Microbiology Case Study: A 44 Year Old Male Finds a Tick on His Leg

Case History A 44 year old male pulled this (image 1) off of his leg after dragging brush out of a tree line in Vermont.

Image 1. Ixodes scapularis under a microscope. Characteristic features such as eight black legs, dorsal shield, and dark red color can be appreciated.

Ixodes scapularis

Ixodes scapularis, also known as the blacklegged tick or deer tick, is commonly found in the eastern and northern Midwest regions of the United States as well as southeastern Canada. This species of tick is approximately 3 mm in length. Morphologically, females have a black head and a dorsal shield with a dark red abdomen, while males are entirely black or dark brown. Both sexes have eight black legs and a characteristic anal opening, appearing within a horseshoe-shaped ridge on the ventral lower abdomen. Unlike other tick species, Ixodes scapularis does not have ridges on the edge of the lower abdomen. Ixodes scapularis can live up to 2 years in the wild and die after reproduction.1

Life Cycle, Transmission, and Infection

Ixodes scapularis is a three-host tick with a different host at each stage of development. Their life cycle lasts approximately 2 years, where they undergo 4 distinct developmental/life stages: egg, six-legged larva, eight-legged nymph, and adult. After hatching from the egg, it should have a blood meal at every developmental stage to survive. Ixodes scapularis is known to parasitize and feed from mammals, birds, reptiles, and amphibians, and its best-known host is the white-tailed deer. This species is unable to fly or jump so it usually waits for a host while resting in the tips of grass or shrubs. Depending on the developmental stage, preparation for feeding can take between 10 minutes to 2 hours.2 Once the tick finds a feeding spot on the host, it grasps onto the skin and cuts into the surface inserting its feeding tube, which can have barbs and can secrete a cement-like surface for better attachment. Moreover, the tick can also secrete small amounts of saliva with anesthetic properties to remain undetected during the blood meal. If attached to a sheltered spot, the tick can remain unnoticed for long periods. Ixodes scapularis will attach to its host and suck on the blood for a few days. The lengthy feeding process makes them good at transmitting infection. If the host has a bloodborne infection (e.g., Lyme disease), the tick may ingest the pathogen and become infected. If the tick feeds on a human later, that human can become infected with the same pathogen if it is a prolonged blood meal. However, if the tick is removed quickly (~ 24 hours), the risk of acquiring disease is reduced.2 The longer the tick is attached, the greater the risk of becoming infected. The risk of human infection is greater during the spring and summer.

Ixodes scapularis as a Disease Vector

Babesiosis

The causative agent of babesiosis are Basebesia microti and other Babesia species. These parasites preferentially infect red blood cells. In the United States, most cases are caused by Babesia microti.3 Babesiosis is most frequently reported in the upper midwestern and northeastern regions of the United States, where Babesia microti is endemic. Although this parasite is generally transmitted by Ixodes scapularis, Babesia parasites can also be transmitted via blood transfusions and, in some cases, congenitally. Babesiosis can range from asymptomatic to life-threatening. Some of the common signs and symptoms include fever, chills, sweats, general malaise or fatigue, myalgia, arthralgia, headaches, anorexia, nausea, and dark urine. Less common symptoms include cough, sore throat, emotional lability, depression, photophobia, conjunctival infection.3 Not all infected persons are symptomatic or febrile. Clinical presentation usually manifests within several weeks after exposure, but may develop or recur months after infection. The incubation period for Babesia species parasites is approximately 1-9+ weeks. Laboratory findings associated with babesiosis include decreased hematocrit due to hemolytic anemia, thrombocytopenia, elevated serum creatinine and blood urea nitrogen values, and mildly elevated hepatic transaminase values.3 To diagnose babesiosis in the laboratory, identification of intraerythrocytic Babesia parasites by light-microscopic examination of a blood smear, positive Babesia (or Babesia microti) PCR analysis, or isolation of Babesia parasites from a whole blood specimen by animal inoculation in a reference lab are recommended procedures. Additionally, demonstration of a Babesia-specific antibody titer by indirect fluorescent antibody testing for IgG can be used as supportive laboratory criteria—although it is not enough evidence to support a diagnosis of an active infection.3 Treatment for babesia usually lasts 7-10 days with a combination of two drugs: atovaquone plus azithromycin or clindamycin plus quinine, with the latter being the standard of care for severely ill patients.

Anaplasmosis

Anaplasmosis, formerly known as Human Granulocytic Ehrlichiosis, is caused by Anaplasma phagocytophilum. Anaplasmosis is commonly reported in the upper Midwest and northeastern regions of the United States. The incubation period for Anaplasma phagocytophilum is 5-14 days.3 Some of the common signs and symptoms of anaplasmosis include fever, chills, rigors, severe headaches, malaise, myalgia, gastrointestinal symptoms such as nausea, vomiting, diarrhea, and anorexia, and, in some cases, rash. The general laboratory findings for anaplasmosis during the first week of clinical disease include mild anemia, thrombocytopenia, leukopenia, and mild to moderate elevations in hepatic transaminases.3 Under the microscope, the visualization of morulae in the cytoplasm of granulocytes during examination of blood smears is indicative of diagnosis. However, to definitely determine diagnosis in the laboratory, detection of DNA by PCR of whole blood is recommended during the first week of illness. Additionally, demonstration of a four-fold change in IgG specific antibody titer by indirect immunofluorescence antibody assay in paired serum samples is recommended. The first serum sample should be taken during the first week of illness and the second serum sample should be taken 2-4 weeks after. Moreover, immunohistochemical staining of the organism from the skin, tissue, or bone marrow biopsies is also recommended for diagnosis.3 Anaplasmosis is treated with doxycycline. Treatment should be started once there is a clinical suspicion of disease, as delaying treatment may result in severe illness or in death.

Lyme Disease

The causative agents for Lyme disease include Borrelia burgdorferi and Borrelia mayonii. Lyme disease is most frequently reported in the Upper Midwestern and northeastern regions of the United States with some cases being reported in northern California, Oregon, and Washington. Data from 2015 shows that 95% of Lyme disease cases were reported in the following 14 states: Connecticut, Delaware, Maine, Maryland, Massachusetts, Minnesota, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont, Virginia, and Wisconsin.3 The incubation period for Borrelia parasites is usually 3-30 days.3 Some of the early (3-30 days after a tick bite) signs and symptoms of Lyme disease include fever, chills, headache, fatigue, muscle and joint aches, and swollen lymph nodes may occur with an absence of rash. Erythema migrans is a characteristic rash of Lyme disease and it occurs in 70%-80% of infected people.4 This rash starts at the site of a tick bite after an average of 3-30 days (average is 7 days) and it gradually expands over several days reaching up to 30 cm across.4 As it enlarges, it can result in the characteristic “bulls-eye” appearance; it may feel warm to the touch and it is rarely itchy or painful. Some of the later (days to months after a tick bite) signs and symptoms include severe headache and neck stiffness, additional erythema migrans rashes in other areas of the body, facial palsy, arthritis with severe joint pain and swelling—especially in the knees, intermittent pain in the tendons, muscles, joints, and bones. It may also lead to heart palpitations or Lyme carditis, episodes of dizziness or shortness of breath, inflammation of the brain and spinal cord, nerve pain, and shooting pains, numbness, or tingling of the hands and feet.4 Laboratory diagnosis for Lyme disease includes the demonstration of IgM or IgG antibodies in serum and a two-step testing protocol is highly recommended.5 Moreover, isolation of an organism from a clinical specimen is also recommended. Treatment for Lyme disease includes antibiotics such as doxycycline, cefuroxime axetil, or amoxicillin.

When assessing a patient for any tick-borne diseases, the clinical presentation should be considered alongside the likelihood that the patient has been exposed to an infected Ixodes scapularis tick, or any other tick. Moreover, if a tick is found, engorgement of the tick should be considered when assessing for the possibility of disease transmission.

References

  1. Thevanayagam S. Ixodes scapularis [Internet]. 2012. Available from: https://animaldiversity.org/accounts/Ixodes_scapularis/.
  2. Centers for Disease Control and Prevention. Lifecycle of Blacklegged Ticks [Internet]. 2011 [updated November 15, 2011]. Available from: https://www.cdc.gov/lyme/transmission/blacklegged.html.
  3. Centers for Disease Control and Prevention. Tickborne Diseases of the United States: A Reference Manual for Healthcare Providers [Internet]2018. Available from: https://www.cdc.gov/ticks/tickbornediseases/TickborneDiseases-P.pdf.
  4. Centers for Disease Control and Prevention. Lyme Disease – Signs and Symtoms [Internet]. 2021. Available from: https://www.cdc.gov/lyme/signs_symptoms/index.html.
  5. Mead P, Petersen J, Hinckley A. Updated CDC Recommendation for Serologic Diagnosis of Lyme Disease. MMWR Morb Mortal Wkly Rep. 2019;68(32):703. Epub 2019/08/16. doi: 10.15585/mmwr.mm6832a4. PubMed PMID: 31415492; PubMed Central PMCID: PMCPMC6818702 potential conflicts of interest. No potential conflicts of interest were disclosed.

