대한흉부영상의학회 Weekly Chest Cases

Case No : 586 Date 2009-01-19

Courtesy of Jin Hee Jang, MD, Myung Hee Chung, MD. / Holy Family Hospital, College of Medicine, The Catholic University of Korea, Korea
Age/Sex 53 / M
Chief ComplaintAcute right side chest pain

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Diagnosis With Brief Discussion

Diagnosis: Methicillin-resistant Staphylococcus aureus (MRSA) infection (pneumonia)
Radiologic Findings: Chest CT shows well demarcated, thin-walled cavities with marginal rim enhancement and nonenhancing low density materials in the whole lung fields. A few, thin-walled cysts in both apices may be nonspecific emphysema rather than pneumatoceles. Acute necrotizing pneumonia are mainly located in the both lower lobes. Right pneumothorax is resulted from outside thoracentesis in addition to probably ruptured parenchymal necrotic portion (bronchopleural fistula).

Underlying DM for 10 yr, insulin therapy, CRF ?HD for 2 yr, HPB.
Blood and urine culture: MRSA positive
No PCR or other DNA assay.
Brief Review: MRSA was first identified in the 1960s, reflecting the response of S aureus to widespread exposure to penicillins. Indeed, MRSA now accounts for 20%-40% of all hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP). Until recently, most of the MRSA strains causing health care-ssociated pneumonia (HCAP), HAP, and VAP were labeled hospital-acquired MRSA (HAMRSA) and contained the staphylococcal cassette chromosome (SCC) mec types I-III. Recently, however, a new variant of MRSA has emerged as a pulmonary pathogen. This new variant of S. aureus that causes pneumonia is community-acquired MRSA (CAMRSA), containing SCCmec type IV. CA-MRSA, although primarily a cause of skin and soft-tissue infection, has proved to be a formidable cause of pneumonia.

Overall, MRSA is an important cause of pneumonia. A survey of 59 US hospitals, involving 4543 patients with culture-positive pneumonia, between January 2002 and January 2004 identified MRSA as a potential pathogen in 8.9% of CAP cases, 26.5% of HCAP cases, 22.9% of HAP cases, and 14.6% of VAP cases.

Diagnosis is based on positive blood cultures accompany only 5%-15% of HAP cases and 24%-36% of VAP cases. Endotracheal microbiological sampling has shown only 40% agreement with lung biopsy, and only 15% of the samples met adequacy criteria for having originated from the lower respiratory tract.

The differentiation HRMRSA from CAMRSA is frequently difficult on clinical settings.
There're are a few reports about the MRSA imaging findings including acute necrotizing pneumonia with cystic changes, a lobar pneumonia, transition from the localized lobar pneumonia to a pattern of diffuse infiltrations consistent with the ARDS, multiple nodular cavities, and empyema. Empyema necessitatis is a rare complication of empyema.
References: 1. Ethan Rubinstein, Marin H. Kollef, Dilip Nathwani. Pneumonia Caused by Methicillin-Resistant Staphylococcus aureus. Clinical Infectious Diseases 2008;46:378-385
2. Kelly N. Mizell, Kimberley V. Patterson, and J. Elliot Carter. Empyema Necessitatis Due to Methicillin-Resistant Staphylococcus aureus: Case Report and Review of the Literature. Journal of clinical microbiology 2008;46(10):3534-3536
3. Scott T. Micek, PharmD; Michael Dunne, PhD; and Marin H. Kollef, MD, FCCP. Pleuropulmonary Complications of Panton-Valentine Leukocidin-Positive Community-Acquired Methicillin-Resistant Staphylococcus aureus Importance of Treatment With Antimicrobials Inhibiting Exotoxin Production. CHEST 2005; 128:2732-2738
4. Bartlett JG. Methicillin-Resistant Staphylococcus aureus infections. Top HIV Med.2008;16(5):151-155
5. Francis JS. Doherty MC. Lopatin U, et al. Severe Community-Onset Pneumonia in Healthy Adults Caused by Methicillin-Resistant Staphylococcus aureus Carrying the Panton-Valentine Leukocidin Genes. Clinical Infectious Diseases 2005;40:100-107
Keywords: Lung, Pleura, Infection, Bacterial infection,

No. of Applicants : 93

▶ Correct Answer : 20/93, 21.5%

- Father Muller Medical College , Mangalore , India nabil mahmood
- CHRU lille , France manuel toledano
- ottawa hospital , Canada nishard abdeen
- jiangsu province hospital , China yuan doctor
- yashodha hospital , India pravin mahadevappa
- Trakya universitesi , Turkey Garip kutlutk
- Chungnam National University hospital , Korea (South) Kyoung Jin Oh
- seoul national university hospital , Korea (South) Ijin Joo
- Louisiana State University - Shreveport , United States Carlos Previgliano
- KMC,Manipal , India satish maddukuri
- Mon Hospital , France sebastien LARIVE
- hospital Sao Paulo , Brazil israel missrie
- Seoul National University Hospital , Korea (South) Sang Min Lee
- CHRU Lille , France Benjamin Damarey
- Clinique Beaulieu, Gene , Switzerland gilles GENIN
- Hospital Sotiria, Athens, Greece , Greece Vasilios Tzilas
- NASA SCANS , India RAKESH BHATIA
- AIIMS , India tariq matin
- al watany hosp , Syria mohamad jader
- Trakya University School of Medicine , Turkey Umut Ugur

▶ Correct Answer as Differential Diagnosis : 15/93, 16.1%

- Hanmaeum Hospital , Korea (South) Kwon Hyoung Kim
- China Medical University,Taiwan,R.O.C. , Taiwan Jun Jun Yeh
- Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
- Gaziantep Kad Hastallarve Dom Hastanesi , Turkey Tay Bakar
- Ondokuz Mayis University , Turkey Cetin Celenk
- Trakya Univercity School of Medicine, , Turkey Belma Kmazaslan
- HOSPITAL SOTIRIA , Greece AIKATERINI DELAVERI
- McGill University Health Center , Canada Alexandre Semionov
- ASL BOLOGNA - MAGGIORE HOSPITAL- ITALY , Italy MARCELLINO BURZI
- Hangang Sacred Heart Hospital , Korea (South) Eil Seong Lee
- IRSA La Rochelle France , France Denis Chabassiere
- NOUR EL-ISLAM RADIOLOGY CENTER , Egypt Elsayed Mousa MD,FRCR
- All India Institute of Medical Sciences , India Ashish Gupta
- Dongguk University International Hospital , Korea (South) Hee Seok Choi
- ULTRA CARE , India Debabrata Das

▶ Semi-Correct Answer : 13/93, 14.0%

- Soonchunhyang university hospital, Bucheon , Korea (South) Hyelin Kim
- batra hospital new delhi , India shiva rastogi
- DCA, , India Rajesh Gothi
- Trakya University School of Medicine, Turkey , Turkey Ahmet POLAT
- care hospital , India chary d
- University of Ottawa , Canada Blair Gill
- KONARK DIAGNOSTIC CENTRE , India AHAMAD MUKARRAB
- Uzunkopru Hospital, Edirne , Turkey Derya Karabulut
- second hospital xian jiaotong university , China li ming
- govt royapettah hospital , India gopinathan kathirvelu
- UZ GASTHUISBERG , Belgium Johan COOLEN
- KASTURBA MEDICAL COLLEGE , India NAVEEN KULKARNI
- clinique de SAVOIE , France, Metropolitan gay-depassier philippe

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 586 Date 2009-01-19

Discussion

No. of Applicants : 93