14 August 2024: Articles
Diabetic Patient with CA-MRSA Pneumonia and Plasma Cell Neoplasm: A Case Report of Severe Complications and Prognosis
Unknown etiology, Unusual clinical course, Challenging differential diagnosis, Diagnostic / therapeutic accidents, Educational Purpose (only if useful for a systematic review or synthesis), Rare coexistence of disease or pathology
Mohammed Ali Al-Mattar1BD*, Mona Al-Zaher2A, Jaafer Sadiq Al-Salman3A, Zahra Sayed Abbas Mohamed4D, Alyaa Zuhair Marhoon4D, Zainab Al-Ghasra4DDOI: 10.12659/AJCR.943914
Am J Case Rep 2024; 25:e943914
Abstract
BACKGROUND: The prevalence of methicillin-resistant Staphylococcus aureus (MRSA) has been increasing in recent years, becoming a cause of community-acquired infection. Interestingly, its role in malignancy recently started to be considered after a noticed increase in reported cases and studies discussing the potential association.
CASE REPORT: In the present case, the patient had known and uncontrolled diabetes mellitus and a history of multiple abscesses that were previously treated by incision and drainage. The patient received a diagnosis of severe pneumonia, and MRSA was found in blood cultures. Further tests for HIV, hemagglutinin type 1, and neuraminidase type 1 (H1N1) were negative. The D test was also performed for macrolide-inducible resistance and was negative, indicating the need for intravenous administration of clindamycin. An echocardiogram ruled out endocarditis. Subsequently, the patient experienced progressive back pain and weakness involving the lower limbs. A pathological fracture was discovered, along with nerve root compression. An urgent posterior spine fixation was then performed by a neurosurgeon. A biopsy was collected at the site of the pathological fracture, and histopathological tests indicated a plasma cell neoplasm.
CONCLUSIONS: MRSA is known to cause serious and dangerous infections, including necrotizing pneumonia. Furthermore, a link between MRSA and plasma cell dyscrasia has been considered in several reports. This necessitates the need for further studies to clarify this hidden association, which may help in the course and prognosis of these patients.
Keywords: Neoplasms, Plasma Cell, Sepsis, FemB Protein, Methicillin-Resistant Staphylococcus aureus
Introduction
Studies have long reported associations between various tumors and different bacteria found in patients. These studies have typically focused on characterizing the bacteria within tumor tissues and their potential contribution to the development and staging of cancerous versus healthy tissue. However, the link between bacteria and cancer has been underestimated, and the role of infection in malignancy remains a subject of contention on whether it is causal or opportunistic [1,2].
Various bacterial species, including
Additionally,
Numerous clinical cases are reporting a significant link between the presence of
The severity of the diseases caused by MRSA is likely due to a combination of virulence factors related to the bacteria and the host. Staphylococcal nuclease domain-containing protein 1 (SND1) is highly expressed in most cancers and has been shown to have a strong correlation with the prognosis of tumor patients [7].
Case Report
In March 2022, a 48-year-old man with a known case of uncontrolled type 2 diabetes mellitus and non-compliance to oral hypoglycemic agents, previous surgical history including right fifth toe amputation, and recurrent incision and drainage of abscess presented to the Emergency Department with concerns of left-sided para-spinal back pain radiating to left chest for 5 days that started after he accidentally contacted a table at the site of the pain.
The patient’s vital signs were obtained and were as follows: temperature of 36.5°C, heart rate of 70 beats per min, respiratory rate of 26 counts per min, blood pressure of 135/874mmHg, and oxygen saturation of 91% on room air.
Chest examination revealed reduced air entry and bilateral crepitations. Upon inspecting the back, the patient had a crescent-shaped scar on the site of trauma with tenderness on palpation, as well as a scar on the mid-upper back, most likely from a previously drained abscess. A missing small toe on the right foot was also noted. The initial laboratory tests conducted on the patient included a complete blood count, renal function tests, liver function tests, a coagulation profile, an electrolytes bone panel, calcium, and measurement of the erythrocyte sedimentation rate (ESR). All the test results were within the reference range except for an elevated ESR, white blood cell (WBC) count, random blood sugar, and HBA1c. The patient’s WBC count was 14.69 cells/μL (reference range 4.5–11 cells/μL), ESR count was 100 mm/h (reference range 0–20 mm/h), random blood sugar level was 298 mg/dL (reference range 74–106 mg/dL), and HBA1c was 8.8% (reference range less than 5.6%). Previous cultures from a previous drained abscess showed pan-sensitive
The chest radiograph demonstrated diffuse bilateral patchy airspace opacity with a bronchogram, in addition to cardiomegaly, with a lower-zone atelectatic band (Figure 1A).
Sputum and blood cultures were obtained, as well as samples for HIV and neuraminidase type 1 (H1N1) testing. Blood culture results for MRSA were positive by hospitalization day 3. H1N1 and HIV tests were negative. An echocardiogram was ordered to rule out infective endocarditis; this was also negative.
The patient received a diagnosis of CA-MRSA pneumonia, and because his D test reported sensitivity for macrolides and clindamycin, he was started on an intravenous course of clindamycin with a dosage of 900 mg 3 times per day.