Amelia Lamberty is a Master’s student in the Pathology Master’s Program.

-Christi Wojewoda, MD, is the Director of Clinical Microbiology at the University of Vermont Medical Center and an Associate Professor at the University of Vermont.

Hematology Case Study: Temporal Arteritis or COVID-19?

What is your least favorite test in hematology? The first things that come to my mind are those tests that are time consuming, tedious, and manual. I’ve worked in a hematology lab that did Kleihaur betke (KB) tests, and whenever I worked, I seemed to get one, or sometimes more, in a given shift. And when I worked in blood bank, we did KBs in blood bank, and I certainly did my share there, too. KBs seem to follow me around! Those, I must admit, are probably my least favorite, but I know that many techs dread parasite smears or % parasitemia, reviewing 150 or more fields or counting thousands of cells on a smear. Manual body fluid counts, manual reticulocyte counts, and manual platelet counts are likely some others on our lists of “not favorites.” Basically, anything that requires a lot of time, manual counting, and math!

One other test that probably doesn’t make many “favorites” list is the Erythrocyte Sedimentation Rate (ESR), or sed rate. Remember old fashioned Westergren Sed Rates that took an hour to do, while the ER doctor kept calling looking for their “STAT” results? There are still labs that set up manual sed rates that take an hour, and modified manual methods that take “only” 15 or 30 minutes. Some semi-automated methods can give us results in a couple minutes, but still require techs to fill a capillary tube and load the instrument. Fortunately, real help may have arrived, in the form of fully automated ESR instruments! There are instruments now that actually make ESRs almost fun. I’ve never seen techs so excited about a new instrument as they were when we got iSeds. This thing is amazing! It’s like a little Ferris wheel for sed rates. You pop the whole tube in, they go for a little ride around the Ferris wheel, then drop out, in less than 30 seconds. And you can keep loading tubes even while it’s running. A truly Stat ESR. Now that’s amazing!

Image 1. Alcor iSED Automated ESR Instrument

While these new instruments make ESR’s easier to run, with more reproducible results, and less hands-on time, they still don’t get much love, because, well…there are newer tests available for inflammation, and we know that the ESR is not a specific test for diagnosis. Across the years, some lab tests have become antiquated and obsolete…bleeding times come to mind, along with CK-MB. In 2010 an article was published that supported discontinuing laboratory tests that no longer have clinical utility in the lab. The ESR was on this list. Yet, many labs still perform ESRs. Should the ESR be phased out, or are there still valid reasons for ordering them?

Even though the test is considered non-specific, the ESR test is considered helpful in diagnosing two specific inflammatory diseasestemporal arteritis (TA) and polymyalgia rheumatica. A high ESR is one of the main test results used to confirm these diagnoses. It is also used to monitor disease activity and response to therapy in both these conditions. Almost all cases present with an elevated ESR, though a normal ESR should not be used to rule out these conditions.

Case 1: A 70 year old White female was admitted to the ER complaining of throbbing headache and blurry vision. She stated that the headache started 2 days ago, had been at her temples at first but in the past few hours was getting worse. She stated that she was prompted to come to the ER because now her whole scalp hurt, and her vision was blurry. A CBC, Basic panel, CRP and ESR were ordered. The CBC results were unremarkable, other than and increased platelet count of 480,000/µL. ESR was 110 mm/hr. Basic panel results were normal. CRP was 2.51 md/dL.

The patient was started on prednisone immediately, and a temporal artery biopsy was scheduled, with a suspicion of temporal arteritis (TA), also known as giant cell arteritis (GCA). TA is an autoimmune disease that causes inflammation of the temporal arteries. Under the microscope, the inflamed cells of these arteries look giant, which is how the disease got its name. The inflammation causes constriction of the arteries, can affect chewing and eating, and may cause blindness if not treated promptly. Treatment of choice are corticosteroids, often prescribed for at least a year. Symptoms are monitored frequently and lab results, including the ESR, can be used to monitor the condition and response to treatment.

If you are still wondering if the ESR should be discontinued as a useful test, we are now seeing patients with COVID infection and elevated ESRs. Over the past 2 years, several articles have been written about elevated ESRs in COVID-19 patients. One study aimed to evaluate the usefulness of ESR in distinguishing severe from non-severe COVID-19 cases. The study suggests that severe COVID-19 cases are associated with higher elevations of ESR, as compared to non-severe cases. A case report of a patient recovering from COVID described an increased ESR. The high ESR persisted for a long time even after the patient recovered from COVID-19, while no other inflammatory processes or other conditions known to raise ESRs were found.

Case 2: My second case is a case of a 58 year old woman who presented with an earache and a pulsing temporal headache. Ear infection was ruled out and the patient was referred to ophthalmology for possible TA. The patient’s CRP was elevated but her ESR and platelet counts were within normal reference range. The patient was COVID tested as part of a pre-op workup before temporal artery biopsy and the COVID-19 test came back positive. There have been cases in literature in the last year of this new set of symptoms in COVID-19 patients. The conclusion from these cases is that if a patient appears with symptoms consistent with TA with an elevated CRP but with a normal ESR and platelet counts, that the patients should be tested for COVID.

The ESR is one of the oldest laboratory tests still in use. The study of the sedimentation of blood was one of the principles on which ancient Greek medicine was based. In the 1700’s, physicians noticed that the rate of red blood cell sedimentation changed during illness. This theory was first introduced as a laboratory test over 100 years ago. Depending on the historic accounts and articles you read, it was first described by a Polish physician, Edmund Biernacki, in 1897, or by a Swedish physician, Robert Fahraeus, in 1915. Biernacki proved the connection between the rate of sedimentation and the amount of fibrinogen in the blood and suggested using the ESR in diagnostics. Alf Vilhelm Albertsson Westergren (a familiar name!) also presented a similar description of the ESR. In the early 1920’s. Dr Westergren went further to develop the blood drawing technique and defined standards for the ESR. To this day, the Westergren Erythrocyte Sedimentation Rate method is recognized as the gold standard reference method for ESR measurement.

Image 2. Manual Westergren ESRs

The sed rate measures the rate at which erythrocytes sediment by gravity, in mm/hour. RBCs usually repel each other due to zeta potential and aggregation is inhibited. In conditions with increased fibrinogen or immunoglobulins, these proteins coat the RBCs, promoting aggregation. The RBCs form rouleaux which settle faster than individual RBCs. In conditions such as anemia, the ESR will be high because with a lower hematocrit, the velocity of the upward flow of plasma is altered and red blood cell aggregates fall faster. In polycythemia the increased blood viscosity can cause a lower ESR. In sickle cell anemia, and other conditions such as spherocytosis, the RBCs are abnormally shaped and will not form rouleaux easily, thus decreasing the ESR.

The ESR is an easy, inexpensive, non-specific test that has been used for many years to help diagnose conditions associated with acute and chronic inflammation. An elevated ESR is not associated with a specific diagnosis; therefore, it must be used in conjunction with other tests. Conversely, a normal ESR cannot be used to exclude the presence of significant disease. The ESR should also not be used as a screening test in asymptomatic patients. Since fibrinogen is an acute-phase reactant, the ESR is increased in many inflammatory and neoplastic conditions that increase fibrinogen, including diabetes, infection, pelvic inflammatory disease, lupus. rheumatoid arthritis, acute coronary syndrome, and neoplasms. However, noninflammatory factors such as older age, female gender, and pregnancy can also cause elevation of the ESR. 

Historically, the ESR was used to indicate inflammatory conditions and monitor disease progression or response to treatment. More specific tests have been developed for many of these conditions, but the ESR still has its advantages. Interestingly enough, for a test that 12 years ago was on the ‘antiquated’ list, in the past 2 years there have been over 50 scientific journal articles written about the ESR. The ESR can eliminate unnecessary testing and help decrease medical costs. It has its advantages in small labs and in rural areas because it can provide quick results without expensive instrumentation. For labs that do not perform more sophisticated tests such as CRP and procalcitonin, the ESR can provide answers without waiting for results from reference laboratories. Even though an ESR may take 1 hour, it is much faster than send out testing. It can therefore expedite a diagnosis, or normal results can give the physician and patient timely reassurance.

What is your favorite or least favorite test in hematology? Let me know and I can highlight it in a future blog!

