University of Santo Tomas

Faculty of Pharmacy
Department of Medical Technology

LIMITED FACE-TO-FACE MODULE

Enriched Virtual Mode During the Quarantine Period

Section: Microbiology

Topic Title: Organism Identification

Duration: 1 Day

Intended Learning Outcomes

1. Correlate patient’s clinical signs and symptoms with organism identification.
2. Understand the uses of selective and differential growth media
3. Determine the properties of some common bacterial types when grown on selective
and differential growth media

CASE HISTORY 1

The patient, a 16 year old female was well until 2 days prior to admission when she had a fever to
39.9oC and vomiting. On the morning of admission, she had loose stools, continued fever, and
vomiting. She was seen by her local pediatrician who noted that she was hypotensive (BP 76/48
mmHg) with a heart rate of 120 beats/min and a temperature of 38 degrees celcius. She had an
erythematous rash, which was most prominent on her trunk. Cultures were obtained. The patient was
given intravenous fluids and IV antibiotics and transported to the hospital, where she was admitted into
the Pediatric Intensive Care Unit.

Laboratory studies indicated elevated liver enzymes, increased creatinine and blood urea nitrogen, and
WBC count of 14,100 mm3 with 78% neutrophils and 18% band forms. The patient had begun her
menstrual period 4 days before she became ill.

Activities

Answer the following review questions:

http://www.meddean.luc.edu/lumen/meded/mech/cases/case3/answers.htm -

1. Does this patient have infection? Is it bacterial or Viral? What evidence can support this claim?

The patient most likely has a bacterial infection. The patient's fever is nonspecific but is
an important sign of infection. Her WBC counts support a response to bacterial
infection in her body.

According to Mahon et al. (2016), in response to bacterial infection, laboratory

findings will usually show leukocytosis and neutrophilia with an increased percentage of
immature forms of granulocytes (termed a left shift). In a WBC differential count, increased
 University of Santo Tomas
Faculty of Pharmacy
Department of Medical Technology
neutrophil is indicative of bacterial infection while increased lymphocyte is indicative of viral
infection.

v3
The patient experienced fever which is nonspecific however, it is still an important
manifestation of infection. In terms of her WBC count, the patient obtained a WBC of
14,100 mm3 with 78% neutrophils and 18% band forms. According to Mank and Brown
(2021), a WBC count above 11.0x10^9/L on a peripheral blood smear collection indicates
leukocytosis. No eosinophils were also found in the blood smear. These manifestations are
consistent with bacterial infection. According to Gamache (2020), Leukocytosis with a left
shift may be observed in any bacterial infection (pls paraphrase nalang kasi ito na yung
sinubmit ko)

Gamache, J. (2020).What may be indicated by leukocytosis or leukopenia in bacterial pneumonia?

Latest Medical News, Clinical Trials, Guidelines - Today on Medscape.
https://www.medscape.com/answers/300157-19142/what-may-be-indicated-by-leukocytosis-or-
leukopenia-in-bacterial-pneumonia.

Mank, V., & Brown, K. (2021). Leukocytosis. StatPearls [Internet].

https://www.ncbi.nlm.nih.gov/books/NBK560882/.

2. What are the potential sites for infection in this patient as judged from the clinical story?
- The potential sites for infection in this patient as judged from its clinical story are
the gastrointestinal tract and vagina. Since most of the symptoms are coming from the
gastrointestinal tract, loose stools and vomiting and it is also noted that the patient
already began her menstrual period 4 days before she became ill.
- The patient also had begun her menstruation period a few days before infection
occurred, which can be associated with vaginal infection since bacteria may travel up
the vagina going to the fallopian tube and uterus, causing infection. Her onset of first
menstruation is related to the infection.
- One potential site of infection would be through the skin because there is an
erythematous rash most prominent on her trunk.
- Based on the clinical history, one of the potential site of infection in this
patient is the blood. The patient has a fever with a temperature of >38oC, rapid
heart rate, and systolic pressure ≤100 mmHg which may indicate septic shock.
This is a life-threatening condition that occurs when bacteria enters the
bloodstream causing severe and systemic infection.

