CASE 5

A 43-year-old male truck driver who has been divorced for two years is driving a full load of wood products from Los Angeles to Dallas by himself. After a long hot day on the road, he decides to eat dinner at an interstate truck stop in a distinctly rural part of eastern New Mexico. While eating dinner at the counter, he is engaged in conversation by an unusually friendly young woman. Eventually, it becomes clear that this woman is a professional "escort" who is looking for some business. The woman appears to be on the desperate end of the escort business, as the proposed charge for services is very reasonable. The man's cargo is not time-sensitive, so he decides to avail himself of this unexpected opportunity. The escort has no entertainment facilities of her own, so they use his truck's sleeper cab. He is concerned about not taking precautions, but the escort assures him that she is not infected with an STD.

About one week later, the man notices that three papular lesions have formed on his penis. The area surrounding these lesions is erythematous. Over the next 2 to 3 days, the papules evolve into pustules, which then rupture and form sharply circumscribed ulcers that are painful and bleed easily if disturbed. By the time the man seeks medical help, two of these ulcers have coalesced to form a larger ulcer. The man's vital signs are normal. The physical examination reveals tender inguinal lymphadenopathy.

Question 5.1: What is your preliminary diagnosis?

Question 5.2: What is the causative agent?

Question 5.3: How is the diagnosis confirmed?

Question 5.4: What is the prevalence of this disease?

Question 5.5: How is this disease transmitted?

Question 5.6: How is this disease connected to AIDS?

Question 5.7: How is this disease treated?

CASE 6

In 1847 Dr. Ignaz Semmelweis's close friend, Jakob Kolletschka, cuts his finger while he is performing an autopsy. Shortly thereafter, Kolletschka dies of symptoms similar to those associated with puerperal fever. That gets Semmelweis's attention. Puerperal fever is killing 13% of the women who give birth in his hospital at the University of Vienna. The mortality rate is driving him crazy. He can't figure it out. A nearby public obstetric hospital, operated by midwives, loses only 2% of its patients to puerperal fever.

No one has connected microorganisms to disease yet. The first hint of that connection will come from England six years later. Joseph Lister won't show the medical community how to kill germs for another 18 years. Semmelweis is a Hungarian doctor teaching medicine in Vienna. He notices that students move between the dissection room and the delivery room without washing their hands. On a hunch, he sets up a policy. Physicians must wash their hands in a chlorinated lime solution whenever they leave the cadavers. The mortality rate from puerperal fever promptly drops to 2%.

Things now become rather strange. Instead of reporting his success at a meeting, Semmelweis remains silent. Finally, a friend publishes two papers describing the method. By now, Semmelweis has started washing medical instruments as well as hands. As outside interest grows, we begin to understand Semmelweis's silence. The hospital director feels his leadership has been criticized and he is furious. He blocks Semmelweis's promotion. Worse, the Viennese doctors begin to turn on this Hungarian immigrant. Finally, he returns to Budapest, where he brings his methods to a far more primitive hospital. He cuts death by puerperal fever to less than 1%. He does more. He systematically isolates the causes of death. He autopsies victims. He sets up control groups. He studies statistics. Finally, he writes a book on his methods (in 1861). The establishment gives it poor reviews. Semmelweis then grows angry and polemical. He hurts his own cause with rage and frustration.

Semmweis suffers a mental breakdown in 1865. Friends commit him to a mental hospital. There-as though to close the circle on this brief 47-year life-he cuts his finger. In days, he dies of the very infection that killed his friend Kolletschka and from which he managed to save thousands of mothers. That same year, Joseph Lister begins spraying a solution of carbolic acid during surgery to kill germs. In the end, it's Lister who finally gives our unhappy hero his due. He says, "Without Semmelweis, my achievements would be nothing."

Question 6.1: What is puerperal fever?

Question 6.2: What is the historical significance of this disease?

Question 6.3: What are the symptoms of this disease?

Question 6.4: How prevalent and significant is this disease today?

Question 6.5: What are the most important causative agents?

Question 6.6: How is this disease treated?

CASE 7

A 28-year-old stockbroker takes his first true vacation in over five years, spending two full weeks at a ski resort in Colorado. During his stay at the resort, he meets and becomes intimately involved with an attractive 25-year-old woman. They engage in vaginal intercourse several times and agree to keep in touch after returning to their respective hometowns and jobs. A few days after returning to his office, the stockbroker develops painful, itchy sores on the shaft of his penis. He also experiences low grade fever, headache, malaise, myalgias, and some inguinal lymphadenopathy. He is so busy at his office (a real workaholic) that he is determined not to seek medical help unless his condition becomes overtly dangerous. As a matter of fact, his symptoms clear up after two weeks or so and the man starts to feel far better. However, he has some awareness of sexually transmitted diseases and is a bit worried about what happened because he realizes that it might be connected to his behavior at the ski resort. During a rather difficult phone call to the young women with whom he was intimate, he learns that she has had past episodes of genital herpes and experienced an outbreak of active lesions herself right after returning from the ski resort.

Question 7.1: What is the most likely causative agent?

Question 7.2: What may happen if the man fails to seek treatment?

Question 7.3: What causes recurrences of this disease?

Question 7.4: Is there a cure for this disease?

Question 7.5: What other infections can this agent cause?

Question 7.6: How is this disease transmitted?

Question 7.7: How prevalent is this disease?