References

  1. Au, Benjamin Wai Yin MBBS, MMed (Ophth); Ku, Dominic J. BMed, MSurg; Sheth, Shivanand J. MBBS, MS (Ophthal) Thinking Beyond Giant Cell Arteritis in COVID-19 Times, Journal of Neuro-Ophthalmology: March 2022 – Volume 42 – Issue 1 – p e137-e139
  2. Brigden ML. Clinical utility of the erythrocyte sedimentation rate. Am Fam Physician. 1999 Oct 1;60(5):1443-50. PMID: 10524488.
  3. Hale AJ, Ricotta DN, Freed JA. Evaluating the Erythrocyte Sedimentation Rate. JAMA. 2019;321(14):1404–1405. doi:10.1001/jama.2019.1178
  4. Pu, Sheng-Lan et al. “Unexplained elevation of erythrocyte sedimentation rate in a patient recovering from COVID-19: A case report.” World journal of clinical cases vol. 9,6 (2021): 1394-1401. doi:10.12998/wjcc.v9.i6.1394
  5. Tishkowski K, Gupta V. Erythrocyte Sedimentation Rate. [Updated 2021 May 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557485/
  6. Alan H. B. Wu, PhDKent Lewandrowski, MD, et al. Antiquated Tests Within the Clinical Pathology Laboratory. The American Journal of Managed Care. September 2010, Volume 16, Issue 9
  7. https://emedicine.medscape.com/article/332483-workup
Socha-small

-Becky Socha, MS, MLS(ASCP)CMBBCM graduated from Merrimack College in N. Andover, Massachusetts with a BS in Medical Technology and completed her MS in Clinical Laboratory Sciences at the University of Massachusetts, Lowell. She has worked as a Medical Technologist for over 40 years and has taught as an adjunct faculty member at Merrimack College, UMass Lowell and Stevenson University for over 20 years.  She has worked in all areas of the clinical laboratory, but has a special interest in Hematology and Blood Banking. She currently works at Mercy Medical Center in Baltimore, Md. When she’s not busy being a mad scientist, she can be found outside riding her bicycle.

The Cure for Expertise Loneliness

“The world is moving so fast, that we have few true experts on tomorrow. All we have are experts on yesterday.” –GYAN NAGPAL, The Future Ready Organization

One of my ingrained memories from my time at Harvard was the set of criteria needed to be promoted up the academic ranks within the medical school. At the “last” level—associate to full professor—one of the criteria was that you have an established international reputation and expertise in a particular area which is clearly demonstrated by your body of written work as well as the external opinions of 20+ people (in formal letters) who have never directly worked with you. Although that may sound like a tall order in words, it is something that musicians, actors, and influencers can easily demonstrate, although their “particular area” is not necessarily something tangible but certainly entertaining. In academia overall, achieving such documented prowess may appear easier for some fields than others. For example, behavioral psychology has spawned an entire industry of self-help books across every possible genre which all are based on the same principles; yet, no one really cares about the reproductive processes of Chytridiomycota. There are many people who call themselves experts in behavioral psychology and so many conventions, book signings, and meetings about the topic that those experts are probably never lonely. But our buddy who studies Chytridiomycota probably doesn’t have lunch with someone every day that includes a spicy discussion about mycelial separation. In certain areas of academia—for example, astronomy and physics—the inclusivity of publications and sharing of credit for collective work is so common that the above criterion really makes no sense but, at the same time, they are an integrated, harmonious community who all know each other and likely have raging keggers where nothing less than all of the known universe is discussed. Unfortunately, in the medical field, there are a plethora of expert cliques (Oncology, Dermatology, Surgery, Pathology, etc.) and then there are many individuals who are experts in their narrow area that the “cool kids” don’t really care about. COVID demonstrated that the cool kids do care when their house is on fire and those dejected experts are the only ones with a fire extinguisher—but I refuse to write any more about COVID. I am declaring it officially dead to me (but still staying on top of it). To quote a friend, I’ll just call it, “our recent unpleasantness.”

The take home is that expertise is excellent for society but for the individual who is burdened with a particular expertise that is uncommon (or unsavory), daily life can be lonely. Of course, there are people around that one can talk to, but they want to talk about mundane things like work, taxes, politics, Instagram, television shows, or actors. No one wants to get down and dirty into Chytridiomycota!! And we all know those folks—and love them—for their enthusiasm and their quirks. But this loneliness is much more common that we’d like to assume. When I was at Harvard, there were a cadre of people—all of different backgrounds and in different specialties—that were “global health” people. I have waxed on in previous blogs about the complex and expansive definition of “global health”, but the point is that anyone who identifies that way speaks a common enough language and has read the same books to have an engaging conversation about the topic. When I moved from Harvard to my current role at ASCP, the pool of immediate colleagues dwindled but my day-to-day job kept me in touch with so many global health people that I was even more engaged. Then the recent unpleasantness struck, and I relocated for remote working. I love my neighbors dearly but none of them have heard of global health. Moreover, because my day involves a computer terminal, innumerable meetings and emails, cross-coverage of activities, and evolving roles to meet the rapidly evolving world, the virtual global health quotient of my week has dwindled further. And sure, I could join a Facebook group or a WhatsApp thread or follow a Twitter thread about global health (and I do all of those things) but it still a little lonely most of the time.

Eureka! I was invited to give a talk—in person, ya’ll! With live people! —in Seattle in late April/early May at the behest of the Binaytara Foundation on Cancer Health Disparities. Most of the people who were invited to this summit were people I already knew but hadn’t seen in 2 years. I was happy to join but under the presumption that, “I’ve heard all this” but thought it would be great to see everyone. I was so wrong!!

The initial session was about health insurance coverage disparities in general and for cancer, and I savored every word. Many of you will read this and likely be highly informed in this area and others may know nothing about it. For me, I’ve been busy with global health disparities (primarily in Africa) and hadn’t paid enough attention to the continued disparities in my own back yard. I was humbled, a little ashamed, but delighted to learn. There were multiple specific projects and programs, presented by the leads, demonstrating how access to insurance programs and other payment programs massively reduced and resolved disparities in particular communities—minorities, inner city, homeless, etc. There were multiple data sets demonstrating how the Affordable Care Act had drastically increased access to care and reduced self-pay (a major barrier to proper cancer care outcomes). But it was not all “rainbows and butterflies”. There was a very upsetting presentation on the Medicaid expansion for cancer coverage which was allowed by the ACA that included descriptions of early expanding, slowly expanding, and nonexpanding states. It is important to note that this Medicaid expansion was money from the federal government to states to allow them to complete this coverage for more people with cancer including screening and early diagnosis. When the ACA became law, the federal government paid 100 percent of the cost of expansion coverage (from 2014 to 2016). After that, the federal share decreased, and now it pays 90 percent (as of 2020). Although the percentage has dropped from 100 to 90, the non-expansion states did have the opportunity to opt-in when there was 100% coverage. From Barnes et al (2021), “Early Medicaid expansion was associated with reduced cancer mortality rates, especially for pancreatic cancer, a cancer with short median survival where changes in prognosis would be most visible with limited follow-up.”1 What was also demonstrated was that, where expansion occurred, many health disparities were reduced. From Han et al (2018), “Disparities in the percentage of uninsured patients by race/ethnicity, census tract-level poverty, and rurality were diminished or eliminated in Medicaid expansion states but remained high in no expansion states, highlighting the promising role of Medicaid expansion in reducing disparities among sociodemographic subpopulations.”2 Medicaid expansion was free money from the federal government so why wouldn’t states take it if it can decrease cancer mortality and eliminate obvious disparities? According to familiesusa.org, Medicaid expansion has benefitted state economies, boosted job growth, and helped working but uninsured individuals improve their health and economic situations.3 The infographic shows the expanded, expanding, and nonexpanding states. Moreover, the decrease in the uninsured rates provided by the Medicaid expansion has provided offsetting savings (less uncompensated care provided by hospitals, more tax revenue on healthcare plans, etc.) that has more than covered state costs for the expansion. I will let you draw your own conclusions about why some states wouldn’t take free money from the government to care for minority groups and the impoverished. But all of that was just a taste of the conversations. And, for some of you, perhaps it sounds like the mating habits of Chytridiomycota. But these were my people and engaging with them for 3 days was an excellent cure for the mental loneliness of the past two years.

So, what did I learn from this event—other than a lot about health insurance, training people in disparities research, LGBTQ+ health access program, etc.? Convening is a very important part of the academic and professional and human process. Convening in person with other people in the same room creates safe dialog, allows for preposterous questions and new ideas, field tests opinions, and introduces people for more collaboration. Prior to our recent unpleasantness, with my global health team at ASCP and in my global health volunteer work at Harvard, we had been using video conferencing tools for years. I was a beta tester for Zoom before it was Zoom. I had been on 5 different meetings in one day using 5 different platforms. Videoconferencing was just a tool that we had to use to talk quickly and constantly with people all over the world. But we still had coffee in the break room, weekly in person meetings, and curbsides with other staff, etc. When the switch to complete videoconferencing occurred for all day work and, along with it, the inevitable virtual conference to replace a live meeting, the loneliness of expertise grew to an almost insufferable level. The cure, however, exists and it is in the live, in person meeting.

Note: Thanks to Matthew Schultz, Jeff Jacobs, and Suzanne Ziemnik of ASCP for their insightful ideas about this topic and input on this blog post.


