Assignment
Here are disease to think of while solving these cases:Viral Hepatitis and Measles, Vaccines and Hospital-Acquired Infections (HAI), Middle East Respiratory Syndrome (MERS), Meningitis and Rabies, Vector-borne and Emerging Infections, Hantavirus and Nipah,Foodborne and Waterborne Diseases, Ebola, Clostridium difficile, and Necrotizing Fasciitis, Acute Respiratory Infections and MRSA,Influenza and Avian and Swine Flu, Tuberculosis, Polio, Candida auris, and more...
CASE I
Today is December 2nd. The local hospital has reported ten cases of a mysterious infectious disease among children. The children have suffered from nausea, diarrhea (profuse and watery), abdominal pain, and fever, primarily. Each of the children has vomited at least twice in the past 24 hours.All of the children are between the ages of 7 and 11 and reportedly have been to Franklin Park Mall in the past three days. Specifically, the play area and cars near the food court. Using your infectious disease knowledge, what would you do to try to identify the agent? What other public health actions should you take to prevent more cases from occurring? What do you think is the likely agent and why? What are the potential fomites in a shopping mall and how would these be assessed?
Some clues: All the children at the McDonald's at the food court on November 28th or November 29th. The same employees worked at McDonald's on both days, though Jenny had been ill from November 24th - 26th, suffering similar symptoms as the children. She rotates duties at McDonald's and is often on her phone while at work, responding to texts at 867-5309.The equipment and storage units at McDonald's have been inspected and are clean. Bathroom is clean but some employee's, like Jenny, do not wash their hands. All the employees rotate between food service, cash register operation, and drinks replacement, table cleaning, and utensil replacement. Nine of the ten children played at the play area on the 27th or 28th. Five of them sat on Santa's lap and told him what they want for Christmas. The play area includes a ball pit, bounce house, Merry-Go-Round, and toys in the middle of the mall (fenced off, but parents are with the kids).
CASE II
Bioterrorism can occur in a variety of ways and may or may not include Category A agents.What makes agents like Bacillus anthracis both a "good" biological weapon and a "bad" one? Do the same for Yersinia pestis. Are either of these transmissible person-to-person? Why must epidemiologists be involved with the aftermath of suicide bombing events? Explain why infectious agents, with varying levels of potential morbidity and mortality, could be a real problem after a bombing. Who needs to be fully examined and treated and why?
CASE III
A 45-year old man visits the emergency department at University of Toledo Medical Center on November 30th. He says he has been very weak the entire weekend; had a fever of101 degrees Fahrenheit; joint pain in his wrists, knees, and ankles; and muscle pain (myalgia). He also has a maculopapular rash on his back and thighs. You ask about his recent activity history and he informs you he has been assisting in the relief and recovery efforts in Puerto Rico following the hurricanes (he was there from November 16th - November 28th). He works for Doctors Without Borders and was there with seven of his colleagues.He said one of his colleagues has similar symptoms but although he is a doctor, is too stubborn and will not get treatment unless it gets "really serious".
A physical exam reveals numerous mosquito bites, which the patient says has been itching for the past five days. What further questions do you ask the patient as an epidemiologist as well as a health care provider? What tests would you run to determine the agent? What do you think is the likely agent based on this detective work and what treatment needs to be performed on the patient? What should you do about his colleagues who were with him?
CASE IV
Mandy comes to the Parkview Medical Center Emergency Room in Pueblo, Colorado with her boyfriend, Kyle. Mandy is complaining of a headache, has a fever of 100.4 Fahrenheit, and chills. Initial physical examination reveals swollen lymph glands and a small ulcer on her right shoulder. She does not recall being bitten by any of their animals but does state there are plenty of insects around. The initial headache started two days ago, but once the fever and chills started, they came to the hospital.
They live on a farm and raise goats, rabbits, sheep, and chickens. They also grow vegetables (carrots, kale, lettuce, tomatoes, peppers). Mandy is often doing the gardening and takes care of the chicken eggs, while Kyle focuses on the other animals and hunting deer for an additional supply of winter food. They have a freshwater pond on their property where they enjoy swimming and playing in. Geese have been known to spend their mornings around the pond, nibbling on the grass and defecating.
What additional information would you ask of Kyle and Mandy? What is/are the potential infectious agent(s) responsible and why? How would you treat this case? Do you do anything for Kyle and if so, what do you do?
