Case Study

© 2011 by D'Maris Allen-Mierl

Andre, a nine month old boy had been breastfed till recently with some supplemental formula. He just began eating solid baby foods with only a bite or two of potato salad. His diarrhea began on Monday without vomiting or loss of appetite, but he began running fever on Tuesday. Upon taking him to the pediatrician, Andreís WBC was normal; he was eating and was hydrated, so he was sent home. Wednesday, mom noticed blood in his stool and the diarrhea was more watery, so she returned to the doc who took a stool sample to analyze; they were sent home again.

1.. What five microbes might be causing his problems.  (this is your differential diagnosis).  Explain why you believe each might be the cause.

By Thursday, Andre was noticeably weaker and his fever was now 102oC.  The doc saw him again and felt Andre just needed time to flush out even though he was pale, but still not vomiting.  His white count still tested normal.  While there, Andre had a bloody diaper which was taken to culture since the previous sample had been misplaced.  That night Andre had higher fever and was very fussy, though still taking bottles.  After seeing a different pediatrician in the practice Friday morning, a blood culture was drawn, but still no treatment was given.

2. Why arenít antibiotics given?  Explain three reasons why.
What should be done to control the fever?

Friday night was the worst!! Andreís fever was from 103oC - 105oC and he refused bottles. Mom called the doctor at 7am Saturday to let them know they going to the ER and the doc from the previous day agreed to meet them there.  The ER doc checked Andreís white count and put in an IV to rehydrate him since he was lethargic, though he wasnít concerned with the outcome and sent them home again, though Andre vomited there for the first time.  As they were leaving the ER, the blood culture report showed Gram negative rods, so Andre was hospitalized.

3.  What do you now think is causing this illness?  Give three most likely microbes and explain your rationale for each.
How do you think he was treated at this time and why?
(Hint:  A spinal tap was done, showing clear fluid.)

The first day in isolation Andre was worse with high fevers and painful, cramping diarrhea (bloody, green and slimy); by Sunday, he improved.  Lab results showed Salmonella enteritidis so the antibiotic was changed. He was also put on Floristor and Prevacid.

4. Why was the antibiotic changed?
Why was he given the other two meds?  Be specific for each.
What often happens when children are given antibiotics for this and how can these problems be monitored?

The family living next door to Andre have chickens and quail (one of Andreís brothers feeds them regularly).  They also had a new puppy as well as turtles and geckos in the house, though both are in an aquarium.

5. Explain three likely scenarios of how Andre may have been infected base on this case study.
Give a review of three recent outbreaks of this Salmonella that might be related to this case.

Don't forget to properly submit your references (endnoting) with your answers!