  1. Barnes JM, Johnson KJ, Boakye EA, Schapira L, Akinyemiju T, Park EM, Graboyes EM, Osazuwa-Peters N. Early Medicaid Expansion and Cancer Mortality. J Natl Cancer Inst. 2021 Jul 14;113(12):1714–22. doi: 10.1093/jnci/djab135. Epub ahead of print. PMID: 34259321; PMCID: PMC8634305.
  2. Han X, Yabroff KR, Ward E, Brawley OW, Jemal A. Comparison of Insurance Status and Diagnosis Stage Among Patients With Newly Diagnosed Cancer Before vs After Implementation of the Patient Protection and Affordable Care Act. JAMA Oncol. 2018 Dec 1;4(12):1713-1720. doi: 10.1001/jamaoncol.2018.3467. PMID: 30422152; PMCID: PMC6440711.
  3. https://familiesusa.org/resources/momentum-on-medicaid-expansion/
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-Dan Milner, MD, MSc, spent 10 years at Harvard where he taught pathology, microbiology, and infectious disease. He began working in Africa in 1997 as a medical student and has built an international reputation as an expert in cerebral malaria. In his current role as Chief Medical officer of ASCP, he leads all PEPFAR activities as well as the Partners for Cancer Diagnosis and Treatment in Africa Initiative.

Microbiology Case Study: A 26 Year Old Female with Diarrhea

Case Description

A 26 year old female with a past medical history of Hemoglobin SC disease (Hb SC) and iron deficiency anemia presented to the emergency department with lower abdominal pain and diarrhea for three days. She began having multiple episodes of watery diarrhea, followed by bloody diarrhea after eating at a restaurant. During this time, she also had fever, chills, body aches, and headache. The patient had been on a course of ceftriaxone and metronidazole started three weeks prior for sore throat, ear infection, and bacterial vaginosis. She completed her metronidazole course prior to the current illness. Abdominal computed tomography revealed splenomegaly and a mildly dilated, fluid-filled appendix without evidence of infectious or inflammatory abnormalities. Hemoglobin on admission was 11.1 mg/dL (Reference Range: 11.2- 15.7 mg/dL) and MCV 62.9 fL (Reference Range: 79.4- 94.8 fL), which is similar to her baseline.

Laboratory Identification

The patient underwent work up for community-acquired diarrhea. Stool cultures grew non-typhoidal Salmonella (Image 1). Blood cultures performed at the time of admission flagged positive with gram negative rods which were also identified as Salmonella species by MALDI-TOF. The organism was susceptible to ampicillin, ceftriaxone, ciprofloxacin, and trimethoprim/sulfamethoxazole. The patient continued on intravenous ceftriaxone and responded to therapy. She was discharged home on oral ciprofloxacin.

Image 1. Salmonella Microbiologic Diagnosis using Xylose Lysine Deoxycholate agar and Triple Sugar Iron slant. A) Non-typhoidal strains of Salmonella are lactose non-fermenting, hydrogen sulfide producing (black colonies) enteric Gram-negative rods on Xylose Lysine Deoxycholate agar (XLD agar). B) Non-typhoidal strains of Salmonella are Alkaline (pink) over Acid (yellow) with the production of copious amounts of hydrogen sulfide on Triple Sugar Iron agar (TSI).

Discussion

Hemoglobin SC disease (Hb SC) is the second most common hemoglobinopathy after Sickle Cell Disease (SCD, Hb SS) globally.1 Hb SC disease occurs when a patient inherits both hemoglobin S and hemoglobin C alleles. Hemoglobin S and C variants are caused by point mutations in the hemoglobin beta- chain, and both variants lead to reduced affinity to the alpha-chain. While hemoglobin C is an abnormal form of hemoglobin that does not cause sickling on its own, when co-inherited with hemoglobin S, the beta chains polymerize, causing red cell sickling when oxygen tension is lowered in the blood.2 Patients develop anemia due to reduced red cell lifespan (27-29 days for Hb SC vs. 15-17 days for Hb SS) and subsequent destruction of red blood cells.3

Complications arise from vascular occlusion and destruction of red blood cells, leading to gallstones, pulmonary infarction, priapism, and/or cerebral infarction. Other complications include avascular necrosis of the femoral head, bone marrow necrosis, renal papillary necrosis, retinopathies, splenomegaly, and recurrent pregnancy loss. Although Hb SC patients often exhibit similar symptomology to sickle cell disease, symptoms are typically milder and present later in childhood.2,3 In comparison to patients with Hb SS, Hb SC patients have milder anemia, less frequent sickle cells, and less severe hemolysis. While Hb SC patients have fewer sickling episodes compared to Hb SS patients, Hb SC patients have more severe retinopathy and splenomegaly. It is also important to note that the enlargement of the spleen is often caused by red blood cell sequestration and the optimal function of the spleen is significantly reduced (functional hyposplenia), which can lead to increased risk of infection from encapsulated bacteria.

Diagnosis of Hb SC disease is typically made by performing hemoglobin electrophoresis (Image 2). Hemoglobin electrophoresis separates the differing varieties of hemoglobin by size and electrical charge. Capillary electrophoresis separates hemoglobin variants based on the “zone” of detection where each variant hemoglobin appears based on a reference pattern. Normal hemoglobin (A, F, A2) is easily discriminated from variant hemoglobins (S, C, E, D), and quantification allows for detection of beta-thalassemia (increased A2 fraction). While useful as a screening tool, the hemoglobin variants identified in the “zones” are not specific. For example, Hb C and Hb Constant Spring share a zone, and Hb A2 shares a zone with Hb O- Arab. Variants detected by capillary electrophoresis are confirmed by a second method, and in this case Hb SC was confirmed by acid agarose gel (Sebia Hydrogel). When subjected to acid gel electrophoresis, Hb C and Hb S migrate in separate bands, while Hb A, A2, D, and E comigrate in the “A” band, and the “F” band may contain F in addition to the glycated fraction of normal adult Hb A. Patients with Hb SC disease will have variants detected in the S and C zones in capillary electrophoresis and lack signal in the A zone.4

Image 2. Laboratory Diagnosis of Hb SC disease includes hemoglobin electrophoresis and peripheral blood smear review. A) Hemoglobin capillary electrophoresis (pH 9.4) separates F, S, C, A2, A (Sebia, Capillarys 2 Flex Piercing). B) Acid agarose gel (pH 6.0-6.2) separates hemoglobins F, A, S, and C (Sebia, Hydragel Acid QC lane).  C) Peripheral blood smear morphology showing characteristic Hb SC forms including target cells, boat shaped cells (single arrow), red cell with crystals (double arrow), and hemighost cells (triple arrow).

Examination of the peripheral blood smear from a patient with Hb SC disease (Image 2C) reveals frequent target cells, boat-shaped cells (taco shaped), and only rarely contains classic sickle cells. Hemoglobin C crystals can be seen, both free floating and inside red cells, a feature of CC and SC disease but not seen in SS disease. Hemi-ghost cells and cells with irregular membrane contractions are also more frequent in Hb SC disease. In contrast, sickle cells are rarely observed in peripheral smears from Hb SC patients.

Salmonellaeare flagellated gram negative bacilli that are members of the Enterobacterales. Salmonellosis is typically foodborne in nature and presents as a self-limiting acute gastroenteritis.5,6 However, these organisms can invade beyond the gastrointestinal tract resulting in bacteremia.6 This case presents Salmonella as a cause of bacteremia in a patient with Hb SC disease following a bout of gastroenteritis. Although there is a well-known association between SCD and invasive infections with Salmonella, the incidence of Salmonella infection in patients with Hb SC disease has not been well studied. Patients with SCD, particularly those in Africa, are at risk for developing invasive disease caused by non-typhoidal Salmonella, including osteomyelitis, meningitis, and bacteremia. It has been hypothesized that disruptions in the gut microbiome and increased permeability of enterocytes makes SCD patients more prone to invasive Salmonella infections.6 Furthermore, the compromised function of the spleen in both patients with SCD and Hb SC disease increases the risk of disseminated infection by encapsulated bacteria and Gram negative rods. The spleen plays an important housekeeping role removing old or damaged erythrocytes, but also has an important immunological function housing memory B cells, producing antibodies and macrophages that phagocytize circulating bacteria, particulates or other debris and then present the antigens to other immunological cells in the spleen.7 Although sepsis caused by Salmonella is an occasional progression of gastroenteritis, this patient’s Hb SC disease likely increased the likelihood of bacteremia because of her functional asplenia.

References

  1. Weatherall DJ. The inherited diseases of hemoglobin are an emerging global health burden. Blood. 2010;115(22):4331–6.
  2. Tim R. Randolph,24 – Hemoglobinopathies (structural defects in hemoglobin),Editor(s): Elaine M. Keohane, Catherine N. Otto, Jeanine M. Walenga,Rodak’s Hematology (Sixth Edition), Elsevier, 2020, Pages 394-423, ISBN 9780323530453, https://doi.org/10.1016/B978-0-323-53045-3.00033-7.
  3. (https://www.sciencedirect.com/science/article/pii/B9780323530453000337)
  4. Nathan, D. G., Orkin, S. H., & Oski, F. A. (2015). Sickle Cell Disease. In Nathan and Oski’s hematology and oncology of infancy and childhood (8th ed., pp. 675-714). Philadelphia, PA: Elsevier. Retrieved from https://www.clinicalkey.com/#!/content/book/3-s2.0-B9781455754144000206y.com/#!/content/book/3-s2.0-B9781455754144000206. Accessed 2022
  5. Bain, BJ. (2020) Haemoglobinopathy Diagnosis, Third Edition. Hoboken: John Wiley and Sons, Ltd
  6. Kurtz, J. R., Goggins, J. A., & McLachlan, J. B. (2017). Salmonella infection: Interplay between the bacteria and host immune system. Immunology letters190, 42–50. https://doi.org/10.1016/j.imlet.2017.07.006
  7. Lim, S.H., Methé, B.A., Knoll, B.M. et al. Invasive non-typhoidal Salmonella in sickle cell disease in Africa: is increased gut permeability the missing link?. J Transl Med 16, 239 (2018). https://doi.org/10.1186/s12967-018-1622-4
  8. Leone G, Pizzigallo E. Bacterial Infections Following Splenectomy for Malignant and Nonmalignant Hematologic Diseases. Mediterr J Hematol

-John Stack is a first year AP/CP resident at UT Southwestern Medical Center.

