Necrotizing pneumonia caused by community-acquired methicillin-resistant Staphylococcus aureus

Aguilar-Company, Juan; Magnífico-Arfinengo, Bruno; Revilla-López, Eva; Pigrau-Serrallach, Carlos

doi:10.1016/j.medcle.2016.04.042

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Although this microorganism produces, in most cases, skin and soft tissue infections, it has also been associated with severe infections. When it affects patients that have not had recent contact with the health system, a high clinical suspicion is the key to guide an appropriate empirical treatment. We report the case of a 22-year-old male who came to the emergency room with fever, pleuritic pain and lip injury, being diagnosed with CA-MRSA necrotizing pneumonia.The patient, a native of Argentina and resident in Spain for 13 years, consulted for pleuritic pain of 6 days of progression, associated with lower lip oedema and erythema. Initially aspirin therapy was prescribed for suspected acute pericarditis, in addition to antihistamines. Faced with the worsening of symptoms after 48 h, the patient came to the emergency room of our hospital. A physical examination revealed 38 °C fever and swelling in the lower lip, with central necrotic lesion and purulent exudate; cardiopulmonary auscultation was normal. Lab tests showed leukocytosis at 20.25×109/l and PCR at 38.5mg/dl. Chest radiography showed left lung anterobasal consolidation. Given the tentative diagnosis of community-acquired pneumonia, blood cultures were collected and empirical antibiotic treatment was initiated with amoxicillin–clavulanate. The patient had persistent fever, progressive dyspnoea and increased pleuritic pain. Chest CT scan showed bilateral pulmonary consolidations with areas of necrosis. Given these findings and the clinical history referred, CA-MRSA necrotizing pneumonia was suspected, initiating antibiotic treatment with intravenous linezolid.An incision and drainage of the labial lesion was performed, obtaining purulent material with Gram stain, which showed abundant Gram positive cocci. Subsequently, the results of blood cultures where received, with methicillin resistant S. aureus (MRSA) being isolated. This microorganism was also isolated in the lip lesion exudate culture. The Panton-Valentine leukocidin (PVL) determination was positive. The subsequent progression of the patient was satisfactory and progression radiography showed a tendency to cavitation and subsequent resolution of pulmonary lesions. The patient was discharged, completing treatment with oral linezolid.We believe that the picture presented by the patient is probably due to a haematogenous-origin pneumonia, secondary to bacteraemia with primary focus on lip lesion superinfected by CA-MRSA. Although the patient comes from a region with high prevalence of CA-MRSA<a class="elsevierStyleCrossRef" href="#bib0045">1</a> she did not recently visited her country of origin; therefore, we consider that the CA-MRSA infection may have been caused through a member of her family, having recently travelled to their country or the acquisition of the bacteria in our community.CA-MRSA infection is an uncommon cause of community-acquired pneumonia, with virtually universal distribution, although its prevalence varies widely between different regions.<a class="elsevierStyleCrossRef" href="#bib0050">2</a> CA-MRSA infection is mainly associated with skin and soft tissue infections, but it has also been linked with cases of necrotizing pneumonia, fasciitis, osteomyelitis and sepsis.<a class="elsevierStyleCrossRef" href="#bib0055">3</a> Its virulence relates to the production of toxins, the best known being the PVL, also present in methicillin-susceptible strains of Staphylococcus S. aureus. In numerous studies, its presence has been associated with severe forms of pneumonia, with extensive necrosis, early onset of empyema, increased need for mechanical ventilation and admission to intensive care unit and increased mortality in young adults without comorbidities.<a class="elsevierStyleCrossRef" href="#bib0060">4</a> However, a recent meta-analysis showed no difference in mortality of patients with pneumonia caused by producing and non-producing PVL S. aureus strains.<a class="elsevierStyleCrossRef" href="#bib0065">5</a> The variability observed in these studies may be due, among other factors, to the concomitant presence of other virulence determinants.The empirical treatment of community-acquired pneumonia as recommended by current clinical guidelines does not include active treatment against MRSA, as it remains a rare aetiology.<a class="elsevierStyleCrossRef" href="#bib0070">6</a> However, empirical treatment with vancomycin or linezolid is recommended in cases of severe pneumonia with necrotizing or cavitary infiltrates.<a class="elsevierStyleCrossRef" href="#bib0075">7</a> Although not proven in randomized clinical trials, linezolid's anti-toxin effect reported in vitro could favour the use of this drug in patients with associated severe pneumonia, sepsis or necrotizing fasciitis.<a class="elsevierStyleCrossRef" href="#bib0080">8</a>Therefore, the indication of administering an antibiotic active against MRSA requires a high clinical suspicion. Cases like the one we report here should put us on alert for this aetiology, which is emerging in our environment. In practice, performing an urgent Gram stain and a quick test for determining MRSA in a respiratory sample or skin lesions exudate may contribute to early diagnosis." "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Aguilar-Company J, Magnífico-Arfinengo B, Revilla-López E, Pigrau-Serrallach C. Neumonía necrosante por Staphylococcus aureus resistente a meticilina adquirida en la comunidad. 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