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Based on the case allocated, please answer the following questions
1.     Based on the information given, what do you think the patient is possibly suffering from? Explain why you think so.

2.     What kind of samples and laboratory test would you perform to effectively diagnose the infection?

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The fever is most likely due to central venous catheter related bio films containing hospital-acquired pathogens or it could from HSV from other patients/personnel in the hosptial. We deduced that it is due to the contaminated catheter as  pathogens related to squamous cell carcinoma in the cervix (cervical cancer) such as Human Papillomavirus do not cause fever as one of their symptoms (symptoms for HPV includes warts and cervical cancer) hence it is unlikely that Mary's fever is due to HPV. Catheter related bacteria (eg. MRSA) is the most likely reason for fever as the pathogen would have had direct access to the bloodstream, allowing it to proliferate in the body. Herpes simplex virus is a potential suspect as the duration of onset of fever is five days which is within the incubation period before development of fever after exposure of HSV. Possibility of transmission may be due to negligence sterlizing catheter used on other patients with HSV  which was then used in Mary.

2. Bacteria;
Swap from lesions or wounds
Culture in blood agar
Clinical and Laboratory Standards Institute (CLSI), recommends the cefoxitin disk diffusion test or a plate containing 6 μg/ml of oxacillin in Mueller-Hinton agar supplemented with 4% NaCl as alternative methods of testing for MRSA. For specific details on these methods, see CLSI Approved Standard M100. In addition, there are FDA-approved assays for molecular detection of the mecA gene and commercially available chromogenic agars that can be used for MRSA detection. Finally, latex agglutination or immunochromatographic membrane tests for PBP2a can be used to detect MRSA.
HSV:
Symptomatic- do a swab of lesions and send for cell culture
Asymptomatic- Herpes serological test to test fpr antibodies tp HSV

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1. The patient is possibly suffering from cervical cancer that is caused by HPV, also known as the human papillomavirus. This is because squamous cell carcinoma is a common type of cervical cancer and HPV plays a role in causing most of the cervical cancer. When exposed to HPV, the body's immune system typically prevents the virus from doing harm. In a small percentage of people, however, the virus survives for years, contributing to the process that causes some cervical cells to become cancer cells.

It is also possible that it could be an S.aureus or S. epidermidis infection because a central venous catheter was used on the day of her surgery. Central venous catheter(CVC) infection is a major cause of healthcare associated MRSA bacteremia, which is a growing problem.

We think that she most likely has central venous catheter infection due to the presence of a high fever after the surgery. The squamous cell carcinoma suggests cervical cancer which could be caused by HPV. As fever is not a symptom of HPV, it is unlikely that her infection was caused by it. Therefore, we think that she could have gotten her infection from a contaminated catheter.

https://www.plannedparenthood.org/learn/stds-hiv-safer-sex/hpv

https://healthengine.com.au/info/cervical-cancer-squamous-cell-carcinoma-of-the-cervix

1. We would perform a routine pap test. Pap smear is a test that collects cells from the surface of the cervix or the vagina and will reveal any cellular abnormalities that may lead to cancer.

If the pap smear is shown to be abnormal, colposcopy may be done to closely examine the cervix, vagina and vulva for signs of disease.

To test for Staphylococcus aureus, we can culture organism on blood agar then do a catalase test. If it is catalase-positive, proceed to grow cells on mannitol salt agar. Staphylococcus aureus ferments mannitol and turns the medium yellow. Additionally, we will check for its susceptibility to methicillin to see if it is methicillin-resistant.

To test for S. epidermidis, susceptibility to novobiocin testing is done. As S. epidermidis is susceptible to novobiocin, there will be a zone of inhibition.

https://www.webmd.com/vaccines/qa/what-are-the-symptoms-of-human-papillomavirus-hpv

