Clinical Cases

This case concerns a ten year old boy presenting with pain and stiffness in his left knee. Previously well, he did suffer from 'septic spots' that usually disappeared after prescription of amoxycillin. On Friday 22 March he became ill with fever (39^oC), a raised pulse (120 beats per minute) and muscle aches and pains. His General Practitioner diagnosed influenza, and prescribed paracetamol for the boy.

The patient's condition deteriorated during the next 24 hours and by 6 p.m. on Saturday 23 March, he had a temperature of 40.2^oC and a pulse of 140 beats per minute. In addition to general aches and pains, he complained of pain in his left leg, just below the knee joint. Flexing the left knee caused severe pain.

His mother was unhappy with the diagnosis of influenza and rang the doctor's deputising service, who reassured her that the infection was self-limiting, and that it might be wise to persist with the paracetamol.

During the next 24 hours he showed no improvement, and the symptoms were aggravated by nausea and vomiting. The boy became flushed and delirious. His temperature was 41.0^oC by Sunday afternoon. The child was taken to the casualty department of St. James' University Hospital. He was seen at 7 p.m. and was diagnosed as suffering from meningitis because of his toxaemia, headache, and reduced level of consciousness. He was given intravenous cefotaxime. A lumbar puncture was performed.

Two hours later, the CSF was reported as normal, but his blood sample showed 3.5x 10⁹ leukocytes per litre, of which 92% were polymorphs. The diagnosis was changed to pyogenic sepsis of unknown aetiology. An emergency brain scan was performed to exclude a cerebral abscess. At midnight this was reported as normal.

The Consultant noted that despite a general restlessness, the patient did not move his left leg spontaneously. Careful examination of the upper part of the left tibia revealed an area where any local pressure caused extreme pain. The limb was swollen and red, and the mother said it had been like this for the past three days.

A diagnosis of acute osteomyelitis was now made, and the patient was referred to the orthopaedic department. Two boreholes were drilled in the upper part of the left tibia where inflammation was most marked. Each aspirate yielded 5 ml of bloodstained pus. The left knee joint was aspirated and its fluid was cloudy. The following results were reported by the laboratory:

The osteomyelitis had not invaded the knee joint - the effusion was sympathetic. The pus aspirate confirmed the diagnosis of osteomyelitis. The patient was treated with flucloxacillin and fusidic acid, begun after surgery was complete.

A 23 year old male, a known asthmatic, developed a 'cold' a week before a referral letter was written in March. He complained of malaise, generalised dull headache, a mild sore throat and non-productive cough. After four days he suffered a severe shaking chill lasting 15 minutes, his cough worsened and the patient produced a rusty coloured sputum. The patient was pyrexial when examined and was admitted to hospital. His notes are given:

This incident occurred in a psychogeriatric hospital, where many inpatients experienced a sudden episode of diarrhoea and vomiting. The first patients became ill on the morning of 21 August.

The affected patients all ate food on the menus below:

19 August

Lunch

Fried Cod Chips and Peas
Apple Crumble and Custard

Supper

Shepherds Pie Brussels Sprouts Boiled Potatoes
Lemon Meringue Pie

20 August

Primary culture of faeces from affected patients on MacConkey agar yielded motile, non-swarming Gram-negative bacilli that did not ferment lactose.

You have now been interviewed on local television because patients have died, and there is a call for a Government enquiry.

Mr AS sustained a compound fracture of the tibia in a motor car accident, and was admitted to the LGI. A swab was taken before cleaning the wound prior to suturing. Mr S was placed on traction to allow the fracture to heal. A culture is provided.

Four days after his accident, Mr. S became pyrexial (39.6^oC) and he had a raised white blood cell count. Whilst in hospital his fracture was immobilised. A sample of pus was aspirated from his wound. The isolate from the pus is provided.

After 70 days the original wound had healed, but the bone did not. Mr. S required a bone graft and fixation with pins attached to an external frame. Post-operatively there was a serosanguinous discharge from the wound. A swab was taken and the culture is provided for you.

Two days later Mr. Simmons was pyrexial (37.5^oC). He was started on gentamicin (120mg tds).

By day 90 Mr. S is progressing well, his wound has now healed, but he has a purulent discharge from the base of one of his pins. A staphylococcus was isolated.