Infectious Diseases Clinical cases- 5th Year PMU

A 19-year-old male took to his bed early one Friday evening, complaining of a flu-like illness and headache. He was previously healthy and had received all age-appropriate vaccinations, including a seasonal influenza vaccine and 2 doses of the quadrivalent meningococcal conjugate ACYW 135 vaccine at ages 12 and 19 years. He lived with his parents and a 14-year-old sister. The next morning his mother found him unresponsive with a widespread rash. He was taken to the ED. Physical examination revealed unresponsive patient with signs of meningeal irritation, pinpoint red and dark purple macules that did no blanch with pressure were noted on hid feet and lower legs. Vital signs: T-39,5°C, BP 120/70 mm Hg, pulse 120 /min, RR 32/min, O2 90 % on room air. A lumbar puncture was done after CT scan. The results of the CSF examination and Gram stain: appearance - turbid, cells - 800.106/l, neutrophils, protein – 0,75g/l, glucose – 0,5 mmol/l (blood glucose – 7,0 mmol/l) , Gram stain – no bacteria seen

What do your think is the most likely cause of this infection?

A 19-year-old male took to his bed early one Friday evening, complaining of a flu-like illness and headache. He was previously healthy and had received all age-appropriate vaccinations, including a seasonal influenza vaccine and 2 doses of the quadrivalent meningococcal conjugate ACYW 135 vaccine at ages 12 and 19 years. He lived with his parents and a 14-year-old sister. The next morning his mother found him unresponsive with a widespread rash. He was taken to the ED. Physical examination revealed unresponsive patient with signs of meningeal irritation, pinpoint red and dark purple macules that did no blanch with pressure were noted on hid feet and lower legs. Vital signs: T-39,5°C, BP 120/70 mm Hg, pulse 120 /min, RR 32/min, O2 90 % on room air. A lumbar puncture was done after CT scan. The results of the CSF examination and Gram stain: appearance - turbid, cells - 800.106/l, neutrophils, protein – 0,75g/l, glucose – 0,5 mmol/l (blood glucose – 7,0 mmol/l) , Gram stain – no bacteria seen

Which of the following is the most appropriate step in this adolescent’s management after the arrival of ambulance?

A 19-year-old male took to his bed early one Friday evening, complaining of a flu-like illness and headache. He was previously healthy and had received all age-appropriate vaccinations, including a seasonal influenza vaccine and 2 doses of the quadrivalent meningococcal conjugate ACYW 135 vaccine at ages 12 and 19 years. He lived with his parents and a 14-year-old sister. The next morning his mother found him unresponsive with a widespread rash. He was taken to the ED. Physical examination revealed unresponsive patient with signs of meningeal irritation, pinpoint red and dark purple macules that did no blanch with pressure were noted on hid feet and lower legs. Vital signs: T-39,5°C, BP 120/70 mm Hg, pulse 120 /min, RR 32/min, O2 90 % on room air. A lumbar puncture was done after CT scan. The results of the CSF examination and Gram stain: appearance - turbid, cells - 800.106/l, neutrophils, protein – 0,75g/l, glucose – 0,5 mmol/l (blood glucose – 7,0 mmol/l) , Gram stain – no bacteria seen

Of the following the most appropriate immediate intervention for his household contacts is

1-year-old male was admitted to the hospital in December because of fever and dehydration. His parents reported that he had a 1-day history of fiver, diarrhea, intractable emesis and decreased urine output. On admission he was somnolent, his vital signs revealed T 39,5°C, pulse 126 beats/min and RR 32 breaths/min. His general PE was remarkable for hyperactive bowel sounds and decreased turgor. Laboratory test showed WBC 14 299.109/l, with 80% PMNs, urinalysis was significant for a high specific gravidity and ketones. Stool, blood, and urine samples were sent for bacterial cultures. The patient was given intravenous normal saline and had nothing by mouth. Over the next 48 hours his emesis abated. All cultures for bacterial pathogens gave negative results, but a rapid viral test from the stool was positive. Once he was rehydrated and was tolerating oral feeding he was discharged home

What is the most common cause of infectious diarrhea in young children

1-year-old male was admitted to the hospital in December because of fever and dehydration. His parents reported that he had a 1-day history of fiver, diarrhea, intractable emesis and decreased urine output. On admission he was somnolent, his vital signs revealed T 39,5°C, pulse 126 beats/min and RR 32 breaths/min. His general PE was remarkable for hyperactive bowel sounds and decreased turgor. Laboratory test showed WBC 14 299.109/l, with 80% PMNs, urinalysis was significant for a high specific gravidity and ketones. Stool, blood, and urine samples were sent for bacterial cultures. The patient was given intravenous normal saline and had nothing by mouth. Over the next 48 hours his emesis abated. All cultures for bacterial pathogens gave negative results, but a rapid viral test from the stool was positive. Once he was rehydrated and was tolerating oral feeding he was discharged home

What is the most likely microbe caused the illness in this case?