-Marisa Juntilla is an Assistant Professor in the Department of Pathology at UT Southwestern Medical Center. Dr. Juntilla is a board certified Clinical Pathologist and is certified in the subspecialty of Hematopathology.

-Dominick Cavuoti is a Professor in the Department of Pathology at UT Southwestern Medical Center. Dr. Cavuoti is a board certified AP/CP who is a practicing Clinical Microbiologist, Infectious Disease pathologist and Cytopathologist.

-Andrew Clark, PhD, D(ABMM) is an Assistant Professor at UT Southwestern Medical Center in the Department of Pathology, and Associate Director of the Clements University Hospital microbiology laboratory. He completed a CPEP-accredited postdoctoral fellowship in Medical and Public Health Microbiology at National Institutes of Health, and is interested in antimicrobial susceptibility and anaerobe pathophysiology.

-Clare McCormick-Baw, MD, PhD is an Assistant Professor of Clinical Microbiology at UT Southwestern in Dallas, Texas. She has a passion for teaching about laboratory medicine in general and the best uses of the microbiology lab in particular.

Microbiology Case Study: An Adult Presents with Hand Wound Following a Dog Bite

Case Presentation

An adult presented to the emergency department with a finger infection persisting for the past 14 days after being bitten by her dog. The finger was swollen, tender and red but the patient denied fever, chills, or purulent drainage. The patient was previously given 10 days of doxycycline and amoxicillin-clavulanic acid without any improvement. The patient underwent incision and drainage and the specimen was sent for aerobic culture and Gram stain. No organisms or WBCs were seen on the Gram stain. On day 3 of incubation, a yellow colony was observed on the chocolate agar. The colony was streaked out onto another chocolate plate for subculture (Image 1). MALDI-TOF identified this organism as Neisseria animoralis.

Image 1. Subculture of Neisseria animoralis.

Discussion

Neisseria animoralis and Neisseria zoodegmatis are primarily zoonotic organisms found as normal oral flora of cats and dogs. Both can cause wound infections in humans following animal bites. However, these organisms are under recognized animal bite pathogens, often leading to their identifications being dismissed as contaminants. While there are limited published studies on this organism, it is important to recognize its role in wound infections, as in our case. Due to lack of awareness and reduced recovery in culture, case studies have shown correlations with this organism and poor healing and chronic wound infections.

On Gram stain, N. animoralis appears as a Gram negative coccoid rod. In culture, N. animoralis is a slow growing organism that produces yellow or white colonies that are shiny and smooth. N. animaloris produces acid from glucose, but not lactose, sucrose, or maltose. MALDI-TOF is most commonly used for identification.

Limited N. animoralis treatment data are available currently. Most animal bite-related infections are polymicrobial in nature and thus, antibiotic treatment is broad spectrum to cover the most common aerobic and anaerobic organisms.

Resources

  • Johannes Elias, Matthias Frosch, and Ulrich Vogel, 2019. Neisseria, In: Carroll KC, Pfaller MA Manual of Clinical Microbiology, 12th Edition. ASM Press, Washington, DC. doi: 10.1128/9781683670438.MCM.ch36
  • Heydecke A, Andersson B, Holmdahl T, Melhus A. Human wound infections caused by Neisseria animaloris and Neisseria zoodegmatis, former CDC Group EF-4a and EF-4b. Infect Ecol Epidemiol. 2013;3:10.3402/iee.v3i0.20312. Published 2013 Aug 2. doi:10.3402/iee.v3i0.20312
  • Kathryn C. Helmig, Mark S. Anderson, Thomas F. Byrd, Camille Aubin-Lemay, Moheb S. Moneim, A Rare Case of Neisseria animaloris Hand Infection and Associated Nonhealing Wound, Journal of Hand Surgery Global Online, Volume 2, Issue 2, 2020, Pages 113-115, ISSN 2589-5141 https://doi.org/10.1016/j.jhsg.2020.01.003.
  • Merlino J, Gray T, Beresford R, Baskar SR, Gottlieb T, Birdsall J. Wound infection caused by Neisseria zoodegmatis, a zoonotic pathogen: a case report. Access Microbiol. 2021;3(3):000196. Published 2021 Feb 10. doi:10.1099/acmi.0.000196

-Paige M.K. Larkin, PhD, D(ABMM), M(ASCP)CM is the Director of Molecular Microbiology and Associate Director of Clinical Microbiology at NorthShore University HealthSystem in Evanston, IL. Her interests include mycology, mycobacteriology, point-of-care testing, and molecular diagnostics, especially next generation sequencing.

Microbiology Case Study: a 53 Year Old Man with a Black Spot on His Shoulder

Case History

A 53 year old man presents to urgent care with a primary complaint of an area of erythema and tenderness around a small black spot on his left shoulder, shortly after returning from Ecuador. He does not report any fevers, chills, or drainage from the affected area. The patient reported that he occasionally felt the area moving. An occlusive Vaseline dressing was applied to the central black spot, and the organism shown below emerged from the wound.

Laboratory Identification

The parasite shown above is a human botfly larva, Dermatobia hominis. The clinical history is strongly suspicious for a botfly infection, and the patient himself suggested the diagnosis.

Dermatobia hominis is identified in large part by its relatively unique presentation combined with identification of the larvae in tissue. Laboratory identification of genus and species involves comparing morphological structures including the anterior and posterior spiracles, mouthparts and cephalopharyngeal skeleton, and cuticular spines. Travel history can also be helpful for genus or species-level identification.

Discussion

The lifecycle of human botflies begins when the female botfly lays her eggs on a mosquito. Once a mosquito feeds on a host, the botfly larva drop onto the host and burrow into the skin. They may remain in that location for up to 10 weeks before dropping off the host into soil to pupate and continue the life cycle.

The human botfly is found in North America, ranging from Mexico to Paraguay and northeast Argentina. Cases in the US are primarily in travelers returning from the botfly’s native range. Measuring the incidence of infection in travelers can be difficult due to the nature of the disease. Experienced travelers may be able to remove the larva at home. In other cases the botfly larva may leave the host before the patient seeks medical care.

Testing for the presence of these larva is easy as they require oxygen coming in through a hole in the skin. Cover the lesion with a thick layer of sterile Vaseline gauze and wait approximately 5-15 minutes for the organism to emerge. Surgery is usually not required as the larva is most often removed intact. Antibiotics should be given following removal of the parasite to prevent secondary infections.

-Britt Boles, MD is a 1st year Anatomic and Clinical Pathology Resident at the University of Vermont Medical Center.

-Christi Wojewoda, MD, is the Director of Clinical Microbiology at the University of Vermont Medical Center and an Associate Professor at the University of Vermont.

Microbiology Case Study: A 27 Year Old with Disseminated Joint Pain

Case History

A 27 year old male presented to the Emergency Department (ED) with complaints of right knee pain and swelling for one week. Two weeks prior, he tripped while walking to work and began to feel pain in his right calf. Upon physical examination, swelling was noted in his ankles, knee, shoulders, and fingers. The knee and shoulder were tender to palpation. In the ED, he was afebrile and vitals were normal. He denied any sort of injury, chills, or rash and no history of tobacco, alcohol, or illicit substance abuse. CT scan of the lower extremity showed no acute fracture but moderate to large knee joint effusion was observed. He and his fiancé (male partner) has been in a monogamous relationship for almost a decade, however the patient did have a history of gonorrhea nine years ago but was treated. Knee arthrocentesis was performed. The fluid was yellow and cloudy and contained 27,000 WBCs. The Gram stain of the synovial fluid showed many intracellular gram negative diplococci and the joint fluid culture grew out Neisseria gonorrhoeae. PCR of the rectal swab also detected N. gonorrhoeae.

