A fit and healthy 8-year old boy presented with a 10-day history of asymptomatic superficial ulcerations initially on the left great toe, and then the left elbow. He was systemically well. The general practitioner had prescribed oral flucloxacillin for infected bite marks but the patient took for 2–3 days as the parents felt some of the lesions were starting to resolve. However within days he developed new lesions on the left foot and toes and was admitted for intravenous antibiotics. On examination there was an exudative ulcerated papule on the dorsum of the left foot and left 3rd toe with surrounding erythema and oedema. Bacterial swab was positive for staphylococcus aureus (SA), and further analysis confirmed the clinical suspicion of panton-valentine-leukocidin SA (PVL-SA) positivity. The patient had a good clinical response to augmentin/clavulanic acid with subsequent decolonisation with chlorhexidine 4% body wash and nasal chlorhexidine with neomycin cream. Close contacts also received eradication therapy.
The prevalence of PVL-SA positive isolates from skin wounds is increasing. In the United Kingdom 20% of SA isolates from skin and soft tissue were found to be PVL-SA positive (compared to 2% in 2005). Patients and/or close contacts present with either persistent purulent wounds resistant to usual treatments, or recurrent boils and abscesses. Risk factors include the ‘five C’s’ – contaminated items, close contact, crowding, cleanliness and cuts or compromised skin integrity. The Health Protection Agency has produced guidance on the diagnosis and management of PLV-SA including eradication regimes, which our patient and close contacts received.
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