The chest radiograph was repeated on the third day of the antibiotic course and revealed marked interval resolution of the bilateral large butterfly consolidation. However, the lower-zone atelectatic band was still apparent (Figure 1). The initial presentation of back pain was resolved 3 days after starting the antibiotics and analgesia administration.
After just 1 week of clindamycin administration, repeated blood cultures showed no growth. Even after 2 weeks, the cultures remained negative, but the repeated ESR indicated an increase in the rate from 100 mm/h on the day of admission to 120 mm/h, while the patient’s WBC count became normal, until the day of discharge.
On day 7 of admission, the patient developed severe back pain, which eventually resulted in a sudden inability to walk, necessitating consultation by a neurosurgeon.
Musculoskeletal examination revealed decreased muscle power (2/5) and a positive Babinski sign on both legs, predominately in the left leg; sensory examination for both legs was intact. On day 7, thoracolumbar magnetic resonance imaging of the spine was performed to obtain imaging for spinal and para-spinal etiologies, showing multilevel discopathy, particularly at T9–10, as well as ongoing nerve root conflict, with paravertebral collection (Figure 2).
On day 9, neurosurgeons performed posterior spine fixation at the site of spinal destruction. Histopathological analysis of the T9 vertebral body biopsy confirmed plasma cell neoplasm (Figure 3).
After 16 days of admission and against medical advice, the patient abruptly left the hospital. Three months later, the patient went to the Emergency Department with excruciating pain.
Further workup was done at his last presentation. A biopsy of the bone marrow in the left iliac crest identified greater than 10% plasma cells. Free light chain assay showed a normal kappa to lambda ratio, and no M band was noticed in serum protein electrophoresis.
After beginning a chemotherapy regimen with bortezomib and lenalidomide, the patient experienced low blood pressure and a fever, which required treatment with inotropes and antibiotics. Blood culture results identified MRSA, and vancomycin was recommended. Unfortunately, the patient only received inotropes and antibiotics for 1 day before dying.
Discussion
Infectious pathogens account for more than 20% of all malignancies worldwide. Bacteria and their role in cancer have received less attention than viruses. Bacteria can promote cancer growth by multiplying host cells’ signaling pathways, generating metabolites, and inducing inflammation [8].
Furthermore,
In our case history, the patient was initially able to walk without any neurological weakness, when diagnosed with severe pneumonia. After several weeks of antibiotic administration as an inpatient, he developed a lower limb neurological deficit that confirmed the presence of spondylotic lesions, suggesting plasma cell neoplasm through histopathological analysis of the destructed lesion from the vertebral body.
In a previous case report, a patient developed plasma cell neoplasm and clinically deteriorated 3 weeks after finishing a course of antibiotics; test results indicated
A limitation of our case study is that we could not conduct additional tests or investigations to determine the type of plasma cell dyscrasia, due to the death of the patient.
Conclusions
MRSA is known to cause serious and dangerous infections, including necrotizing pneumonia. With growing virulence, it has been linked to cancer cases and has been found to reduce survival rates. Moreover, a link between MRSA and plasma cell dyscrasia has been specifically identified in several reports. This necessitates the need for further studies to clarify this link, which could aid in the course and prognosis of these patients.
Figures
Figure 1.. Portable chest radiograph taken of a patient’s case. Images show (A) diffuse bilateral patchy air space opacity with cardiomegaly, bronchogram, and lower zone atelectatic band, which indicates severe pneumonia at the day of admission, in comparison with (B) marked interval resolution of the bilateral large butterfly consolidation, only 1 day after starting antibiotics. Figure 2.. Sagittal view of magnetic resonance imaging of thoracolumbar spine showing multilevel discopathy, particularly at T9–10, as well as ongoing nerve root conflict with paravertebral collection. Figure 3.. Specimen consisting of disc 2 fragments of tan, firm tissue, measuring 2×1×0.5 cm. AT1c sections reveal (A) bony tissue showing destruction of the bone marrow with diffuse infiltration of plasma cells; (B) Russell bodies; (C) some cells showing high N/C ratio with binucleation; and (D) immunohistochemistry showing positive CD38, CD138, kappa, and lambda.References:
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2.. Liao F, Gu W, Fu X: Mol Immunol, 2021; 140; 167-74
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4.. Wei Y, Sandhu E, Yang X: Microorganisms, 2022; 10; 2353
5.. Zhang QR, Chen H, Liu B, Zhou M: Chin Med J (Engl), 2019; 132; 1429-34
6.. Falagas ME, Rafailidis PI, Kapaskelis A, Peppas G, Pyomyositis associated with hematological malignancy: Case report and review of the literature: Int J Infect Dis, 2008; 12; 120-25
7.. Kalambokis G, Theodorou A, Kosta P, Tsianos EV: Int J Hematol, 2008; 87; 516-19
8.. Menati Rashno M, Mehraban H, Naji B, Radmehr M, Microbiome in human cancers: Access Microbiol, 2021; 3(8); 000247
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Figures
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