Septic Pulmonary Emboli and Bacteremia Associated with Deep Tissue Infections Caused by Community-Acquired Methicillin-Resistant Staphylococcus aureus

Abstract

We report four adult patients who presented with septic pulmonary emboli and community-acquired methicillin-resistant Staphylococcus aureus bacteremia associated with deep tissue infections, such as pyomyositis, osteomyelitis, and prostatic abscess. The patients lacked evidence of right-sided endocarditis or thrombophlebitis. This association, previously described in children, may also be important in adults. CASE REPORTFour adult patients from the community presented to a large urban hospital (John H. Stroger Jr. Hospital of Cook County, Chicago, IL) with septic pulmonary emboli and community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) bacteremia from December 2005 to February 2007. Each patient underwent a transesophageal echocardiogram that was negative for endocarditis. In addition, clinical and radiographic evaluations for deep-vein thrombosis were negative. No history or stigmata of intravenous drug use, thrombophlebitis, or prior intravascularcatheter use were found. Instead, each patient was diagnosed with a deep tissue infection or abscess as a possible primary focus of infection.Patient 1. A 36-year-old obese man with type 2 diabetes mellitus presented with 1 week of fever, cough, chest pain, and difficulty walking. Computed tomography (CT) of the chest demonstrated bilateral pulmonary nodules, some cavitary, consistent with septic pulmonary emboli (Fig. 1a). Blood cultures grew MRSA on admission and remained positive for 12 days. Despite receipt of appropriate antimicrobials, the patient remained intermittently febrile for 3 weeks. CT of the abdomen/ pelvis, as well as magnetic resonance imaging (MRI) of the spine did not reveal thrombophlebitis or abscess. On hospital day 25, a gallium scan demonstrated increased uptake in the left thigh. CT of the lower extremities revealed an enhancing fluid collection extending the full length of the left quadriceps muscle, consistent with pyomyositis, without evidence of deepvein thrombosis (Fig. 1c). Surgical drainage revealed grampositive cocci in clusters on Gram stain; the culture (obtained during vancomycin therapy) was negative. The patient defervesced after drainage and recovered with 6 weeks of vancomycin therapy. Patient 2.A 55-year-old man with a history of hypertension, benign prostatic hypertrophy, and chronic rectal hemorrhoids was admitted with urinary hesitancy and rectal pain for 4 days. He had chills, but no pulmonary complaints. On examination, the patient was febrile and had large nonbleeding external rectal hemorrhoids and an enlarged nontender prostate. Blood cultures from the first 6 days of hospitalization were positive for MRSA. Pelvic CT revealed an enhancing cystic lesion in the inferior aspect of the prostate, consistent with a prostatic abscess, without evidence of pelvic thrombophlebitis (Fig. 1d). Pulmonary nodules consistent with septic pulmonary emboli were noted on CT. The patient was treated with 4 weeks of vancomycin and improved without surgical drainage.Patient 3. A 45-year-old man was admitted with acute lo...

Disseminated Community-Acquired USA300 Methicillin-ResistantStaphylococcus aureusPyomyositis and Septic Pulmonary Emboli in an Immunocompetent Adult

“…Although local MRSA pyomyositis confined to a single muscle group has been reported, even in conjunction with septic pulmonary emboli, no cases of communityacquired MRSA pyomyositis with such a severe clinical presentation have been reported [10]. The case reported here is also remarkable for widespread disease involving axial and appendicular muscle groups.…”

“…Staphylococcus aureus as the offending organism, affecting a single muscle group, is the most common presentation, although cases of disseminated infection have been reported [2,9]. Recently, methicillin-resistant Staphylococcus aureus (MRSA) isolates have been recognized as a cause of tropical pyomyositis [4][5][6][7]10].…”

Community-acquired methicillin resistant Staphylococcus aureus: a new aetiological agent of prostatic abscess

“…In this case, although the patient was relatively young and without pre-existing urological complaints, diabetes was an important risk factor 7 8. So far, there have only been four additional reports in the medical literature describing prostatic compromise by CA-MRSA, in three of which there was also immunosuppression 9–12…”

A young adult with a fulminant Staphylococcus aureus infection and multiple thrombi

“…2 However, Lin et al have described four adult patients with septic pulmonary emboli, bacteremia, and deep tissue infection. 6 These patients didn't have deep venous thrombi, and, therefore, DVT is not a consistent complication of these infections. Splanchnic vein thrombosis often occurs in patient with cirrhosis, inflammatory disorders in the abdomen, abdominal trauma and hypercoagulable states.…”