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Community-acquired methicilin-resistant Staphylococcus aureus as a cause of pyonephrosis necessitating emergent nephrectomy. A new clinical entity

Abstract number: P1449

Koukoulaki M., Baraboutis I., Belesiotou E., Platsouka E., Papastamopoulos V., Kontothanasis D., Petraki K., Paniara O., Skoutelis A.

Introduction: Community acquired-methicilin-resistant Staphylococcus aureus (CA-MRSA) carrying the Panton-Valentine leucocidin (PVL) toxin has been linked to skin and soft tissue infections and necrotising pneumonia. We report a new clinical syndrome related to this emerging pathogen.

Case presentation: An 84 year-old man, with history of diabetes mellitus type II, nephrolithiasis, recurrent urinary tract infections and prostatectomy, presented with constitutional symptoms and fever. He denied invasive procedures of the genitourinary tract in the last 2 years. Evaluation revealed tenderness of the right costophrenic angle, leukocytosis, CRP of 35.6 mg/dl and preserved renal function. A computed tomography revealed a right-sided staghorn calculus, with dilatation of the pelvicalyceal system and attenuation of renal cortex. Further focal infection was noted at the upper and middle pole of the right kidney along with enlargement of right ileopsoas muscle. Blood and urine cultures collected on admission were positive for MRSA. The patient's initial therapy with ticarcillin/clavulanate and amikacin was changed on the third hospital day to meropenem and vancomycin. The patient gradually became septic, necessitating right nephrectomy on the fourth hospital day. At surgery, the kidney was found small, with multiple scars and also with pus inside the renal pelvis and ureter. Perirenal tissue and psoas muscle were inflamed. The MRSA strain had the ``community'' phenotype with preserved sensitivity to trimethoprim-sulfamethoxazole and clindamycin). The assay for PVL toxin was positive, while PCR for mecA type III and IV was negative (PCR for mecA type V has been scheduled). Histopathology analysis reported chronic obstructive pyelonephritis secondary to nephrolithiasis, along with interstitial nephritis with tubular atrophy and nephrosclerotic glomerulae. Further infection was extended to pyelocalyceal system, ureter and peri-renal fatty tissue. The patient completed three weeks of intravenous vancomycin and was discharged in good condition, albeit with residual renal insufficiency.

Discussion: Community-acquired-MRSA differs from healthcare associated MRSA both in epidemiology and genetic characteristics. Recent reports indicate that CA-MRSA strains have entered tertiary care hospitals and are the cause of healthcare infections. This is a novel type of syndrome caused by CA-MRSA. Interestingly, the patient involved did have risk factors for invasive MRSA infection.

Session Details

Date: 19/04/2008
Time: 00:00-00:00
Session name: 18th European Congress of Clinical Microbiology and Infectious Diseases
Subject:
Location: Barcelona, Spain
Presentation type:
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