The Case of the Newborn Nightmare
By Andrea Wade
Department of Medical Laboratory Technology
Broome Community College, Binghamton, NY
National Center for Case Study Teaching in Science
Part I—Trouble in the Nursery
“Flesh eating bacteria? You’re kidding, right?” Dr. Mark Maddison winced as he tried to understand the
alarmed nurse at the other end of the phone. “Slow down and tell me again what’s happening.” Mark
knew that he needed to stay calm and try to buy time to understand the problem. It was the first time
he had been left as the sole physician in charge of the struggling Black Rock Clinic. Dr. Jullie Elridge, the
seasoned senior physician in their partnership, had left for Nepal two weeks earlier on a three-week
expedition to climb Mount Everest.
The nurse, Jill Benoit, continued, “All I know is that I have three really sick babies down here. The Willis
twins started to go bad yesterday. They have a strange rash on their thighs and they’re running a fever. I
thought it was just ordinary diaper rash, but this evening when I was rubbing some ointment on it, the
skin started coming off in sheets! Now the Levi baby looks like she has the same thing under her arms.”
“You haven’t started using some new lotion or soap on them, have you?” asked Mark, hoping that he
wasn’t going to have to resurrect his knowledge of infectious diseases. “Perhaps you’re using something
that’s too harsh for the skin of neonates.”
“No, no,” Jill answered impatiently. “I’ve been working in neonatal nurseries for 25 years. I think I know
a thing or two about washing babies. Can you reach Dr. Elridge? She knows how to handle these sorts of
Mark resisted the urge to snap back at her. If he had to call Jullie in Nepal, he’d never live it down. “No
need to call her. She left me in charge. I just need to take a look at the little guys. I’ll be right up.”
Mark took the stairs up to the nursery two steps at a time. Turning down the hallway, he could see a
small cluster of visitors cooing and waving at a small red-faced infant being displayed through the
nursery’s large plate glass window. Behind them Nurse Benoit was hovering over an isolette. Mark
hurriedly washed his hands and walked over to the isolette to examine the baby.
Jill didn’t look up when he arrived but simply murmured “Dr. Maddison” under her breath as if his name
were something distasteful. The Levi baby was wearing a tiny knit cap and was wrapped tightly in a
hospital blanket. Mark gently unwrapped the blanket and lifted up the baby’s white undershirt to
examine her skin. He could see some small vesicular lesions on the inside of her upper arm. Farther up,
in the axillary area, there was a moist red area about the size of a quarter. The baby girl seemed warm
to the touch, and she began to fuss and wave her fists in response to his probing. He replaced the
blanket and walked over to the isolette that held the first of the Willis twins.
“Baby Boy A is worse than his brother,” Jill called from across the nursery. Mark undressed Baby Boy A
and removed his diaper to look at the affected area. The entire area of the tiny baby’s groin appeared to
be involved, demonstrating the same strange skin infection. Maybe Jill was right—perhaps this was the
beginning of necrotizing fasciitis, the famed “flesh eating bacteria” of tabloid lore. No matter what it
was, he needed to act quickly to avoid any kind of negative publicity.
Mark looked up in time to see Bill Alkin, the clinic administrator, enter the nursery wearing a grey
pinstripe suit that seemed oddly out of place in the antiseptic and starched white surroundings of the
nursery. “Dr. Maddison,” Bill said curtly. “Nurse Benoit has notified me that we have a potential
situation here in the nursery. It looks as though we need to give Dr. Elridge a call.” Mark shot Jill a
withering glance, but she studiously ignored it. “No, no,” he replied. “I’m sure I can handle this. Besides,
Jullie has probably already started up the mountain. She’s undoubtedly out of contact with everyone,
except perhaps her Sherpa guides.”
“For your sake, I hope you’re right about being able to handle this,” Bill countered. “We can’t afford to
have an epidemic in the news. You know that Whitley Memorial Hospital has been looking for an excuse
to shut us down. I’m sorry, but I can’t risk losing this clinic just so that you can pursue some idea of being
a hero. I’ll give you 24 hours—after that I’m quarantining the nursery and calling in the county health
department. If there is any negative publicity about delaying even a day, I’m holding you personally
responsible.” With that, Bill turned abruptly and headed out of the nursery.
