Community-acquired MRSA epiduritis in an Australian prison inmate

To the Editor: Community-acquired methicillin-resistant Staphylococcus aureus (CAMRSA) infection is an increasingly recognised cause of skin and soft tissue infection, as well as more serious manifestations, including necrotising pneumonia, endocarditis, osteomyelitis and severe sepsis.1,2 We report another serious manifestation of CAMRSA infection.

A 24-year-old Australian-born white, HIV-negative, male prison inmate was transferred to hospital. He had previously injected drugs, but not for more than 2 years. He reported a 10-day history of cervical neck pain, left-sided pleuritic chest pain and a 2-cm occipital carbuncle, which developed after a laceration on the scalp from a close haircut with barber’s shears.

Examination revealed a temperature of 37.9°C, sinus tachycardia, profound neck stiffness and signs of left basal consolidation with a left pleural effusion. There were no focal neurological signs or other signs of meningism. Investigations revealed a neutrophil leukocytosis of 22.7 × 109/L (reference range, 1.7–7.0 × 109/L) with mild elevation of hepatic transaminases and hypoalbuminaemia.

CAMRSA was isolated from blood cultures and a swab of the occipital carbuncle. The organism was susceptible to erythromycin, vancomycin, rifampicin and fusidic acid.

A chest radiograph showed extensive left-sided consolidation consistent with pneumonia. A magnetic resonance imaging scan of the entire spine revealed asymmetric thickening and enhancement of the epidural tissue from C2 to C5, with no discrete abscess, osteomyelitis or discitis.

The patient made a full recovery after 4 weeks of intravenous therapy with vancomycin (1 g every 12 hours) and clindamycin (600 mg every 6 hours).

This is the first reported case of epidural tissue infection (epiduritis) caused by CAMRSA, and adds to the spectrum of potential clinical manifestations. In addition, this is the first reported case of CAMRSA infection occurring in an Australian prison inmate. There have been several reported outbreaks of CAMRSA in US correctional facilities.3,4 Although no similar outbreaks have been described in Australia, clinicians should be aware that correctional facilities may contribute to the spread of CAMRSA.

The most common manifestations of CAMRSA infection in the prison setting in the United States are skin and soft tissue infections, with invasive infection occurring in 1.7% of patients.4

Clinicians providing care to inmates should be aware that strategies have been identified to reduce the incidence of CAMRSA infection.5 Clinicians need to be aware of the increasing incidence of CAMRSA infection, the diverse and potentially severe manifestations, and the treatment and preventive strategies available.