| Abstract|| |
After the introduction of methicillin, Staphylococcus has evolved into a major cause of infection. We report a case of previously healthy middle-aged women with community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) multiloculated empyema, which unmasked diabetes in her. There was no parenchyma involvement on chest X-ray as well as computed tomography scan, but only pleural cavity was involved, secondary to the bacteremia caused by skin lesion. CA-MRSA multiloculated empyema is rare, and it should be included in the differential diagnosis of the multiloculated empyema, as it can be lifesaving.
Keywords: Diabetes, empyema, methicillin, Staphylococcus
|How to cite this article:|
Beigh A, Malik J, Bachh A, Mir M, Ahangar B. Community acquired methicillin resistant Staphylococcus aureus multiloculated empyema unmasking diabetes mellitus in a middle-aged female: A rare case report. Ann Trop Med Public Health 2014;7:206-8
|How to cite this URL:|
Beigh A, Malik J, Bachh A, Mir M, Ahangar B. Community acquired methicillin resistant Staphylococcus aureus multiloculated empyema unmasking diabetes mellitus in a middle-aged female: A rare case report. Ann Trop Med Public Health [serial online] 2014 [cited 2019 Sep 18];7:206-8. Available from: http://www.atmph.org/text.asp?2014/7/4/206/152584
| Introduction|| |
Methicillin-resistant Staphylococcus aureus (MRSA) infection was first reported in 1960s. After the introduction of methicillin and evolved into an important cause of infection.  A case of Community acquired (CA) is defined as an illness compatible with CA pneumonia in which MRSA is cultured from blood or sputum in an outpatient setting or <48 h after of hospital admission with none of the health care risk factors. Empyema thorasis is a collection of pus in the pleural cavity, and it has been recognized since the time of Hippocrates and historically has been associated with high mortality, ranges between 6% and 24%.  We report a case of previously healthy middle-aged women with CA-MRSA multiloculated empyema which unmasked diabetes in her.
| Case Report|| |
A previously healthy 39-year-old female was seen at emergency room, because of an 8-day history of moderate to high-grade fever, nonproductive cough, breathlessness and pain left side of the chest, which gradually increased over a period of illness. There was no history of previous hospitalization, antibiotic use or sick contact. On physical examination, the patient appeared to be in moderate distress, respiratory rate of 38/min, had a temperature of 103°F, pulse of 120 beats/min and pallor was present. Patient had central cyanosis. No rash was noted over her body except pustular lesion over right infrascapular region with the perilesional erythema. Chest examination revealed a dull note infrascapular and infraaxillary area on both sides. Breath sounds were decreased over the same area on the both sides. The remainder of the examination was unremarkable.
Laboratory data showed a white blood cell count of 19.40 × 10³/μl with neutrophils 83.4% lymphocytes 8.2% and monocytes 6.9%. Hemoglobin was 11.0 g/dl, and platelet count of 302,000. Fasting blood sugar 266 mg/dl and glycated hemoglobin 6.6%. Negative for hepatitis and HIV. Kidney function test was unremarkable. Chest radiograph showed bilateral blunting of costophrenic angles more on the left side [Figure 1]. Ultrasonography of thorax showed the right side multiple pockets of pleural effusion and left sided mild pleural effusion. Pleural aspirate yielded 20 ml of foul smelling turbid fluid, exudative on biochemistry analysis and gram staining revealed Gram-positive cocci in clusters suggestive of Staphylococcus. The organism was not acid fast with Ziel-Nielson stain. On the culture, the pleural fluid grew organisms suggestive of S. aureus and was resistant to methicillin. Blood culture reported MRSA. Gram staining and culture of sputum was negative for any cocci, acid fast bacilli or fungal hyphae. A contrast-enhanced computed tomography (CECT) scan of the chest showed, multiple collections in mediastinal and parietal pleura on both sides [Figure 2], and normal lung parenchyma [Figure 3]. Diagnosis of multilocular empyema (pleural and mediastinal) due to CA-MRSA was made. Pleural fluid was drained under ultrasound guidance and intravenous antibiotics, pipracillin plus tazobactum 4.5 g three times a day started before blood and pleural fluid culture report and then switched to vancomycin 1 g twice a day, after culture reports for a period of 4 weeks. Moreover, her raised blood sugar was managed by insulin mixtard 30/70, 12 units before breakfast and 8 units before dinner.
