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Cases in Clinical Microbiology.

Clinical Case Report:

A 19-year-old African American male undergoing apheresis developed sudden rigors 50 minutes into a therapeutic plasma exchange (TPE) treatment for recurrent focal segmental glomerulosclerosis (FSGS). The patient had a history of recurrent FSGS despite ongoing TPE and 2 kidney transplants. Upon physical examination at onset of rigors, the patient was observed to have tachycardia, 120-130 beats per minute (normal: 60-100 beats per minute) and an elevated temperature of 38.6[degrees]C /101.5[degrees]F. The patient was taken to the Emergency Department for possible sepsis. He was admitted to the pediatric immunocompromised critical care unit and was started on empiric vancomycin and cefepime.

Specimens for laboratory testing were collected, including blood cultures. Laboratory results indicated high BUN, creatinine, AST and ALT. While the patient had a normal WBC count, the differential showed a marked increase in segmented neutrophils. These trends persisted over the next 24 hours upon repeat testing (Table 1).

After approximately 28 hours of incubation the aerobic bottle of the set was signaled as positive. The Gram-stained smear of the bottle showed Gram-positive bacilli and the rapid molecular identification method did not identify the organism. After 18 hours of incubation at 35[degrees] C, colonies appeared clear, wet and spready on 5% Sheep Blood agar and chocolate agar plates (Figure 1).

Focal Segmental Glomerulosclerosis (FSGS)--Kidney disease in which scarring occurs in each glomerulus leading to the inability to properly filter blood. Kidney failure occurs over time as scarring worsens. Symptoms of the disease include proteinuria, edema, low blood albumin, high cholesterol and high blood pressure.

The case description on this page and its follow-up discussion presented elsewhere in this issue is the 33rd in a series of articles presenting clinical microbiology cases that will appear in this journal. Readers should study the case description below and formulate their own answers to the questions posed. After coming up with a solution to the problem, see page 24 and read the Case Follow-up and Discussion. This is followed by Questions for STEP Participants on page 27.

Joel E. Mortensen, PhD, MLT(AMT), Series Editor

Caption: Figure 1. Growth of patient isolate on 5% sheep blood agar at 18 hours at 35[degrees]C; Gram-stained smear of pure culture.

Table 1. Initial Patient Laboratory Values

Test                Patient Value    Reference Range
BUN                 21 mg/dL         7-19 mg/dL
Creatinine          1.34 mg/dL       0.67-1.17 mg/dL
AST                 448 unit/L       9-37 unit/L
ALT                 285 unit/L       12-78 unit/L
WBC count           8.1 K/mcL        4.5-13.0 K/mcL
Neutrophil count    92%              40-70%
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Author:Mortensen, Joel E.
Publication:Journal of Continuing Education Topics & Issues
Date:Jan 1, 2019
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