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A 24-Year-Old Man With Cough, Rhabdomyolysis, and Pneumomediastinum

Andrs F. Sosa and Gisela Banauch J Intensive Care Med 2012 27: 55 originally published online 21 January 2011 DOI: 10.1177/0885066610393468 The online version of this article can be found at: http://jic.sagepub.com/content/27/1/55

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Case Reports
Journal of Intensive Care Medicine 27(1) 55-57 The Author(s) 2012 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0885066610393468 http://jicm.sagepub.com

A 24-Year-Old Man With Cough, Rhabdomyolysis, and Pneumomediastinum

s F. Sosa, MD1 and Gisela Banauch, MD1 Andre

Abstract Background: Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) frequently causes severe necrotizing pneumonia in young patients. Case: We present the case of a 24-year-old male, who was brought to the emergency department with persistent fevers, confusion, and severe cough. He was found to have necrotizing pneumonia, pneumomediastinum, and rhabdomyolysis with renal failure. Cultures were positive for influenza A and CA-MRSA. After a prolonged intensive care unit (ICU) stay, he made a complete recovery. Conclusion: Community-acquired MRSA pneumonia is a growing health threat that typically presents in young adults after, or in conjunction with, a flu-like illness. It is characterized by a rapidly progressive deteriorating clinical course. Keywords community-acquired MRSA, pneumonia, pneumomediastinum, rhabdomyolysis
Received February 4, 2010. Submitted April 19, 2010.

Introduction
Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) pneumonia is a growing threat that causes severe necrotizing pneumonia in young adults. It is often preceded by a flu-like illness and characterized by a stormy disease course and high mortality.1 Community-acquired MRSA very often carries the Panton-Valentine leukocydin (PVL), a pore-forming toxin that significantly increases the microorganisms virulence.2 Pneumomediastinum and rhabdomyolysis are rare complications that have been described with staphylococcal pneumonia3,4 and may misguide the clinicians initial impression.

Case
A 24-year-old man was brought to the emergency department with a 1-week history of persistent high fevers, intense productive cough, and progressive confusion and lethargy. Initially he complained of sore throat, fevers, chills, headache, nausea, myalgias, and fatigue; the cough was severe enough to trigger vomiting. Two days before admission, he had been diagnosed with community-acquired pneumonia and prescribed a 5-day course of azithromycin by his primary care physician. Despite the oral antibacterial therapy, his condition continued to deteriorate. On the day of admission, his family noticed him to be lethargic and confused, prompting them to seek further medical attention in the emergency room. The patient had no prior medical history of note. He did not have known allergies

and had been taking azithromycin for the past 2 days. He was a lifelong nonsmoker. The patient was from central Massachusetts and had not traveled outside this area during his adult life. His physical examination was remarkable for temperature, 39.5 C; heart rate, 149 beats/min; respiratory rate, 28 breaths/min; blood pressure, 70/58; oxygen saturation 95% on 4 L of supplemental oxygen delivered by nasal cannula. The patient was well developed and appeared acutely ill and diaphoretic. His breathing was labored, and he was using his accessory musculature. He was aroused promptly to voice; there was minimal confusion to current events. Oral mucosa was dry. The findings on cardiac examination were normal. His pulmonary examination revealed dullness to percussion, decreased tactile fremitus, diminished breath sounds, rales, ronchi, and wheezes throughout the right hemithorax. The remainder of his physical examination was unremarkable. Laboratory findings were remarkable for leukocyte count 9.8 thousand/mm3, hemoglobin 13.1 g/dL, platelets 165 thousand/mm3, 46% bandemia. Serum chemistry showed

Pulmonary, Allergy & Critical Care Medicine, University of Massachusetts Medical School, UMass-Memorial Medical Center, Worcester, MA, USA Corresponding Author: Andres F. Sosa, Umass Memorial Medical Center, 55 Lake Av. North,Worcester, MA 01655, USA Email: andres.sosa@umassmemorial.org

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56

Journal of Intensive Care Medicine 27(1)

Figure 1. Chest X-ray.

Figure 3. Chest computed tomography (CT).

Figure 2. Chest computed tomography (CT).

sodium 124 mmol/L, potassium 3.7 mmol/L, chloride 93 mmol/L, urea nitrogen 47 mg/dL, creatinine 2.87 mg/dL, calcium 6.5 mg/ dL, magnesium 1.1 mg/dL; creatine kinase > 45 100 U/L, creatine kinase muscle brain subfraction 95.8 ng/mL, aspartate aminotransferase 734 IU/L, alanine aminotransferase 173 IU/L, lactate dehydrogenase 1145 IU/L. Microbiological analysis yielded methicillin-resistant Staphylococcus aureus isolated from blood and pulmonary secretions. Respiratory virus cultures were positive for influenza A. Admission chest radiographs and representative images from a chest computed tomography (CT) on admission are shown in Figures 1 to 3. The patient was intubated within 24 hours of arrival in the intensive care unit

(ICU). Bronchoscopy after intubation revealed copious amounts of bloody, purulent secretions, and severe mucosal inflammation with sloughing, more pronounced throughout the right tracheobronchial tree. The patient was treated with oseltamivir and rimantadine for influenza A infection. In addition, he received linezolid, vancomycin, and rifampin for severe MRSA pneumonia. The presence of pneumomediastinum resolved shortly after admission without further specific therapy. The patient required a tube thoracostomy for drainage of an infected right pleural space. His acute renal failure and rhabdomyolysis resolved promptly with supportive therapy that included volume resuscitation and forced diuresis with urine alkalinization. A percutaneous tracheotomy was inserted on hospital day#11 for prolonged mechanical ventilatory support. After a 30-day ICU stay, he was discharged without further organ support to a rehabilitation facility. He was seen 3 months later in the pulmonary outpatient clinic and was doing remarkably well, living at home and close to returning to work. His last chest CT showed complete resolution of the large cavitating infiltrates.