Discussion

N. gonorrhoeae is the causative agent of gonorrhea, a sexually transmitted disease. In the United States, it is the second most commonly reported communicable disease.1 While infections can be asymptomatic, in men, gonorrhea commonly causes acute urethritis with dysuria, urethral discharge, and rarely, epididymitis.2,3,4 In women, gonorrhea can cause cervicitis and lead to pelvic inflammatory disease (PID), infertility, ectopic pregnancy, and chronic pelvic pain.5,6 Those with gonococcal endocervicitis can be co-infected with Chlamydia trachomatis and/or Trichomonas vaginalis, other causative agents of sexually transmitted diseases. N. gonorrhoeae can cause extragenital infections in the pharynx and rectum, which are most commonly seen among men who have sex with men (MSM). Disseminated gonococcal infection is rare (0.5-3% of infected individuals) and can be characterized by low grade fever, hemorrhagic skin lesions, tenosynovitis, polyarthralgia and septic arthritis. Complications of disseminated infections may include permanent joint damage, endocarditis, and meningitis. Gonococcal conjunctivitis mainly affects newborns from untreated mothers.7

Gonorrhea can be diagnosed clinically by a history and physical examination and also, by microbiological methods. Home collection kits are available to increase convenience. On a Gram stain, N. gonorrhoeae, a gram negative coccus, frequently appears within or closely associated polymorphonuclear leukocytes (PMNs) typically as diplococci pairs. Direct smears can be prepared from urethral, endocervical sites, and normally sterile or minimally contaminated sites such as joint fluid. Swab specimens (e.g. urogenital, pharyngeal, vaginal or rectal) should be collected with a Dacron or Rayon swab as calcium alginate and cotton swabs may be toxic or inhibitory for the bacteria.8 Specimens must be transported to the microbiology immediately. 9 Blood and joint fluid are also acceptable specimen types for culture for detection of disseminated gonococcal infection.

Enriched selective media for culture of N. gonorrhoeae includes MTM medium, ML medium, GC-Lect and the New York City medium. Plates should be incubated in a CO2 incubator (between 3-7%) at 35C to 37C for optimal growth.9 Gram negative diplococci recovered from urogenital sites that grow on the selective media and are oxidase-positive can be presumptively identified as N. gonorrhoeae. Another quick biochemical test that can be done is superoxol; N. gonorrhoeae produce immediate bubbling whereas N. meningitidis and N. lactamica produce weak, delayed bubbling. Confirmation using other testing methods such as carbohydrate utilization tests (e.g. N. gonorrhoeae produces acid from glucose only), immunological methods, enzymatic procedures, or DNA probe are also available.10

Compared to standard culture methods, Nucleic Acid Amplification Tests (NAAT) offer more rapid results and increased sensitivity. Additionally, NAATs may also include additional targets such as C. trachomatis, a frequent co-pathogen, as part of the assay. NAATs should be used according manufacturer’s protocols and on validated specimen types. For example, the Cepheid Xpert CT/NG test (as used by our patient here) can be used to test asymptomatic and symptomatic individuals and the acceptable specimen types are urine, pharyngeal, and rectal swabs, patient-collected vaginal swabs, and clinician-collected endocervical swabs.11 Given the legal implications of a N. gonorrhoeae diagnosis in a child, the CDC recommends that NAATs can be used to test for N. gonorrhoeae from vaginal and urine specimens from females and urine for males.12 For extragenital specimens, only validated FDA-cleared NAATs assays using pediatric specimens should be used.

The CDC recommends that uncomplicated gonorrhea be treated with ceftriaxone and azithromycin. However, between 2000-2010s, elevated MICs to both ceftriaxone and cefixime were seen and emerging azithromycin resistance is still a concern. The CLSI M100 currently recommends agar dilution or disk diffusion for antimicrobial susceptibility testing for N. gonorrhoeae. Susceptible and resistant interpretative breakpoints are available for penicillin, most cephems, tetracycline, ciprofloxacin, and spectinomycin. Of note, for azithromycin, only the susceptible category has a breakpoint.13

Image 1. Gram stain of synovial fluid showing many intracellular gram negative diplococci.
Image 2. Chlamydia trachomatis and Neisseria gonorrhoeae PCR. Orange and Brown= targets for N. gonorrhoeae; light and dark green=control genes.

References

  1. CDC. Sexually Transmitted Disease Surveillance, 2020. Atlanta, GA: Department of Health and Human Services; April 2022.
  2. John J, Donald WH. Asymptomatic urethral gonorrhoea in men. Br J Vener Dis 1978; 54:322.
  3. Handsfield HH, Lipman TO, Harnisch JP, et al. Asymptomatic gonorrhea in men. Diagnosis, natural course, prevalence and significance. N Engl J Med 1974; 290:117.
  4. Sherrard J, Barlow D. Gonorrhoea in men: clinical and diagnostic aspects. Genitourin Med 1996; 72:422.
  5. McCormack WM, Johnson K, Stumacher RJ, Donner A, Rychwalski R. Clinical spectrum of gonococcal infection in women. Lancet, 1(8023), 1182–1185 (1977).
  6. Curran J, Rendtorff R, Chandler R, Wiser W, Robinson H. Female gonorrhea: its relation to abnormal uterine bleeding, urinary tract symptoms, and cervicitis. Obstet Gynecol, 45(2), 195–198 (1975).
  7. O’Brien JP, Goldenberg DL, Rice PA. Disseminated gonococcal infection: a prospective analysis of 49 patients and a review of pathophysiology and immune mechanisms. Medicine (Baltimore) 1983; 62:395.
  8. Laurer BA, Masters HB. Toxic effect of calcium alginate swabs on Neiserria gonorrhoeae. J Clin Microbiol 1988: 26:54-56
  9. Leber, A. 3.9 Genital Cultures. Clinical Microbiology Procedures Handbook, 4th Edition. ASM Press, Washington, DC. 2016. p.3.9.3.1-3.9.3.15. 
  10. Knapp JS. Historical perspectives and identification of Neisseria and related species. Clin Microbiol Rev 1988;1:415-431.
  11. Cepheid GeneXpert. Xpert CT/NG (English). 2019. 301-0234 Rev.K
  12. CDC. Gonococcal Infections Among Infants and Children. Sexually Transmitted Infection Treatment Guidelines, Atlanta, GA: Department of Health and Human Services; 2021.
  13. CLSI. Performance Standards for Antimicrobial Susceptibility Test. CLSI supplement M100. Wayne, PA: Clinical and Laboratory Standards Institute; 2022, Edition 32

-Maikel Benitez Barzaga, MD is a Pathology Resident (PGY-1) at The George Washington University Hospital. His academic interest include hematology, microbiology, molecular and surgical pathology.

-Rebecca Yee, PhD, D(ABMM), M(ASCP)CM is the Chief of Microbiology, Director of Clinical Microbiology and Molecular Microbiology Laboratory at the George Washington University Hospital. Her interests include bacteriology, antimicrobial resistance, and development of infectious disease diagnostics.

BOGO: Biopsy One, Get One Free

I’ve mentioned before how important it is to know clinical history before attending a biopsy, and I cannot stress this point enough. As the first line of screening, the intermediary between clinician and pathologist, the role of the cytologist is to prepare, assess, and convey. In a cancer center, we have three main populations: the patients with the unknown primary, the patients with the suspected primary, and the patients with the suspected metastasis. In the event of a suspected metastasis, we’ll review previous relevant pathology material if we have it onsite. Unless the clinician is requesting additional prognostic markers, the review process helps us eliminate the unnecessary repetition of immunostains (IHC) by confirming that the current material is morphologically consistent with the prior material. Sometimes we still perform old-school cytology without a plethora of ancillary studies. HA!

Most of the endobronchial ultrasound (EBUS) procedures performed at our institution are for lung cancer staging or differentiation between a lung cancer metastasis and an extra-pulmonary metastasis. Not that we don’t see the occasional sarcoid- or anthracosis-related process from time to time, but our most common indication is cancer. For an 88-year-old male patient with multiple lung nodules and both mediastinal and hilar lymphadenopathy, confirmation of metastasis was the main objective of the EBUS procedure. The patient’s pertinent medical history includes former tobacco use, squamous cell carcinoma of the lung (diagnosed percutaneously in 2022), clear cell renal cell carcinoma (s/p partial nephrectomy in 2020), prostate cancer (radiated in 2007), melanoma (excised in 2001), and cutaneous squamous cell and basal cell carcinoma (also previously excised in 2002 and 2008). With an extensive cancer history, the lung nodules and thoracic nodes could be any of them, although metastatic squamous cell carcinoma of the lung was clinically favored. My awesome cytologist colleague, Kelly, attended the EBUS procedure. The Rapid Onsite Evaluation (ROSE) was a clear-cut “adequate for diagnostic material,” and the attending pathologist added “tumor cells present.” The following morning, Kelly stopped by my desk to ask my opinion of the 12R (right hilar) lymph node she was screening. She said, “look at my dots. Do these look like the same cells to you? Or are they different? Because I feel like they’re different.” Before putting the slide on my scope, I asked, “so… like a combined adenosquamous? Or a small cell component?” She replied, “not small cell. Something… I don’t know, but they look different. The patient was recently diagnosed with lung cancer and has a history of renal cell.” I fixated on the H&E cell block slides (Images 1-3) before perusing the Diff-Quik and Papanicolaou-stained slides (Images 4-5). “Uhm… Why are there two different types of tumor cells here?! The cytoplasm here is so… vacuolated, but it’s not quite like lung adeno, and the other group… even the n/c (nuclear-to-cytoplasmic) ratio is different. What is this?” Kelly replied, “okay, so there are definitely two different types of tumor here.” I looked up, “It has to be. Absolutely, yes.”

