Weak Weight Lifter

A seventeen-year-old Caucasian male is brought to the Emergency Room with a high fever. He was brought in by his friends, who say he collapsed while at a party. He is not unconscious, but is somewhat disoriented. His history reveals that the fever, as far as he recalls, began about an hour after he arrived at the party. He had felt fine until then, except for a painful lump under his left arm. Until this evening he had been in excellent health. He was a football player on his high school team, and now in the off season he uses weights regularly. He had experienced a headache prior to the party, but took some advil for it.

Question 1 - Single Best Answer

What could be the most urgent problem for someone who is disoriented, and has a headache and fever?   

A) encephalitis
B) viral meningitis
C) bacterial meningitis
D) botulism food poisoning
E) advil overdose

Question 2 - Single Best Answer

What is the most characteristic sign of bacterial meningitis?   

A) throbbing headache
B) earache
C) numbness in the fingers
D) a rash
E) a stiff neck

Question 3 - Single Best Answer

If you are considering bacterial meningitis in your differential diagnosis, what should you always do?   

A) CAT scan
B) Gram stain of CSF
C) blood culture
D) blood pressure
E) culture of CSF

You are relieved to find that he does not have a stiff neck, so you decide to question him some more. He appears to be more weak and afraid than mentally confused. For the moment you put meningitis in the back of your mind. He does not know how he got the lump under his arm, but says it is quite painful. He did contract a severe case of mononucleosis last year, but recovered after use of anti-inflammatory drugs. He is currently on no medication, and denies use of illegal drugs. He had taken only two advil caplets. He has had several sexual partners, but had always used condoms to avoid STDs. He does admit drinking at the party, but had only two beers prior to his collapse. He claims also to never have had thoughts of suicide or harming himself in any way.

His fever is 102.5 F and he is perspiring. His blood pressure is 70/40. His respiration is also low, and you suspect he may soon develop metabolic acidosis. His heart is beating quite rapidly.

Question 4 - Single Best Answer

What should the blood pressure be for a normal healthy football player?   

A) 180/120
B) 180/90
C) 150/90
D) 120/85
E) 90/ 50

Question 5 - Single Best Answer

Could his abscess be causing his constitutional symptoms?   

A) yes
B) no

Question 6 - Single Best Answer

Infections with which of the following groups of bacteria can result in low blood pressure and shock?   

A) Gram positives only
B) Gram negatives only
C) both Gram positives and Gram negatives
D) anaerobes only
E) aerobes only

Question 7 - Single Best Answer

Pick the bacteria from the following list that can cause abscess formation:   
1: Actinomyces
2: Bacteroides
3: Clostridium tetani
4: Eikenella
5: Haemophilus ducreyi
6: Helicobacter
7: Neisseria meningitidis
8: Peptostreptococcus
9: Salmonella
10: Staph aureus

A) 1-5
B) 6-10
C) 1, 2, 5, 7, 8
D) 2, 3, 4, 8, 10
E) 1, 2, 4, 8, 10

Your examination continues. His lungs sound clear, and his heart reveals no rubs or murmurs. His throat is not inflamed or sore. He displays no abdominal tenderness upon palpation. There is no purulent discharge from his penis. Upon examination of his extremities you find evidence of needle marks, though none near any vessels. The lump under his left arm, lateral to his axilla, is red and inflamed. There is evidence of cellulitis, and a pustule with a purulent discharge at the center of the inflamed area. The skin surrounding the area looks almost like it has been burned. Near it you see several needle marks. You suspect this may be a deep abscess, but you cannot tell its extent.

Direct questioning and warnings about the medical consequences of giving false information coax him to admit to sharing needles with other athletes to inject intramuscular steroids.

You order some initial lab tests primarily to determine the etiology of the abscess.

The patient has begun to vomit and appears slightly dehydrated. You decide to admit him to the hospital and immediately begin an IV of saline, glucose and an antibiotic. The abscess appears to be almost to the bone, and you order immediate surgical drainage.

Question 8 - Single Best Answer

When dealing with an abscess the most important procedure is?   

A) an antibiotic that can penetrate into the abscess
B) an antibiotic that can kill the bacteria and keep it from spreading
C) surgical drainage
D) maintaining normal blood pressure
E) keeping the fever low

FINAL TEST RESULTS PURULENT DISCHARGE: LARGE YELLOWISH COLONIES THAT ARE GRAM+; BETA HAEMOLYTIC ON BLOOD AGAR (AEROBIC); CATALASE+; COAGULASE+; ALSO SOME TINY GREY-WHITE COLONIES THAT "PIT" THE AGAR. BOTH ALSO GROW UNDER ANAEROBOC CONDITIONS

Question 9 - Single Best Answer

What is the definitive identification of the Gram positive bacterium in the discharge?   

A) Staphylococcus aureus
B) Staphylococcus epidermidis
C) Streptococcus pyogenes
D) Peptostreptococcus
E) undetermined at this point

Question 10 - Single Best Answer

What is of most concern when dealing with an S. aureus infection?   

A) that it could cause scalded skin syndrome
B) that is could cause toxic shock syndrome
C) that it is highly antibiotic resistance
D) that it can cause hemolysis of red blood cells
E) that it can be sexually transmitted

The patient was diagnosed as having toxic shock syndrome, with an accompanying infection by Eikenella corrodens. This latter organism may have aided in the invasion of the bone and could also be contributing to the shock. The toxic shock needs to be treated with supportive care until the cause is removed. The patient was warned about sharing needles, and the use of illegal steroids. He has been counseled as to the possible health risk of being infected with Hepatitis B; however, there appears to be no viral activity. This may not last depending what effect the steroids will have on his liver. He is given appropriate antibiotics and discharged from the hospital after three days. The area of cellulitis shows mild desquamation after a follow up wound inspection two weeks later. The bone shows no signs of infection after an axillary X ray.

Question 11 - Single Best Answer

What is the relation between the abscess and toxic shock?   

A) none
B) Shock is a possible consequence of any abscess because of the localized inflammatory response.
C) S. aureus is causing the abscess by producing a toxin that stimulates cytokine production and causes shock.
D) S. aureus is causing the abscess by producing coagulase and protein A.

Question 12 - Single Best Answer

Can all strains of S. aureus cause toxic shock?   

A) yes
B) no

Question 13 - Single Best Answer

Besides the TSST-1, what other virulence factor(s) was/were operative in this case?   

A) adhesin
B) peptidoglycan
C) coagulase
D) catalase
E) all of the above

Question 14 - Single Best Answer

Can toxic shock syndrome occur in the absence of tampon usage?   

A) yes
B) no

Question 15 - Single Best Answer

Could shock have occurred in this case if the S. aureus had been a non-TSST-1 producing strain?   

A) yes
B) no