A 14-year-old fully vaccinated African girl born in Belgium, without any medical background and whose last travel with her family had been 10 years before to Congo Brazzaville. She was admitted to the Emergency Department of our institution for chest pain and dyspnea associated with deterioration of general condition for a few hours. She also had fever (around 38.7 C) and cough for 3 days.
A week before these complaints, she had a dizzy spell in the shower, which resulted in a fall. The day after she started to complain of coccygeal pain.
She presented with pulmonary infection and a major inflammatory syndrome on a blood test (CRP at 275 mg/L). She was admitted to the PICU for circulatory failure needing hemodynamic support with norepinephrine and milrinone for 2 days. The differential diagnosis between toxic shock syndrome, pediatric inflammatory multisystemic syndrome, and septic shock with pulmonary onset led to the initiation of IV broad-spectrum antibiotic therapy, ceftriaxone (100 mg/kg/day), and clindamycin (900 mg 3 times per day) combined with IV human immunoglobulins (2 g/kg).
At admission to PICU, a pancarditis with endocarditis of the mitral valve apparatus and pericardial effusion were highlighted. The extended workup showed cerebral, pulmonary, renal, and cutaneous emboli. An MRI of the pelvis, performed because of the history of coccygeal pain, revealed sacral osteomyelitis and multiple adjacent abscesses (Figure 3). Therefore, the suspected mechanism of septic shock was endocarditis with multiple emboli secondary to sacral osteomyelitis.
MSSA was found in multiple samples, namely: blood cultures (during 7 days), urine cultures, and cultures from pericardial fluid and pelvic abscesses. The liquid from ascites was negative.
From the first identification of MSSA, the second day of hospitalization, antibiotic treatment was changed for high-dose IV flucloxacillin (200 mg/kg/day) and clindamycin, held for 8 weeks and 11 days, respectively.
A test for PVL was found to be positive in a spa-type t5691 isolate. Investigations for other exotoxins (TSST-1, eta, and etb) were negative. Enterotoxins had not been tested. She had never been in contact with anyone presenting with recurrent skin or soft tissue infections.
Sustained bacteremia for 7 days despite a well-conducted antibiotic therapy and the numerous infected sites secondary to emboli required the drainage of the infected site (pelvic abscesses) to stop blood cultures to be positive.
Seven months after the beginning of this medical history, the patient started sport again with good tolerance. She had no sequelae.