Working Diagnosis:
Community-acquired MRSA pneumonia and sepsis secondary to right femoral osteomyelitis

Treatment:
In the emergency department, the patient initially required extensive fluid resuscitation, epinephrine, dopamine, and hydrocortisone for persistent hypotension. Once his blood pressure stabilized he was intubated and placed on mechanical ventilation. He continued on vancomycin and ceftriaxone, with clindamycin and doxycycline added shortly after presentation. He was transferred to the PICU and cannulated for extracorporeal membrane oxygenation (ECMO; Case Photo #4 . The following day he was started on dialysis for renal failure. After the blood culture results became available his antibiotic therapy was changed to vancomycin, daptomycin, and linezolid.

Outcome:
The patient’s initial PICU course was further complicated by subdural hemorrhage, left hemiparesis secondary to ischemic brain infarct, ARDS, bronchopleural fistula with persistent right hemopneumothorax, Klebsiella tracheitis, pericardial effusion, gastrointestinal bleeding, anemia, persistent lower extremity thrombi, persistent electrolyte derangements, and delirium. Over the following two months, however, he was decannulated from ECMO, weaned to room air, taken off dialysis, successfully initiated a PO diet, and slowly returned to his neurological baseline with minimal residual left upper extremity weakness. Repeat MRI 3 months after presentation demonstrated chronic osteomyelitis with extensive areas of necrotic bone, improved circumferential myositis, and a small, residual subperiosteal distal femoral abscess that required further incision and drainage. He was ultimately discharged from the hospital fifteen weeks after initial presentation to an inpatient rehabilitation facility. He has since returned home and repeat x-rays show chronic osteomyelitis and continued new periosteal bone formation Case Photo #5 , Case Photo #6 . remains on digoxin, carvedilol, and enalapril for cardiac contractility and afterload reduction. He has a a trach collar without an oxygen requirement and a right chest tube for persistent hemopneumothorax. He continues magnesium supplementation as well as enoxaparin for thrombus prophylaxis. Finally, he is completing a prolonged course of clindamycin monotherapy. He is currently planning to return to school in the fall of 2012.

Author's Comments:
MRSA infection is a well-documented problem among athletic populations and can be a cause of invasive, life-threatening disease among previously healthy individuals. While most serious MRSA infections result from a primary skin or soft tissue infection, this patient exhibited MRSA sepsis likely resulting from an underlying femoral osteomyelitis. This represents a rare case of osteomyelitis as the primary source of pneumonia and septic shock in an otherwise healthy adolescent athlete. As MRSA infection continues to be prevalent in the community, this case illustrates the importance of suspicion for MRSA infection among athletes with joint pain and fever, even without obvious superficial infection.

Editor's Comments:
none

References:
1. Benjamin HJ, Nikore V, Takagishi J. Practical management: Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA): the latest sports epidemic. Clin J Sport Med 2007;17:393-7.
2. Redziniak DE, Diduch DR, Turman K, et al. Methicillin-resistant Staphylococcus Aureus (MRSA) in the athlete. Int J Sports Med 2009;30:557-62.
3. Rihn JA, Michaels MG, Harner CD. Community-acquired methicillin-resistant Staphylococcus aures: an emerging problem in the athletic population. Amer J Sports Med 2005;33:1924-9.
4. Pepper M, Willick S, Beals T, Randall RL. An unusual cause of heel pain in a young athlete: a case report. Phys Med Rehab 2010;2:1145-8.
5. Community-acquired methicillin-resistant Staphylococcus aureus: a potential diagnosis for a 16-year-old athlete with knee pain. Larkin-Thier SM, Barber VA, Harvey P, et al. J Chir Med 2010;9:32-7.

Acknowledgments:
none

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