Images 1-4. Lymph node, 12R, EBUS-guided FNA. 1-3: H&E cell block sections 1, 100x; 2, 400x; 3, 100x. 4: Diff-Quik stained smear.
Image 5. Lymph Node, 12R, EBUS-guided FNA. Pap-stained smear.

Kelly entered her diagnosis into our laboratory information system and brought the case over to the pathologist on cytology service for the day. She explained her thought process, and the pathologist also questioned if it was a combined process, such as a lung adenosquamous and maybe the original lung biopsy only sampled the squamous component. With the most recent clinical history of both lung squamous cell carcinoma and clear cell renal cell carcinoma, an IHC panel was appropriately selected. Later that afternoon, the pathologist exclaimed, “IT’S BOTH! IT’S SQUAMOUS AND RCC!” The clusters of squamous cell carcinoma did not stain for PAX8 (a renal cell carcinoma marker) (Image 6), and the same cluster stained positive for p40 (a squamous cell carcinoma marker) (Image 7). Within the same level of the cell block, the cluster of cells that appeared morphologically different than squamous cluster stained positive for PAX8 (Image 8) and negative for p40 (Image 9), confirming a renal cell carcinoma component. A small focus of p40-positive cells was present next to the p40-negative renal cell carcinoma (Image 9), further demonstrating mixed histology. This finding was shared with other pathologists, and the results were immediately called to the pulmonologist as this was a critical finding. Sometimes we encounter a partially involved node where the tumor cells are intermixed with lymphocytes, sometimes the lymph node yields more tumor than the primary site, and sometimes, albeit rarely, we encounter a lymph node infiltrated by two different carcinomas.

Images 6-9. Lymph Node, 12R, EBUS-guided FNA. Cell block section immunocytochemistry. Squamous cell carcinoma cluster – 6: PAX8-negative; 7: p40-positive. Renal cell carcinoma cluster – 8: PAX8-positive, 9: p40-negative (with small focus of p40-positive squamous cell carcinoma).

Due to the patient’s bulky disease and PD-L1 expression of 30%, the medical oncologists primary aim was to treat the squamous cell carcinoma first and follow up renal cell carcinoma therapy second. After the first few cycles of treatment, the lung nodules have decreased in size, but the thoracic nodes remain unchanged. Once the squamous cell carcinoma is controlled or demonstrates a more significant response, immunotherapy may be added to target both, with a tyrosine kinase inhibitor directed at renal cell carcinoma metastases in the event of progression.

-Taryn Waraksa-Deutsch, MS, SCT(ASCP)CM, CT(IAC), has worked as a cytotechnologist at Fox Chase Cancer Center, in Philadelphia, Pennsylvania, since earning her master’s degree from Thomas Jefferson University in 2014. She is an ASCP board-certified Specialist in Cytotechnology with an additional certification by the International Academy of Cytology (IAC). She is also a 2020 ASCP 40 Under Forty Honoree.

“Being a Doctor” Vs. “Doing Your Job”

I awoke to a text recently that simply said, “Can I ask you a question?” Having finished medical school 22 years ago, I get this very frequently and know from personal anecdotal statistics that it’s either a medical issue (high probability) or someone needs money (much less common). This is not a text from work nor is it from a channel that will result in additional funds deposited on my behalf. This is from an acquaintance, by which I mean it could be any of the following: family member, friend, colleague, ex-girlfriend of an ex-boyfriend, co-worker, random person I met somewhere, etc. I spent some time on the phone in response to this text, recommended a course of action, and solved the problem. The details of this discussion (or the hundreds of others I had over the years) are privileged and irrelevant. The point is that I was “being a doctor’. A problem was presented by a person in need with real concerns about their health (or a loved one’s), I assessed the information they provided, and suggested a next step. My advice is usually spot on and appreciated which stems from my being cautious but concerned. Another important feature of my advice derives from one of my mantras: “Don’t scare the straights!” (which I learned from the comic genius, Bill Murray, in Ghostbusters).

This is one of the hardest aspects of being a doctor (especially when you are a student). It’s really great that you recognize (sometimes immediately) that someone has a life-threatening illness… but they don’t need to know that unless they are within a safe, secure medical environment where action can be taken. Moreover, medical issues are private for the same reason. It’s pretty clear to all of us that we shouldn’t yell “Fire!” in a crowded theatre or even jokingly say words that sound like “bomb,” at an airport. But here’s a true story of what I mean with medicine. Many years ago, I happen to be on an airplane (at cruising altitude) coming back from Africa, where my friend, Paul Farmer (RIP), was also a passenger. Another colleague of ours (a surgeon) was also on the plane. Paul was having an eye issue which looked mild but irritating. Our colleague said, loudly in her confident tone, “Do you think it could he Ebola?” Paul and I exchanged a quick glance, both thinking, “Don’t scare the straights!” I think you see my point. But, for clarity, a personal example. One winter, my husband and I were returning from the city to our suburb, which required a brisk, long walk from the train. The sidewalks were icy and, in places, uneven. He stepped off and fell full force on his shoulder. The next morning he couldn’t move it and it was painful. My immediate thought was, “He broke his shoulder.” Did I say, “Dude, you totally broke your shoulder!” No. We were having an open house to sell our place and he was all stressed about it. So, I said, “Be careful with your arm and we will go to urgent care afterward.” This made him calm. I even made him drive to urgent care (it was not his dominant shoulder) to reassure him he was okay. In urgent care, the ortho surgeon (who happened to be that day’s coverage) walked in after the x-ray and said, “Dude, you broke your shoulder!” And my husband promptly passed completely out onto the examination table. It’s all about understanding the acuity of the situation and striving to not make it worse.

Have I ever been wrong? Of course! Because the only way to truly care for a medical concern is to evaluate it yourself in person with appropriate tools. And almost all of the times I have been wrong (which is only a few), there was some crucial aspect that was not shared because either it wasn’t known or there was discomfort with sharing.

But what I am describing is not unique to me. I’m quite sure every doctor gets these calls with frequency. It’s the purest form of practice because there is no financial transaction presumed, assumed, or demanded.

But what about “doing my job?” Let’s break that down. I work for a non-profit and have a private consultation practice (non-overlapping, non-conflicting). Currently, I am financially compensated (at about $175/hour (pre-tax)) for any/all of the following: health system implementation, grant writing/administration, education, research management, social media production/communication, expert scientific/business consultations, committee participation, abnormal laboratory case review, daily laboratory management, intra-operative consultation, market insights/research, etc. Not much of that sounds like I’m fighting death and stamping out disease at the individual patient level, the life task I as trained for in medical school. Importantly, I’m also hard salaried across all my work so I don’t do individual billing except for a few things like abnormal slide review. Many of my physician colleagues do have to engage in individual billing. But I think much of what I do still sounds very familiar to many of my physician colleagues who see patients every day. When (in my opinion) my physician colleagues should be spending every hour of every day “being a doctor,” as I described above, I fear they spend a lot of time instead documenting, managing, and administrating to ensure they are compensated. I am of the very unpopular opinion that healthcare should be free but I also believe healthcare workers should be compensated aligned to their impact on patients. The medical profit insistence paradigm continues to widen inequity while decreasing the care time for patients in lieu of format/template/documentation to justify billing. I have to spend time doing this non-patient care but, fortunately, they are limited because of the narrow slice of medical billing to which my services are privy.

Here is a specific example to demonstrate the difference I’m discussing. I received an abnormal smear to review from the laboratory. The white blood cell count was over 400,000 cells (ref 10 – 30), the smear was a “medical student”-level diagnosis, the patient was on a supposedly effective treatment, but they had left against medical advice. There are many ways to respond to this case. My question was, “Is this patient okay, right now?” and my immediate action reflex said, “This patient needs to see an oncologist right now.” But she left AMA. How you as a patient or doctor respond to this says a lot about you as a person but also about the fiscal constraints in which you work. What did I do? I called the patient who had, thankfully, been admitted elsewhere, and asked them to please have their doctor call me back. The doctor did, I told them the information, and my suggestion that oncology see them immediately. Oncology saw them a few hours later. Let’s summarize. I spent about 20 minutes reviewing all of the clinical and laboratory information, about 1 hour on the phone over 2 days, and about 10 minutes documenting all of this in the patient’s medical record. I was subsequently paid an additional $25 two months later for that documentation by the patient’s insurance company. So, I “did my job” for $16.67/hour over my base but I was also “being a doctor,” which likely was best for the patient. Which is most important at the end of the day? I certainly didn’t need the extra $25 but the patient definitely needed my input. Importantly, note that the insurance company valued my time at a 10-fold lower rate than did my hospital.

A recent study demonstrated that when nurse practitioners are used instead of physicians, healthcare costs were higher.1 This study follows other studies which have shown the opposite. I don’t have an opinion about quality of care, appropriateness, or territorial pissings in the current debate between MDs and NPs about scope of practice; in fact, I see NP’s quite frequently for my healthcare. But we are all being asked to always be conscious of costs in healthcare when all we should be focusing on is, “How is the patient doing right now?” Grand efforts, like task shifting domestically and internationally, are assumed to save money but they simply don’t do so universally. Where costs could be easily cut (i.e., administration) or outsourced (i.e., finance, HR, IT), they aren’t because C-suites are in charge of cost cutting. But doctors (and NPs and all front line medical workers) are the ones being told to be cost conscious and find cost savings—when their job should only be asking the question, “How is the patient doing right now?”

