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5 Feb 2018

Ben, a seven-year-old second grader, quickly finished his homework after school so he could play outside with his friend form next door. Since Ben had started coughing the day before, his mother insisted he wear his jacket. At bedtime, Ben was exhausted from his busy day. When kissing his forehead goodnight, Ben’s mother noted that he felt a little warm. To help Ben sleep more comfortably since he was likely getting a cold, his mother gave him a dose of pediatric Tyenol, “Poor Ben,” she thought. “Three weeks ago he had the flu and now a cold is starting. He could really use a break.”

In the morning, Ben didn’t come to the breakfast table when called. His mother found Ben still in bed, barely responsive, and extremely feverish. She immediately drove him to the walk-in clinic in their neighborhood. Ben’s oral temperature was 40.8C (105.4F). IV fluids were started and an ambulance transported Ben to the nearest hospital.

In the hospital emergency room, Ben presented with the following vital signs: temperature = 41.9C (107.4F), pulse = 162 bpm, pulse ox = 90%, respirations = 24/minutes and labored, BP = 62/54 mmHg. Ben was completely unresponsive. His physical exam was remarkable for rales or “crackles” heard over both right and left lower lung fields. Bilateral chest radiographs were ordered and revealed infiltrates in the lower lobes of both lungs.

Blood was drawn for hematology and metabolic panels. Two sets (1 set = 1 aerobic bottle and 1 anaerobic bottle) of blood cultures were also drawn and a lumbar puncture performed to collect CSF. Ben was air lifted to a major medical facility for treatment.

Preliminary lab results yielded a white blood cell count of 16,200 cells/mm^3 and a differential count with 74% neutrophils, including 18% bands. Respiratory acidosis was indicated by an arterial blood pH of 7.2. These results were immediately called from Ben’s local hospital to his new facility and broad-spectrum IV antibiotic therapy was initiated.

Within 6 hours of incubation, three of Ben’s four blood culture bottles were positive for bacterial growth. Aliquots from each of the three cultures were plated on blood agar plates (BAP) and on chocolate media and incubated for an additional 12 hours. At this time, a Gram stain was performed on the blood cultures which consistently yielded a Gram-positive diplococci. Ben’s CSF was sterile.

How did it end up in his blood if Ben’s initial problem was respiratory?

Approximately 6 hours later, the clinical microbiologist examined the BAP and chocolate agar plates. What morphological features did she likely observe on the plates? Why were these two media types selected for culturing?

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Lelia Lubowitz
Lelia LubowitzLv2
8 Feb 2018

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