Emergence of Panton-Valentine leukocidin-positive ST59 methicillin-susceptible Staphylococcus aureus with high cytolytic peptide expression in association with community-acquired pediatric osteomyelitis complicated by pulmonary embolism

A 15-year-old boy, who had had a furuncle on his femur, developed femoral pyomyositis and osteomyelitis complicated by septic pulmonary embolism. Panton-Valentine leukocidin-positive (PVL + ) ST59 methicillin-susceptible Staphylococcus aureus (MSSA) was isolated from pus and blood. Chemotherapy was started with cefazolin, followed by combination therapy with meropenem/vancomycin with surgery. The MSSA (strain KS1) was positive for increased levels of cytolytic peptide ( psmα and hld ) and staphylococcal enterotoxin B (SEB), and manifested IS 1216V -mediated multidrug resistance (to erythromycin, clindamycin, kanamycin, streptomycin, and chloramphenicol), similar to a genome-analyzed reference strain (PM1) of ST59/SCC mec V(5C2&5) community-associated methicillin-resistant S. aureus (Taiwan CA-MRSA), but unlike another reference strain (M013) of Taiwan CA-MRSA in terms of resistance. The data suggest that CA-MSSA KS1, characterized by PVL, increased levels of cytolytic peptide, SEB, and multidrug resistance, is a possible ancestral strain of Taiwan CA-MRSA and causes the unique association of osteomyelitis and septic pulmonary embolism, requiring complicated management.