Mark looked down at the mewling infant and soberly rewrapped him in his powder blue blanket. “Well,
Dr. Maddison?” Jill inquired, her voice tinged with sarcasm. “What are your instructions?”
“I’ll have them written out for you as soon as I check on a few details,” Mark responded. He was going to
have to read up on infectious agents that could cause this kind of a skin disorder—and fast. Mark wished
he had been a better student of infectious diseases. He hated to admit it but he had just barely passed
that part of his education. The reference collection in the clinic library was a bit sparse and somewhat
outdated, but at least it was a place to start.
Part I Questions
1. What are the challenges Dr. Maddison is facing?
2. What information does he have so far about the infection? (use terminology from unit 3)
3. Nurse Jill is worried that this is flesh-eating bacteria. If so, which pathogen would be responsible?
Describe one additional possible cause of this skin infection.
Part II—Plan of Attack
Mark sighed as he took a look at the list of potential pathogens he had jotted down while paging
through the library textbooks and reference manuals. The organisms and diagnoses seemed limitless.
The few hours he had spent researching a possible cause had jogged his memory of infectious diseases.
He decided his best course of action was simply to take samples from the affected areas and submit
them to the microbiology laboratory for stain and culture.
Mark returned to the nursery armed with a set of culture swabs. Jill peered furtively through lidded eyes
as he collected specimens from each baby. Brandishing the culture swabs like weapons, he then
marched out of the nursery and down the stairs to the microbiology lab.
“Good afternoon, Dr. Maddison.” Mark stole a glance at the badge pinned to the lab coat of the young
woman who greeted him. Anne Mosel, MT(ASCP)SM, the badge said. “Ms. Mosel, I have a few
specimens from the nursery that need priority treatment. The specimens were taken from some unusual
skin lesions on three of our infants. I know that we need at least a routine culture and sensitivity with
“We’ll set up the Gram stain right away. I’ll have one of my best microbiologists work just on this case
until we can get some answers. If you wish, Dr. Maddison, you can stay here and read the direct Gram
After the microbiologist finished Gram staining the specimens and had examined them, Dr. Maddison
sat down to see if his assessment of the specimen agreed with the microbiologist’s. He peered into the
microscope, straining to see if he could find any clues there to the mystery. As his eyes focused, he
began to see clusters of purple spheres. “Gram positive cocci!” he exclaimed. “Now which genera of
clinically significant bacteria are Gram positive cocci that could cause an infection of the skin?” he said
to no one in particular.
“Staphylococcus, of course,” responded Anne Mosel. “And Streptococcus. They’re two of our most
popular isolates from skin specimens.”
Mark found the idea of bacteria being “popular” an odd one, especially bacteria that could cause the
nasty lesions he had seen in the nursery. Moreover, both staph and strep struck him as too tame to be
causing the problem. The flesh eating bacterium, Streptococcus pyogenes, fell into that group though.
Perhaps it would be an open-and-closed case after all. Mark shuddered as he imagined the reporters
who would storm the clinic once word leaked out to the media that the Black Rock babies were being
“eaten alive.” “I was just thinking about media,” Mark remarked to Anne. “We can use pretty typical
media to isolate those, right?”
“Yes, we would usually set up these specimens on five percent sheep blood agar, MacConkey agar, and
PEA agar. We also frequently set up a liquid culture along with the plates.”
“That sounds like a good plan. I’ll check back first thing in the morning to see if there’s any growth on
the plates.” Dr. Maddison thanked Anne and the microbiologist who had helped him and went back
upstairs for a last check on the sick babies before heading home for some much-needed rest.
Mark looked through the window of the nursery in order to size up the situation before entering. He
saw a well-dressed couple in their mid-30s standing beside the Willis twins’ cribs. The woman was
quietly weeping while the man had his arm protectively wrapped around her. Nurse Benoit was standing
next to Baby Girl Levi’s isolette, deep in conversation with a woman with red hair wearing a chenille
bathrobe. The woman was clearly agitated.
Mark heard Jill say to the woman in the bathrobe, “Here’s Dr. Maddison now. I’m sure he has some
information for you.”
Mark approached the woman with his right hand extended. “I’m Dr. Maddison. You must be Mrs. Levi.
Congratulations on the birth of your daughter.”
“Where’s Dr. Elridge?” said the woman, ignoring his outstretched hand. “She’s taken care of my other
two. No offense, but I want my own doctor taking care of Lilly.”