1-year-old male was admitted to the hospital in December because of fever and dehydration. His parents reported that he had a 1-day history of fiver, diarrhea, intractable emesis and decreased urine output. On admission he was somnolent, his vital signs revealed T 39,5°C, pulse 126 beats/min and RR 32 breaths/min. His general PE was remarkable for hyperactive bowel sounds and decreased turgor. Laboratory test showed WBC 14 299.109/l, with 80% PMNs, urinalysis was significant for a high specific gravidity and ketones. Stool, blood, and urine samples were sent for bacterial cultures. The patient was given intravenous normal saline and had nothing by mouth. Over the next 48 hours his emesis abated. All cultures for bacterial pathogens gave negative results, but a rapid viral test from the stool was positive. Once he was rehydrated and was tolerating oral feeding he was discharged home

What is the reason for the “epidemiological success” of the virus?

A 34-year-old man presented to the ED complaining of decreased oral intake, low-grade fevers, fatigue, nausea, and occasional vomiting for a week and dark urine and yellow eyes for one day He had a prior history
of injection drug use with cocaine but currently used marijuana and ecstasy. He had no other PMH, but was unable to donate blood 4 years previously for reason that he couldn’t recall. He worked as a veterinary assistant. On sexual history, he was active with men and women. He did not consistently use condoms. On PE he appeared ill and jaundiced.
He had tender hepatomegaly but no splenomegaly. There were no stigmatas of chronic liver disease. His AST was 1232 E/l, ALT - 1150 E/l, ALP-395 E/l, total bilirubin - 168 µmol/l, and direct bilirubin 127 µmol/l, INR - 1,3.
Hepatitis serologies were sent and revealed thе following:
anti-HAVIgM (-)
anti-HAVIgG(-)
HBsAg(+)
anti-HBcIgM(+)
HBeAg (+)
anti-HBe(-)
anti-HBcIgG(-)
аnti-HCV (+)
Based on the history, LFTs and serological markers of viral hepatitis in the patient:

What is the most likely cause of his current clinical presentation?

A 34-year-old man presented to the ED complaining of decreased oral intake, low-grade fevers, fatigue, nausea, and occasional vomiting for a week and dark urine and yellow eyes for one day He had a prior history
of injection drug use with cocaine but currently used marijuana and ecstasy. He had no other PMH, but was unable to donate blood 4 years previously for reason that he couldn’t recall. He worked as a veterinary assistant. On sexual history, he was active with men and women. He did not consistently use condoms. On PE he appeared ill and jaundiced.
He had tender hepatomegaly but no splenomegaly. There were no stigmatas of chronic liver disease. His AST was 1232 E/l, ALT - 1150 E/l, ALP-395 E/l, total bilirubin - 168 µmol/l, and direct bilirubin 127 µmol/l, INR - 1,3.
Hepatitis serologies were sent and revealed thе following:
anti-HAVIgM (-)
anti-HAVIgG(-)
HBsAg(+)
anti-HBcIgM(+)
HBeAg (+)
anti-HBe(-)
anti-HBcIgG(-)
аnti-HCV (+)
Based on the history, LFTs and serological markers of viral hepatitis in the patient:

What might be the reason for his inability to donate blood?

A 34-year-old man presented to the ED complaining of decreased oral intake, low-grade fevers, fatigue, nausea, and occasional vomiting for a week and dark urine and yellow eyes for one day He had a prior history
of injection drug use with cocaine but currently used marijuana and ecstasy. He had no other PMH, but was unable to donate blood 4 years previously for reason that he couldn’t recall. He worked as a veterinary assistant. On sexual history, he was active with men and women. He did not consistently use condoms. On PE he appeared ill and jaundiced.
He had tender hepatomegaly but no splenomegaly. There were no stigmatas of chronic liver disease. His AST was 1232 E/l, ALT - 1150 E/l, ALP-395 E/l, total bilirubin - 168 µmol/l, and direct bilirubin 127 µmol/l, INR - 1,3.
Hepatitis serologies were sent and revealed thе following:
anti-HAVIgM (-)
anti-HAVIgG(-)
HBsAg(+)
anti-HBcIgM(+)
HBeAg (+)
anti-HBe(-)
anti-HBcIgG(-)
аnti-HCV (+)
Based on the history, LFTs and serological markers of viral hepatitis in the patient:

Which vaccination is strongly recommended for this patient?

