WLRN 2006 Case Study

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WLRN 2006 Case Study
Tim Monson Laboratory Program Coordinator, Food
Water-Borne Diseases Phone
608-262-3302 Email mony_at_mail.slh.wisc.edu
Julie Tans-Kersten Laboratory Program
Coordinator, TB Phone [phone] Email
tanskejl_at_mail.slh.wisc.edu
Wisconsin State Laboratory of Hygiene
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Case Study Day 1

• Three boys, ages 8-9, show up in the ER of
  Hospital A December 14 15.
• Symptoms
• Abrupt onset of pharyngitis(2)
• Fever
• Chills
• Nausea
• Vomiting
• Diarrhea
• Myalgia
• Malaise
• Boys are playmates.

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Case Study Day 1

• Rapid Strep antigen test negative on two boys
  with pharyngitis
• Routine stool cultures ordered on all 3 boys
• Strep A culture ordered for the 2 boys with
  pharyngitis
• Treatment Amoxacillin/clavulanate sent home
• Parent of one boy comments to intake nurse
  regarding the oddity of all three boys ill.
• Rapid Flu test(s) negative.

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Case Study Day 3

• The 3 boys seen in follow-up by personal
  physicians - symptoms persisting.
• Have developed cervical lymphadenopathy
• Stool cultures Strep A cultures are negative.
• Blood cultures collected.
• Elevated WBC noted (24,500/mm)
• No response to Amox/clavulanate
• Doxycyline treatment initiated

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Case Study Day 5

• Father of one of the boys arrives at ER.
• Symptoms
• Ulcerative lesion on finger thumb
• History of painful papules at site of lesions
• Enlarged regional lymph nodes
• Fever
• Chills
• Myalgia
• Malaise
• Mild GI symptoms
• Started about a week ago

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Case Study Day 5

• Father (continued)
• Elevated WBC counts
• Blood cultures initiated
• Wound culture collected
• Serum collected for possible serology studies
  later
• Treatment Ciprofloxacin
• No growth in blood cultures of the 3 ill boys

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Case Study Day 5Fathers Hand Lesion
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Case Study Day 5Fathers 2nd Hand Lesion
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Case Study Day 7

• Fathers wound culture showed normal skin flora
  pin-point colonies at 48 hour on chocolate agar,
  normal flora on sheep blood agar.

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Case Study Day 8

• Your machine flags one blood culture positive
  from one of the boys.
• No organisms seen on gram stain.
• Blood culture subcultured onto chocolate agar
  sheep blood agar.
• Cultures remain negative for the remaining 2
  boys.
• The father is responding to cipro therapy.
• The 3 boys are responding to doxycycline.

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Case Study Day 11

• Microbiologist who worked on the blood cultures
  calls in sick with
• Abrupt onset of fever
• Chills
• Myalgia
• Malaise
• Nausea

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Case Study Day 11

• Blood subcultures
• SBA shows possible pinpoint colonies
• Chocolate agar shows some small colonies.
• Want to see the cultures?

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Case Study Growth at 48 hours
Chocolate Agar
Sheep Blood Agar
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Case Study Day 11

• Want to see the gram stain?

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Case Study Gram Stain
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Case Study Day 11

• What would you do next?

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Case Study Day 11

• Which rule out tests would you perform?
• Oxidase
• Oxidase - Negative
• Catalase
• Catalase Weak Positive
• Beta-Lactamase
• Beta-Lactamase - Positive
• Urease
• Urease - Negative

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Case Study Additional Information

• ID doctor provides some additional case
  information.
• No history of travel outside the U.S.
• No common meals to all four initial cases
• The father had butchered several rabbits 1 week
  prior to his onset of illness
• The 3 boys had played extensively with the hides
  of the butchered rabbits while they were drying
• Treatment changed to Streptomycin for 10 days
  for all 4.

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Case Study

• What would you do next?
• Send subculture of isolates to WSLH for F.
  tularensis PCR DFA confirmatory testing.
• PCR DFA both positive at WSLH for F.
  tularensis.

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Case Study Serology Test Results

• F. tularensis serology ? 1160
• Is this confirmatory or presumptive?
• What happens next?
• Follow up with convalescent serum to look for
  4- fold rise in titer.

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Case Study Infection Control

• What is the response by Infection Control?
• Isolation of patients?
• Prophylaxis of contacts?
• What is the lab response regarding biosafety and
  potential exposures?

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Case Study Reporting

• When would this be reported to
• Local Public Health Agency?
• Wisconsin Division of Public Health?
• WSLH?
• Tularemia is a Category II reportable disease in
  Wisconsin
• The following diseases shall be reported to the
  local health officer on an Acute and Communicable
  Disease Case Report (DPH 4151) or by other means
  within 72 hours of the identification of a case
  or suspected case. See s. HFS 145.04 (3) (b).

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Case Study Definitions

• Presumptive Laboratory Positive Single elevated
  serum antibody level to F. tularensis antigen in
  a patient without history of vaccination or a
  positive fluorescent assay result
• Confirmatory Laboratory Positive Isolation of
  F. tularensis from a clinical sample or a
  four-fold or greater rise in antibody titer to
  F. tularensis antigen
• Presumptive Case Clinically compatible case with
  lab results indicative of presumptive infection
• Confirmed Case Clinically compatible case with
  confirmatory lab results

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Case Study Select Agent Issues

• Sentinel Laboratory Responsibilities
• Call, Fax, or Email CDC Select Agent Program
  IMMEDIATELY after you receive confirmatory report
  from WSLH.
• Secure the Select Agent from theft or loss
• Within 7 days of confirmation
• Submit Form 4 to CDC destroy specimens/
  isolates by recognized method
• OR submit Form 2 4 to CDC and transfer to
  registered facility (may require prior approval)
• Please fax a copy of the form(s) to WSLH

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Case Study Select Agent Issues

• WSLH Responsibilities
• Report results to you with guidance on Select
  Agent requirements
• Report to CDC Select Agent Program by Phone, Fax
  or Email immediately after confirmation
• Report results to WDPH ASAP (presumptive
  confirmatory results)

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Case Study F. tularensis Review

• Agent of Tularemia
• Category A Select Agent
• Clinical Presentation ulceroglandular,
  glandular, oculoglandular, oropharyngeal,
  intestinal, pneumonic and typhoidal presentations
  possible
• Treatment Streptomycin or Gentamicin
  Doxycycline, Cipro or Chloramphenicol alternates

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Case Study F. tularensis Review

• Small, gram negative coccobacillus
• Culture
• May not grow or may grow very slowly in the
  laboratory (extended blood culture necessary)
  generally grows very poorly on standard blood
  agar plates.
• May be enhanced by enriched plating media, e.g.,
  chocolate agar with isovitalex or similar, rabbit
  blood agar, or cysteine-enriched media (cysteine
  heart agar or BCYE agar)
• Highly infectious well-known cause of laboratory
  acquired infections

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Case Study F. tularensis Review

• May be acquired via tick bite (after a blood meal
  on an infected animal)
• May be aerosolized by lawn mowers and brush
  cutters
• May persist in the environment (cold soil
  water)
• Generally rural occurrences rarely seen in urban
  populations
• U.S. averaged 124 cases per year during 1990-2000
  
• WI has had 5 reported cases since 1999

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U.S. Cases of Tularemia Reported to CDC, 1990-2000

• 1,368 cases from 44 states
• Average of 124 cases per year

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Case Study Growth on Cysteine Heart Agar after
72 hours