Part I—Trouble in the Nursery “Flesh eating bacteria? You’re kiddi...

Part I—Trouble in the Nursery
“Flesh eating bacteria? You’re kidding, right?” Dr. Matthew Mitchell winced as he tried to understand the alarmed nurse at the other end of the phone. “Slow down and tell me again what’s happening.” Matt knew that he needed to stay calm and try to buy time to understand the problem. It was the first time he had been left as the sole physician in charge of the struggling White Rock Clinic. Dr. Jennifer Eckenrode, the seasoned senior physician in their partnership, had left for Nepal two weeks earlier on a three-week expedition to climb Mount Everest.
The nurse, Joan Benjamin, continued, “All I know is that I have three really sick babies down here. The Wandell twins started to go bad yesterday. They have a strange rash on their thighs and they’re running a fever. I thought it was just ordinary diaper rash, but this evening when I was rubbing some ointment on it, the skin started coming off in sheets! Now the LaComb baby looks like she has the same thing under her arms.”
“You haven’t started using some new lotion or soap on them, have you?” asked Matt, hoping that he wasn’t going to have to resurrect his knowledge of infectious disease. “Perhaps you’re using something that’s too harsh for the skin of neonates.”
“No, no,” Joan answered impatiently. “I’ve been working in neonatal nurseries for 25 years. I think I know a thing or two about washing babies. Can you reach Dr. Eckenrode? She knows how to handle these sorts of things.”
Matt resisted the urge to snap back at her. If he had to call Jen in Nepal he’d never live it down. “No need to call her. She left me in charge. I just need to take a look at the little guys. I’ll be right up.”
Matt took the stairs up to the nursery two steps at a time. Turning down the hallway he could see a small cluster of visitors cooing and waving at a small red-faced infant being displayed through the nursery’s large plate glass window. Behind them Nurse Benjamin was hovering over an isolette. Matt hurriedly washed his hands and walked over to the isolette to examine the baby.
Joan didn’t look up when he arrived but simply murmured “Dr. Mitchell” under her breath as if his name were something distasteful. The Lacomb baby was wearing a tiny knit cap and was wrapped tightly in a hospital blanket. Matt gently unwrapped the blanket and lifted up the baby’s white undershirt to examine her skin. He could see some small vesicular lesions on the inside of her upper arm. Farther up, in the axillary area, there was a moist red area about the size of a quarter. The baby girl seemed warm to the touch, and she began to fuss and wave her fists in response to his probing. He replaced the blanket and walked over to the isolette that held the first of the Wandell twins.
“Baby Boy A is worse than his brother,” Joan called from across the nursery. Matt undressed Baby Boy A and removed his diaper to look at the affected area. The entire area of the tiny baby’s groin appeared to be involved, demonstrating the same strange skin infection. Maybe Joan was right—perhaps this was the beginning of necrotizing fasciitis, the famed “flesh eating bacteria” of tabloid lore. No matter what it was, he needed to act quickly to avoid any kind of negative publicity.
Matt looked up in time to see Ben Albin, the clinic administrator, enter the nursery wearing a grey pinstripe suit that seemed oddly out of place in the antiseptic and starched white surroundings of the nursery. “Dr. Mitchell,” Ben said curtly. “Nurse Benjamin has notified me that we have a potential situation here in the nursery. It looks as though we need to give Dr. Eckenrode a call.” Matt shot Joan a withering glance, but she studiously ignored it. “No, no,” he replied. “I’m sure I can handle this. Besides, Jen has probably already started up the mountain. She’s undoubtedly out of contact with everyone, except perhaps her Sherpa guides.”
“For your sake, I hope you’re right about being able to handle this,” Ben countered. “We can’t afford to have an epidemic in the news. You know that Whittaker Memorial Hospital has been looking for an excuse to shut us down. I’m sorry, but I can’t risk losing this clinic just so that you can pursue some idea of being a hero. I’ll give you 24 hours—after that I’m quarantining the nursery and calling in the county health department. If there is any negative publicity about delaying even a day, I’m holding you personally responsible.” With that, Ben turned abruptly and headed out of the nursery.
Matt looked down at the mewling infant and soberly rewrapped him in his powder blue blanket. “Well, Dr. Mitchell?” Joan inquired, her voice tinged with sarcasm. “What are your instructions?”
“I’ll have them written out for you as soon as I check on a few details,” Matt responded. He was going to have to read up on infectious agents that could cause this kind of a skin disorder—and fast. Matt wished he had been a better student of infectious diseases. He hated to admit it but he had just barely passed that part of his education. The reference collection in the clinic library was a bit sparse and somewhat outdated, but at least it was a place to start.

