array:23 [
  "pii" => "S1413867022004305"
  "issn" => "14138670"
  "doi" => "10.1016/j.bjid.2022.102737"
  "estado" => "S300"
  "fechaPublicacion" => "2023-03-01"
  "aid" => "102737"
  "copyright" => "Sociedade Brasileira de Infectologia"
  "copyrightAnyo" => "2023"
  "documento" => "article"
  "crossmark" => 1
  "subdocumento" => "crp"
  "cita" => "Braz J Infect Dis. 2023;27:"
  "abierto" => array:3 [
    "ES" => true
    "ES2" => true
    "LATM" => true
  ]
  "gratuito" => true
  "lecturas" => array:1 [
    "total" => 0
  ]
  "itemSiguiente" => array:18 [
    "pii" => "S141386702300003X"
    "issn" => "14138670"
    "doi" => "10.1016/j.bjid.2023.102742"
    "estado" => "S300"
    "fechaPublicacion" => "2023-03-01"
    "aid" => "102742"
    "copyright" => "Sociedade Brasileira de Infectologia"
    "documento" => "article"
    "crossmark" => 1
    "subdocumento" => "crp"
    "cita" => "Braz J Infect Dis. 2023;27:"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:1 [
      "total" => 0
    ]
    "en" => array:10 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Case Report</span>"
      "titulo" => "Pediatric case of septic arthritis due to <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> serotype 19A"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => "en"
      "contieneResumen" => array:1 [
        "en" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Preslava M&#46; Hristova, Hristina Y&#46; Hitkova, Nikolay K&#46; Balgaranov, Raina &#1058;&#46; Gergova, Alexandra S&#46; Alexandrova"
          "autores" => array:5 [
            0 => array:2 [
              "nombre" => "Preslava M&#46;"
              "apellidos" => "Hristova"
            ]
            1 => array:2 [
              "nombre" => "Hristina Y&#46;"
              "apellidos" => "Hitkova"
            ]
            2 => array:2 [
              "nombre" => "Nikolay K&#46;"
              "apellidos" => "Balgaranov"
            ]
            3 => array:2 [
              "nombre" => "Raina &#1058;&#46;"
              "apellidos" => "Gergova"
            ]
            4 => array:2 [
              "nombre" => "Alexandra S&#46;"
              "apellidos" => "Alexandrova"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S141386702300003X?idApp=UINPBA00003Y"
    "url" => "/14138670/0000002700000002/v3_202304071918/S141386702300003X/v3_202304071918/en/main.assets"
  ]
  "itemAnterior" => array:18 [
    "pii" => "S1413867023000041"
    "issn" => "14138670"
    "doi" => "10.1016/j.bjid.2023.102743"
    "estado" => "S300"
    "fechaPublicacion" => "2023-03-01"
    "aid" => "102743"
    "copyright" => "Sociedade Brasileira de Infectologia"
    "documento" => "article"
    "crossmark" => 1
    "subdocumento" => "rev"
    "cita" => "Braz J Infect Dis. 2023;27:"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:1 [
      "total" => 0
    ]
    "en" => array:11 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Review Article</span>"
      "titulo" => "Epoxy-&#945;-lapachone &#40;2&#44;2-Dimethyl-3&#44;4-dihydro-spiro&#91;2H-naphtho&#91;2&#44;3-b&#93;pyran-10&#44;2&#8242;-oxirane&#93;-5&#40;10H&#41;-one&#41;&#58; a promising molecule to control infections caused by protozoan parasites"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => "en"
      "contieneResumen" => array:1 [
        "en" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:8 [
          "identificador" => "fig0002"
          "etiqueta" => "Fig&#46; 2"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr2.jpeg"
              "Alto" => 916
              "Ancho" => 2000
              "Tamanyo" => 136105
            ]
          ]
          "detalles" => array:1 [
            0 => array:3 [
              "identificador" => "alt0002"
              "detalle" => "Fig "
              "rol" => "short"
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spara002" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Predicted epoxy-&#945;-lapachone regions interactions with amino acid residues of the active site of trypanosomatid proteases&#46;</span> Epoxy-&#945;-lapachone &#40;2&#44;3-Dihydro-3&#44;3-dimethylspiro&#91;1H-4-oxanthracene-5&#44;2&#8242;-oxiran&#93;&#8722;10&#40;5H&#41;-one&#41; is formed by an aromatic ring &#40;A&#41;&#44; a central six-membered ring &#40;B&#41; and a ring with two methyl groups &#40;C&#41;&#46; The chiral center being the C12 atom&#44; which is also part of the three-membered epoxide ring&#46;<a class="elsevierStyleCrossRef" href="#bib0044"><span class="elsevierStyleSup">44</span></a> CID&#58; 12&#44;000&#44;280&#59; molecular formula&#58;C<span class="elsevierStyleInf">16</span>H<span class="elsevierStyleInf">16</span>O<span class="elsevierStyleInf">3</span> and molecular mass&#58; 256&#46;3&#160;g&#47;mol&#46; Epoxy-&#945;-lapachone regions interactions with amino acid residues of cysteine-proteinase &#40;green&#41; of <span class="elsevierStyleItalic">Trypanosoma cruzi</span><a class="elsevierStyleCrossRef" href="#bib0048"><span class="elsevierStyleSup">48</span></a> and serine-proteinase &#40;orange&#41; of <span class="elsevierStyleItalic">Leishmania</span> &#40;<span class="elsevierStyleItalic">Leishmania</span>&#41; <span class="elsevierStyleItalic">amazonensis</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">50</span></a></p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Juliana Figueiredo Peixoto, Adriane da Silva Oliveira, Luiz Filipe Gon&#231;alves - Oliveira, Franklin Souza - Silva, Carlos Roberto Alves"