3. What additional history would you like to have? How can infection be linked to her periods?
● History of using tampons. The use of tampons can be associated with infection.
● Tampons that are left in the vagina for a long time may encourage the bacteria to grow.
Tampons can stick to the vaginal walls, especially when blood flow is light, causing tiny
abrasions when they are removed.
 University of Santo Tomas
Faculty of Pharmacy
Department of Medical Technology
(https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/toxic-shock-
syndrome-tss)

4. What are the types of shock you can encounter with infection?
● Toxic Shock
● Septic shock
------------
The types of shock that an individual can encounter as a result of infection include the toxic shock and
the septic shock. Septic shock and toxic shock syndrome (TSS) are both caused by bacterial infections
in children wherein, toxic shock is caused by the bacteria's exotoxins, whereas septic shock is caused
by excessive immune reaction of an individual against an infection (“Septic and toxic shock syndrome
(TSS)”, n.d.).
Toxic shock syndrome (TSS) is a toxin-mediated, life-threatening disease caused by Staphylococcus
aureus or group A Streptococcus (GAS), commonly known as Streptococcus pyogenes
(Venkataraman, 2020a). In some cases, toxic shock syndrome may as well be caused by an infection
of Clostridium sordellii – a normal bacterial flora of the vagina that could enter the uterus during
childbirth, normal menstruation, and gynecological surgeries like abortion (“Toxic shock syndrome
(TSS)”, n.d.). According to Venkataraman (2020a), acute symptoms start to manifest after one to two
weeks from the onset of the infection, which may include high fever, rash, hypotension, multiorgan
failure, and desquamation, usually of the palms and soles; moreover, severe myalgia, vomiting,
diarrhea, headache, and non-focal neurologic abnormalities are all possible symptoms of the clinical
syndrome. This syndrome was believed to be classically associated with the use of super-absorbent
tampons during menstruation, however, non-menstrual cases also occur (Ross & Shoff, 2020).
On the other hand, septic shock is a severe and fatal condition that results from sepsis-induced
hypotension due to an abundant immune reaction against an infection (Felman, 2021). Sepsis is
characterized as a life-threatening organ dysfunction resulting from dysregulated infection host
response wherein such organ dysfunction is described as having an acute change of two points in total
Sequential Organ Failure Assessment (SOFA) or greater secondary to the infection cause (Singer et
al., 2016). Symptoms of septic shock are usually nonspecific and may include fever (i.e., >38 °C), chills,
or rigors, difficulty breathing, anxiety, confusion, nausea and vomiting, and fatigue and malaise (Kalil,
2020).
References:
Septic and toxic shock syndrome (TSS). (2021). Children’s Health. Retrieved August 19, 2021, from
https://www.childrens.com/specialties-services/conditions/septic-and-toxic-shock
Venkataraman, R. (2020a, October 8). Toxic shock syndrome: Background, pathophysiology, etiology .
Medscape. https://emedicine.medscape.com/article/169177-overview
Toxic shock syndrome (TSS). (n.d.). John Hopkins Medicine. Retrieved August 19, 2021, from
https://www.hopkinsmedicine.org/health/conditions-and-diseases/toxic-shock-syndrome-tss
Ross, A., & Shoff, H. W. (2020, November 19). Toxic shock syndrome. Nih.gov; StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK459345/
Felman, A. (2021, June 9). How to avoid septic shock . Medical News Today.
https://www.medicalnewstoday.com/articles/311549
 University of Santo Tomas
Faculty of Pharmacy
Department of Medical Technology
Singer, M., Deutschman, C. S., Seymour, C. W., Shankar-Hari, M., Annane, D., Bauer, M., Bellomo, R.,
Bernard, G. R., Chiche, J.-D., Coopersmith, C. M., Hotchkiss, R. S., Levy, M. M., Marshall, J. C.,
Martin, G. S., Opal, S. M., Rubenfeld, G. D., van der Poll, T., Vincent, J.-L., & Angus, D. C. (2016). The
third international consensus definitions for sepsis and septic shock (Sepsis-3). Journal of the
American Medical Association, 315(8), 801. https://doi.org/10.1001/jama.2016.0287
Kalil, A. (2020, October 7). Septic shock: Practice essentials, background, pathophysiology . Medscape.
https://emedicine.medscape.com/article/168402-overview
------------