Question 1 (10 points)

What are some possible causes of skin infections? List at least 5 DIFFERENT organisms (include genus and species, if applicable). Briefly describe the problem each can cause. 10 points

Part II—Plan of Attack
Matt sighed as he took a look at the lengthy list of potential pathogens he had jotted down while paging through the library textbooks and reference manuals. The organisms and diagnoses seemed limitless. The few hours he had spent researching a possible cause had, however, jogged his memory of infectious disease. He decided his best course of action was simply to take samples from the affected areas and submit them to the microbiology laboratory for stain and culture.
Matt returned to the nursery armed with a set of culture swabs. Joan peered furtively through lidded eyes as he went from isolette to isolette collecting specimens from each baby. Brandishing the culture swabs like weapons, he then marched out of the nursery and down the stairs to the microbiology lab.
“Good afternoon, Dr. Mitchell.” Matt stole a glance at the badge pinned to the lab coat of the young woman who greeted him. He could never figure out how people he couldn’t remember ever meeting seemed to know him by name. Amber Muirhead, MT(ASCP)SM, the badge said.
“Ms. Muirhead, I have a few specimens from the nursery that need priority treatment. The specimens were taken from some unusual skin lesions on three of our infants. I know that we need at least a routine culture and sensitivity with Gram stain. I could order some more esoteric testing, but I’m hoping that we can get some clues from this initial work.”
“We’ll set up the Gram stain right away. I’ll have one of my best microbiologists work just on this case until we can get some answers. If you wish, Dr. Mitchell, you can stay here and read the direct Gram stain yourself.”

Question 2 (2 points)

You are the microbiologist in charge of reading the Gram stain for this case. You observe Gram positive cocci, epithelial cells, and neutrophils. List at least two genera of clinically significant bacteria that are consistent with your observations.


Part III—Tracking the Culprit
“I was just thinking about media,” Matt remarked to Amber. “We can use pretty typical media to isolate those, right?”
“Yes, we would usually set up these specimens on five percent sheep blood agar, MacConkey agar, and CNA or PEA agar. We also frequently set up a liquid culture along with the plates.”
“That sounds like a good plan. I’ll check back first thing in the morning to see if there’s any growth on the plates.” Dr. Mitchell thanked Amber and the microbiologist who had helped him and went back upstairs for a last check on the sick babies before heading home for some much-needed rest.
Upstairs, he nearly ran into Ben Albin, the hospital administrator who had given him an ultimatum earlier. “Hello, Ben,” Dr. Mitchell said tersely. “What brings you out of the administrative suite for a second time today?”
“There are some mighty agitated parents in the nursery, Matt. I think you need to convince them that you have a reasonable plan for taking care of their kids.” Ben turned and began walking back toward his office. “Remember,” he called over his shoulder to Matt. “Controlling this outbreak is only half of your problem—controlling the damage is also your concern.”
Matt looked through the window of the nursery in order to size up the situation before entering. He saw a well-dressed couple in their mid-30s standing beside the Wandell twins’ cribs. The woman was quietly weeping while the man had his arm protectively wrapped around her. Nurse Benjamin was standing next to Baby Girl LaComb’s isolette, deep in conversation with a woman with red hair wearing a chenille bathrobe. The woman was clearly agitated.
Resisting the urge to turn on his heel and flee, Matt pushed open the door and entered the nursery. The couple next to the Wandell twins continued their mournful vigil without seeming to notice his presence. Matt heard Joan say to the woman in the bathrobe, “Here’s Dr. Mitchell now. I’m sure he has some information for you.”