Discussion
In recent years, a new variant of CA-MRSA has emerged as a serious threat, frequently affecting younger patients who have a prior presentation of a flu-like illness and a violent disease course with high mortality rates and prolonged admissions to the ICU. Community-acquired MRSA pneumonia typically has a different clinical course and epidemiologic incidence from that of hospital-acquired MRSA pneumonia: hospital-acquired MRSA pneumonia tends to affect older individuals with

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Sosa and Banauch significant comorbidities and has a more indolent course albeit comparable mortality.1 During the 2006 to 2007 influenza season, 440 adults and 117 children were hospitalized due to community-acquired pneumonia caused by S aureus; 386 (72%) were methicillinresistant, 49% required mechanical ventilation, and 13% died; 26% of these patients had an associated influenza infection.5 Other sources6 have reported mortality rates as high as 56%, with a median survival of 10 days Community-acquired MRSA was initially mostly isolated from skin infections, typically of young athletes; the development of severe pneumonia has been a growing problem of the last decade. In 2002, the association with PVL was made. Up to 85% of CA-MRSA strains have PVL, a pore-forming toxin that affects cells of the immune system and induces a strong inflammatory response that substantially enhances staphylococcal virulence.2 PVL () strains have a higher binding affinity for exposed basement membrane of damaged human airway epithelium than PVL () strains7; this may play an important role in their attachment to epithelium that has been previously injured by a viral infection. Panton-Valentine leukocydin also enhanced the transcription of secreted and cell wall-anchored staphylococcal proteins.3 The classic clinical presentation of CA-MRSA pneumonia is characterized by severe respiratory symptoms, hemoptysis, hypotension, and high fever. Laboratory analyses often reveal leukopenia and very high levels of C-reactive protein. The chest radiograph may show necrotizing pneumonia with multilobar cavitating infiltrates. In a series of 50 patients with PVL MRSA pneumonia by Gillet et al,6 the median duration of symptoms before hospitalization was 3 days, and 67.3% of patients had a preceding flu-like illness. Virological studies were done in 9 patients and 4 had influenza A infection. Preexisting skin infections were found in only 24% of patients. The clinical course during the first 48 hours was very severe, and airway bleeding was often described (44%). Airway bleeding, erythroderma, and leukopenia were associated with fatal outcomes. Autopsy findings have shown that the entire respiratory tract may be affected. Extensive necrotic ulcerations of the tracheal and bronchial mucosa and massive hemorrhagic necrosis of the interalveolar septa in the presence of a large concentration of microorganisms have been described.2

57 We found only 2 previous cases of pneumomediastinum in the presence of methicillin-sensitive staphylococcal pneumonia, both young patients with a rapidly progressive deteriorating clinical course.4,8 Declaration of Conflicting Interests
The author(s) declared no conflicts of interest with respect to the authorship and/or publication of this article.

Funding
The author(s) received no financial support for the research and/or authorship of this article.

References
1. Rubinstein E, Kollef MH, Nathwani D. Pneumonia caused by methicillin-resistant Staphylococcus aureus. Clin Infect Dis. 2008;46(suppl 5):S378-S385. 2. Gillet Y, Issartel B, Vanhems P, et al. Association between Staphylococcus aureus strains carrying gene for Panton-Valentine leukocidin and highly lethal necrotizing pneumonia in young immunocompetent patients. Lancet. 2002;359(9308):753-759. 3. Labandeira-Rey M, Couzon F, Boisset S, et al. Staphylococcus aureus Panton-Valentine leukocidin causes necrotizing pneumonia. Science. 2007;315(5815):1130-1133. 4. Roshan M, Venkatesha BM, Bhat EK, Nayak UA. Pneumomediastinum and pneumopericardium in staphylococcal bronchopneumonia. J Assoc Physicians India. 2003;51:884. 5. Kallen AJ, Hageman J, Gorwitz R, Beekmann SE, Polgreen PM. Characteristics of Staphylococcus aureus community-acquired pneumonia during the 20062007 influenza season. Clin Infect Dis. 2007;45(12):1655. 6. Gillet Y, Vanhems P, Lina G, et al. Factors predicting mortality in necrotizing community acquired pneumonia caused by Staphylococcus aureus containing Panton-Valentine leukocidin. Clin Infect Dis. 2007;45(3):315-321. 7. de Bentzmann S, Tristan A, Etienne J, Brousse N, Vandenesch F, Lina G. Staphylococcus aureus isolates associated with necrotizing pneumonia bind to basement membrane type I and IV collagens and laminin. J Infect Dis. 2004;190(8):1506-1515. 8. Finnie IA, Jack CI, McKay JS. Pneumomediastinum and subcutaneous emphysema complicating staphylococcal pneumonia. Ulster Med J. 1995;64(1):105-107.

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