Neonatal methicillin-resistant Staphylococcus aureus pneumonia–related recurrent fatal pyopneumothorax: A case report and review of literature

BACKGROUND: Although neonatal Staphylococcus aureus pneumonia is common and usually curable, it can also be refractory and life-threatening. Herein, we report a case of severe neonatal community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) necrotizing pneumonia with bilateral recurrent pyopneumothorax, respiratory failure, heart failure, and cardiac arrest. We hope our report will add to the understanding of this disease. CASE SUMMARY: An 18-d-old boy presented with cough for five days, fever for three days, and dyspnea for two days. Preadmission chest radiograph revealed high-density shadows in both lungs. On admission, his oxygen saturation fluctuated around 90% under synchronized intermittent mandatory ventilation. He was unconscious, with dyspnea, weak heart sounds and hepatomegaly. Moist crackles were present throughout his left lung, while the breath sounds in the right lung were decreased. After high-frequency oscillatory ventilation, empiric antimicrobials (meropenem and vancomycin), improved circulation, and right pleural cavity drainage for right pneumothorax (approximately 90% compression), his oxygen saturation level stayed above 95%, and recruitment of the right lung was observed. His condition did not deteriorate until the 5(th) day of hospitalization (DOH 5). On the morning of DOH 5, his oxygen saturation decreased. Subsequent chest radiograph showed bilateral pneumothorax with nearly 100% compression of the left lung. Desaturation was not relieved after urgent left pleural cavity drainage, and cardiac arrest occurred soon thereafter. Although his spontaneous heartbeat returned through emergency resuscitation and salvage antibacterial therapy (linezolid and levofloxacin) was administered given the detection and antimicrobial susceptibility of MRSA, he showed no improvement, with recurrent pyopneumothorax and continued drainage of purulent fluid and necrotic lung tissue fragments from the pleural cavity. Eventually, his parents refused extracorporeal membrane oxygenation (ECMO) and gave up all the treatments, and the newborn passed away soon after withdrawal on DOH 13. CONCLUSION: Neonatal MRSA pneumonia can be refractory and lethal, especially in cases where necrotizing pneumonia leads to extensive lung necrosis and recurrent pneumothorax. Despite treatment with linezolid and other medical measures, it may still be ineffective. Currently, ECMO has been a remedial therapy, but if the lung tissue is too severely eroded to be repaired, it may be useless unless the infection can be controlled and lung transplantation can be performed. Regardless of whether ECMO is initiated, the key to successful treatment is to achieve control over the pneumonia caused by MRSA as soon as possible and to reverse lung injury as much as possible.