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Staphylococcal necrotising pneumonia

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In most paediatricians’ minds the term staphylococcal pneumonia is associated with a picture of severe bilateral disease in infants and young children, often with pleural effusion, empyema, pneumothorax or pyopneumothorax, lung abscesses, and pneumatoceles. That disease has been uncommon in the wealthier countries since the 1960s. Now an even more virulent form of staphylococcal pneumonia has been described from France (

).

Staphylococcus aureus sometimes carries the gene for a toxin called Panton-Valentine leukocidin (PVL). In 1998 a review of data held by the French Reference Centre for Staphylococcal Toxaemia, in Lyon, showed that there had been eight cases of PVL-positive community-acquired staphylococcal pneumonia since 1986, six of whom had died. The Lancet report includes these eight cases, eight more cases from 1999, and 36 PVL negative cases also from 1999.

PVL positive S aureus pneumonia affected children and young adults (median (interquartile range) age 14.8 (5.4–24.0) years whereas PVL-negative pneumonia was a disease of the elderly (70.1 (59.2–81.4)). Three quarters of the PVL-positive cases died, average survival after admission being only 4 days. The disease often began with an influenza-like illness progressing within 2 days to very severe pneumonia. Common clinical features included high fever, hypotension, tachycardia, cyanosis, haemoptysis, and leucopenia. Pneumothorax or pneumatoceles did not occur. Radiologically there were multilobar alveolar infiltrates on admission, often with the later development of bilateral interstitial infiltrates consistent with acute respiratory distress syndrome. Ten patients had, or developed, pleural effusion.

Three of the 16 PVL positive patients had postmortem examinations that showed massive alveolar haemorrhage with necrosis of the interalveolar septa. There was also extensive necrosis of the mucosa of the trachea and bronchi with haemorrhagic foci.

Since the end of 1999 this laboratory has confirmed another 13 PVL positive cases and they also confirmed three fatal cases in the USA in 1999. This clinical picture seems to have been rare in the past but a similar illness caused the deaths of 385 American soldiers in 1918 soon after the influenza pandemic.

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