Near-fatal Panton-Valentine leukocidin-positive Staphylococcus aureus pneumonia, shock and complicated extracorporeal membrane oxygenation cannulation: A case report

Abstract

BACKGROUND

Panton-Valentine leukocidin (PVL) is an exotoxin secreted by Staphylococcus aureus (S. aureus), responsible for skin and soft tissue infections. As a cause of severe necrotising pneumonia, it is associated with a high mortality rate. A rare entity, the epidemiology of PVL S. aureus (PVL-SA) pneumonia as a complication of influenza coinfection, particularly in young adults, is incompletely understood.

CASE SUMMARY

An adolescent girl presented with haemoptysis and respiratory distress, deteriorated rapidly, with acute respiratory distress syndrome (ARDS) and profound shock requiring extensive, prolonged resuscitation, emergency critical care and venovenous extracorporeal membrane oxygenation (ECMO). Cardiac arrest and a rare complication of ECMO cannulation necessitated intra-procedure extracorporeal cardiopulmonary resuscitation, i.e., venoarterial ECMO. Coordinated infectious disease, microbiology and Public Health England engagement identified causative agents as PVL-SA and influenza A/H3N2 from bronchial aspirates within hours. Despite further complications of critical illness, the patient made an excellent recovery with normal cognitive function. The coordinated approach of numerous multidisciplinary specialists, nursing staff, infection control, specialist cardiorespiratory support, hospital services, both adult and paediatric and Public Health are testimony to what can be achieved to save life against expectation, against the odds. The case serves as a reminder of the deadly nature of PVL-SA when associated with influenza and describes a rare complication of ECMO cannulation.

CONCLUSION

PVL-SA can cause severe ARDS and profound shock, with influenza infection. A timely coordinated multispecialty approach can be lifesaving.

Keywords: Panton-Valentine leukocidin-Staphylococcus aureus; Adolescent; Extracorporeal membrane oxygenation; Extracorporeal cardiopulmonary resuscitation; Case report

Core Tip: We present a case of profound vasoplegic shock and acute respiratory distress syndrome in a healthy adolescent after a mild prodromal illness. Acute cardiorespiratory failure persisted despite aggressive resuscitation and vasoactive support. Cardiac arrest and complicated extracorporeal membrane oxygenation (ECMO) cannulation necessitated emergency venoarterial-ECMO during cardiopulmonary resuscitation. Early respiratory samples confirmed H3N2 influenza and Panton-Valentine leukocidin-Staphylococcus aureus (PVL-SA) pneumonia: A rare and serious manifestation of the PVL-SA, usually associated with less severe skin and soft-tissue infections. The patient’s ultimate survival and recovery depended on the extraordinary interplay and rapid utilisation of multidisciplinary teams which we highlight for the benefit of other services to ensure optimal outcomes, even against the odds.