Matt approached the woman with his right hand extended. “I’m Dr. Mitchell. You must be Mrs. LaComb. Congratulations on the birth of your daughter.”
“Where’s Dr. Eckenrode?” said the woman, ignoring his outstretched hand. “She’s taken care of my other two. No offense, but I want my own doctor taking care of Lisa.”
“Lisa—what a beautiful name,” Matt said, hoping to put Mrs. LaComb at ease. “Dr. Eckenrode is out of the country for a few weeks. She left me in charge. I’ve already ordered some tests to help us determine the best treatment for Lisa.”
“Treatment? Just what did she catch from those other babies? Her skin has this terrible rash that’s peeling off! She looks awful. What kind of a place is this anyway?” The color rising in Mrs. LaComb’s face was beginning to match that of her hair. “If Dr. Eckenrode can’t take care of her, I’m taking her to Whittaker Memorial Hospital right now.”
Dr. Mitchell took a deep breath and responded in a measured tone. “I’m sorry, Mrs. LaComb, but I can’t allow you to take Lisa right now. She’s too sick to be discharged, and Whittaker won’t admit her into their nursery in this condition anyway.”
“You can’t keep my baby here! I’m calling my brother-in-law first thing in the morning. He’s editor of the biggest newspaper in the county. He’ll make sure people know what kind of a clinic you’re running.”
“Let’s try not to panic, Mrs. LaComb. The microbiology lab is zeroing in on the cause of your daughter’s illness even as we speak.” A bit of an exaggeration, Matt knew, but not an outright lie. “I’ll stop by your room in the morning and let you know what we’ve found. I’m sure we’ll have this solved by then.”
“You better have it solved by then. I’ll be waiting to hear from you, Dr. Mitchell—but I won’t be waiting for long.” Mrs. LaComb turned, pushed open the nursery door, and walked out.
Matt sighed. “Would you please fill in the Wandell parents?” he said to Nurse Benjamin. Joan looked stunned by the exchange she had just observed. Surprisingly, she simply nodded and walked over to the couple standing by the cribs and gently began speaking with them. Matt took the opportunity to escape, walking quickly to the clinic exit and out into the cold night air. Tomorrow would be here sooner than he wanted.

Question 3 (8 points)

What is the purpose of the four types of media listed (5% sheep blood agar, MacConkey agar, CNA and PEA agar)? Be specific.

Question 4 (2 points)

Which aerobic Gram positive cocci are normal flora on the skin (at least 2)?


Part IV—Eureka!
Matt cautiously pushed open the door to the microbiology lab and glanced around the room. He could just make out the top of Amber’s head, barely visible behind several tall stacks of multi-hued bacteriological media as she bent over a culture. “Don’t these people ever sleep?” he wondered, simultaneously admitting to himself that his night had not been exactly restful. Matt cleared his throat, hoping to get her attention without appearing too eager. Amber looked up, smiled, and set aside the culture she had been examining.
“Any new information on those nursery cultures, Ms. Muirhead?”
“Oh, yes, of course, Dr. Mitchell. We called the report up to the floor earlier this morning. Let me show you what we found.” She pulled a microscope slide from a small cardboard box and placed it under her microscope. “Take a look for yourself.”
Matt sat down and began to scan the slide. Spread out across it was a sea of round purple spheres that looked like those he had seen on yesterday’s slide of the lesions. “So many,” he observed.
“Yes,” Amber responded. “This smear was taken from a culture plate, so there will be a large number of organisms. Here are the plates, if you’d like to have a look.”
Matt picked up the sheep blood plate first. It was covered with round, opaque creamy colonies. He held the plate up to the light to get a better look and noticed that there was a halo around each tiny colony where the sheep blood appeared to be missing from the agar. The plate labeled “PEA” looked nearly identical. Matt sniffed the plate, enjoying the scent, which reminded him of the Rose Milk lotion his grandmother used to use. Finally, he picked up the lavender plate labeled “MAC” and held it up to the light. Except for the tracks left in the pattern of the microbiologist’s inoculating needle, the plate looked completely barren.
“We performed catalase testing on the isolate,” interjected Amber. “You should have seen the way it bubbled! We have a rapid agglutination test in this laboratory that we used instead of the coagulase test. This isolate was a strong positive. There’s no doubt about its identity now, is there?”
Matt closed his eyes and rubbed his temples in an attempt to dislodge the buried bits of information. “Why, it looks for all the world like ________________!” he said, surprised by the confidence of his answer.
“Exactly!” replied Amber. “We have antimicrobial susceptibility testing already set up and running. Using our automated system, we may have the results available later today.”
“Great day in the morning!” Matt jumped up from his seat, grabbed the shoulders of a very startled Amber Muirhead, and planted a kiss right in the middle of her forehead. He then turned, tossed open the laboratory door, and trotted down the hallway toward the medical library.
Back in the library, Dr. Mitchell went straight to the small pile of reference books he had been working with the previous evening. Choosing a likely looking volume entitled Pediatric Infectious Disease, he looked up ___________________ in the index. There were about a dozen pages listed. “Hmmm, … food poisoning in breast-fed babies just doesn’t sound right at all….” Matt continued to flip pages, more and more impatiently. Abruptly, he turned a page and met the gaze of a newborn staring unflinchingly out at him. Except for the tiny hat stenciled with the name of an unknown hospital, the newborn could have been one of his patients in the nursery. The baby was pictured lying in a crib naked except for the hat. There was an angry looking rash extending from the baby’s groin upward to above his umbilicus. The skin had peeled away from the rash, leaving a moist, bright red surface. The caption read “_______________________.”
“Time to write some orders!” Dr. Mitchell pushed back his chair and strode down the hall toward the nursery. As he entered, he could see that Ben Albin was there trying to soothe Mrs. LaComb. The Wandell parents were still staring mournfully down into the twins’ isolettes. Nurse Benjamin glanced resignedly at him.
“Good morning, everyone! How are our patients doing today?” Matt walked over to the LaComb baby’s chart and flipped it open. “Good news, Mrs. LaComb, we have a diagnosis for Lisa, and I am prescribing a medication that should have her skin back to its former beauty in just a few days. Mr. and Mrs. Wandell, your little ones should be on the mend very soon, too.”
Matt pulled Ben aside and discreetly murmured, “We still need to work with the health department to trace the source for this organism. I’d like to collect nasal swabs from anyone who has had contact with these babies. Clinic staff, including myself, are the most likely source.”
Ben’s eyes darted furtively to the others in the room as he whispered, “You won’t mention this to anyone else, of course.” He placed his hand on Matt’s shoulder. “I knew we could count on you, Matt.”
“Sure, Ben. Thanks,” Matt answered wryly.
The nursery phone rang and Matt walked over to answer it. He could hear static and then, faintly in the background, Dr. Eckenrode’s voice. “Matt, is that you? I only have a few seconds on this line. I’ve just returned from the summit! I’m having the time of my life! How is everything there?”
“Well, hello, explorer! Everything’s under control here, Jen. I’ll fill you in when you get home. Have a great time!”

