1. Introduction
Staphylococcal pleuropulmonary is a relatively common condition in infants, rare in newborns.
Despite the progress of pediatric resuscitation measures, this pathology remains formidable in developing countries.
It is a very worrying disease because of the toxicity of staphylococcus aureus, which can lead to a serious infectious shock, its necrotizing power, which causes mechanical complications, and especially because of the resistance of staphylococcus aureus to various antibiotics [1] [2].
Staphylococcal remains a pathology exclusively of young infants, very rare in the newborn see exceptional which explains all the particularity of our observation.
Positive diagnosis and management in the new child is a real challenge for each clinician, especially since the scientific literature is of particular interest to infants and the older child.
2. Objective
To report the medical observation of a newborn baby hospitalized in the neonatal intensive care unit of university hospital center MOHAMMED VI MARRA-KECH who presented a purulent cutaneous collection at the xiphoid level complicated by pleuropulmonary staphylococcus aureus with meningeal and hematogenous diffusion.
Interest: Rare entity in the neonatal period, with acute and sometimes chronic complications.
3. Medical Observation
Female newborn, 13 days old, premature at 34 weeks of amenorrhea and 2 days according to the ultrasound of the first trimester, from a first-degree related marriage, with no particular pathological history in the mother.
The newborn was initially hospitalized from birth for 3 days in our department for weak sucking reflex, having received parenteral nutrition by an intravenous route taken from the right hand, reeducation of the reflex by the finger and pacifier technique, rewarming with good evolution.
The patient was readmitted 10 days after her discharge for febrile respiratory distress associated with a purulent collection at the xiphoid level with liquid content measuring 3 cm in width, warm with an inflammatory aspect, and a refusal to suckle evolving for 5 days.
On admission, the newborn was hypotonic, dehydrated, febrile at 38.5 degrees, polypneic at 67 cycles/minute with signs of respiratory struggle such as moderate intercostal and subcutaneous draught. Pulmonary auscultation did not reveal any abnormalities.
The skin recoloration time was normal, no mottling, with a refusal to suckle.
The initial biological workup noted an infectious syndrome with white blood cells 18,700/ul, neutrophilic predominance at 10,050/ul with a platelet count of 132,000/ul, a C REACTIVE PROTEIN was 132.52 mg/l.
The puncture of the xiphoid collection showed a fetid purulent aspect with isolation of Meticillin-resistant Staphylococcus aureus in the bacteriological sample and in the blood culture.
In front of the refusal of suckling a lumbar puncture with study of the cerebrospinal fluid objectifying meningitis to staphylococcus aureus resistant to the Meticillin.
The patient was treated since her admission with vancomycin and amikacin with good clinical and biological evolution.
As part of the investigation of the field, an immune deficiency assessment was performed in our patient, including HIV serology, which was negative, the dosage of lymphocyte subpopulations and complement was normal.
The initial chest X-ray showed an alveolar opacity of the right middle lobe, (Figure 1).
A follow-up chest X-ray performed 8 days after antibiotic therapy revealed a right cavitary image related to the excavation of the initial opacity with a minimal pneumothorax on the left, (Figure 2).
Chest X-ray performed after a 8-week follow-up showed clear radiological cleaning (Figure 3).
The evolution of our patient was favorable after 2 months, pleura-pulmonary examination was normal, disappearance of the xiphoid collection and good intake of its food ration.
The infectious check-up was negative.
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Figure 1. ADMISSION CHEST X-RAY. Alveolar opacity in the right middle lobe.
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Figure 2. CONTROL CHEST X-RAY. In right cavitary image. Minimal pneumothorax on the left.
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Figure 3. Cleaning of radiological anomalies.
4. Discussion
Pleuropulmonary staphylococcal disease is still the preserve of infants, accounting for 70% of children under one year of age [3] - [8], and is a fairly rare and serious condition in newborns.
Clinical manifestations are dominated by fever and rapid onset of respiratory signs [5] [6] [7] [8] [9].
Digestive symptoms, on the other hand, are often silent [5] [6]; when they are studied [3] [8] [9], their frequency is of the order of 50%; abdominal meteorism, often significant, is the best sign.
Clinical atypia in newborns is frequent, making the diagnosis difficult and often delayed.
