Critical Care: Student/Resident Case Report Poster - Critical Care II |

The Case of the Vanishing Lung FREE TO VIEW

Biplab Saha, MD; Kristin Fless, MD; Paul Yodice, MD; Vagram Ovnanian, MD; Fariborz Rezai, MD; Nirav Mistry, MD
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Saint Barnabas Medical Center, West Orange, NJ

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):402A. doi:10.1016/j.chest.2016.08.415
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SESSION TITLE: Student/Resident Case Report Poster - Critical Care II

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION:Staphylococcus aureus (SA) is a rare cause of community acquired pneumonia(CAP) and a major cause of influenza related mortality and morbidity. Necrotizing pneumonia due to Panton Valentin leucocidin (PVL) toxin secreting strains of S. aureus is associated with a mortality rate of up to 40-60%. Both methicillin resistant (MRSA) and methicillin sensitive S. aureus (MSSA) can carry gene for PVL toxin.

CASE PRESENTATION: A sixty three year old female with a history of asthma, who had lost her husband 1 week ago from pneumonia, presented to the emergency room with a fever, generalized malaise, nasal discharge, cough, sputum production and shortness of breath for 3 days. She was found to be febrile, tachypneic and hypoxic, saturating 84% on room air. Lung exam revealed bilaterally reduced breath sound with diffuse rales and mild wheezing. Blood work demonstrated leukocytosis with bandemia. Chest X-Ray showed bilateral infiltrates. She was treated for CAP with Ceftriaxone and Azithromycin. Blood culture grew MSSA. She received nafcillin but her condition deteriorated. She required high flow 100% oxygen. Chest CT scans done 7 days apart showed blossoming bilateral infiltrate and development of multiple cavitary lesions of the lung. She was started on Linezolid, Clindamycin and intravenous immunoglobulin (IVIG) for suspected necrotizing pneumonia with PVL toxin producing MSSA. She underwent prolonged extra corporeal membrane oxygenation therapy but with subsequent recovery. The genetic study confirmed PVL gene consistent with MRSA USA 300.

DISCUSSION: The PVL toxin is composed of 2 components, LukS-PV and LukF-PV. They assemble on the leukocyte membrane causing lysis of the neutrophil with resultant release of pro-inflammatory cytokines. Although the presence of PVL producing organism has generally been considered to be associated with worse outcome, the notion hasn’t been proved beyond doubt in the literature. Skin and soft tissue infection due to PVL producing S. aureus is associated with increased risk for surgical intervention. Influenza like prodrome, leukopenia, thrombocytopenia, hemorrhage and pleural effusion are indicators of fatal outcome in patients with pneumonia. Clindamycin and Linezolid have antitoxin effect and may improve clinical outcome. IVIg has also been used with some success. In the U.K. routine testing is done as most European PVL strains are MSSA, however it is not recommended in the U.S.

CONCLUSIONS: The suspicion of PVL toxin producing SA strain as a cause of necrotizing pneumonia is extremely important. Early initiation of treatment with appropriate antibiotics directed at the toxin and IVIG might be lifesaving. Checking for PVL toxin may help in early determination of a fatal pathogen.

Reference #1: Voyich JM, Otto M, Mathema B, et al. (2006). “Is Panton-Valentine leukocidin the major virulence determinant in community-associated methicillin-resistant Staphylococcus aureusdisease?”. J. Infect. Dis.194 (12): 1761-1770. doi:10.1086/509506

DISCLOSURE: The following authors have nothing to disclose: Biplab Saha, Kristin Fless, Paul Yodice, Vagram Ovnanian, Fariborz Rezai, Nirav Mistry

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