Fulminant Soft Tissue Infection with Intestinal Ischemia Associated with Staphylococcus lugdunensis

Staphylococcus lugdunensis (S. lugdunensis), first discovered in 1988,1 has been implicated in skin and soft tissue, heart valve, and joint infections. However, necrotizing soft tissue infections due to S. lugdunensis are rarely reported. We describe a life-threatening soft tissue infection due to S. lugdunensis associated with septic shock and intestinal ischemia in a healthy male. A 36-year-old male with no significant past medical history presented to the emergency room with abdominal pain, diarrhea, nausea, and vomiting in the past 24 hours. He had no sick contacts or recent antibiotic use. He reported swimming in a pond a few days before presentation, but a review of systems was otherwise unremarkable. On initial evaluation, he had a temperature of 98.2 °F, pulse of 96/min, respiratory rate of 18/min, and blood pressure of 144/94 mmHg with oxygen saturation of 99 per cent on room air. His abdomen was soft, nondistended with tenderness in the right lower quadrant without any rebound or guarding. Otherwise, his physical examination was unremarkable. Body mass index was 42. Blood serum analysis was significant for the following: sodium 131 meq/L, bicarbonate 16.6 meq/L, blood urea nitrogen 15 mg/dL, creatinine 1.93 mg/dL, glucose 309 mg/dL, serum lactate 5.4 mEq/L, hemoglobin 13.5 g/dL, and white blood cell count 2800/mm with 33 per cent neutrophils. Initial CT of his abdomen and pelvis showed evidence of inflammation around the ileocecal area without pneumatosis or extraluminal air. The patient was started on antibiotics and aggressively hydrated. After a few hours of observation, he developed septic shock, requiring endotracheal intubation and vasopressor support. Repeat CT scan of the chest, abdomen, and pelvis was performed, which revealed extraluminal air around the ileocecal junction as well as new subcutaneous emphysema of the left shoulder and axilla (Fig. 1). Urgent laparotomy was performed which showed diffuse bowel and liver ischemia, and infarction of the terminal ileum and ascending colon. A right hemicolectomy was performed with patient left in bowel discontinuity. The acute care surgery service was consulted regarding the left shoulder findings. On examination, there was no crepitus or edema but very subtle skin mottling over the anterior left shoulder. The left axilla and chest wall were explored through infraclavicular and transverse left chest wall incisions (Fig. 2). There was significant seropurulent fluid and air tracking along the fascial planes of the pectoralis, serratus anterior, intercostal muscles, and the subscapular muscles. However, all muscle and fascia were viable and extensive debridement was not needed after wide drainage. The orthopedic consultant felt that the left shoulder was not the source of this infection and no aspiration or drainage of the left shoulder was needed. Final intraoperative cultures were positive for Staphylococcus epidermidis and S. lugdunensis. His hospital course was complicated by multiorgan system dysfunction requiring hemodialysis, but he recovered and was discharged on hospital day 65. Staphylococcus lugdunensis is an unusually virulent coagulase-negative staphylococcus first described in 1988 by Freney et al.1 It has been implicated in skin and soft tissue, valve, ocular, bone and joint, and central nervous system infections, often associated with implanted medical devices and postoperative infections.2 Previously misidentified as Staphylococcus aureus because of production of a clumping factor that yields a positive result in slide coagulase or rapid latex agglutination tests, other techniques have enabled differentiation between S. lugdunensis and S. aureus using the tube coagulase test, and testing for the presence of ornithine decarboxylase and pyrrolidonyl arylamidase.2 A real-time polymerase Presented as a poster at the Southeastern Surgical Congress 2018 Annual Meeting, February 10–13, 2018, Tampa, FL. Address correspondence and reprint requests to Adrian Ong, M.D., Department of Surgery, Reading Hospital, 420 5th Avenue, West Reading, PA 19611. E-mail: Adrian.ong@towerhealth.org.