The rapid evolution of the respiratory disease is reflected in the admission chest X-ray, which is very suggestive of the diagnosis: existence of a pleural effusion, often discreet (simple filling of a pleural sac), bullous images or even a pyopneumothorax.
The maximum delay between the first clinical signs and the radiological signs is 3 days [10] [11].
This is explained by the pathophysiology of the disease based on contamination through a cutaneous or mucosal lesion, a bacterial proliferation occurs with a localized thrombophlebitis. This will produce a pulmonary septic metastasis in the form of a furuncle with an inflammatory crown. This one will evolve from one step to the next. Pleural involvement may be via the lymphatic route from the parenchymal focus or directly via the hematogenous route [4].
Bacteriological evidence is most often provided by pleural samples, with blood cultures only rarely proving positive.
The germ most responsible is the staphylococcus (Staphylococcus aureus or Staphylococcus aureus), a gram-positive, immobile cocci with a grape-like or rarely small chain-like grouping.
According to the biochemical characteristics, a distinction is made between coagulase-positive staphylococci (SCP) and coagulase-negative staphylococci (SCN).
The different constituents of staphylococcus, namely the bacterial wall, exotoxins and exoenzymes, explain the pathogenic effects of staphylococcus. Thus, the staphylococcus has toxic, necrotic, dissemination and foreign material adhesion capacities.
To facilitate the diagnosis in infants, the combination of a general condition, respiratory signs and abdominal bloating in an infant is characteristic of pleuropulmonary staphylococcal disease and requires urgent hospital care.
Once the diagnosis of pleuropulmonary staphylococcal has been made, it is necessary to look for a cutaneous or mucous membrane entry point, which may be more than one month old, or for a staphylococcal focus in the surrounding environment, such as a breast abscess, panic attack, or other.
In newborns, however, the atypical clinical presentation makes clinical diagnosis very difficult.
For pleuropulmonary staphylococcal disease of non-hospital origin, Begue reports nearly 45% of resistant staphylococci in children in Togo and Saravolatz an increase from 3% to 38% between March 1980 and September 1981 [11].
The antibiotic therapy generally recommended combines: a penicillin M: Oxacillin or Meticillin at a rate of 150 to 200 mg/kg/day, the former having a lower minimum inhibitory concentration and causing fewer complications [12] [13] and an aminoglycoside.
From the 1980s onwards, this phenomenon of resistance accelerated, most markedly for strains of hospital origin, with percentages varying according to the nature of the services and the pathologies encountered [14], but exceeding 50% of staphylococcus aureus strains in most pediatric intensive care units [15] [16], and 60% to 74% of coagulase-negative staphylococcus strains [1] [17].
In the case of meticillin-resistant staphylococci, the most consistently active antibiotics are vancomycin [11] [18] [19] [20] [21] and rifampicin, whose minimal inhibitory concentration appears to be very low [18] [21] [22] [23] and whose tissue penetration is satisfactory [23].
The choice of antibiotic therapy is in any case based on the antibiogram of the germ and the study of the bactericidal power of the different combinations.
In our patient, the treatment was based on vancomycin for a period of 4 weeks in association with amikacin for 5 days with a good clinico-biological and radiological evolution.
The usual evolution was towards a cure without sequelae with normal respiratory function tests [24] [25] [26] [27], due to the resorption capacity of pachypleuritis in children [6] [28] [29].
The main prognostic factors found in the literature are: young age (the disease is more severe in the first 3 months of life), [6] [8], particularly in the first month with the risk of apnea [20], deterioration of the general condition on admission [9], leukopenia [5] [8] [20] [30] more than thrombocytopenia [9], absence of initial effective therapy on the strain in question [5] [8] [31] [32] [33] [34].
5. Conclusions
Pleuropulmonary staphylococcal disease in newborns is a rare condition with a variety of clinical and radiological presentations, and the prognosis in this age group remains poor.
The rapid increase in the percentage of meticillin-resistant strains is cause for concern, and the appropriateness of first-line antibiotic therapy with vancomycin and an aminoglycoside should be questioned.
The mortality of this disease remains high depending on the extent of the pulmonary lesions, hence the interest of an early and effective antibiotic therapy.