Severe infections of Panton-Valentine leukocidin positive Staphylococcus aureus in children

Abstract

Infections caused by Panton-Valentine leukocidin-positive Staphylococcus aureus (PVL-SA) mostly present as recurrent skin abscesses and furunculosis. However, life-threatening infections (eg, necrotizing pneumonia, necrotizing fasciitis, and osteomyelitis) caused by PVL-SA have also been reported.We assessed the clinical phenotype, frequency, clinical implications (surgery, length of treatment in hospitals/intensive care units, and antibiotic treatments), and potential preventability of severe PVL-SA infections in children.Total, 75 children treated for PVL-SA infections in our in- and outpatient units from 2012 to 2017 were included in this retrospective study.Ten out of 75 children contracted severe infections (PVL-methicillin resistant S aureus n = 4) including necrotizing pneumonia (n = 4), necrotizing fasciitis (n = 2), pyomyositis (n = 2; including 1 patient who also had pneumonia), mastoiditis with cerebellitis (n = 1), preorbital cellulitis (n = 1), and recurrent deep furunculosis in an immunosuppressed patient (n = 1). Specific complications of PVL-SA infections were venous thrombosis (n = 2), sepsis (n = 5), respiratory failure (n = 5), and acute respiratory distress syndrome (n = 3). The median duration of hospital stay was 14 days (range 5-52 days). In 6 out of 10 patients a history suggestive for PVL-SA colonization in the patient or close family members before hospital admission was identified.PVL-SA causes severe to life-threatening infections requiring lengthy treatments in hospital in a substantial percentage of symptomatic PVL-SA colonized children. More than 50% of severe infections might be prevented by prompt testing for PVL-SA in individuals with a history of abscesses or furunculosis, followed by decolonization measures.

Figure 1

Patient 4 at admission. Coronal CT of the chest. Lobar pneumonia of the left lung. Small arrows: border of pleural empyema with gas inclusions (small black arrows). CT = computed tomography.

Figure 2

Patient 6 at admission. Anteriorposterior radiograph of the chest at the time of admission. Left lung: Primarily basal lobar pneumonia. Right lung: perihilar infiltration. Intubation tube, central line, and gastric tube in loco typico.

Figure 3

Patient 6 at 4 months after admission. Coronal CT of the torso. Small arrows: epiphrenic residual lesions. Small black arrows: hilar lymph nodes. CT = computed tomography.

Figure 4

Patient 5 at 4 weeks after admission. Coronal MRI with TIRM sequence of the torso. Large arrow: axillary abscess formation. Small arrows: cellulitis. MRI = magnetic resonance imaging; TIRM = turbo-inversion recovery-magnitude.

Figure 5

Patient 1 at 3 days after admission. Coronal contrast-enhanced MRI with TIRM sequence of the lower extremities. Indicative of myositis and fasciitis. Large arrow: feathered intramuscular enhancement. Small arrows: subcutaneous enhancement. Small black arrows: fascial enhancement. MRI = magnetic resonance imaging; TIRM = turbo-inversion recovery-magnitude.

Figure 6

Patient 7 at admission. Coronal contrast-enhanced T1-weighted MRI of the head with fat suppression. Large arrow: abscess-forming, destructive mastoiditis with infiltration into the cerebellum. Small arrows: meningeal enhancement. Small black arrows: cervical lymphadenopathy. MRI = magnetic resonance imaging.

Figure 7

Patient 1 at 3 days after admission. Axial contrast-enhanced T1-weighted MRI with fat suppression of the proximal left lower thigh. Large arrow: abscess formation with circular contrast enhancement in the ventral compartment. Small arrows: thrombosis of deep veins. Small black arrows: subcutaneous veins with contrast. MRI = magnetic resonance imaging.

Figure 8

Patient 7 at admission. Coronal contrast-enhanced T1-weighted cranial MRI with fat suppression. Large arrow: thrombosis of sigmoid sinus. Small arrows: meningeal enhancement. MRI = magnetic resonance imaging.

Figure 9

History of SSTI in patients and relatives of our cohort before admission for serious infection (n = 10). SSTI = skin and soft tissue infections.