          "autores" => array:5 [
            0 => array:2 [
              "nombre" => "Juliana Figueiredo"
              "apellidos" => "Peixoto"
            ]
            1 => array:2 [
              "nombre" => "Adriane da Silva"
              "apellidos" => "Oliveira"
            ]
            2 => array:2 [
              "nombre" => "Luiz Filipe"
              "apellidos" => "Gon&#231;alves - Oliveira"
            ]
            3 => array:2 [
              "nombre" => "Franklin"
              "apellidos" => "Souza - Silva"
            ]
            4 => array:2 [
              "nombre" => "Carlos Roberto"
              "apellidos" => "Alves"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1413867023000041?idApp=UINPBA00003Y"
    "url" => "/14138670/0000002700000002/v3_202304071918/S1413867023000041/v3_202304071918/en/main.assets"
  ]
  "en" => array:19 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Case Report</span>"
    "titulo" => "Systemic infection caused by the methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> USA300-LV lineage in a Brazilian child previously colonized"
    "tieneTextoCompleto" => true
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "Carolina de Oliveira Whitaker, Raiane Cardoso Chamon, Tamara Lopes Rocha de Oliveira, Simone Aranha Nou&#233;r, K&#225;tia Regina Netto dos Santos"
        "autores" => array:5 [
          0 => array:3 [
            "nombre" => "Carolina de Oliveira"
            "apellidos" => "Whitaker"
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0001"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">1</span>"
                "identificador" => "fn1"
              ]
            ]
          ]
          1 => array:4 [
            "nombre" => "Raiane Cardoso"
            "apellidos" => "Chamon"
            "email" => array:1 [
              0 => "raianechamon@id.uff.br"
            ]
            "referencia" => array:4 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0002"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">c</span>"
                "identificador" => "aff0003"
              ]
              2 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">1</span>"
                "identificador" => "fn1"
              ]
              3 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "cor0001"
              ]
            ]
          ]
          2 => array:3 [
            "nombre" => "Tamara Lopes Rocha"
            "apellidos" => "de Oliveira"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0001"
              ]
            ]
          ]
          3 => array:3 [
            "nombre" => "Simone Aranha"
            "apellidos" => "Nou&#233;r"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">d</span>"
                "identificador" => "aff0004"
              ]
            ]
          ]
          4 => array:3 [
            "nombre" => "K&#225;tia Regina Netto"
            "apellidos" => "dos Santos"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0001"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:4 [
          0 => array:3 [
            "entidad" => "Universidade Federal do Rio de Janeiro&#44; Instituto de Microbiologia Paulo de G&#243;es&#44; Departamento de Microbiologia M&#233;dica&#44; Laborat&#243;rio de Infec&#231;&#227;o Hospitalar&#44; Rio de Janeiro&#44; RJ&#44; Brazil"
            "etiqueta" => "a"
            "identificador" => "aff0001"
          ]
          1 => array:3 [
            "entidad" => "Universidade Federal Fluminense&#44; Faculdade de Medicina&#44; Departamento de Patologia&#44; Niter&#243;i&#44; RJ&#44; Brazil"
            "etiqueta" => "b"
            "identificador" => "aff0002"
          ]
          2 => array:3 [
            "entidad" => "Universidade Federal Fluminense&#44; Hospital Universit&#225;rio Ant&#244;nio Pedro&#44; Unidade de Pesquisa Cl&#237;nica&#44; Laborat&#243;rio de Microbiologia&#44; Niter&#243;i&#44; RJ&#44; Brazil"
            "etiqueta" => "c"
            "identificador" => "aff0003"
          ]
          3 => array:3 [
            "entidad" => "Universidade Federal do Rio de Janeiro&#44; Hospital Universit&#225;rio Clementino Fraga Filho&#44; Faculdade de Medicina&#44; Rio de Janeiro&#44; RJ&#44; Brazil"
            "etiqueta" => "d"
            "identificador" => "aff0004"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0001"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "resumenGrafico" => array:2 [
      "original" => 0
      "multimedia" => array:8 [
        "identificador" => "fig0001"
        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1438
            "Ancho" => 1667
            "Tamanyo" => 216756
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "alt0001"
