On May 6, l975, a midwife delivered a male infant at home in a town across the Mexican border from Laredo, Texas. The umbilical cord was cut with unsterilized scissors and olive oil was applied to the stump. The child was adopted on the day of birth by a family from Chicago and appeared to be well until the third day of life, when, en route to Chicago, he became irritable, had a runny nose and ate poorly. His parents thought he just had a cold. When he was 5 days old he could no longer nurse and was having some muscle spasms. He also had trouble breathing and was, at times, cyanotic.
Question 1 - Single Best Answer
What are some bacteria which are special problems in infants of this age?
A) Haemophilus influenzae, Streptococus pneumoniae, Neisseria meningitidis
B) Neisseria gonorrhoea, Treponema pallidum, Chlamydia pneumonia
C) Clostridium tetani, Clostridium botulinum, Clostridium perfringins
D) Listeria monocytogenes, E. coli K, Streptococcus agalactiae (Group B. Strep)
E) Staphylococcus aureus, Streptococcus pyogenes, Legionella pneumophilia
Question 2 - Single Best Answer
What are some viruses that are special problems in newborn babies?
A) Herpes, rabies, pertussis
B) Mycoplasma, rubella, coxsackie
C) CMV, Herpes, echovirus
D) echovirus, syphilis, Herpes simplex II
E) rhinovirus, tetanus, CMV
Question 3 - Single Best Answer
Look up the symptoms of the diseases that can be caused by organisms that are problems for newborn babies (not all are necessarily included in the correct answers to the previous two questions) and, considering both the organisms and the symptoms, write down (on a separate piece of paper) the best differential diagnosis for the baby described in the presenting paragraph. After you have written down what you think is the best differential diagnosis, choose the list of differential diagnoses below that most closely corresponds to your list.
A) Herpes, tetanus, Group B Strep, Listeriosis, congenital syphilis
B) Neisseria gonorrhoea, congenital syphilis, Chlamydia trachomatis
C) congenital rubella, CMV, infant botulism, congenital syphilis
D) echovirus, Group B. Strep, Campylobacter fetus, rabies
Question 4 - Single Best Answer
How are Herpes, Group B. Strep, and Listeria transmitted to babies?
A) Through the placenta before birth.
B) From doctors or nurses
C) From the mother, as the baby traverses the birth canal.
D) From the skin of the mother as the baby nurses.
E) From the mother, via the respiratory route.
Question 5 - Single Best Answer
How is syphilis transmitted to newborns?
A) Through the placenta before birth.
B) From doctors or nurses.
C) From the mother, as the baby traverses the birth canal.
D) From the skin of the mother as the baby nurses.
E) From the father, via sexual abuse.
Question 6 - Single Best Answer
How is tetanus transmitted to newborns?
A) Through the placenta before birth.
B) From doctors or nurses.
C) From the mother, as the baby traverses the birth canal.
D) From the skin of the mother as the baby nurses.
E) From spores in the environment, into an open wound, usually the umbilicus.
The child's symptom's worsened and on the sixth day he was taken to the hospital. On admission it was noted that he had risus sardonicus, opisthotonos, and trismus. His umbilicus was inflamed and exuded a yellow purulent discharge. Laboratory evaluations included a negative CSF examination.
Question 7 - Single Best Answer
A negative CSF exam would tend to rule out which of the following?
A) syphilis and tetanus
B) Listeria and Group B Streptococcal infection
C) tetanus and Listeria
D) a viral infection
Question 8 - Single Best Answer
What is opisthotonos?
A) a grinning expression
B) difficulty in opening the mouth
C) spasms of the back that bend the back, head, and neck backward
D) a characteristic odor associated with congenital syphilis
Question 9 - Single Best Answer
Opisthotonos, risus sardonicus, and trismus are all symptoms of what disease?
A) rabies
B) tetanus
C) syphilis
D) Group B Streptococcal infection
E) Listeria
Question 10 - Single Best Answer
What is the causative agent of tetanus?
A) Chlamydia tetani
B) Staphylococcus aureus
C) Clostridium perfringens
D) Treponema pallidum
E) Clostridium tetani
Question 11 - Single Best Answer
What would a Gram stain of the umbilical pus show if the child had tetanus?
A) a mixed flora with Gram positive and Gram negative rods and cocci
B) a pure culture of Gram negative rods
C) a pure culture of Gram positive rods
D) only anaerobic organisms
E) there would be no pus
Question 12 - Single Best Answer
How do the tetanus bacteria cause the symptoms (muscle spasms) of the disease?
A) by invading the CNS and killing cells there
B) by producing a toxin that acts at the neuromuscular junction
C) by producing a toxin that acts in the spinal cord
D) by inducing an inappropriate immune response
Question 13 - Single Best Answer
How is tetanus usually diagnosed?
A) Gram stain
B) culture of the organism under anaerobic conditions
C) PCR test
D) clinical grounds
Neonatal tetanus was diagnosed on clinical grounds and the infant was given 1000 units of human tetanus immune globulin intramuscularly. Antibiotic therapy with penicillin and gentamicin was begun. Phenobarbital and chlorpromazine were given and the infant was then rehydrated and maintained by continuous intravenous infusion.
Question 14 - Single Best Answer
What was the purpose of the phenobarbital and chlorpromazine?
A) to release cell-bound toxin
B) to help kill the bacteria
C) to neutralize the toxin
D) to control the muscle spasms
Question 15 - Single Best Answer
How did the olive oil contribute to the pathogenesis of the disease?
A) It was contaminated with Corynebacterium tetani organisms.
B) It was contaminated with Clostridium tetani organisms.
C) It was contaminated with spores of the causative agent.
D) It supplied the fatty acids necessary for the causative organism to grow.
E) It contributed to an anaerobic environment so the causative agent could grow.
Episodes of muscle spasm and periods of restricted respirations and cyanosis gradually decreased over the first two days of hospitalization; by the third day the infant could tolerate feeding and administration of a sedative via a nasogastric tube. Hypothermia was noted on the fourth hospital day and was attributed to chlorpromazine. Diazepam was substituted for the chlorpromazine and phenobarbital to control the spasms. On about the 13th hospital day the tendency to have spasms began to decrease, and by the 19th day no symptoms related to tetanus toxin were discernible.
Question 16 - Single Best Answer
Will the infant be left with residual nerve damage?
A) yes
B) no
Question 17 - Single Best Answer
What would have been the best way to prevent the infant from getting tetanus?
A) Using sterile scissors and keeping the umbilical area clean
B) Giving the infant tetanus toxoid
C) Giving the mother tetanus toxoid several weeks before the baby was born
D) Giving the infant tetanus antitoxin
E) More than one of the above would help prevent the disease