MRSA COMPLICATING A PARAPNEUMONIC EFFUSION DESPITE TIMELY ANTIBIOTICS

Abstract

TYPE: Case Report Publication TOPIC: Chest Infections INTRODUCTION: Parapneumonic effusions (PE) can be complicated by empyema or loculations and predicts worse morbidity and mortality. PE management is guided by fluid characteristics instead of organism. We present a case of methicillin resistant Staphylococcus aureus (MRSA) pneumonia causing uncomplicated PEs, which eventually developed into loculations despite timely long-term antibiotics. CASE PRESENTATION: A 69-year-old male presented for nausea, vomiting, and altered mentation. On admission, his blood pressure was 93/60 mmHg, heart rate 106/min, temperature 98 F, oxygen saturation 96%. White blood cells were 10.15 10E9/L, procalcitonin was 15.9 ng/mL, and both blood cultures were positive for MRSA. Chest computed tomography (CT) showed multifocal pneumonia. Blood culture cleared on hospital day (HD) 6 after intravenous (IV) vancomycin and piperacillin/tazobactam. Repeat chest CT on HD 10 showed bilateral PEs. Pleural fluid had pH 7.45, glucose 145 mg/dL, lactate dehydrogenase (LDH) 475 U/L, and negative Gram-stain and culture; serum LDH 358 U/L. He was discharged with 6 weeks of IV vancomycin without chest tube placement. Six weeks later, he presented for nausea and vomiting. CT chest showed right pleural rim enhancement of a loculated effusion. He underwent thoracoscopic adhesiolysis, decortication, 2 lung wedge resections, and mechanical pleurodesis with subsequent resolution of symptoms. Tissue biopsy culture was negative. DISCUSSION: Complicated PE from MRSA is a well-documented complication due to the virulent pro-coagulant behavior of MRSA. Current guidelines do not specifically address the management of MSRA pneumonia related PE. CONCLUSIONS: Early intervention or close monitoring of MRSA PE will need to be considered to reduce morbidity and mortality. DISCLOSURE: No significant relationships. KEYWORDS: Parapneumonic effusion, MRSA pneumonia