prompt multidisciplinary management of hand infections is essential to prevent stiffness , loss of function and long - term disability . although hand infections are relatively common in young patients particularly males engaged in sports , recurrent hand infections are not .
panton - valentine leukocidin ( pvl ) is a toxin produced by some strains of s. aureus and usually implicated in skin and soft tissue infections .
it can also cause invasive infections , in particular haemorrhagic pneumonia . to date , there is only one previous case describing recurrent hand infections associated with panton - valentine leukocidin - positive staphylococcus aureus ( pvl - sa ) .
this case highlights the need for multidisciplinary management of these patients as the diagnosis of pvl - sa may have been missed with potentially devastating consequences .
a 25-year - old right - hand dominant male warehouse operative presented to the emergency department ( ed ) with a three - day history of redness , pain and swelling in the right palm .
he removed a wooden splinter from the palmar aspect of the metacarpophalangeal joint of his right middle finger 24 h before the symptom onset . in his past medical history , he had childhood - onset eczema and recalled always having  cracked hands 
he was not currently managing his eczema with medical therapy but described several flare - ups of his eczema since childhood . 

there was no recent history of skin and soft tissue infection in his household contacts .
he was on noregular medications , had no allergies and smoked 10 cigarettes a day . on examination ,
his temperature was 37.5c and he had tenderness , swelling and overlying erythema localised to his palm and extending to the proximal interphalangeal joint of his middle finger .
admission blood tests showed a serum white cell count of 10.71    10/l ( reference range 3.510.5    10/l ) and c - reactive protein of 14.1  mg /
specimens cultured methicillin susceptible s. aureus ( mssa ) for which he completed a 14-day course of intravenous flucloxacillin 1  g qds . following surgical drainage the wound was left open and dressed daily with bethidine wicks .
twelve weeks later he represented to his general practitioner ( gp ) with a four - day history of increasing pain , redness and swelling over his dorsal left wrist .
he was referred to the ed 48 h later when he failed to respond to oral flucloxacillin . on examination he had a 3    3  cm fluctuant swelling over his dorsal wrist with surrounding cellulitis ( figure 2a ) .
g / l and c - reactive protein of 57.8  mg / l . 
 figure 2.(a ) patient s second presentation with abscess dorsal left wrist and surrounding erythema .
( a ) patient s second presentation with abscess dorsal left wrist and surrounding erythema .
further investigations were requested in the context of a recurrent infection in a healthy , young patient .
these included an oral glucose tolerance test , a mantoux test , serum hiv antibodies , immunoglobulin levels , complement levels , antibodies to atypical infections and a transesophageal echocardiogram .
similar to his previous admission , he required incision and drainage of the abscess followed by daily bethidine wick dressings ( figure 2b ) . on this occasion pus
was sent to the national methicillin resistant s. aureus ( mrsa ) reference laboratory and was reported positive for pvl - sa .
the patient completed a 10-day course of intravenous flucloxacillin 1 g qds with five days of clindamycin 600  mg qds for anti - toxin cover .
a decolonization regimen of five days 4% chlorhexidine wash and intranasal mupirocin was prescribed once his wounds had fully healed .
he was advised not to share bedding or towels and the same decolonisation regimen was advised for his household contacts .
he was discharged following completion of antibiotic therapy and followed - up in the outpatient clinic ( figure 3 ) .
pvl is a cytotoxin produced by 5% of staphylococci ( both mssa and mrsa ) .
it primarily occurs sporadically in young healthy patients and as a consequence can be missed .
although , predominately detected in isolates causing skin and soft tissue infections , pvl - sa strains can become invasive leading to necrotising fasciitis , purpura fulminans and necrotising pneumonia with a high mortality rate ; up to 75% in necrotising pneumonia despite medical treatment .
pvl - sa infections are thought to be more highly transmissible than pvl - negative infections .
healthcare workers , contact sports players and closed communities are considered as high - risk groups for transmission .
pvl - sa infections have been described since the 1930s , but within the last decade their incidence in the community is rapidly increasing .
although surveillance and improved case recognition may have contributed , this rapid increase is of growing international concern . in the united states ,
mrsa isolates increased from 24% to 54% and mssa isolates overall increased from 9% to 12% . in ireland , an increased prevalence of pvl - positive mrsa ( from 0.2% to 8.8% ) and a decrease in pvl - positive mssa ( from 20% to 2.5% ) from 2004 to 2011 have been reported .
this contrasts to uk where pvl - positive mrsa infections are rare ( 0.8% of all isolates ) but pvl - positive mssa are more common ( 9.0% of all specimens ) .
mssa isolates are not routinely referred to the reference laboratory for analysis in ireland , which may partially explain these discrepancies . to date , one case of recurrent pvl - sa hand abscesses has been reported in the literature . in 2013 ,
described a pvl - sa right palmar abscess in a healthy 24-year - old who developed a second abscess six weeks later in the contralateral palm .
although pvl - positive mrsa was identified , the age , immune status and clinical course were comparable to this case .
similar to wearn et  al . , we consider our patient 's second presentation to be a recurrence of pvl - sa . following
the initial infection he likely remained colonised with pvl - sa and his eczematous skin then facilitated further entry of pvl - sa with development of the second abscess .
in addition to appropriate surgical and antibiotic management of this infection , management of his underlying skin condition , patient education regarding appropriate hygiene and decolonisation of the patient and his contacts facilitated prevention of a further recurrence .
clinical suspicion of pvl production is key and if suspected , advice should be sought from the clinical microbiological service regarding patient management and referral of positive specimens to a reference laboratory for pvl testing .
the recommended management of pvl - sa infection includes treatment of infection ( abscess drainage and antibiotic therapy ) , decolonisation of the index patient , increased individual ( covering wounds and hand hygiene ) and environmental hygiene and appropriate management of close contacts .
the main strategy to prevent reinfection with or transmission of pvl - sa is stringent hygiene combined with decolonisation treatment . in this case guidance from the centers for disease control and prevention
it refers to the  five cs  of risk factors for pvl - related infection : contaminated items , close contact , crowding , cleanliness , and cuts and compromised skin integrity .
particular emphasis was placed on the management of our patient s eczema to optimise skin integrity .
health protection agency ( hpa ) guidelines recommend that all patients and their close contacts undergo decolonisation ( chlorhexidine wash 4% with intranasal mupirocin ) , although internationally there is no consensus on this approach .
this relates to individual countries testing policies for the pvl toxin . in the uk where cases are considered rare and severe ,
testing is recommended as it is an aggressive approach to treatment including decolonisation . despite these published guidelines , risk factors and recommendations to prevent recurrence
recurrent primary hand abscesses in the young , healthy patient are uncommon and should raise suspicion of an underlying condition , atypical infection or pvl - sa .
prompt multidisciplinary management of these infections is needed to prevent stiffness , loss of function and long - term disability .
the authors report no conflicts of interest . the authors alone are responsible for the content and writing of this article .
 a 25-year - old male right - hand dominant warehouse operator presented with two hand infections within 12 weeks both requiring surgical drainage and antimicrobial therapy . 
 subsequent testing confirmed panton - valentine leukocidin - positive staphylococcus aureus ( pvl - sa ) . 
 this case highlights the need for prompt multidisciplinary management of hand infections to consider , diagnose and manage atypical infections . 