Scientific letter
Pediatric case of fatal necrotizing pneumonia due to Panton-Valentine leukocidin-positive methicillin-resistant Staphylococcus aureus in Spain
Caso pediátrico de neumonía necrotizante fatal debida a Staphylococcus aureus productor de Leucocidina de Panton-Valentine en España
Margarita Mosqueraa,b,
, Laura Monteroa, Francisco J. Pérez-Lescurec, Andrés Aragónd
Corresponding author
a Preventive Medicine Department, Alcorcon University Hospital Foundation, Madrid, Spain
b Preventive Medicine and Public Health and Medical Immunology and Microbiology Department, King Juan Carlos University, Madrid, Spain
c Paediatric Department, Alcorcón University Hospital Foundation, Madrid, Spain
d Epidemiology Unit, Regional Ministry of Health, Community of Madrid, Madrid, Spain
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However, over recent decades, MRSA epidemiology has changed causing infections in the healthy community.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Production of Panton-Valentine leukocidin (PVL), a cytotoxin that causes leukocyte destruction and tissue necrosis in these strains is considered a virulence factor. PVL genes are consistently associated with skin and soft-tissue infections<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> in immunocompetent young patients although its role in invasive disease with poor prognosis is controversial.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2–4</span></a> PVL toxin can be produced by both methicillin-susceptible <span class="elsevierStyleItalic">S. aureus</span> (MSSA) and MRSA strains and is associated with more severe infections, regardless of methicillin resistance.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> We report the case of a 12-years old, previously healthy girl born in Venezuela, triplet from a multiple gestation with two healthy sisters and family with low socioeconomic status. She had been living in Spain for the last seven months.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient started with progressive worsening flu-like symptoms, high fever and cough that progressed to haemoptysis in less than 24<span class="elsevierStyleHsp" style=""></span>h presenting sudden death at her home while sleeping. The autopsy established multiple organ failure after bilateral abscessed pneumonia as a cause of death, with pleurisy fibrinopurulent and bilateral adrenal hemorrhage. Blood culture, pleural fluid, cerebrospinal fluid and tissue biopsy of lungs, spleen, adrenal and pharynx were collected and sent for microbiology cultures postmortem. MRSA, also resistant to clindamycin and erythromycin, was isolated in all samples. Typing of MRSA strains was performed by phage typing and detection of PVL genes by the polymerase chain reaction technique, with the following results: fagogroup III, phage types 84 and 85, with positive PVL and <span class="elsevierStyleItalic">mecA</span> genes. All strains isolated showed the same pulsed-field gel electrophoretic pattern.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The risk of infection and/or colonization of the adolescent based on any current skin infections or previous healthcare contact during the previous year of the patient or her relatives were evaluated with no findings.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The status of colonization of the patient's cohabitants was studied. Screening was performed on 4 family members (mother, 2 sisters and brother) and 2 roommates originating from Ecuador. Screening included a swab of any suspicious lesion, nose, throat, perineum and inguinal area. Contacts underwent a five-day decolonization treatment including an intranasal application of mupirocin ointment three times a day, gargle with an antiseptic solution and chlorhexidine 4% as liquid soap in place of body wash and shampoo.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> A sister of the deceased was found to be carrying MRSA in mucous, which was negative for the PVL gene. New decolonization-treatment was not indicated as the efficacy of decolonization in patients with community-associated MRSA has not been established by any data and the possibility of relapsing following decolonization treatment has been described.