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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 6  |  Issue : 2  |  Page : 254-256

Case of disseminated community-acquired methicillin-resistant Staphylococcus aureus: Unique behavior of the organism in an immunocompetent adult


1 Department of Medicine, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India
2 Department of Cardiology, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India
3 Department of Radiodiagnosis, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India

Date of Web Publication27-Dec-2018

Correspondence Address:
Dr. Rupinderjeet Kaur
Department of Medicine, Guru Gobind Singh Medical College and Hospital, Baba Farid University of Health Sciences, Faridkot, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amhs.amhs_15_18

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  Abstract 


Purulent pericarditis resulting from community-acquired methicillin-resistant Staphylococcus aureus (MRSA) is rare in immunocompetent adults. Here, we present the case of disseminated MRSA infection with origin in tibial osteomyelitis, resulting in bacteremia, purulent pericarditis with tamponade, and panophthalmitis in a previously healthy individual.

Keywords: Methicillin-resistant Staphylococcus aureus, osteomyelitis, purulent pericarditis


How to cite this article:
Khutan H, Kaur R, Singh G, Singh P, Kaur A. Case of disseminated community-acquired methicillin-resistant Staphylococcus aureus: Unique behavior of the organism in an immunocompetent adult. Arch Med Health Sci 2018;6:254-6

How to cite this URL:
Khutan H, Kaur R, Singh G, Singh P, Kaur A. Case of disseminated community-acquired methicillin-resistant Staphylococcus aureus: Unique behavior of the organism in an immunocompetent adult. Arch Med Health Sci [serial online] 2018 [cited 2019 Oct 13];6:254-6. Available from: http://www.amhsjournal.org/text.asp?2018/6/2/254/248663




  Introduction Top


Purulent pericarditis in adults is a rare condition. The one occurring secondary to community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) is a potentially lethal condition, resulting from hematogenous spread, direct spread from an adjacent infectious focus, trauma, or surgery.[1] Predisposing factors are pericardial effusion, chronic renal failure, immunosuppression, alcohol abuse, cardiac surgery, and chest trauma.[2] We report the case of a young male with purulent pericarditis presenting with cardiac tamponade with underlying disseminated CA-MRSA infection causing osteomyelitis and panophthalmitis. The case was managed by an aggressive multidisciplinary approach.


  Case Report Top


A previously healthy 17-year-old male patient was referred to our hospital with a 15-day history of fever and breathlessness. Before his current admission, he was taking treatment for a wooden stick injury over his left leg 1 month back and now complained of purulent discharge from the same for the last 15 days. The patient developed progressive dyspnea and pain in the left eye 7 days before the admission. There was no history of cough with expectoration and no chest pain. On physical examination, the patient also had redness of the left eye along with purulent discharge and proptosis of the same eye. Simultaneously, he had a purulent discharge from the wound on the left leg above the ankle joint. On presentation, the patient was found to have orthopnea, with heart rate of 130 bpm, and blood pressure was 90/60 mmHg with pulsus paradoxous, oxygen saturation of 98% on oxygen supplementation, and distended neck veins. He also had respiratory distress with chest retractions and muffled heart sounds on auscultation. The clinical suspicion of cardiac tamponade was kept which was confirmed by an echocardiogram (ECHO), which demonstrated a large amount of pericardial fluid with diastolic collapse of the right cavities. A needle pericardiocentesis was performed, and 1.5 l of purulent fluid was aspirated resulting in the remarkable improvement in his clinical condition. The pericardial fluid, pus from the lateral canthus of the left eye, wound swab from the left leg, and blood sample were sent simultaneously for the bacterial culture and sensitivity testing.

Investigations showed total leukocyte count of 15,600/cmm with predominant neutrophils and normal platelet count. The biochemical profile including renal and liver function tests and total and differential serum protein levels were within normal limits. The samples of blood, pericardial fluid, pus from the lateral canthus, and lesion on the left leg all showed the growth of MRSA sensitive to vancomycin and linezolid. The magnetic resonance imaging of the left leg showed osteomyelitis with cortical breach in tibia distally above the ankle joint and involvement of medulla throughout [Figure 1]. The imaging study of brain was normal, but the left orbit showed phthisis bulbi. Thyroid profile and protein electrophoresis were normal. Test for HIV antibodies was negative. Screening for rheumatoid factor, antinuclear antibody, and Mantoux was also negative. The patient was given vancomycin and linezolid for 6 weeks. Screening ECHO was done and showed no pericardial effusion and the patient was shifted to the orthopedics department for the management of osteomyelitis of the left tibia. On follow-up echocardiography at 1–6 months, there was neither any evidence of effusion nor constriction.
Figure 1: (a) Magnetic resonance imaging (short tau inversion recovery) images showing hyperintense signal involving the medulla of tibia. (b) Cortical breach and skin ulceration seen in the region of distal tibia just above the ankle joint

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  Discussion Top


This was a case of purulent cardiac tamponade with panophthalmitis with osteomyelitis of the left tibia secondary to community-acquired MRSA in a previously healthy male. He survived because of early and aggressive antimicrobial therapy in addition to pericardiocentesis which was both diagnostic and therapeutic. He had an unremarkable personal or family history. There was no clinical suspicion to suggest underlying immune dysfunction, and the patient never experienced invasive infections or subsequent hospitalization for the same again, suggesting immune competence. Thus, further immunological evaluation was not done.

