Copyright 2009 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.
Facial malignant staphylococcal infection is a rare infectious disorder characterized by a septic facial venous thrombosis. Herein we report the first case to our knowledge in a healthy young woman due to Panton-Valentine leukocidin (PVL)–positive Staphylococcus aureus.
A 20-year-old woman with no medical history was admitted for facial edema with high fever. She had been treated with amoxicillin plus clavulanic acid for 48 hours without efficacy. For a few days prior to presentation, she had a handled intranasal pock. Physical examination revealed significant inflammatory facial edema with periorbital predominance (Figure 1) and bilateral cervical adenopathies. Neurological and ophthalmological findings were normal.
Figure 1. Marked facial edema with predominance about the periorbital region, especially of the right eye (A) and total recovery after treatment (B).
Laboratory tests showed leukocytosis (white blood cell count, 15 200/μL [reference range, 4000-10 000/μL]) and an increased C-reactive protein serum concentration (170 mg/L [reference, <5 mg/L]). (To convert white blood cells to number of cells × 109 per liter, multiply by 0.001; to convert C-reactive protein to nanomoles per liter, multiply by 9.524.) Blood cultures and nasal swabs grew gram-positive cocci, which were identified as PVL-positive, methicillin-sensitive S aureus.
On computed tomography (CT), extended facial cellulitis was found with facial veins and right superior ophthalmic vein thrombosis (Figure 2). A transthoracic echocardiogram showed no abnormalities. The diagnosis of malignant staphylococcal infection of the face was confirmed. Intravenous penicillin M (100 mg/kg/d) was given for 3 weeks in combination with gentamicin (3 mg/kg/d) for the first 48 hours. Effective anticoagulation was maintained for 6 months until the venous thrombosis had completely disappeared.
Figure 2. Computed tomography images. A and B, Important infiltration of facial soft tissues and filling defects of the bilateral facial veins (arrow). C, Filling defects of the right superior ophthalmic vein (left arrow); the left superior ophthalmic vein is permeable (right arrow).
Malignant staphylococcal infection of the face is a rare but life-threatening Staphylococcus aureus septicemia. The death rate is around 20%.1 It corresponds to a septic facial vein thrombosis and commonly follows facial furuncle handling. The causal lesion is not always defined, as it was not in our patient. Onset is sudden and includes clinical status deterioration, high fever, and chills. Clinical examination shows an inflammatory purpuric facial edema with fast-spreading and severe pain. On account of cerebral venous thrombosis, careful neurologic and ophthalmologic examination is essential. The main complication is cavernous sinus thrombosis.
In the present case, the painful periorbital edema with fever and the ineffective 2-day large-dose antibiotic therapy prompted physicians to perform a CT scan looking for septic facial thrombosis. Magnetic resonance imaging is currently the gold standard for septic venous thrombosis diagnosis. Initially, thrombus is T2 hypointense and then T1 and T2 hyperintense1 with sinus broadening.
Our case is remarkable because it involved a virulent, community-acquired PVL-positive, methicillin-sensitive S aureus skin infection in a healthy young woman. Panton-Valentine leukocidin S aureus is responsible for recent outbreaks of severe invasive infections in young patients without substantial predisposing risk factors.2 In the United Kingdom, 4.9% of S aureus clinical diseases are PVL positive.3 Panton-Valentine leukocidin–positive S aureus is strongly associated with skin and soft-tissue infections such as abscesses, skin lesions, and boils (P < .001), but it is not statistically significantly associated with impetigo, blisters, and staphylococcal scalded skin syndrome.3
With regard to the thrombosis care, we did not perform thrombophilia exploration. Invasion of endothelial cells by S aureus is responsible for septic thrombosis.4
In conclusion, severe facial infection (painful palpebral edema with high fever, clinical state deterioration, and neurologic and ophthalmologic symptoms) must raise the diagnostic possibility of facial malignant staphylococcal infection. Intravenous antibiotic therapy combined with anticoagulation therapy must be started as early as possible.
Correspondence: Dr Bagot, Service de Dermatologie, Hôpital Henri Mondor, 51 avenue Maréchal de Lattre de Tassigny, 94010 Créteil, France (martine.bagot@hmn.aphp.fr).
Financial Disclosure: None reported.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
Instructions
Comments are moderated and will appear on the site at the discretion of the Archives of Dermatology editors. Comments should not exceed 500 words of text and 10 references.
Do not submit personal medical questions or information that could identify a specific patient, questions about a particular case, or general inquiries to an author. Only content that has not been published, posted, or submitted elsewhere should be submitted. By submitting this Comment, you and any coauthors transfer copyright to the journal if your Comment is posted.
* = Required Field
Disclosure of Any Conflicts of Interest* Indicate all relevant conflicts of interest of each author below, including all relevant financial interests, activities, and relationships within the past 3 years including, but not limited to, employment, affiliation, grants or funding, consultancies, honoraria or payment, speakers’ bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. If all authors have none, check "No potential conflicts or relevant financial interests" in the box below. Please also indicate any funding received in support of this work. The information will be posted with your response.
Register and get free email Table of Contents alerts, saved searches, PowerPoint downloads, CME quizzes, and more
Subscribe for full-text access to content from 1998 forward and a host of useful features
Activate your current subscription (AMA members and current subscribers)
Some tools below are only available to our subscribers or users with an online account.
Download citation file:
Customize your page view by dragging & repositioning the boxes below.
and access these and other features:
Register Now
Enter your username and email address. We'll send you a reminder to the email address on record.
Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.