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Additional measures to reduce the risk of cross-infection within household as regular vacuuming, dusting, cleaning hard surfaces and soft furnishings with soap and water and/or 1:10 diluted bleach were provided.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The increase of morbidity and mortality associated with PVL-SA is of concern in Spain. A significant increase in the incidence of community-associated MRSA from 0.7% in 2004 to 8.8% in 2012 has been reported. The emergence of PVL-MRSA is more recent in Spain (mainly from South America immigrants) than in the rest of Europe.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> One of the most important life-threatening conditions due to PVL-<span class="elsevierStyleItalic">Staphylococcus aureus</span> (PVL-SA) reported is hemorrhagic necrotizing pneumonia with a high mortality rate.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Characteristic patterns include a rapidly extensive pneumonia occurring in young patients after an influenza-like illness.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7,8</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">A PVL-SA infection should be suspected if a patient with influenza-like illness associate haemoptysis, hypotension, high fever, leukopenia and/or multilobal lung infiltrates, which can be cavitated,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> especially in epidemic flu period. The rareness in our country of severe cases of PVL-SA infection, especially when we found a MSSA, needs a greater awareness,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> establishing an action guide with preventive measures and systematic notification to the epidemiological surveillance network as exist in other countries.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">No honorarium, grant, or other form of payment was given to anyone to produce the manuscript. No conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Molecular epidemiology of community-associated methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> in Spain: 2004–12" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A. Vindel" 1 => "P. Trincado" 2 => "O. Cuevas" 3 => "C. Ballesteros" 4 => "E. Bouza" 5 => "E. 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| 2024 January | 16 | 7 | 23 |
| 2023 December | 15 | 7 | 22 |
| 2023 November | 18 | 10 | 28 |
| 2023 October | 24 | 11 | 35 |
| 2023 September | 18 | 5 | 23 |
| 2023 August | 9 | 4 | 13 |
| 2023 July | 9 | 5 | 14 |
| 2023 June | 16 | 7 | 23 |
| 2023 May | 16 | 7 | 23 |
| 2023 April | 14 | 6 | 20 |
| 2023 March | 12 | 1 | 13 |
| 2023 February | 11 | 9 | 20 |
| 2023 January | 5 | 10 | 15 |
| 2022 December | 16 | 11 | 27 |
| 2022 November | 25 | 9 | 34 |
| 2022 October | 17 | 12 | 29 |
| 2022 September | 12 | 14 | 26 |
| 2022 August | 24 | 13 | 37 |
| 2022 July | 11 | 17 | 28 |
| 2022 June | 17 | 16 | 33 |
| 2022 May | 17 | 14 | 31 |
| 2022 April | 16 | 23 | 39 |
| 2022 March | 18 | 22 | 40 |
| 2022 February | 35 | 16 | 51 |
| 2022 January | 17 | 21 | 38 |
| 2021 December | 34 | 21 | 55 |
| 2021 November | 38 | 13 | 51 |
| 2021 October | 28 | 17 | 45 |
| 2021 September | 29 | 14 | 43 |
| 2021 August | 18 | 10 | 28 |
| 2021 July | 33 | 18 | 51 |
| 2021 June | 21 | 11 | 32 |
| 2021 May | 36 | 9 | 45 |
| 2021 April | 58 | 55 | 113 |
| 2021 March | 23 | 20 | 43 |
| 2021 February | 23 | 10 | 33 |
| 2021 January | 13 | 18 | 31 |
| 2020 December | 11 | 3 | 14 |
| 2020 November | 13 | 2 | 15 |
| 2020 October | 18 | 9 | 27 |
| 2020 September | 28 | 10 | 38 |
| 2020 August | 14 | 5 | 19 |
| 2020 July | 14 | 6 | 20 |
| 2020 June | 8 | 10 | 18 |
| 2020 May | 10 | 10 | 20 |
| 2020 April | 9 | 8 | 17 |
| 2020 March | 13 | 8 | 21 |
| 2020 February | 17 | 7 | 24 |
| 2020 January | 15 | 6 | 21 |
| 2019 December | 20 | 10 | 30 |
| 2019 November | 6 | 3 | 9 |
| 2019 October | 11 | 7 | 18 |
| 2019 September | 8 | 7 | 15 |
| 2019 August | 12 | 5 | 17 |
| 2019 July | 14 | 5 | 19 |
| 2019 May | 1 | 0 | 1 |
| 2019 March | 6 | 4 | 10 |
| 2019 February | 10 | 8 | 18 |
| 2019 January | 75 | 29 | 104 |
| 2018 May | 0 | 2 | 2 |
| 2018 April | 0 | 22 | 22 |
Show all
