Archives of Medicine and Health Sciences

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


Himanshu Khutan1, Rupinderjeet Kaur1, Gagandeep Singh2, Paramdeep Singh3, Amanpreet Kaur1,  
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

Correspondence Address:
Dr. Rupinderjeet Kaur
Department of Medicine, Guru Gobind Singh Medical College and Hospital, Baba Farid University of Health Sciences, Faridkot, Punjab
India

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.



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;6:254-256


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 Nov 12 ];6:254-256
Available from: http://www.amhsjournal.org/text.asp?2018/6/2/254/248663


Full Text



 Introduction



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



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}

 Discussion



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}

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.

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