A 4-year-old female presented to her pediatrician in early summer with a 3-day history of fever, vomiting and bloody, mucus-flecked diarrhea. She had 10 painful bowel movements/day and moderate abdominal pain. She had no recent travel or camping history, no recent change in diet, no one at home was with a similar illness; she was cared at home.
On PE she was alert with vital signs within normal limits. She had normal skin color and turgor, and her skin was warm and dry. There was no lymphadenopathy. Her abdomen was with normal bowel sounds and no organomegaly, guarding or rebound, but tender to palpation. A stool was sent to culture. She was tolerating oral liquids when she was
discharged home.

What is the most likely diagnosis

A 4-year-old female presented to her pediatrician in early summer with a 3-day history of fever, vomiting and bloody, mucus-flecked diarrhea. She had 10 painful bowel movements/day and moderate abdominal pain. She had no recent travel or camping history, no recent change in diet, no one at home was with a similar illness; she was cared at home.
On PE she was alert with vital signs within normal limits. She had normal skin color and turgor, and her skin was warm and dry. There was no lymphadenopathy. Her abdomen was with normal bowel sounds and no organomegaly, guarding or rebound, but tender to palpation. A stool was sent to culture. She was tolerating oral liquids when she was
discharged home.

What organisms might cause her disease?

A 4-year-old female presented to her pediatrician in early summer with a 3-day history of fever, vomiting and bloody, mucus-flecked diarrhea. She had 10 painful bowel movements/day and moderate abdominal pain. She had no recent travel or camping history, no recent change in diet, no one at home was with a similar illness; she was cared at home.
On PE she was alert with vital signs within normal limits. She had normal skin color and turgor, and her skin was warm and dry. There was no lymphadenopathy. Her abdomen was with normal bowel sounds and no organomegaly, guarding or rebound, but tender to palpation. A stool was sent to culture. She was tolerating oral liquids when she was
discharged home.

Which antibiotic is warranted?

A 22-year-old woman was brought to hospital accompanied by her boyfriend. Earlier that day the young woman and her boyfriend had argued and he had walked out of the house. On his returned 6 h later he found
her unresponsive and vomiting and there were empty bottles of medications on the floor. He called 999 and the ambulance brought the young woman to hospital. On admission she was conscious but uncooperative, vital signs: afebrile, BP 96/52 mm Hg, RR 20 /min, pulse 109/min, O2 95% on room air. O/E- jaundiced only on the sclera, mild nonspecific abdominal pain to palpation, the liver was not enlarged, the remainder pf physical examination was without abnormalities. Initial CBC, electrolytes, kidney function, glucose levels and coagulation parameters – normal. Laboratory test were only notable for AST 1020 E/l, ALT 1300 E/l, ALP 120 E/l, bilirubin 56 µmol/l; INR 1,6. Her evaluation continued

What is your suspected diagnosis of the patient ?

A 22-year-old woman was brought to hospital accompanied by her boyfriend. Earlier that day the young woman and her boyfriend had argued and he had walked out of the house. On his returned 6 h later he found
her unresponsive and vomiting and there were empty bottles of medications on the floor. He called 999 and the ambulance brought the young woman to hospital. On admission she was conscious but uncooperative, vital signs: afebrile, BP 96/52 mm Hg, RR 20 /min, pulse 109/min, O2 95% on room air. O/E- jaundiced only on the sclera, mild nonspecific abdominal pain to palpation, the liver was not enlarged, the remainder pf physical examination was without abnormalities. Initial CBC, electrolytes, kidney function, glucose levels and coagulation parameters – normal. Laboratory test were only notable for AST 1020 E/l, ALT 1300 E/l, ALP 120 E/l, bilirubin 56 µmol/l; INR 1,6. Her evaluation continued

What consultant should be called?