I love “being a doctor,” especially when I can help someone reach a positive outcome. I love “doing my job” because it’s variable, ever-changing, challenging, rewarding, and I feel my compensation is appropriate. I really love when “doing my job” and “being a doctor” align around the same task. Finding this alignment as frequently as possible produces the happiest healthcare workers and the best care for patients, in my opinion.

Note: As an employee of a 501(c)(3), my salary information is public knowledge.

Reference

  1. https://www.ama-assn.org/practice-management/scope-practice/amid-doctor-shortage-nps-and-pas-seemed-fix-data-s-nope
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-Dan Milner, MD, MSc, spent 10 years at Harvard where he taught pathology, microbiology, and infectious disease. He began working in Africa in 1997 as a medical student and has built an international reputation as an expert in cerebral malaria. In his current role as Chief Medical officer of ASCP, he leads all PEPFAR activities as well as the Partners for Cancer Diagnosis and Treatment in Africa Initiative.

Microbiology Case Study: A 32 Year Old with Lower Extremity Swelling

Case History

A 32 year old male with alcoholic cirrhosis presented to the emergency department with progressive lower extremity swelling. On presentation he was found to have jaundice due to hemolytic anemia secondary to spur cell anemia. Admission hemoglobin was 4.3 mg/dL (4.0-11.0 mg/dL) and bilirubin, both total and direct, were 6.3 mg/dL (0.2-1.3 mg/dL) and 2.9 mg/dL (0.0-0.5 mg/dL), respectively. He also had acute kidney injury (AKI) thought to be secondary to hepatorenal syndrome leading to the development of anasarca. A urinalysis was performed as part of the evaluation for his AKI that showed 100 WBC/HPF, > 187 RBC/HPF, and moderate bacteria which triggered a urine culture.

Laboratory Identification

Urine received in the microbiology laboratory was plated on Blood and MacConkey/CNA agars and grew non-hemolytic, lactose-fermenting gram negative rods (Image 1). Indole testing was negative. Given this biochemical pattern, a member of the Enterobacterales was suspected as typically seen in urine cultures. However, MALDI-TOF MS provided the surprising identification of Salmonella enterica subsp. arizonae. Xylose Lysine Deoxycholate (XLD) agar was set up to confirm the unusual identification (Image 2). Hydrogen sulfide production is typical of Salmonellae, and lactose fermentation, a trait unique to some isolates of S. enterica subsp. arizonae, was confirmed. The organism was submitted to the Texas Department of Health laboratory where the isolate was definitively identified as Salmonella enterica subsp. arizonae (IIIa 14:z4,z23) by whole genome sequencing.

Image 1. Patient isolate of S. enterica subsp. arizonae exhibiting lactose fermentation on MacConkey agar after 18 hours of incubation at 35°C (A). Lactose-fermentation is a unique hallmark of S. enterica subsp. arizonae compared to other Salmonellae (B).
Image 2. Patient isolate of S. enterica subsp. arizonae exhibiting hydrogen sulfide production and lactose fermentation on XLD agar after 18 hours at 35°C (A). Note the abundant yellow color of the medium (black arrowhead) compared to S. enterica subsp. Enterica serovar Enteritidis which does not ferment lactose, but also produces hydrogen sulfide (B, white arrowhead).

Discussion

This is a rare case of an extraintestinal infection caused by Salmonella enterica subsp. arizonae. Salmonellaeare motile, gram negative, facultatively anaerobic bacilli that are members of the Enterobacterales. The genus is composed of two species, S. enterica and S. bongori. Salmonella enterica is further subdivided into six subspecies: enterica (group I), salamae (group II), arizonae (group IIIa), diarizonae (group IIIb), houtenae (group IV), and indica (group VI). Salmonella bongori used to be classified as group V but was separated as a unique species based on genomic analysis.1 S. bongori almost exclusively causes zoonotic infections, while S. enterica subsp. enterica is the most frequent cause of human clinical disease. Salmonella taxonomy is complicated further by the division of members of S. enterica subsp. enterica into >2500 unique serovars based on immunoreactivity to lipopolysaccharide (O) and two flagellar (H) surface antigens. These are then further separated into “typhoidal” and “non-typhoidal” serovars based upon the characteristics of infection (Image 3).

Image 3. Hierarchical structure of Salmonella taxonomy. S. enterica subsp. arizonae is boxed in red to highlight is taxonomic position away from other pathogenic Salmonellae. Adapted from reference number 6.

Until recently, determinative testing was almost uniformly performed by serological confirmation of agglutination with O and H antigen-specific antisera. This has been a mainstay of epidemiological analysis of foodborne Salmonella outbreaks. Only recently has whole genome sequencing been adapted as a higher throughput and more discriminatory alternative to classical serotyping schemes. Salmonella nomenclature often uses a genus-species-subspecies format followed by serovar (e.g. Salmonella enterica subsp. enterica serovar Typhi), or it can be reported as genus-serovar for short (e.g. Salmonella Typhi). Formal identification will include information concerning the two flagellar antigens and lipopolysaccharide antigens, in addition to the formalized subspecies using the formula: genus-species-subspecies [space] O antigens [colon] Phase 1 H antigen [comma] Phase 2 H antigen. In this case, the formal identification from the state laboratory for this isolate was Salmonella enterica subsp. arizonae IIIa 14:z4,z23.

About 99% of human infections are due to Salmonella enterica subspecies enterica (group I)including the serotypes Enteritidis, Typhimurium, Typhi, Paratyphi.2 Infections due to Salmonella enterica subspecies arizonae are rare; serovar IIIa 41:z4,z23 is associated with 10-20 infections per year.3 Infection typically begins as gastroenteritis from food poising or from animal sources, particularly reptiles or poultry. Disease is typically seen in the young and immunocompromised and can progress to invasive disease including sepsis, meningitis, and osteomyelitis.4 It is unclear why there are lower rates of Salmonella enterica subspecies arizonae infections in humans as compared to Salmonella enterica subspecies enterica, but there is evidence to suggest Salmonella enterica subspecies arizonae and diarizonae have altered intestinal colonization in murine models leading to failure of Salmonella to persist in the mammalian intestinal tract.5

This patient had alcoholic cirrhosis and uncomplicated cystitis secondary to Salmonella extraintestinal infection at the time of presentation. It is unclear if this patient had gastroenteritis prior to developing cystitis and the limited medical history did not reveal exposure to reptiles or poultry. In this case, the patient completed seven days of ceftriaxone without complication or recurrence of infection.

References

  1. Agbaje M, Begum RH, Oyekunle MA, Ojo OE, Adenubi OT. Evolution of Salmonella nomenclature: a critical note. Folia Microbiol (Praha) 2011; 56(6): 497-503.
  2. Brenner FW, Villar RG, Angulo FJ, Tauxe R, Swaminathan B. Salmonella nomenclature. J Clin Microbiol 2000; 38(7): 2465-7.
  3. Shariat NW, Timme RE, Walters AT. Phylogeny of Salmonella enterica subspecies arizonae by whole-genome sequencing reveals high incidence of polyphyly and low phase 1 H antigen variability. Microb Genom 2021; 7(2).
  4. Abbott SL, Ni FC, Janda JM. Increase in extraintestinal infections caused by Salmonella enterica subspecies II-IV. Emerg Infect Dis 2012; 18(4): 637-9.
  5. Katribe E, Bogomolnaya LM, Wingert H, Andrews-Polymenis H. Subspecies IIIa and IIIb Salmonellae are defective for colonization of murine models of salmonellosis compared to Salmonella enterica subsp. I serovar typhimurium. J Bacteriol 2009; 191(8): 2843-50.
  6. Achtman M, Wain J, Weill FX, Nair S, Zhou Z, et al. (2012) Multilocus Sequence Typing as a Replacement for Serotyping in Salmonella enterica. PLOS Pathogens 8(6): e1002776. https://doi.org/10.1371/journal.ppat.1002776

Denver Niles, MD is the Medical Microbiology fellow at UT Southwestern Medical Center. Prior to his Medical Microbiology fellowship, he completed pediatric infectious disease training at Baylor College of Medicine/Texas Children’s Hospital.

Muluye Mesfin, SM(ASCP)CM is the microbiology laboratory supervisor at UT Southwestern Medical Center where he has worked for 12 years.  Prior to this, Mo completed a bachelor of science degree in medical technology at the University of Maryland.

-Clare McCormick-Baw, MD, PhD is an Assistant Professor of Clinical Microbiology at UT Southwestern in Dallas, Texas. She has a passion for teaching about laboratory medicine in general and the best uses of the microbiology lab in particular.

-Andrew Clark, PhD, D(ABMM) is an Assistant Professor at UT Southwestern Medical Center in the Department of Pathology, and Associate Director of the Clements University Hospital microbiology laboratory. He completed a CPEP-accredited postdoctoral fellowship in Medical and Public Health Microbiology at National Institutes of Health, and is interested in antimicrobial susceptibility and anaerobe pathophysiology.