5. Which shock do you think the patient is in and why did you come to that conclusion?
● Toxic Shock Syndrome? since accdg to Mahon, TSS is a rare but potentially fatal,
multisystem disease characterized by a sudden onset of fever, chills, vomiting,
diarrhea, muscle aches, and rash, which can quickly progress to hypotension and
shock. It was first described in 1978 and was associated with women using highly
absorbent tampons, although some cases appeared in men, children, and
nonmenstruating women.
● TSS typically presents with rapid onset of fever, rash, and hypotension. It
may be preceded by a prodrome of fever and chills with nausea and vomiting
as well as nonspecific symptoms such as myalgias, headache, or symptoms of
pharyngitis (e.g., a sore throat, painful swallowing), which then progresses to
sepsis and organ dysfunction. Risk factors include superabsorbent tampon
use, nasal packing, post-operative wound infections, recent influenza
infection, as well as immunocompromised states.
https://www.ncbi.nlm.nih.gov/books/NBK459345/

6. What type of infections can lead to Toxic shock syndrome?

Toxic shock syndrome is caused by strains of

● Staphylococcus aureus producing a toxin (TSST-1)

○ commonly associated with menstruation or post surgical infection
○ TSST-1 is a superantigenic chromosomal-mediated toxin
● Streptococcus pyogenes producing pyrogenic exotoxin A, B. or C.
○ infections show severe manifestations with symptoms similar to of staphylococcal TSS

7. What cultures would you consider obtaining form this patient?

A blood culture using Mannitol Salt Agar (MSA). This will differentiate mannitol fermenting
bacteria and can isolate S. aureus.
- Mannitol salt agar can be used to isolate S. aureus since it ferments mannitol. This can
differentiate it with another bacteria that causes TSS, which is S. pyogenes.
- Vagina cultures may be obtained from the vagina or cervix so they can be analyzed for the
presence of Staphylococcus aureus. Because of the increased concentration and absorption of
TSST-1 in the vaginal mucosa, vaginal cultures for TSS diagnosis produce S. aureus in 85
percent of menstrual TSS cases. (Lowell & Daum, 2008)
 University of Santo Tomas
Faculty of Pharmacy
Department of Medical Technology
Lowell, G. S., & Daum, R. S. (2008). Staphylococcus aureus. Principles and Practice of Pediatric
Infectious Disease, 679–693. https://doi.org/10.1016/b978-0-7020-3468-8.50121-8

8. The vaginal culture was positive for many catalase positive, Gram positive cocci. What
organism do you expect this to be?

Staphylococcus aureus (pls check, i think it’s most likely this) i agree!

Toxic shock syndrome–associated S aureus can be found in the vagina, on tampons, in wounds or
other localized infections. Toxic shock syndrome is manifested by an abrupt onset of high fever,
vomiting, diarrhea, myalgias, a scarlatiniform rash, and hypotension with cardiac and renal failure in the
most severe cases. It often occurs within 5 days after the onset of menses in young women who use
high-absorbency tampons. -(Jawetz, Melnick & Adelberg’s Medical Microbiology 27th edition).

Certain strains of S. aureus cause toxic shock syndrome (TSS),a serious outcome of staphylococcal
infection, characterized by high fever, rash, vomiting, diarrhea, and death. TSS was first recognized in
women and was associated with the use of highly absorbent tampons. -(Brock Biology of
Microorganisms 14th edition).

Staphylococcal TSS generally results from a localized infection by S. aureus; only the toxin TSST-1 is
systemic. The initial clinical presentation of TSS consists of high temperature, rash, and signs of
dehydration, particularly if the patient has had watery diarrhea and vomiting for several days. In
extreme cases, patients may be severely hypotensive and in shock. -Mahon, C. R., & Lehman, D. C.,
(2016). Textbook of diagnostic microbiology (6th ed.).