Case Study a
It was so exciting! Caitlyn was the only freshman girl selected for Varsity Singers, her high school’s touring show choir. Their summer “retreat” was a six-day mega-rehearsal to learn all of the choreography for their upcoming show season. Monday through Saturday the week before school resumed, the 28 performers danced from 8 A M to 8 P M in their un-air-conditioned gymnasium. Caitlyn didn’t particularly mind the hot, humid rehearsal conditions, but sweating profusely in dance leotards every day was really starting to aggravate the acne on her shoulders and back. After a special preliminary performance for their families on Saturday night, Caitlyn showered and dressed to go home. It was then she discovered a very large, angry “pimple” that rubbed uncomfortably on the back waistband of her jeans. By morning, it was raised and the size of a dime. Caitlyn’s mother washed the
affected area, cleansed it with hydrogen peroxide, and applied an antibiotic ointment, telling her they would call the doctor tomorrow if it didn’t improve.
Monday morning, the ﬁrst day of school, Caitlyn’s back was sore. “A great way to start high school,” she thought. Caitlyn’s mother took her to the pediatrician’s ofﬁce right after school. The PA examined her back and was alarmed to see a lesion almost two inches in diameter. It was tender to the touch with poorly demarcated margins. The region was raised, warm, and Erythematous (reddened) with several smaller red lines radiating outward.
After consulting with the pediatrician, Keﬂex was prescribed for Caitlyn. She was sent home with instructions to monitor the infection. If it was not obviously improved by the next day, she was to return for reevaluation.
On Tuesday morning, Caitlyn went immediately to see her pediatrician. The lesion was the size of an egg and quite sore. Caitlyn also presented with a temperature of 38.4°C (101.2°F). Motrin and compresses were advised as comfort measures. The Keﬂex was continued and the lesion cultured for laboratory
analysis. Again, she was told to return if she didn’t notice improvement.
The preliminary Gram stain of the specimen showed many Gram-positive cocci in clusters. After 24 hours, the TSA with 5% sheep blood plate demonstrated pure growth of small, round, smooth, white, gamma-hemolytic colonies. The same colony morphology was observed on the PEA (or CNA) plate with zero growth on the EMB (or MacConkey) plate. Colonies were also observed on the MSA plate, which was completely pink in color.
Colonies from the TSA plate were suspended in sterile saline and introduced into the Vitek II analyzer. It conﬁrmed Staphylococcus epidermidis was the pathogen involved and indicated Keﬂex sensitivity.
HATS Off to MRSA b
They had toyed with the idea for years, and now, Jacob, Tony, and Tom had ﬁnally made their dream of a family business a reality. With Jacob’s computer expertise, Tom’s experience from his marketing internship, and Tony’s apprenticeship with a master painter, the three brothers were conﬁdent that “Color Your World Painters, Inc.” would be a successful business venture. After only six months, their Internet and local TV advertising had made them a household name in their community. Tony had to hire additional painters to handle their burgeoning workload. The brothers moved to a larger ofﬁce, purchased improved equipment, and issued all employees uniforms and painter’s caps with their ﬂashy new logo.
Business that summer was booming. The hot, sweaty paint crew worked from sun up to sun down every day. Upon returning to headquarters, they hung their caps on the wall, changed out their uniforms for street clothes, and collected nice fat paychecks. Jacob boasted smugly that things couldn’t be better…until one morning Tony didn’t show up for work. Annoyed, Jacob grabbed a uniform and Tony’s hat, got the painters organized, and took his brother’s place on the work crew while Tom tried to track down Tony. Tom’s second phone call reached his ﬁve-year-old niece, who was answering her mother’s cell phone. In a small and tearful voice, she told her uncle that they were at the hospital and daddy was
very sick because he had slime leaking out of his head. Conﬁdent that his niece’s imagination had run away with her, Tom reassured the little girl and told her he would be right there. Tom left a voicemail message on Jacob’s cell phone and headed to the hospital. When he met his sister-in-law, Julia, Tom was shocked to ﬁnd his brother was in surgery. Stunned, Tom listened to Julia describe the events of the last few days. Out of embarrassment, Tony never mentioned to his brothers that he periodically suffered from boils around his hairline when working under hot, humid conditions. Two days ago, when Tony noticed the ﬁrst few boils appear, he assumed it was just a recurrence of his seasonal problem. But, after 24 hours, Tony was becoming concerned. This was the worst case he had ever experienced. He had at least a dozen boils on the back of his neck and into his hairline. Despite his discomfort, Tony continued work without complaint, although he secretly blamed his problem on wearing the new company cap that made him sweat more around his hairline.
That evening, Tony showed Julia his neck and asked her to help him disinfect and bandage the area. His frightened wife pleaded with him to go to the emergency room, but Tony ﬂatly refused. Number one, they didn’t have health insurance and he certainly did want to run up a bill. But number two, Tony was not about to be humiliated by going to the hospital for something so simple. In his mind, boils could hardly be considered life-threatening. Julia gently cleansed the area for her husband, counting 13 boils the size of a dime or larger. Tony winced in pain.
line. Tony found it humorous that his “gooey zits” got quick attention at an ED known for its long wait times. Dr. Bergmann, an infectious disease physician, examined Tony, noting heat, extreme erythema, folliculitis, 15 boils ~1–2 cm in diameter, some draining copious amounts of pus, and numerous seeping ulcerations. Dr. Bergmann applied a topical anesthetic before lancing several boils for culture. He ordered four sets of blood cultures drawn, started broad spectrum IV antibiotics, and immediately scheduled Tony for surgical debridement of his infection.
Tom and Julia sat for about an hour in the waiting room before Dr. Bergmann arrived with an update on Tony’s condition. Preliminary Gram stain results from the lab conﬁrmed Gram-positive clusters of cocci in Tony’s boils. Due to the extensive tissue damage, Dr. Bergmann conﬁded to the family that he suspected community acquired-MRSA. Although Tony was “resting uncomfortably,” the surgical debridement of a 3.5 cm 10 cm area was a success. Tony would receive a three-week course of IV vancomycin before being permitted to return to work.