Smoking Colonel

   A 63-year-old retired Army colonel was transferred to Shands via helicopter from a community hospital in Ft. Myers. He had a high fever, cough, and chest pain. He had presented to his local physician 3 days previously complaining of fever, headache, malaise, and vague respiratory symptoms. Over the next 3 days, his symptoms became progressively worse and he now had considerable difficulty breathing, and was disoriented and lethargic. Chest x-rays indicated patchy alveolar infiltrates on both the right and left sides, indicative of a pneumonia. He had been sent to the local Ft. Meyers hospital, and they had referred him to Shands.

Question 1 - Single Best Answer

What organisms are causes of community-acquired bacterial pneumonia?   
1:  Nocardia asteroides
2:  Pneumococcus
3:  Legionella pneumophila
4:  Staphylococcus aureus
5:  Chlamydia psittaci
6:  Corynebacteria diphtheria
7:  Klebsiella pneumonia
8:  Mycoplasma pneumonia
9:  Salmonella typhi
10:  Rhodococcus equi

A) 1, 2, 3, 4, 8
B) 2, 3, 5, 6, 9
C) 5, 7, 8, 9, 10
D) 2, 3, 4, 7, 8

Question 2 - Single Best Answer

What should be done to diagnose the cause?   

A) white cell count
B) sputum gram stain
C) sputum culture
D) blood culture
E) all of the above

His white cell count was 12,000 with 70% neutrophils. The "sputum" sample consisted of only thin, watery secretions. A gram stain of the sputum showed few neutrophils, some mononuclear cells, no epithelial cells, and a very few poorly staining gram negative bacteria. Multiple routine cultures of blood and sputum were negative. His wife tells you that he is a very heavy drinker and that he has smoked two packs of cigarettes a day since he was 14 years old.

Question 3 - Single Best Answer

The absence of many bacteria in the sputum are an indication that?   

A) the sample was saliva, not sputum
B) he has mycoplasma pneumonia
C) he has influenza, not pneumonia at all
D) he has pneumococcal pneumonia
E) you need to do some other tests to determine the cause of his pneumonia

Question 4 - Single Best Answer

The thin watery secretions are an indication of which of the following?   

A) Pneumococcal pneumonia
B) Legionnaire disease
C) Staph aureus pneumonia
D) Klebsiella pneumonia
E) Mycoplasma pneumonia

Question 5 - Single Best Answer

The smoking and drinking in elderly are risk factors for which of the following?   

A) Pneumococcal pneumonia
B) Legionnaire disease
C) Staph aureus pneumonia
D) Haemophilus pneumonia
E) Mycoplasma pneumonia

Question 6 - Single Best Answer

On the basis of the gram stain, culture, and clinical picture you decide that the patient has Legionnaire's disease. Why did the laboratory not grow the organism from the sputum?   

A) Legionella is an obligate intracellular parasite
B) the IgG in the lungs inactivated the causative bacteria
C) the gram negative rods seen in the stained sputum were a contaminant that killed the causative organism
D) the laboratory was not informed that Legionnaire disease was suspected

Question 7 - Single Best Answer

Why must the laboratory be informed if Legionella is suspected?   

A) so that all personnel can wear protective clothing
B) so the cultures can be incubated at a cold temperature
C) so the organism can be incubated in human cell cultures
D) so the laboratory will use the proper medium to grow the organism
E) so the laboratory will test for antibiotic resistance which is common in this organism

Question 8 - Single Best Answer

How could a diagnosis of Legionnaire disease be confirmed without waiting for the organism to grow?   

A) Legionella antigen in the urine
B) stain the sputum with a fluorescent antibody
C) DTH
D) spinal tap
E) more than one of the above

Question 9 - Single Best Answer

What are the sometimes catastrophic consequences of Legionnaire disease?   

A) it is spread to family members who may die, as the organism becomes more virulent with human passage
B) the patient develops hepatic and renal dysfunction
C) the community needs to be immunized at great expense
D) lung cancer may ensue
E) viral pneumonia usually follows and can kill the patient

Question 10 - Single Best Answer

If Legionella is not spread between people, where does it come from?   

A) it is acquired from cats and dogs
B) it is spread only by mosquitoes who get it from white tailed deer
C) it is a nosocomial infection spread by unsterilized dental equipment
D) it is spread by aerosolized water from air conditioners or shower heads
E) it comes from unpasteurized milk

Question 11 - Single Best Answer

If a special medium is needed to grow Legionella in the laboratory, how can it survive in water sources?   

A) the iron it needs to grow is concentrated in tap water from the pipes
B) there are other bacteria in the tap water that supply the necessary growth requirements
C) it grows in amoeba in the water
D) it doesn't grow in the water or without special growth requirements, but its elementary body can survive for long periods of time.

Question 12 - Single Best Answer

What is Pontiac fever?   

A) a rabid desire for a Trans Am
B) a disease that only occurs in Michigan
C) a mild disease also caused by Legionella pneumophila
D) another name for Legionnaire disease

Question 13 - Single Best Answer

What is the major virulence mechanism for Legionella?   

A) a capsule prevents phagocytosis
B) pili cause its adherence to the cilia in the lung
C) it produces a toxin that ADP-ribosylates the G subunit of adenyl cyclase, thereby deregulating cellular metabolism
D) it grows intracellularly in the phagosome by preventing the fusion with the lysosome
E) it has an IgA protease