“Lilly—what a beautiful name,” Mark said, hoping to put Mrs. Levi at ease. “Dr. Elridge is out of the
country. I’ve already ordered some tests to help us determine the best treatment for Lilly.”
“Treatment? Just what did she catch from those other babies? Her skin has this terrible rash that’s
peeling off! She looks awful. What kind of a place is this anyway?” The color rising in Mrs. Levi’s face was
beginning to match that of her hair. “If Dr. Elridge can’t take care of her, I’m taking her to Whitley
Memorial Hospital right now.”
Dr. Maddison took a deep breath and responded in a measured tone. “I’m sorry, Mrs. Levi, but I can’t
allow you to take Lilly right now. She’s too sick to be discharged, and Whitley won’t admit her into their
nursery in this condition anyway.”
“You can’t keep my baby here!”
“Let’s try not to panic, Mrs. Levi. The microbiology lab is zeroing in on the cause of your daughter’s
illness even as we speak.” A bit of an exaggeration, Mark knew, but not an outright lie. “I’ll stop by your
room in the morning and let you know what we’ve found. I’m sure we’ll have this solved by then.”
Part II Questions
4. What would we expect to see from the gram stain for Staphylococcus vs. Streptococcus? What
would be similar and what would be different.
5. What results would you expect from each pathogen on the media used to grow these organisms:
5% Sheep’s Blood Agar
6. What additional tests could be used to identify Staphylococcus vs. Streptococcus? What results
would we expect for each?
7. Why is it important to keep Lilly and the other infected babies in this nursery instead of allowing
them to transfer to another hospital?
Part III—Some clues come to light
Mark cautiously pushed open the door to the microbiology lab and glanced around the room. Mark
cleared his throat, hoping to get her attention without appearing too eager. Anne looked up, smiled, and
set aside the culture she had been examining.
“Any new information on those nursery cultures, Ms. Mosel?”
“Oh, yes, of course, Dr. Maddison. We called the report up to the floor earlier this morning. Let me show
you what we found.” She pulled a microscope slide from a small cardboard box and placed it under her
microscope. “Take a look for yourself.”
Mark sat down and began to scan the slide. Spread out across it was a sea of round purple spheres that
looked like those he had seen on yesterday’s slide of the lesions. “So many,” he observed.
“Yes,” Anne responded. “This smear was taken from a culture plate, so there will be a large number of
organisms. Here are the plates, if you’d like to have a look.”
Mark picked up the sheep blood plate first. It was covered with round, opaque creamy colonies. He held
the plate up to the light for a better look and noticed that there was a halo around each colony where
the blood appeared to be missing from the agar. The plate labeled “PEA” was also covered with
colonies. Finally, he picked up the lavender plate labeled “MAC” and held it up to the light. Except for
the tracks left in the pattern of the inoculating needle, the plate looked completely barren.
“We performed catalase testing on the isolate,” interjected Anne. “You should have seen the way it
bubbled! We have a rapid agglutination test in this laboratory that we used instead of the coagulase
test. This isolate was a strong positive. There’s no doubt about its identity now, is there?”
Mark closed his eyes and rubbed his temples in an attempt to dislodge the buried bits of information.
“Why, it looks like Staphylococcus aureus!” he said, surprised by the confidence of his answer.
“Exactly!” replied Anne. “We have antimicrobial susceptibility testing already set up and running. This is
similar to the Kirby-Bauer test you probably learned about in college. But by using our automated
system, we may have the results available later today.”
“Great day in the morning!” Mark jumped up from his seat, grabbed the shoulders of a very startled
Anne Mosel, and planted a kiss right in the middle of her forehead. He then turned, tossed open the
laboratory door, and trotted down the hallway toward the medical library.
Part III questions
8. How do the results listed above help to identify the pathogen as S. aureus?
9. Why did the lab also include antimicrobial susceptibility testing for this pathogen?
Part IV – Eureka!
