Unusual Combination of Gastrointestinal Pathogens Detected by Multiplex PCR

Introduction/Objective

Infectious gastroenteritis (IGE) is a common but complex entity which is a major cause of global morbidity and mortality. IGE is caused by a wide range of etiologic agents such as viruses, bacteria, and parasites. In the United States there are approximately 373 million of IGE cases per year. Most cases of IGE resolve without identification of a specific pathogen. Multiplex molecular assays allow identification of multiple possible pathogens with rapid turnaround time and increased sensitivity, facilitating to formulate an effective treatment plan and control measures.

Methods/Case Report

We present a case of a pediatric patient with no significant past medical history who has been having runny stools that have progressively worsened in the last 3 months and 2 days history of bloody stools with mucus before emergency room presentation. She had no fever, vomiting, joint pain, oral ulcer, and rash. Physical exam showed that the patient appeared well, nontoxic, and vital signs were within normal limit. Copious rhinorrhea was noted. She was at 50th percentile for age on the growth chart. Family denied any recent travel or sick contacts however stated that all the family members have been on well water. Complete blood count was obtained and showed a platelet count of 669 x 10(3)/mcL and WBC of 16.6 x 10(3)/mcL with differential showing absolute lymphocytosis, absolute monocytosis and absolute eosinophilia. Biofire FilmArray gastrointestinal panel performed on the stool detected Giardia lamblia, Campylobacter, Shiga-like toxin producing E. coli and Adenovirus F 40/41. Repeat of the panel per protocol detected the same four pathogens.

Results (if a Case Study enter NA)

N/A.

Conclusion

This case report highlights the significance of detecting multiple causative pathogens. While long term watery diarrhea may guide clinicians to malabsorptive process and the use of well water to Giardia, a sensitive and specific multiplex assay can detect all the pathogens involved in the disease process and greatly simplify the treatment plan for patients. This unusual combination of pathogens can explain the unique symptomology of the patient including long term watery diarrhea, recent bloody diarrhea as well as copious rhinorrhea and failure to thrive.

The infrared reflex: a potential new method for congenital cataract screening

OBJECTIVE

To compare the accuracy of infrared (IR)-reflex assessment using a prototype imaging device to standard non-mydriatic red-reflex screening with direct ophthalmoscope (DO) in the diagnosis of neonatal and childhood cataract.

METHODS

The comparison of the techniques was made in two distinct cohorts: in the first, newborns underwent IR and red-reflex testing by a medical student, with results compared to a reference red-reflex examination by an experienced midwife. In the second, an enriched cohort of children attending a specialist paediatric ophthalmology clinic had IR and red-reflex testing by a medical student to reference examination by a paediatric ophthalmologist. The medical students were considered inexperienced screeners due to their limited exposure to ophthalmology. The sensitivity and specificity of the IR and red-reflex assessments in respect to reference examination were calculated. Diagnostic accuracy was compared in Caucasian and non-Caucasian eyes.

RESULTS

IR and red-reflex imaging were possible in all 180 neonatal eyes examined. A total of 5% of newborn eyes were found to have embryological remnants in the anterior segment of the eye with IR-reflex imaging which were not detected on reference red-reflex examination. IR-reflex assessment had significantly better sensitivity (100 vs 71%, p < 0.05) and specificity (100 vs 63%, p < 0.01) than red-reflex assessment in the diagnosis of childhood cataract. Red-reflex specificity was particularly poor in non-Caucasian eyes compared to Caucasian eyes (32 vs 72%, p < 0.05).

CONCLUSION

This pilot study indicates that IR-reflex imaging has the potential to improve the diagnostic accuracy of eye screening for cataract by inexperienced healthcare staff, particularly in non-Caucasian children.

Abdominal CT scans in patients with blunt trauma: low yield in the absence of clinical findings

This study undertook to determine the yield of abdominal CT scans ordered only because the patient's sensorium was decreased or general anesthesia was planned. The abdominal CT scans and hospital charts of 191 consecutive patients examined following blunt trauma were reviewed with respect to clinical indications prompting the study. In 143, some clinical or laboratory justification was in evidence. In this group, 55 patients (38.5%) were found to have trauma-related pathology at CT scan. In 48 patients, no clinical or laboratory suggestion of abdominal pathology was evident. Instead, the primary indications for ordering the CT scan were decreased sensorium (28 cases), the planning of general anesthesia for orthopedic procedures (8 cases), and a variety of non-abdominal-trauma-related reasons. In this group, only a single positive finding was identified (small pneumothorax), and in no case was the clinical course altered by findings at abdominal CT scan. Performance of abdominal CT scans without clinical or laboratory evidence of trauma, merely because of decreased patient sensorium or prophylactically prior to general anesthesia for non-abdomen-related surgery, is an extremely low yield study and should be discouraged. In the current study, no significant abdominal pathology would have been overlooked by omission of such scans. Similar findings have been reported in children. To our knowledge, this is the first such report in a largely adult population.

Medulloblastoma. Period of risk reviewed

Collins postulated that patients with Wilms' tumor surviving for a period equal to their age at diagnosis plus 9 months were no longer at risk for a recurrence. Although this no longer holds for Wilms' tumor, it has been applied to patients with medulloblastoma. Case histories of patients who survived a period of risk designated by Collins' rule and later developed a histologically confirmed recurrent medulloblastoma are discussed. Reported cases violating Collins' rule constitute less than 2% of all medulloblastomas. The continued use of Collins' rule is advocated. Patients who have survived this period of risk, are neurologically stable, and have a negative computerized tomography (CT) head scan are exceedingly unlikely to develop a recurrent medulloblastoma.

Variables in recording motor conduction of the radial nerve

Motor conduction examinations of the right radial nerve were performed on 25 healthy students. The purposes of this study were to determine the optimum position for placement of the active recording electrode, to determine the optimum position of the elbow during conduction examinations, and to report normal values for radial motor nerve characteristics. The radial nerve was stimulated at the supraclavicular notch, axilla, lateral surface of the brachium, and over the middle third of the forearm. The evoked responses were recorded from the abductor pollicis longus or the extensor pollicis brevis. The optimum site for placement of the active recording electrode was found over the medial aspect of the abductor pollicis longus or the extensor pollicis brevis and at a point that represents 28 percent of the forearm length. The optimum position for the elbow was full extension. The distal latency of 2.6 msec, the velocity of the brachium-forearm segment of 50 meters per second, and amplitude of muscle action potentials of 4.0 mv may serve as the limits of normal values for motor conduction of the radial nerve.