patient complaining of fever, diarrhoea and vomitingCase Study 1A 47-year-old male presented to University College Hospital complaining of fever, diarrhoea and vomiting. He had travelled to the Ivory Coast in West Africa a fortnight previously to attend a job interview. He had a history of fever, chills, and rigors for 5 days, with generalized tonic-clonic seizures, occurring 2-3 times per day, for 5 days. He also had a history of loss of consciousness 2-3 times a day, each episode lasting for 2-3 min. He complained of loss of power in the right upper limb for 4 days. CNS examination revealed that he was conscious and oriented. There was no neck rigidity. Power in the right upper limb was 4/5. His sensory and motor systems were normal and there was no cranial nerve deficit.He had spiking fevers at irregular intervals of 36 or 48 hours. He was jaundiced and had haematuria. Noting the patient?s history of diarrhoea and vomiting and also his recent travel to Africa, a Widal test and blood culture were requested withbiochemical and hematological investigations.The Widal and blood culture tests were negative. Liver function tests showed elevated ALY and AST. The haematologicaltest results showed aheamoglobin level of 10.2 g/dL (normal range 13-18 g/dL); elevated white blood cell count of 14,000/mm3(normal range 4,000-11,000/mm3 ), composed of 70% neutrophils, 11.8% lymphocytes, 11.6% monocytes, 6.4% eosinophils and 0.2% basophils. The platelet count was reduced at 135,000/mm3 (normal range 150,000-450,000/mm3) and C-reactive protein level was elevated at 1.2 mg/dL (normal range 0.2 to 1.1mg/dL).Figure 1: Peripheral blood at 5 pm. Wright-Giemsa staining a): thin smear ?1,000 magnification. b): thin smear ? 400 magnification.Wright-Giemsa staining of blood smears was performed and the forms shown in Figure 1 were found.Case Study 2A 6-year old girl was first seen in the clinic because of failure to thrive and vague symptoms like poor appetite and failure to gain weight. The child was apparently fine until about two months ago. Subsequent to a holiday when the family went swimming in fresh water lakes, she developed diarrhoea with light coloured stools, and started to lose weight. She was not eating well, and her mother indicated she was generally listless and not very active. Although stool examinations were performed, it was unclear exactly what diagnostic methods were used and the examinations were reported as negative. The child was placed on a high protein, high calorie diet with vitamins and supplements but showed very little improvement.On examination the child had flatus and was belching with a foul rotten egg smell. Her parents reported that the child had bouts of abdominal pain, vomiting, and low grade fever that were cyclical and not continuous. They had noted occasional blood in her stools and stated that her tiredness, weight loss, nausea, and headache had persisted for 21 days. Stool examinations were performed; the first two specimens were negative while the third revealed the form shown in Figure 1 in a wet preparation of stool. Motility was seen, but it was very limited and the organism identification could not be confirmed. Further specimens were negative but re-examination of the third specimen showed the forms in Figure 2.The girl was given treatment and recovered.HOW TO ANSWER QUESTIONS IN CASE STUDIESFirst of all, analyse the symptoms and, if any, the results of initial diagnostic tests performed. Think about what kind of disease you are dealing with. Think about what microorganism might possibly cause this disease.ALWAYS GIVE A REASONED EXPLANATION TO YOUR ANSWERS.What is the likely diagnosis?What is the clinical disease?What is the clinical diagnosis?Please do not just mention the microorganism you think is the cause of the illness. You need to give a diagnosis, explaining what kind of disease the patient has (based on the data given when the case study is presented, considering the symptoms, and initial diagnostic tests, if any).What is the likely cause of illness?What is the likely cause of this person?s condition?Which organism is most likely responsible for this infection?What is the most likely aetiology of this person?s symptoms?Please answer giving an explanation, with a complete reasoning, taking into consideration the symptoms, and why you choose one microorganism as the cause of this illness over another (e.g.Trypanosomacruzirather than Trypanosomabrucei).How can the clinical diagnosis be confirmed?What other investigations may be helpful?Which tests can be used for the identification of this microorganism?Which media would you use and what laboratory tests would you carry out?What further request would you make to isolate the aetiological agent? Give reasons for your requests.Please answer with a logical order:? What samples do you need? E.g. blood sample, swab from throat, sputum, etc.? Can you perform microscopy? What kind of staining technique? And what do you expect to see?? Can any of the samples be plated on solid media? What precautions do you need to take, if any? What selective media would you use? What are you expected to see?? Please mention all the appropriate diagnostic tests you can think of (appropriate to the situation, of course)What is the treatment of choice?What antimicrobial therapy is indicated?What options are available for the treatment?What is the appropriate therapy for this patient?Which drug should be used to treat this infection?Please do not just make a list of antibiotics. Suggest the appropriate one at first, then add what could be used if, for example, there is an allergy (e.g. to penicillin), or co-infection, or resistance.How could this infection have been prevented?Please do not just say ?vaccination?. Explain which vaccine would be appropriate for the patient; different ages/risk groups might be needing different vaccines. Explain these differences.What factors are associated with an unfavourable prognosis?What factors could make this infection deteriorate in something else/worse? E.g. blood infection, being part of a risk group, other chronic diseases, etc.Once again, above all, ALWAYS GIVE A REASONED EXPLANATION TO YOUR ANSWERS.!
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