Back in the library, Dr. Maddison went straight to the reference books he had been working with the
previous evening. Choosing a likely looking volume entitled Pediatric Infectious Disease, he looked up
Staphylococcus aureus in the index. There were about a dozen pages listed. “Hmmm, impetigo is less
generalized than these babies are showing… food poisoning in breast-fed babies just doesn’t sound right
at all….” Mark continued to flip pages, more and more impatiently. Abruptly, he turned a page and met
the gaze of a newborn staring unflinchingly out at him. The baby was pictured lying in a crib naked
except for the hat. There was an angry looking rash extending from the baby’s groin upward to above
his umbilicus. The skin had peeled away from the rash, leaving a moist, bright red surface. The caption
read “Neonatal Staphylococcal Scalded Skin Syndrome.”
“Hmmm,” Mark muttered. “I know that staphylococci can cause some wicked wound infections, but why
the rash?” He scanned the chapter looking for information about the disease mechanism. “Of course.
There’s a toxin, an exfoliatin, that’s causing the skin to peel away.” He continued reading:
When treating staphylococcal scalded skin syndrome, the first goal is to stabilize the patient through
measures such as rehydration. Elimination of the offending S. aureus is the next goal. Most
commonly, antibiotics are administered, including beta-lactamase resistant penicillins, first
generation cephalosporins, macrolides, and aminoglycosides. With treatment, the prognosis for
children is excellent.
“Time to write some orders!” Dr. Maddison pushed back his chair and strode down the hall toward the
As he entered, he could see that Bill Alkin was there trying to soothe Mrs. Levi. The Willis parents were
still staring mournfully down into the twins’ isolettes. Nurse Benoit glanced resignedly at him. “Good
morning, everyone! How are our patients doing today?” Mark walked over to the Levi baby’s chart and
flipped it open. “Good news, Mrs. Levi, we have a diagnosis for Lilly, and I am prescribing a medication
that should have her skin back to its former beauty in just a few days. Mr. and Mrs. Willis, your little
ones should be on the mend very soon, too.”
Mark pulled Bill aside and discreetly murmured, “We still need to work with the health department to
trace the source for this organism. I’d like to collect nasal swabs from anyone who has had contact with
these babies. Clinic staff, including myself, are the most likely source.”
Bill’s eyes darted furtively to the others in the room as he whispered, “You won’t mention this to anyone
else, of course.” He placed his hand on Mark’s shoulder. “I knew we could count on you, Mark.”
“Sure, Bill. Thanks,” Mark answered wryly.
Part IV - Questions
10. . Many people, especially healthcare workers, carry Staphylococcus aureus in the anterior nares.
How, then, are infections passed from these caregivers to their patients? How can transmission be
Part V—From Nightmare to Naptime
Mark stuffed his pen into the pocket of his rumpled white coat and flipped shut the chart he had been
working on. It made a comforting thud as Mark slid it back into the rack. “Discharge orders are written
for the Willis twins and the Levi baby, Nurse Benoit,” he announced. He felt a sense of elation, as though
he were completing an arduous journey. “Would you please let the parents know they can take their
children home this afternoon?”
“Thanks, I’ll take care of that,” Jill responded. “Mrs. Levi is in with her baby now. She was looking for you
Mark’s heart sunk a little. He had been hoping to avoid any more confrontations. Jill Benoit had been
considerably less challenging the past few days. The report from the health department that she carried
in her nares the same staphylococci that caused the outbreak in the nursery had subdued her
Mark had treated her with an antibiotic, and together they had reviewed the gloving and handwashing
protocols for the nursery.
Given the dramatic improvement in the babies, Mark just couldn’t imagine what Mrs. Levi could come
up with to cast a shadow over his day. Slowly he turned and headed into the nursery.
“Dr. Maddison!” He turned toward the voice and greeted Mrs. Levi. “Dr. Maddison, I’ve been waiting for
“Mrs. Levi, how are you this morning?” Mark tried to conjure up his most charming smile. “Can I answer
any questions for you?”
“Oh, Dr. Maddison! I just wanted to thank you for everything you did for Lilly. I’d like to have you
continue to be her doctor after she is discharged. Do you think that Dr. Elridge would be offended?”
“I’m sure she would want you to do whatever makes you comfortable, Mrs. Levi. Besides, she often
covers for me when I’m unavailable. I’d like to see Lilly on Monday, just to make sure that she continues
to do well.”
“I’ll make an appointment for Monday, then. Thank you again, Dr. Maddison!”
Mark gave her an appreciative smile and headed out the door and toward the parking lot. He was
thinking he had an appointment of his own to make—for a long, restful weekend nap.
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