Persistent Air Leak Complicating Staphylococcus Aureus Necrotizing Pneumonia

Abstract

Introduction: Staphylococcus aureus necrotizing pneumonia is a highly lethal infection that mainly affects healthy young adults and children. Persistent air leak is a rare complication associated with significant morbidity, mortality, and prolonged mechanical ventilation (MV). Case presentation: A 19-year-old woman presented to the emergency department with a history of one month fever, odinophagya and fatigue. She developed respiratory failure, demanding orotracheal intubation and MV. She had been previously treated with empirical oral antibiotics in an outpatient clinic without improvement. Laboratory examinations evidenced a hemoglobin level of 9.0 g/dL and a leucocyte count of 310/mm³. A computed tomography (CT) of the chest revealed large infiltrates on the right superior lobe, with multiple small cavitations. She developed septic shock, and intravenous broad spectrum antibiotics, vasopressors, and renal replacement therapy were started. A bone marrow biopsy evidenced reactive findings and on day 4, her leucocyte count reached 103.000/mm³. On day 5 of MV, she developed a tension pneumothorax with significant air leak and hypoxemia. Comparative chest CT findings evidenced hydropneumothorax with extensive consolidations with cavitations and a bronchopleural fistula on the right upper lobe of the lung (Figure 1). A chest tube was inserted and a pleuroscopy with removal of purulent material and lung decortication was performed. Methicilin-sensitive Staphylococcus aureus was isolated from surgical samples and oxacillin was started. On day 20, she remained dependent of MV with a persistent large air leak, and a new surgical procedure was under discussion. Discussion: Necrotizing pneumonia is a rare complication of suppurative lung diseases characterized by destruction of the lung parenchyma resulting in multiple cavities, associated with high mortality. Therefore, rapid recognition is crucial, since treatment delay may lead to extensive necrosis, empyema and development of persistent air leak, septic shock and multiple organ failure. Reference: Masters IB,