A 22-year-old woman was brought to hospital accompanied by her boyfriend. Earlier that day the young woman and her boyfriend had argued and he had walked out of the house. On his returned 6 h later he found
her unresponsive and vomiting and there were empty bottles of medications on the floor. He called 999 and the ambulance brought the young woman to hospital. On admission she was conscious but uncooperative, vital signs: afebrile, BP 96/52 mm Hg, RR 20 /min, pulse 109/min, O2 95% on room air. O/E- jaundiced only on the sclera, mild nonspecific abdominal pain to palpation, the liver was not enlarged, the remainder pf physical examination was without abnormalities. Initial CBC, electrolytes, kidney function, glucose levels and coagulation parameters – normal. Laboratory test were only notable for AST 1020 E/l, ALT 1300 E/l, ALP 120 E/l, bilirubin 56 µmol/l; INR 1,6. Her evaluation continued

That is the best treatment approach

A 63-year old woman complained of severe abdominal pain and diarrhea. She had a history of congestive heart failure and atrial fibrillation. She was allergic to shrimps. Her medication included furosemide and digitalis. On physical examination her abdomen was soft with mild tenderness and guarding; bowel sound were hypoactive; Vital signs: temperature 36,6 °C, heart rate 100/min, respiratory rate 30/min, O2 % on room air. The remainder of examination is unremarkable. LAB: WBC 19 500.109 /l, K 3 E/l, arterial pH 7,27, XR of the abdomen showed adynamic ileus, but no free gas. ECG didn’t reveal any new findings

What is the most likely diagnosis?

A 63-year old woman complained of severe abdominal pain and diarrhea. She had a history of congestive heart failure and atrial fibrillation. She was allergic to shrimps. Her medication included furosemide and digitalis. On physical examination her abdomen was soft with mild tenderness and guarding; bowel sound were hypoactive; Vital signs: temperature 36,6 °C, heart rate 100/min, respiratory rate 30/min, O2 % on room air. The remainder of examination is unremarkable. LAB: WBC 19 500.109 /l, K 3 E/l, arterial pH 7,27, XR of the abdomen showed adynamic ileus, but no free gas. ECG didn’t reveal any new findings

What are the clue to this diagnosis?

A 63-year old woman complained of severe abdominal pain and diarrhea. She had a history of congestive heart failure and atrial fibrillation. She was allergic to shrimps. Her medication included furosemide and digitalis. On physical examination her abdomen was soft with mild tenderness and guarding; bowel sound were hypoactive; Vital signs: temperature 36,6 °C, heart rate 100/min, respiratory rate 30/min, O2 % on room air. The remainder of examination is unremarkable. LAB: WBC 19 500.109 /l, K 3 E/l, arterial pH 7,27, XR of the abdomen showed adynamic ileus, but no free gas. ECG didn’t reveal any new findings

What is the next step to order?

A 48-year-old woman presented complaining of fatigue, arthralgia and pruritus for 2 months and dark urine and yellow eyes for 1 day. Her PMH was significant only for hypothyroidism for which she took levothyroxine. She drank 1 glass of wine per week and used 2 g acetaminophen daily for her current complaints. On PE she had mild jaundice, hepatomegaly but no splenomegaly and excoriations on the trunk.
Laboratory studies demonstrated: WBC 8 900.109 /L, Hb 13,3 G/l, Pl 160 109/L, AST 152 E/l, ALAT 162 E/l, AF 662 E/L, total bilirubin 56 µmol/l, direct 180, INR 1.5, protein 92,0 g/l, and IgG 3,5 g/dl ( N<1,6).
Abdominal US showed a normal gallbladder. CT scan of the abdomen was unremarkable.

What is the most likely diagnosis?

A 48-year-old woman presented complaining of fatigue, arthralgia and pruritus for 2 months and dark urine and yellow eyes for 1 day. Her PMH was significant only for hypothyroidism for which she took levothyroxine. She drank 1 glass of wine per week and used 2 g acetaminophen daily for her current complaints. On PE she had mild jaundice, hepatomegaly but no splenomegaly and excoriations on the trunk.
Laboratory studies demonstrated: WBC 8 900.109 /L, Hb 13,3 G/l, Pl 160 109/L, AST 152 E/l, ALAT 162 E/l, AF 662 E/L, total bilirubin 56 µmol/l, direct 180, INR 1.5, protein 92,0 g/l, and IgG 3,5 g/dl ( N<1,6).
Abdominal US showed a normal gallbladder. CT scan of the abdomen was unremarkable.