https://familydoctor.org/condition/human-papillomavirus-hpv/

https://www.medicalnewstoday.com/articles/246670.php#treatment

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[12:37 PM, 2/5/2020] Zong Qing: Mary is most likely suffering from a surgical site infection (SSI). According to Lachiewicz, Moulton and Jaiyeoba (2015), surgical site infection (SSI) remains the most common complication of gynaecologic surgical procedures, and results in significant patient morbidity. Gynaecologic procedures pose a unique challenge in that potential pathogenic microorganisms from the skin or vagina and endocervix may migrate to operative.
A possible agent of SSI at the pelvis is Klebsiella pneumoniae carbapenemase. According to Park et al. (2016), Carbapenem-resistant Klebsiella pneumoniae (CRKP) is a rising public health threat, and is the most common causative agent for surgical site infection (Billoro, Nunemo & Gelan, 2019). Carbapenem-resistant Klebsiella pneumoniae possess the ability to produce carbapenemases, inactivating carbapenems, which are considered the antibiotics of choice for Gram-negative bacteria that produce plasmid-encoded extend-spectrum β-lactamase. This will explain, why she suffers from an infection despite administering broad spectrum antibiotics after the surgery (Park et al., 2016).
According to the Centers for Disease Control and Prevention (2010), Klebsiella bacteria can spread through person-to-person contact (for example, from patient to patient via the contaminated hands of healthcare personnel, or other persons) or less commonly, by contamination of the environment. The bacteria are not spread through the air. In addition, patients in healthcare settings also may be exposed to Klebsiella when they are on ventilators (breathing machines), or have intravenous (vein) catheters or wounds (caused by injury or surgery). Unfortunately, these medical tools and conditions may allow Klebsiella to enter the body and cause infection.
In order to test for Carbapenem-resistant , we perform bacterial lawn on Mueller-Hinton Agar together with Carbapenem Antibiotic Disc.
Analysis of Klebsiella pneumoniae, Indole (-), Lactose (+) , H2S (-), Motility (-) , Gas (+) , Citrate (+) , Urease (+) , MR VP (+) , PPA (-), ONPG (+)
According to the European and Asian guidelines on management and prevention of catheter-associated urinary tract infections the most frequently occurring bacteria during short-term catheterisation are E. coli, Pseudomonas aeruginosa, Klebsiella pneumoniae, Proteus mirabilis, Staphylococcus epidermidis, Enterococcus spp. and Candida spp.

REFERENCES
Park, S.O., Liu, J., Furuya, Y., Larson, E.L., 2016. Carbapenem-Resistant Klebsiella pneumoniae Infection in Three New York City Hospitals Trended Downwards from 2006 to 2014.  Open Forum Infectious Diseases. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5144654/ [Accessed 5th February 2020]
Billoro, B.B., Nunemo, M.H., Gelan, S.E., 2019. Evaluation of Antimicrobial Prophylaxis Use and Rate of Surgical Site Infection In Surgical Ward of Wachemo University Nigist Eleni Mohammed Memorial Hospital, Southern Ethiopia: Prospective Cohort Study [Online]. BMC Infection Diseases. Available from: https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-019-3895-5 [Accessed 5th February 2020]

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What is she suffering from ?

Mary is most likely suffering from cervical cancer caused by the Human Papillomavirus (HPV). This is evident as she had a recurrence of poorly differentiated squamous cell carcinoma of the cervix. Furthermore, she went through excision of the anterior pelvis which is the removal of all reproductive organs and bladder which are normally done to treat some form of cancer.

Long-lasting infections with high-risk HPVs can cause cancer in parts of the body where HPV infects cells, such as in the cervix, oropharynx (the part of the throat at the back of the mouth, including the soft palate, the base of the tongue, and the tonsils), anus, rectum, penis, vagina, and vulva.

HPV infects the squamous cells that line the inner surfaces of these organs. For this reason, most HPV-related cancers are a type of cancer called squamous cell carcinoma. Some cervical cancers come from HPV infection of gland cells in the cervix and are called adenocarcinoma.

Likely viral infection is evident from the lack of subsiding inflammation even after antibiotic use.

Sample needed & Tests Needed?

HPV Testing using multiplex PCR following the procedures, for the detection of high risk strains, probable high risk and low risk.

https://www.hindawi.com/journals/isrn/2012/186915/ (Multiplex PCR)

Combination Pap-HPV Test

PAP Smear- Cervical swab sample is needed.

An HPV test is usually done at the same time as a Pap test — a test that collects cells from your cervix to check for abnormalities or the presence of cancer. An HPV test can be done using the same sample from the Pap test or by collecting a second sample from the cervical canal.

Positive HPV test: A positive test result means that you have a type of high-risk HPV that's linked to cervical cancer. It doesn't mean that you have cervical cancer now, but it's a warning sign that cervical cancer could develop in the future. Your doctor will probably recommend a follow-up test in a year to see if the infection has cleared or to check for signs of cervical cancer.

Negative HPV test: A negative test result means that you don't have any of the types of HPV that cause cervical cancer.

https://www.mayoclinic.org/tests-procedures/hpv-test/about/pac-20394355

Visual inspection with Acetic Acid (VIA)

1. After applying acetic acid, the cervix is observed in search for pathological aceto-white areas.

2. Changes in the epithelium can be noted one minute after application of 3% acetic acid.

3. The presence of aceto-white areas in the T-Zone can be suggestive of cervical dysplasia

Liquid based Cytology