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Letter to the Editor
Necrotizing pneumonia caused by community-acquired methicillin-resistant Staphylococcus aureus
Neumonía necrosante por Staphylococcus aureus resistente a meticilina adquirida en la comunidad
Juan Aguilar-Companya,
Corresponding author
juanaguilarcompany@gmail.com

Corresponding author.
, Bruno Magnífico-Arfinengoa, Eva Revilla-Lópezb, Carlos Pigrau-Serrallacha
a Servei de Malalties Infeccioses, Hospital Universitari Vall d’Hebron, Barcelona, Spain
b Servei de Pneumologia, Hospital Universitari Vall d’Hebron, Barcelona, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Infections by community acquired methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> &#40;<span class="elsevierStyleItalic">S&#46; aureus</span>&#41; &#40;CA-MRSA&#41; are increasingly frequent in our environment&#46; Although this microorganism produces&#44; in most cases&#44; skin and soft tissue infections&#44; it has also been associated with severe infections&#46; When it affects patients that have not had recent contact with the health system&#44; a high clinical suspicion is the key to guide an appropriate empirical treatment&#46; We report the case of a 22-year-old male who came to the emergency room with fever&#44; pleuritic pain and lip injury&#44; being diagnosed with CA-MRSA necrotizing pneumonia&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient&#44; a native of Argentina and resident in Spain for 13 years&#44; consulted for pleuritic pain of 6 days of progression&#44; associated with lower lip oedema and erythema&#46; Initially aspirin therapy was prescribed for suspected acute pericarditis&#44; in addition to antihistamines&#46; Faced with the worsening of symptoms after 48 <span class="elsevierStyleHsp" style=""></span>h&#44; the patient came to the emergency room of our hospital&#46; A physical examination revealed 38 <span class="elsevierStyleHsp" style=""></span>&#176;C fever and swelling in the lower lip&#44; with central necrotic lesion and purulent exudate&#59; cardiopulmonary auscultation was normal&#46; Lab tests showed leukocytosis at 20&#46;25<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;l and PCR at 38&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#46; Chest radiography showed left lung anterobasal consolidation&#46; Given the tentative diagnosis of community-acquired pneumonia&#44; blood cultures were collected and empirical antibiotic treatment was initiated with amoxicillin&#8211;clavulanate&#46; The patient had persistent fever&#44; progressive dyspnoea and increased pleuritic pain&#46; Chest CT scan showed bilateral pulmonary consolidations with areas of necrosis&#46; Given these findings and the clinical history referred&#44; CA-MRSA necrotizing pneumonia was suspected&#44; initiating antibiotic treatment with intravenous linezolid&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">An incision and drainage of the labial lesion was performed&#44; obtaining purulent material with Gram stain&#44; which showed abundant Gram positive cocci&#46; Subsequently&#44; the results of blood cultures where received&#44; with methicillin resistant <span class="elsevierStyleItalic">S&#46; aureus</span> &#40;MRSA&#41; being isolated&#46; This microorganism was also isolated in the lip lesion exudate culture&#46; The Panton-Valentine leukocidin &#40;PVL&#41; determination was positive&#46; The subsequent progression of the patient was satisfactory and progression radiography showed a tendency to cavitation and subsequent resolution of pulmonary lesions&#46; The patient was discharged&#44; completing treatment with oral linezolid&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">We believe that the picture presented by the patient is probably due to a haematogenous-origin pneumonia&#44; secondary to bacteraemia with primary focus on lip lesion superinfected by CA-MRSA&#46; Although the patient comes from a region with high prevalence of CA-MRSA<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> she did not recently visited her country of origin&#59; therefore&#44; we consider that the CA-MRSA infection may have been caused through a member of her family&#44; having recently travelled to their country or the acquisition of the bacteria in our community&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">CA-MRSA infection is an uncommon cause of community-acquired pneumonia&#44; with virtually universal distribution&#44; although its prevalence varies widely between different regions&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> CA-MRSA infection is mainly associated with skin and soft tissue infections&#44; but it has also been linked with cases of necrotizing pneumonia&#44; fasciitis&#44; osteomyelitis and sepsis&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> Its virulence relates to the production of toxins&#44; the best known being the PVL&#44; also present in methicillin-susceptible strains of Staphylococcus <span class="elsevierStyleItalic">S&#46; aureus</span>&#46; In numerous studies&#44; its presence has been associated with severe forms of pneumonia&#44; with extensive necrosis&#44; early onset of empyema&#44; increased need for mechanical ventilation and admission to intensive care unit and increased mortality in young adults without comorbidities&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> However&#44; a recent meta-analysis showed no difference in mortality of patients with pneumonia caused by producing and non-producing PVL <span class="elsevierStyleItalic">S&#46; aureus</span> strains&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> The variability observed in these studies may be due&#44; among other factors&#44; to the concomitant presence of other virulence determinants&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The empirical treatment of community-acquired pneumonia as recommended by current clinical guidelines does not include active treatment against MRSA&#44; as it remains a rare aetiology&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> However&#44; empirical treatment with vancomycin or linezolid is recommended in cases of severe pneumonia with necrotizing or cavitary infiltrates&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> Although not proven in randomized clinical trials&#44; linezolid&#39;s anti-toxin effect reported <span class="elsevierStyleItalic">in vitro</span> could favour the use of this drug in patients with associated severe pneumonia&#44; sepsis or necrotizing fasciitis&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Therefore&#44; the indication of administering an antibiotic active against MRSA requires a high clinical suspicion&#46; Cases like the one we report here should put us on alert for this aetiology&#44; which is emerging in our environment&#46; In practice&#44; 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&#46;</p></span>"
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ISSN: 23870206
Original language: English
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