Question 5 (12 points)

1 Identify the organism. Include both genus and species. (4 points)
2 Identify the disease. (2 point)
3 Explain the rash. Here I am looking for a specific virulence factor that is responsible for the rash. (4 points)
How should it be treated? (2 point)

Question 6 (10 points)

Many people, especially healthcare workers, carry Staphylococcus aureus in the anterior nares. How, then, are infections passed from these caregivers to their patients? How can transmission be prevented?


Part V—From Nightmare to Naptime
Matt stuffed his pen into the pocket of his rumpled white coat and flipped shut the chart he had been working on. It made a comforting thud as Matt slid it back into the rack. “Discharge orders are written for the Wandell twins and the LaComb baby, Nurse Benjamin,” he announced. He felt a sense of elation, as though he were completing an arduous journey. “Would you please let the parents know they can take their children home this afternoon?”
“Thanks, I’ll take care of that,” Joan responded. “Mrs. LaComb is in with her baby now. She was looking for you earlier.”
Matt’s heart sunk a little. He had been hoping to avoid any more confrontations. Joan Benjamin had been considerably less challenging the past few days. The report from the health department that she carried in her nares the same staphylococci that caused the outbreak in the nursery had subdued her somewhat. Matt had treated her with an antibiotic, and together they had reviewed the gloving and handwashing protocols for the nursery.
Given the dramatic improvement in the babies, Matt just couldn’t imagine what Mrs. LaComb could come up with to cast a shadow over his day. Slowly he turned and headed into the nursery.
“Dr. Mitchell!” He turned toward the voice and greeted Mrs. LaComb. “Dr. Mitchell, I’ve been waiting for you.”
“Mrs. LaComb, how are you this morning?” Matt tried to conjure up his most charming smile. “Can I answer any questions for you?”
“Oh, Dr. Mitchell! I just wanted to thank you for everything you did for Lisa. I’d like to have you continue to be her doctor after she is discharged. Do you think that Dr. Eckenrode would be offended?”
“I’m sure she would want you to do whatever makes you comfortable, Mrs. LaComb. Besides, she often covers for me when I’m unavailable. I’d like to see Lisa on Monday, just to make sure that she continues to do well.”
“I’ll make an appointment for Monday, then. Thank you again, Dr. Mitchell!”
Matt gave her an appreciative smile and headed out the door and toward the parking lot. He was thinking he had an appointment of his own to make—for a long, restful weekend nap.

Question 7 (6 points)

Write 100 words on the significance of the case study to you and how it relates to problems we face today.