|Figure 1: Chest radiograph showing bilateral blunting of costophrenic angles more on left side|
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|Figure 2: A contrast enhanced computed tomography scan of the chest showing, multiple collections in mediastinal and parietal pleura on both sides|
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|Figure 3: contrast enhanced computed tomography scan of the chest showing, normal lung parenchyma|
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Her symptoms improved dramatically after 1 week of antibiotic therapy. Moreover, after 4 weeks of treatment, her all of her symptoms resolve. Chest radiography and ultrasonography of thorax after 1 week of treatment showed partial resolution of previous fluid collections on both sides and complete resolution after 4 weeks of treatment [Figure 4]. A repeat blood count decreased to 11.5 × 10³/μl and her blood sugar was in normal range, after 1 week of the treatment. Moreover, after 4 weeks blood counts and blood sugar was within normal range. Patient discharged on metformin 500 mg. A CECT repeated and showed complete resolution of all pleural and mediastinal collections [Figure 5].
|Figure 4: Chest radiograph and ultrasonography of thorax after 1 week of treatment showing partial resolution of previous fl uid collections on both sides and complete resolution after 4 weeks of treatment|
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|Figure 5: A contrast enhanced computed tomography repeated and showing complete resolution of all pleural and mediastinal collections|
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| Discussion|| |
More than 30 staphylococcal species are pathogenic. S. aureus is distinguished from other staphylococcal species by its production of coagulase. S. aureus, the most virulent of many staphylococcal species, has demonstrated its versatility by remaining a major cause of morbidity and mortality despite the availability of numerous effective antistaphylococal antibiotics. This organism is responsible for both nosocomial and community-based infection that ranges from relatively minor skin and soft tissues infections primarily to life-threatening systemic infection. 
Empyema defined by the presence of pus in the pleural space. Direct extension of a pulmonary parenchymal infection into the pleural space causes more than half the cases of empyema; postsurgical infection accounts for an additional 20%. Empyema also occurs after penetrating or blunt trauma to the thorax.  A number of factors that predispose patients to empyema include diabetes, glucocorticoid therapy, chemotherapy, acquired immune deficiency syndrome, hematological malignancies,  previous hospitalization, especially in intensive care units, preexisting pulmonary tuberculosis, bronchopleural fistula, pleural intubation or drainage, and lung resection.  Many patients have a previous history of multiple antibiotic therapy administration. In our case, the infection was CA with no medical history. The patient was apparently healthy and had no previous predisposing factor.
Empyema thoracis secondary to CA aspergillosis has been reported without lung parenchymal involvement in controlled diabetic patient,  but no case of empyema thoracis without lung parenchymal involvement due to CA-MRSA has been reported until date with best of our knowledge.
In our case, there is no parenchyma involvement on chest X-ray as well as CT scan but only pleural cavity was involved, secondary to the bacteremia caused by skin lesion and presenting as a multiloculated empyema which unmasks patient's diabetes. After management of high blood sugars with insulin in hospital patient was discharged on metformin 500 mg once a day and her blood sugar remained within the normal limits. Unmasking of diabetes is explained by stress due to infectious pathology.
| Conclusion|| |
Community-acquired MRSA multiloculated empyema is rare, and it should be included in the differential diagnosis of the multiloculated empyema as it can be lifesaving.
| References|| |
Deresinski S. Methicillin-resistant Staphylococcus aureus
: An evolutionary, epidemiologic, and therapeutic odyssey. Clin Infect Dis 2005;40:562-73.
Davies CW, Kearney SE, Gleeson FV, Davies RJ. Predictors of outcome and long-term survival in patients with pleural infection. Am J Respir Crit Care Med 1999;160:1682-7.
Franklin D. Lowy: Staphylococcal infections. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, editors. Harrison's Principles of Internal Medicine. 18 th
ed., Vol. 1. New York: McGraw Hill; 2012. p. 1160-70.
Martin L. Mayse: Non-malignant pleural effusions. In: Fishman AP, Elias JA, Fishman JA, Grippi MA, Senior RM, Pack AI. editors. Fishman's Pulmonary Disease and Disorders. 4 th
ed., Vol. II. The McGraw-Hill Companies; 2008. p. 1487-504.
Davies SF. Fungal pneumonia. Med Clin North Am 1994;78:1049-65.
Herring M, Pecora D. Pleural aspergillosis: A case report. Am Surg 1976;42:300-2.
Goel MK, Juneja D, Jain SK, Chaudhuri S, Kumar A. A rare presentation of aspergillus infection as empyema thoracis. Lung India 2010;27:27-9.
Department of Chest Medicine, SKIMS, Medical College and Hospital, Bemina, Srinagar, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]