV program on it recently , prompting her to make the
appointment.
History
The patient is healthy and has no significant past medical history. She takes no medications and
does not illicit drugs or alcohol. She smokes roughly one pack of cigarettes per day. The woman is
heterosexual and has multiple previous sexual partner, using birth control pills and condoms
sporadically.
PE
The PE reveals no significant abnormalities. Full pelvic exam and pap smear are performed.
Lab.tests
Urine pregnancy test: negative
Pap smear: atypical cells
Routine culture for gonorrhea and Chlamydia : negative
Cervical biopsy: koilocytic atypia in cell of upper epithelial laver.
Qs:
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Which infectious organism is likely responsible for the changes?
What is koilocyic atypia?
What common clinical condition does this organism cause?
What is relationship between this organism and cancer?
Case-study in Mycologyology (Dr. Kareema Amine Al-Khafaji):
the Case No.1 : A young aged lady presented with small rounded erythematous scaly lesion on the
forearm with a mild itching , increases gradually in size especially after application of topical steroid (see
the photograph).
Q1 what is your diagnosis?
Q2.what is the important test is used to confirm the diagnosis?
Q3.How can you treat this patient?
Q4. Is the topical steroid is the treatment of choice in the treatment?
A1. Tinea corporis (here called Tinea incognito due to treatment by steroid).
CaseNo2. A young- aged chide presented with multiple erythematous scaly lesions on the scalp, with
localized hair loss of three weeks duration.(see photograph).
Q1. What is your diagnosis.
Q2.what is second differential diagnosis?
Q3.How you can confirm the diagnosis?
Q4. How can you treat such a case?