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Indian Pediatr 2011;48: 563-565 |
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Scarlet Fever Caused by Community-associated
Methicillin-resistant Staphylococcus aureus |
Ying-Chun Lu, Shyi-Jou Chen and Wen-Tsung Lo
From Department of Pediatrics, Tri-Service General
Hospital, National Defense Medical Center, Taipei, Taiwan.
Correspondence to: Dr Wen-Tsung Lo, Department of
Pediatrics, Tri-Service General Hospital, National Defense Medical Center,
No. 325, Cheng-Kung Road, Section 2, Nei-hu 114, Taipei, Taiwan.
Email: [email protected]
Received: January 27, 2010;
Initial review: March 03, 2010;
Accepted: April 5, 2010.
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We describe a previously healthy 2½-year-old boy with staphylococcal
scarlet fever associated with acute suppurative otitis media due to
community-associated methicillin-resistant Staphylococcus aureus.
The patient was successfully treated by spontaneous drainage in
combination with trimethoprim-sulfamethoxazole therapy.
Key words: Acute suppurative otitis media,
Community-associated methicillin-resistant Staphylococcus aureus,
Staphylococcal scarlet fever.
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A cute otitis media (AOM) is
pervasive in children with high incidence rates reported both in
developed and emerging nations [1]. Recently, strains of
community-associated methicillin-resistant S. aureus (CA-MRSA)
are increasingly found in skin and soft-tissue infections of
children, usually linked to intravenous drug abuse, cystic fibrosis,
chronic diseases and repeated antimicrobial therapy [2]. However,
CA-MRSA otorrhea after tympanostomy tube insertion in well children
has been reported previously [3]. Here we describe a child with
bilateral acute suppurative OM and staphylococcal scarlet fever (SSF)
associated with CA-MRSA. To the best of our knowledge, this is the
first pediatric case of such an association.
Case Report
A previously healthy 2-year-and-6-month-old boy
was seen in the emergency department because of the acute onset of
turbid discharge with pus and bloody component over the left ear,
and generalized itching skin rashes followed by upper respiratory
tract infection 4 days prior to admission. The family denied
previous trauma or foreign body ingestion, and the boy had not been
exposed to auricular, dental or oropharyngeal manipulation. Physical
examination of the skin showed generalized pruritic scarlatiniform
rash with positive blanching sign, but no enanthema, bullae or
exfoliation. Oropharyngeal examination disclosed good dental
hygiene, normal oral mucosa, and erythematous tonsils; no other
abnormalities were noted. Other findings of physical examination
were unremarkable.
Otorhinolaryngologists were consulted due to the
abnormal discharge and poor visibility of both ear canals. After
clearance, air-fluid level with pus formation over the right middle
ear, and copious yellowish and bloody discharge through the
perforated left eardrum were noted. The leukocyte count was 8,000/mm 3
with 65.2% segmented neutrophils, C-reactive protein (CRP) level was
47 mg/l, and rapid antigen test for group A Streptococcus was
negative; the remainder of the hematologic and blood chemistry
findings were within normal reference ranges.
The diagnosis of bilateral acute suppurative OM
and SSF was established and pus specimen, blood, and throat cultures
were obtained. Cephazolin was empirically administered at a dosage
of 100 mg/kg/day intravenously in three divided doses. Two days
after admission, the initial pus cultures grew MRSA, susceptible in
vitro to many antibiotics including gentamicin,
trimethoprim-sulfamethoxazole, ciprofloxacin, fusidic acid, rifampin
and vancomycin. The isolate was resistant to penicillin-G, cefazolin,
oxacillin, clindamycin and erythromycin. Based on these findings,
the antibiotic regimen was subsequently changed to oral
trimethoprim-sulfa-methoxazole. After 3 days of oral
trimethoprim-sulfamethoxazole therapy, the patient’s condition
improved gradually and he was discharged home with a prescription of
oral trimethoprim-sulfametho-xazole. Previous blood culture remained
negative and throat culture revealed growth of normal pharyngeal
flora. After completing a 2-week course of oral
trimethoprim-sulfamethoxazole therapy, he was doing well at his
1-month follow-up evaluation with no evidence of recurrence.
Further molecular typing of the MRSA isolate
revealed it carried the staphylococcal cassette chromosome mec
(SCCmec) type V T,
possessed both Panton-Valentine Leukocidin (PVL) and staphy-lococcal
enterotoxin B (SEB) genes, and multilocus sequencing typing (MLST)
disclosed the genotype was sequence type (ST) 59. The presence of
the lukS-PV and lukF-PV genes encoding PVL components
and the seb encoding SEB were determined by polymerase chain
reaction (PCR)-based method with the primer pair and thermocycler
conditions [4]. SCCmec typing was performed using a multiplex
PCR strategy with sets of region-specific primers [5]. MLST was
performed by PCR amplification and sequencing of seven housekeeping
genes using primers designed by Enright, et al. [6]. Each
sequence was submitted to the MLST database website for assignment
of the allelic profile and ST. These findings suggest that this case
of bilateral acute suppurative OM and SSF was caused by ST 59, PVL-
and SEB-positive CA-MRSA infection.
Discussion
In recent times, there has been a steady increase
in the number of cases of MRSA otorrhea [3], CA-MRSA has rarely been
reported in discharging ears [2,3,7]. Previous cases of MRSA
otorrhea were associated with bilateral myringotomy with
tympanostomy tube insertion [3].
SSF is a rare disease first described in 1900
[8]. The diagnosis of SSF is traditionally made based on the
consistent clinical manifestation of generalized scarlatiniform
rash; no enanthem, bullae, or exfoliation; followed by desquamation
similar to toxic shock syndrome and no evidence of streptococcal
infection [8]. In a recent study of 49 children with SSF, cutaneous
abscesses predomi-nated (100%), and all responded to
incision-and-drainage, manual expression of pustule contents, or
spontaneous drainage, with fair outcomes despite treatment with
ineffective antibiotics [9]. Review of literature suggests that CA-MRSA
is very rarely associated with SSF originating from bilateral acute
suppurative OM. Recovery of CA-MRSA from the pus specimen of our
patient is strong evidence that this organism was the cause of both
bilateral acute suppurative OM and SSF. Fortunately, our patient’s
clinical condition improved after spontaneous drainage in
combination with trimethoprim-sulfa-methoxazole therapy.
Currently, the infecting strains of CA-MRSA in
Taiwan are thought to have unique microbiologic characteristics such
as resistance to multiple antibio-tics (including clindamycin,
erythromycin, tetracy-cline and chloramphenicol), different exotoxin
gene profiles (e.g., PVL and SEB), common pulsed-field gel
electrophoresis patterns (which are different from those of the
major pandemic clones of hospital-acquired MRSA), ST 59 genotype by
MLST, and smaller SCCmec variants: SCCmec type V T,
or less frequently, type IV [5]. The microbiological characteristics
of the CA-MRSA strain infecting our patient are consistent with the
results of previous studies. The present case suggests that CA-MRSA
should also be considered a potential cause of both suppurative OM
and SSF in children.
Contributors: WTL: Conception and design; YCL,
SJC and WTL: analysis and interpretation of the data; YCL and WTL:
drafted the article; WTL: Critical revision of the article for
important intellectual content and YCL, SJC and WTL: approved the
article.
Funding: None.
Competing interests: None stated.
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