Prostatic abscesses and severe sepsis due to methicillin-susceptible Staphylococcus aureusproducing Panton-Valentine leukocidin
© Dubos et al.; licensee BioMed Central Ltd. 2014
Received: 4 June 2014
Accepted: 19 August 2014
Published: 27 August 2014
Prostatic abscesses are an uncommon disease usually caused by enterobacteria. They mostly occur in immunodeficient patients. It is thus extremely rare to have a Staphylococcal prostatic abscess in a young immunocompetent patient.
A 20-year-old patient was treated with ofloxacin for a suspicion of prostatitis. An ultrasonography was performed because of persisting symptoms and showed acute urinary retention and prostatic abscesses. So the empirical antibiotic therapy was modified with ceftriaxone/amikacin. The disease worsened to severe sepsis and the patient was admitted in ICU. CT-scan and MRI confirmed three abscesses with perirectal infiltration and the bacteriological samples (abscesses and blood cultures) were positive to methicillin-susceptible Staphylococcus aureus producing Panton-Valentine leukocidine. The treatment was changed with fosfomycin/ofloxacin which resulted in a general improvement and the regression of the abscesses.
Staphyloccocus aureus producing Panton-Valentine leukocidin are most commonly responsible for skin and soft tissue infections. To this day, no other case of prostatic abscess due to this strain but susceptible to methicillin has been described.
KeywordsProstatic abscess Staphylococcus aureus Panton-valentine leukocidin Severe sepsis
Prostatic abscesses have become uncommon and their incidence has dropped since the introduction of antibiotics . They are mostly due to enterobacteria, especially Escherichia coli. Sometimes Staphylococcus aureus is involved  and most of the cases are due to methicillin-resistant strains in patients with immunodeficiency risk factors. These patients generally present with chronic or subacute infections which rarely progress into severe sepsis or septic shock. Some Staphylococcus aureus strains can produce Panton-Valentine leukocidin (PVL), this toxin being a virulence factor. We present here a case of prostatic abscesses due to methicillin-susceptible Staphylococcus aureus (MSSA) producing PVL in an immunocompetent patient.
Evaluation for an oropharyngeal and nasal Staphylococcus aureus carriage realised by swab on day 17 was negative.
Discussion and conclusions
Prostatic abscesses have become rare since the onset of antibiotics and are found in 0.5 to 2.5% of patients with a prostate inflammation . They mostly occur in patients with local risk factors (urine retention, indwelling urethral catheter, chronic prostatitis…) or immunodeficiency risk factors .
The gold-standard for prostatic abscesses diagnostic is still transrectal ultrasonography [5, 6]. It allows a needle aspiration which is used to confirm the diagnostic and identify the microorganism involved . CT-scan and MRI are useful to assess extension around the prostate or to look for remote focuses .
The most common etiologic agent is Escherichia coli but Staphylococcus aureus is often associated with prostatic abscesses . Several cases of prostatic abscesses due to community-acquired methicillin-resistant Staphylococcus aureus (MRSA) have been reported in the literature [9–12]. In our case, the etiologic agent was MSSA producing PVL. Prevalence of Staphylococcus aureus producing PVL seems to have increased for several years: in 1995, Prevost et al. study reported 5% of strains in Western Europe  whereas in 2012, 36% of strains producing PVL were reported in the United-States . This statement is particularly true for the USA. In Europe, it is unclear whether the prevalence has truly increased or if it is due to increased ascertainement. Moreover, in Europe, there is clonal heterogeneity . In the USA, there is a strong association between strains producing PVL and MRSA . In Europe, Australia and Africa, there is a high proportion of MSSA producing PVL [16–19]. In our case the strain producing PVL was susceptible to methicillin. MSSA strains producing PVL are often from the clonal complex CC121, ST 121 [20, 21].
The PVL is a synergohymenotropic toxin that acts through the association of two components F and S. It destroys cells by creating pores in the membrane  and is responsible for leukocyte and macrophage destruction and tissue necrosis. Its role in the pathogenesis and the spreading of infections is still unclear . Strains producing PVL are usually linked with skin infections such as furuncles and abscesses, with necrotising pneumonia  and with bone and joint infections  that mostly occur in healthy children and young adults.
PVL may contribute to the infection severity and be a virulence factor. This could explain that our patient presented with severe sepsis. Studies conducted in animals showed that PVL led to the persistence of infection and made its local extension easier . Other studies highlighted a higher frequency of hemoptysis, general signs (tachycardia, low blood pressure, polypnea and cyanosis) and deaths in pneumonia caused by Staphylococcus aureus producing PVL, which illustrates the virulence of the toxin . In 2013, Shallcross et al. showed in a meta-analysis that infections were most likely to recur and surgery performed more often in skin and soft tissue infections caused by strains producing PVL . Of note, the patient had a history of repetitive furuncles for a year and a half which could be linked with recurrence. To our knowledge, this is the first case of prostatic abscess due to Staphylococcus aureus producing PVL with the toxin possibly responsible for the severe sepsis.
Prostatic abscesses treatment usually includes an antibiotic therapy adapted to the microorganism and drainage of the abscess. Ultrasound-guided transrectal needle aspiration must be preferred to surgical drainage or transurethral prostatic resection as the needle path is shorter and the tolerance rate higher . The antibiotic treatment aims at eradicating Staphylococcus aureus but it must also decrease the toxin effects. In 2008, a study evidenced the ability of linezolid, clindamycin and rifampicin to inhibit PVL production .
Prostatic abscesses must be searched for in all patients presenting with prostatitis symptoms associated with abdominal pain. A Staphylococcus aureus origin must be suspected if the disease worsens and develops to severe sepsis despite an adapted antibiotic therapy, especially in a young subject. Moreover, if this pathogen producing PVL is discovered, an antibiotic therapy including toxin inhibition must be started.
Written informed consent was obtained from the patient for publication of this case report and of the images associated. A copy of the written consent is available for review by the Editor of this journal.
Human immunodeficiency virus
Intensive care unit
Magnetic resonance imaging
Methicillin-resistant Staphylococcus aureus
Methicillin-susceptible Staphylococcus aureus
Polymerase chain reaction
We thank Sarah Demai who provided medical writing services.
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