Which datа support the diagnosis

A 48-year-old woman presented complaining of fatigue, arthralgia and pruritus for 2 months and dark urine and yellow eyes for 1 day. Her PMH was significant only for hypothyroidism for which she took levothyroxine. She drank 1 glass of wine per week and used 2 g acetaminophen daily for her current complaints. On PE she had mild jaundice, hepatomegaly but no splenomegaly and excoriations on the trunk.
Laboratory studies demonstrated: WBC 8 900.109 /L, Hb 13,3 G/l, Pl 160 109/L, AST 152 E/l, ALAT 162 E/l, AF 662 E/L, total bilirubin 56 µmol/l, direct 180, INR 1.5, protein 92,0 g/l, and IgG 3,5 g/dl ( N<1,6).
Abdominal US showed a normal gallbladder. CT scan of the abdomen was unremarkable.

What to test next?

A 17-year-old previously healthy student was admitted to the ED. Her flatmates were unable to wake her up her that morning and called 911. In the evening before the admission she complained of a low-grade fever,
mild headache and vomited once. Initial assessment showed that she was unresponsive, had a temperature of 38,5ºC, BP 80/50 mm Hg, RR 30/min, her feet were cold, 02 was 85% on room air. She had mild neck stiffness, mild abdominal tenderness to palpation and a purpuric rash on her buttocks. Fundoscopy revealed papilledema. She was resuscitated with intravenous fluids and O2. Blood was taken for CBC, biochemistry and blood culture

What is the next important step in the management of the patient?

A 17-year-old previously healthy student was admitted to the ED. Her flatmates were unable to wake her up her that morning and called 911. In the evening before the admission she complained of a low-grade fever,
mild headache and vomited once. Initial assessment showed that she was unresponsive, had a temperature of 38,5ºC, BP 80/50 mm Hg, RR 30/min, her feet were cold, 02 was 85% on room air. She had mild neck stiffness, mild abdominal tenderness to palpation and a purpuric rash on her buttocks. Fundoscopy revealed papilledema. She was resuscitated with intravenous fluids and O2. Blood was taken for CBC, biochemistry and blood culture

What is your presumptive diagnosis?

A 17-year-old previously healthy student was admitted to the ED. Her flatmates were unable to wake her up her that morning and called 911. In the evening before the admission she complained of a low-grade fever,
mild headache and vomited once. Initial assessment showed that she was unresponsive, had a temperature of 38,5ºC, BP 80/50 mm Hg, RR 30/min, her feet were cold, 02 was 85% on room air. She had mild neck stiffness, mild abdominal tenderness to palpation and a purpuric rash on her buttocks. Fundoscopy revealed papilledema. She was resuscitated with intravenous fluids and O2. Blood was taken for CBC, biochemistry and blood culture

What might be the causative agent?

A 4-year-old previously healthy girl was brought to the ED because of a 4-day history of fever, headache, sore throat, dry cough, coryza and rash of one day. She was treated with amoxicillin without improvement. She lived with her parents and an 8-month-old baby brother. The family had traveled to Italy often, where their relatives lived. Her vaccinations were not completed because of her parents’ hesitance about their side effects, particularly MMR vaccine. O/E - impaired condition, conjunctivitis, temperature 39,5ºC, heart rate 120/min, BP 90/60 mm Hg, respiratory rate 40/ min, Sore throat, bluish-gray lesion on buccal mucosa and enlarged cervical lymph nodes were seen. Pink-red confluent maculopapular rash on the face and upper part of the trunk was also seen. Her lungs were cleat to auscultation, her abdomen was soft and not tender. WBC -5600. 109/l, normal differential, CXR - normal

What is the most likely cause of the rash?

A 4-year-old previously healthy girl was brought to the ED because of a 4-day history of fever, headache, sore throat, dry cough, coryza and rash of one day. She was treated with amoxicillin without improvement. She lived with her parents and an 8-month-old baby brother. The family had traveled to Italy often, where their relatives lived. Her vaccinations were not completed because of her parents’ hesitance about their side effects, particularly MMR vaccine. O/E - impaired condition, conjunctivitis, temperature 39,5ºC, heart rate 120/min, BP 90/60 mm Hg, respiratory rate 40/ min, Sore throat, bluish-gray lesion on buccal mucosa and enlarged cervical lymph nodes were seen. Pink-red confluent maculopapular rash on the face and upper part of the trunk was also seen. Her lungs were cleat to auscultation, her abdomen was soft and not tender. WBC -5600. 109/l, normal differential, CXR - normal

Is the child contagious and why

A 4-year-old previously healthy girl was brought to the ED because of a 4-day history of fever, headache, sore throat, dry cough, coryza and rash of one day. She was treated with amoxicillin without improvement. She lived with her parents and an 8-month-old baby brother. The family had traveled to Italy often, where their relatives lived. Her vaccinations were not completed because of her parents’ hesitance about their side effects, particularly MMR vaccine. O/E - impaired condition, conjunctivitis, temperature 39,5ºC, heart rate 120/min, BP 90/60 mm Hg, respiratory rate 40/ min, Sore throat, bluish-gray lesion on buccal mucosa and enlarged cervical lymph nodes were seen. Pink-red confluent maculopapular rash on the face and upper part of the trunk was also seen. Her lungs were cleat to auscultation, her abdomen was soft and not tender. WBC -5600. 109/l, normal differential, CXR - normal

Do you need to take preventive measures concerning the baby brother and how?