CASE V
Bob (age 36) is a builder and contractor. His company, Bob the Builder, Inc., is in charge of constructing new landscape to the outside of the Bellagio Hotel and Casino in Las Vegas, Nevada. During this process, they have had to uproot some palm trees, tear down a fountain, and re-construct a swimming pool. Every day, he comes home tired and usually covered with dirt and debris. His wife, Anne (40), is a dentist. They have two kids, Leonard (13) and Penny (10). Leonard is a seventh-grade student at CalTech Prep and a talented cellist. Penny is a 4-H fair all-star, winning many awards for her goats, rabbits, and pigs.
Bob and two of his fellow employees have been sore for days, not surprising for such strenuous work. However, all of them are now suffering from headaches, have fevers, and are coughing a lot, sometimes coughing up blood with their sputum. Additionally, Penny has has a fever of 101 Fahrenheit currently, and was complaining of chills the night before. Her mom noticed that Penny's lymph glands around her arms appear swollen and Penny says they hurt.
Based on the scenario provided, what additional questions do you need to ask of Bob, Penny, and Anne? List all of them and provide a rationale as to why you are asking these questions.
Is there anyone else you need to interview and if so, why? Is this a public health emergency and if so, why?
What infectious agents appear to be the culprits here and why? Provide a rationale for your differential diagnosis. Then, list the steps you need to follow, in order, to treat everyone affected. Specify which authorities must be contacted throughout the process and indicate who is providing what medications/vaccines/treatments.
CASE VI
A 47 year-old man went to the emergency department after ten days of pain and progressive numbness in the left hand and arm and pain in is lower neck and upper back. He had sought treatment from a chiropractor for the past week but only helped his back pain, as his numbness and tingling had worsened and he was experiencing weakness in his left hand and arm. A neurologic examination revealed normal strength and sensation of his lower extremities. His right arm showed normal strength, but the left hand showed no grip, and the patient could only lift his left arm a few inches. The patient was afebrile, and his blood pressure was normal when he arrived at the emergency department.
You ask about any contact with animals and pets, especially out of the ordinary. He informs you that he had been awakened, eight months earlier, by a bat on his left arm, but he did not seek medical attention. Rather, he killed the bat with a tennis racquet and disposed of it in his outdoor trash can. He is married to his wife (Mary, age 42) and has two daughters (Jane 16, Mandy 11). His wife and kids report no symptoms but do say they never contacted a pest control specialist to inspect their home for any nests.
What additional questions do you ask the man? The family? Tests that you could run? Based on what they may tell you, what do you think may be the infectious disease and why? What is the man's prognosis?
CASE VII
Pam (age 40) presents to the emergency department with droopy eyelids, blurred vision, difficulty speaking, and difficulty breathing. Her family (husband Jack (41), and son Tyler (10) brought her to the emergency department. Neither appears to be symptomatic.
Jack informs the healthcare providers that they are part of a farm co-op and raise livestock (pigs, sheep, cows, goats), raise bees for which they make honey and beeswax candles. They make their own cheese and smoked meats, along with the honey, candles, and even organic soap that they take to local markets to sell. Pam does take medical marijuana for pain but Jack does not think that has to do with her current situation.
Pam has had difficulty defecating. Jack suspects this is due to her recent lack of appetite. She cannot seem to eat anything. Prior to the lack of appetite, she had some nausea, vomiting, and diarrhea. Now, she moves slowly, talks slowly, and breathes slowly.
What questions would you ask Pam? Her family? What tests could you run? Would you communicate anyone else regarding the local markets (e.g. staff, customers, news stations)? What do you think is the infectious disease and why?
CASE VIII
On December 1st, a 47-year-old African-American man, a US Postal Service employee who worked in the District of Columbia mail distribution center came to the emergency department with mild nonproductive cough, nausea, vomiting, and stomach cramps. A less-than-thorough examination was provided and he was given some antibiotics and sent home. Later in the day, he arrived back at the emergency department complaining of vomiting and profuse sweating. His past medical history included asthma and renal calculi. Therapy for asthma had not recently included corticosteroids. He was afebrile and had orthostatic hypotension.
He informed the physicians that on December 1st, one of the envelopes had a white substance, resembling talcum powder, leaking out it. He did not think anything of it and continued working. He also said that some of his co-workers had been feeling ill and they were going to other hospitals in the area for treatment. What would you do at the post office? What samples would you take from the post office? From the employee(s)? What do you think is the infectious agent (and why) and what would you do in terms of preventing additional cases and potentially identifying new cases as soon as possible?
CASE IX
Let us finish off with some potpourri. List all of the Category A agents. Why are they considered to be in this category? Of these agents, which one is considered to be the most lethal and why (provide evidence)? Why might some of the diseases here be misdiagnosed at the initial healthcare encounter? Which agent has three major types of entry/disease? Which agent is often thought to be associated with honey and what are other ways this agent could be acquired?
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