Before the advent of antibiotics, purulent pericarditis was relatively common.[3] The pathogens Pneumococcus and Streptococcus, with their tendency to infect contiguous lung tissues, often gave rise to purulent pericarditis. However, the widespread use of antibiotics has changed the microbiologic spectrum of purulent pericarditis, and there is a dramatic decline in the incidence of purulent pericarditis.[4] S. aureus (a species well known for hematogenous dissemination) is now the most frequent cause of purulent pericarditis.[4] Other (less commonly implicated) species include Gram-negative bacteria, fungi, and other atypical organisms.[4]

In spite of the obvious frequency of S. aureus as a pathogen, only four adult cases of CA-MRSA have been reported which are described in [Table 1].
Table 1: Cases of community acquired methicillin-resistant Staphylococcus aureus reported in literature

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In a previous series of patients with acute bacterial pericarditis, Majid and Omar[9] reported that only one of the twelve cases was secondary to S. aureus infection that arose from a remote focus of septic osteomyelitis or septic arthritis. Our case is unique in the way this CA-MRSA infection behaved in an immunocompetent individual with the probable origin at the site of osteomyelitis, disseminating to the extent of causing panophthalmitis and pericarditis.

Purulent pericarditis is a frequently lethal condition that can now be treated by rapid diagnostic and therapeutic efforts of informed clinicians who will provide appropriate antibiotic therapy while diagnostic efforts are underway. Echocardiography-guided pericardiocentesis has a well-established diagnostic and therapeutic role.[10] Constrictive pericarditis, a complication of acute pyogenic pericarditis, can be prevented by early diagnosis and institution of therapy. Early evacuation of pericardial fluid minimizes the developmental constriction.[11],[12]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sagristà-Sauleda J, Barrabés JA, Permanyer-Miralda G, Soler-Soler J. Purulent pericarditis: Review of a 20-year experience in a general hospital. J Am Coll Cardiol 1993;22:1661-5.  Back to cited text no. 1
    
2.
Maisch B, Seferović PM, Ristić AD, Erbel R, Rienmüller R, Adler Y, et al. Guidelines on the diagnosis and management of pericardial diseases executive summary; the task force on the diagnosis and management of pericardial diseases of the European society of cardiology. Eur Heart J 2004;25:587-610.  Back to cited text no. 2
    
3.
Klacsmann PG, Bulkley BH, Hutchins GM. The changed spectrum of purulent pericarditis: An 86 year autopsy experience in 200 patients. Am J Med 1977;63:666-73.  Back to cited text no. 3
    
4.
Hall IP. Purulent pericarditis. Postgrad Med J 1989;65:444-8.  Back to cited text no. 4
    
5.
Patel S, Maves R, Barrozo CP, Mullens F, Russell K, Truett A, et al. Mycotic pseudoaneurysm and purulent pericarditis attributable to methicillin-resistant Staphylococcus aureus. Mil Med 2006;171:784-7.  Back to cited text no. 5
    
6.
Lee YP, Hoi WH, Wong RC. A case of myopericarditis in a patient with methicillin-resistant Staphylococcus aureus community-acquired pneumonia. Ann Acad Med Singapore 2008;37:243-2.  Back to cited text no. 6
    
7.
Hussam MA, Ragai MF, Iman MF, Zakaria A. Community-acquired methicillin-resistant Staphylococcus aureus pericarditis presenting as cardiac tamponade. South Med J 2010;103:834-6.  Back to cited text no. 7
    
8.
Arora NP, Kottam A, Mahajan N, Bhasin B, Krishnamoorthi R, Shenoy M, et al. Purulent pericardial effusion from community-acquired methicillin-resistant Staphylococcus aureus. Am J Med Sci 2012;344:160-2.  Back to cited text no. 8
    
9.
Majid AA, Omar A. Diagnosis and management of purulent pericarditis. Experience with pericardiectomy. J Thorac Cardiovasc Surg 1991;102:413-7.  Back to cited text no. 9
    
10.
Goodman LJ. Purulent pericarditis. Curr Treat Options Cardiovasc Med 2000;2:343-50.  Back to cited text no. 10
    
11.
Mok GC, Menahem S. Large pericardial effusions of inflammatory origin in childhood. Cardiol Young 2003;13:131-6.  Back to cited text no. 11
    
12.
Thébaud B, Sidi D, Kachaner J. Purulent pericarditis in children: A 15 year-experience. Arch Pediatr 1996;3:1084-90.  Back to cited text no. 12
    


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