The patient was a female in her late 80s with pulmonary hypertension requiring chronic O2 by nasal cannula. She had a hospital admission 1 mo previously for right middle lobe pneumonia. She was given a 14-day course levofloxacin and discharged to a skilled nursing home. Three weeks later she had the onset of loose, watery stools, which increased in frequency to >10 times/day, diffuse abdominal pain, vomiting, weakness and later was unable to walk. Her family and social history was significant only for her having recently moved to a nursing home. On readmission, she had 2,5 kg weight loss since her prior admission. She continued to have shortness of breath but no cough. Vital signs - pulse 120 /min, RR 24/min, and BP 82.45 mm Hg. On examination her abdomen was soft, diffusely tender and mildly distended with no rebound or guarding, with decreased bowel sounds. Otherwise her PE was consistent with her underlying disease. Laboratory data were significant for WBC 28 00.109/l. Her abdominal XR showed grossly dilated loops of bowels. Abdominal CT revealed colonic wall thickening consistent with pancolitis. Over the next 4 hospital days her WBC progressively increased from 29 000.109/l to 127 000.109/l. She had increased abdominal girth and decreased bowel sounds. She was judged to be a poor surgical risk. On the fourth hospital day the patient expired.

What is the most likely diagnosis?

The patient was a female in her late 80s with pulmonary hypertension requiring chronic O2 by nasal cannula. She had a hospital admission 1 mo previously for right middle lobe pneumonia. She was given a 14-day course levofloxacin and discharged to a skilled nursing home. Three weeks later she had the onset of loose, watery stools, which increased in frequency to >10 times/day, diffuse abdominal pain, vomiting, weakness and later was unable to walk. Her family and social history was significant only for her having recently moved to a nursing home. On readmission, she had 2,5 kg weight loss since her prior admission. She continued to have shortness of breath but no cough. Vital signs - pulse 120 /min, RR 24/min, and BP 82.45 mm Hg. On examination her abdomen was soft, diffusely tender and mildly distended with no rebound or guarding, with decreased bowel sounds. Otherwise her PE was consistent with her underlying disease. Laboratory data were significant for WBC 28 00.109/l. Her abdominal XR showed grossly dilated loops of bowels. Abdominal CT revealed colonic wall thickening consistent with pancolitis. Over the next 4 hospital days her WBC progressively increased from 29 000.109/l to 127 000.109/l. She had increased abdominal girth and decreased bowel sounds. She was judged to be a poor surgical risk. On the fourth hospital day the patient expired.

Describe three factors that redisposed the patent to this infection

The patient was a female in her late 80s with pulmonary hypertension requiring chronic O2 by nasal cannula. She had a hospital admission 1 mo previously for right middle lobe pneumonia. She was given a 14-day course levofloxacin and discharged to a skilled nursing home. Three weeks later she had the onset of loose, watery stools, which increased in frequency to >10 times/day, diffuse abdominal pain, vomiting, weakness and later was unable to walk. Her family and social history was significant only for her having recently moved to a nursing home. On readmission, she had 2,5 kg weight loss since her prior admission. She continued to have shortness of breath but no cough. Vital signs - pulse 120 /min, RR 24/min, and BP 82.45 mm Hg. On examination her abdomen was soft, diffusely tender and mildly distended with no rebound or guarding, with decreased bowel sounds. Otherwise her PE was consistent with her underlying disease. Laboratory data were significant for WBC 28 00.109/l. Her abdominal XR showed grossly dilated loops of bowels. Abdominal CT revealed colonic wall thickening consistent with pancolitis. Over the next 4 hospital days her WBC progressively increased from 29 000.109/l to 127 000.109/l. She had increased abdominal girth and decreased bowel sounds. She was judged to be a poor surgical risk. On the fourth hospital day the patient expired.

Antibiotic of choice for this condition is