| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Corresponding author: Aaron Bruns, MD, The Ohio State University Medical Center, 201 DHLRI, 473 West 12th Ave, Columbus, OH 43221 (e-mail: Aaron.Bruns{at}osumc.edu).
 |
Abstract |
|---|
 Top Abstract References |
|---|
Children and adolescents are at particularly high risk for CA-MRSA infections. This risk most likely is due to the pattern of antibiotic use in children and an increase in the use of day care, which has been associated with transmission of CA-MRSA.5 Approximately 35% to 50% of staphylococcal strains in children appear to be community acquired.6 Although soft-tissue skin infections remain the most common infection due to CA-MRSA,7 invasive and severe infections, sometimes resulting in death, do occur and appear to be increasing in frequency.8,9 Before 1999, severe infections with CA-MRSA in children without risk factors for the infections were rare, with only a few cases reported.9 Since then, multiple reports have been published.2,7–9 Four deaths due to CA-MRSA occurred in Minnesota during a 2-year period.8 In one Texas hospital, 14 cases of severe sepsis due to community-acquired S aureus, 12 of the 14 due to CA-MRSA, in adolescents were treated during a 2-year period.9 A total of 3 patients died, and 13 had bone, joint, and pulmonary involvement; no endocarditis occurred. In this report we describe a case of severe CA-MRSA infection in a hospital-naive adolescent.
| Community-acquired MRSA strains have increased from 6% to 45% over a 2-year period.
|
A 17-year-old girl with no history of respiratory problems went to an emergency department because of a cough, and a course of antibiotics was prescribed. One week later she returned with neck pain and fever; further evaluation revealed an epidural abscess. Findings on a chest radiograph were abnormal, and a computed tomography scan of the chest showed multiple abscesses and diffuse ground-glass opacities with consolidative air-space disease. Innumerable well-defined cystic lesions throughout both lungs were evident. The cysts were approximately 4 mm to 6 cm in diameter (see Figure
).
|
The patient had no obvious risk factors for CA-MRSA infection. She had never been hospitalized or worked in a health care environment. Furthermore, no family member had been hospitalized recently, and extensive questioning of several family members revealed no history of drug use by the patient. Therefore, other routes of possible exposure were investigated. The patient was estranged from her parents and was living with her 20-year-old boyfriend, who had a history of intravenous drug use. Upon further questioning, the patient reported back pain of 1-month duration and an extensive psychiatric history of self-cutting behavior and self-piercing of various body parts, but no recent skin infections. Cultures of blood and bronchoalveolar lavage revealed MRSA with sensitivities again consistent with those of a community-acquired strain.
| The patient’s history of self-cutting behavior and self-piercing was the likely source of her infection.
|
The patient required prolonged mechanical ventilation following surgery. Multiple pneumotho-races developed, most likely due to lung destruction by the CA-MRSA. Multiple chest tubes were required because of the continued rupturing of blebs. The patient underwent extensive immunological testing. Results of assays for HIV, hepatitis viruses, and immunoglobulins (including IgG subclasses) were all normal. Results of a CH50 assay, which is used to measure the total serum complement level and determine if a complement deficiency exists, were also normal.
Chronic granulomatous disease is a hereditary disorder resulting in a defect in the NADPH oxidase of neutrophils. Neutrophils with this defect cannot destroy bacteria once the microorganisms have been phagocytosed. Consequently, patients with this disease are at a much higher risk for abscesses, pneumonia, and skin infections, particularly ones caused by staphylococci. The nitroblue-tetrazolium test is used to screen for chronic granulomatous disease. Nitroblue-tetrazolium is reduced to an insoluble compound by superoxide, which is created by NADPH oxidase. In blood from patients without chronic granulomatous disease, the colorless nitroblue-tetrazolium changes to a deep blue (positive result). Our patient had a positive result in this test, indicating that she did not have the disease. Because of her history, we thought that her self-cutting and self-piercing were the likely source of her infection.
In addition to pulmonary complications, the patient initially required support with norepinephrine and met the criteria for severe septic shock. A transesophageal echocardiogram revealed no evidence of valvular involvement. The infectious disease team recommended an 8-week course of linezolid 600 mg twice daily, which the patient received. Blood cultures eventually became negative for CA-MRSA during the patient’s hospital stay, and her white blood cell count and body temperature eventually returned to normal.
Because of the severity of the pulmonary involvement, the patient required low tidal volume ventilation with high oxygen requirements and supranormal levels of positive end-expiratory pressure. A tracheostomy was required for long-term mechanical ventilation. The patient was weaned from the norepinephrine quickly, and during the course of several weeks was successfully weaned from mechanical ventilation. Before she was discharged to a rehabilitation facility, the chest tubes were removed, with no recurrence of the pneumothoraces. A psychiatric evaluation during her stay revealed that she had bipolar disorder, and treatment and outpatient follow-up were arranged.
This case highlights an emerging problem of CA-MRSA infections in health care–naive patients and underscores the indolent manifestation of the infections in an immunocompetent host. In addition, the case is a reminder of the need for heightened awareness of psychological problems in adolescents that may predispose them to resistant and severe infections.
eLetters
Now that you’ve read the article, create or contribute to an online discussion on this topic. Visit www.ajcconline.org and click "Respond to This Article" in either the full-text or PDF view of the article.
None reported.
|
REFERENCES |
|---|
|
TopAbstractReferences |
|---|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