            "detalle" => "Fig "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spara001" class="elsevierStyleSimplePara elsevierViewall">Computed tomography &#40;CT&#41; of the abdomen&#46;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0001" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0003">Introduction</span><p id="para0002" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Staphylococcus aureus</span> colonizes about 30&#37; of human nares&#46; Such colonization is an important source of person-to-person bacterial transmission&#44; especially in low socioeconomic status communities&#44; characterized by a large number of subnormal agglomerates&#46;<a class="elsevierStyleCrossRef" href="#bib0001"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0002"><span class="elsevierStyleSup">2</span></a> Recent studies have proposed that previous nasal colonization with methicillin-resistant <span class="elsevierStyleItalic">S&#46; aureus</span> &#40;MRSA&#41; strains could increase the risk of a subsequent staphylococcal infection&#44; such as skin and soft tissue infections &#40;SSTI&#41;&#44; pneumonia&#44; osteomyelitis&#44; bloodstream infections &#40;BSI&#41; and endocarditis&#46;<a class="elsevierStyleCrossRef" href="#bib0001"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a></p><p id="para0003" class="elsevierStylePara elsevierViewall">Community-associated MRSA &#40;CA-MRSA&#41; USA300&#47;ST8&#47;SCC<span class="elsevierStyleItalic">mec</span>IVa strains are considered epidemic and widely disseminated in North America as a causative agent of SSTI&#46;<a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a> In general&#44; CA-MRSA strains are known for their ability to carry a wide range of virulence determinants&#44; such as the Panton-Valentine leucocidin &#40;PVL&#41; gene &#40;<span class="elsevierStyleItalic">pvl</span>&#41;&#44; which has been associated with invasive and severe diseases&#44; particularly in children&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a> However&#44; differently from North America&#44; a USA300-related genetic lineage &#40;designated USA300 Latin American variant &#91;USA300-LV&#93;&#41; emerged and has become epidemic in countries of the northern region of South America&#44; such as Colombia&#44; Venezuela&#44; and Ecuador&#44; as the causative agents of bloodstream infections&#46; It has replaced the hospital-associated MRSA clone designated &#8220;Chilean&#47;Cordobes&#8221;&#46;<a class="elsevierStyleCrossRefs" href="#bib0006"><span class="elsevierStyleSup">6&#8211;9</span></a> The first description of USA300-LV was in 2009 in a prospective multicenter study that aimed to evaluate the molecular epidemiology of MRSA isolates recovered from 32 high-level care hospitals distributed in four Latin American countries in 2006 and 2008&#46;<a class="elsevierStyleCrossRef" href="#bib0009"><span class="elsevierStyleSup">9</span></a> Similarly to other CA-MRSA strains&#44; USA300-LV isolates can harbor the PVL gene&#59; however&#44; unlikely USA300&#47;ST8&#47;SCC<span class="elsevierStyleItalic">mec</span>IVa&#44; the USA300-LV lacks the arginine catabolic mobile island element &#40;ACME&#41;&#44; and most USA300-LV isolates carry different variants of type IV methicillin resistance cassette&#46;<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0009"><span class="elsevierStyleSup">9</span></a></p><p id="para0004" class="elsevierStylePara elsevierViewall">In Rio de Janeiro&#44; Brazil&#44; hospital-associated MRSA &#40;HA-MRSA&#41; USA100&#47;ST5&#47;SCC<span class="elsevierStyleItalic">mec</span>II and CA-MRSA USA1100&#47;ST30&#47;SCC<span class="elsevierStyleItalic">mec</span>IV lineages are frequently associated with BSI and SSTI&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">10</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0011"><span class="elsevierStyleSup">11</span></a> However&#44; in this study&#44; we aimed to describe for the first time in Brazil the occurrence of a systemic infection caused by a CA-MRSA isolate belonging to the <span class="elsevierStyleItalic">pvl</span>-positive USA300-LV&#47;SCC<span class="elsevierStyleItalic">mec</span>IVd&#47;t008 lineage in the nares of a Brazilian 15-year-old boy colonized by the same MRSA strain&#46;</p></span><span id="sec0002" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0004">Case report</span><p id="para0005" class="elsevierStylePara elsevierViewall">On October 19<span class="elsevierStyleSup">th</span>&#44; 2019&#44; a 15-year-old boy from a low-income neighborhood of Rio de Janeiro&#44; with no previous history of travel outside Brazil and with no comorbidity&#44; entered a Brazilian university hospital with a two-week history of lumbar pain and polyarthralgia after a body trauma during a soccer game&#46; Upon admission&#44; the patient was febrile and presented edema&#44; redness&#44; and heat in right elbow and left shoulder&#44; suggesting a disseminated and complicated <span class="elsevierStyleItalic">S&#46; aureus</span> SSTI&#46; Computed tomography &#40;CT&#41; of the abdomen evidenced an extensive abscess in left psoas &#40;<a class="elsevierStyleCrossRef" href="#fig0001">Fig&#46; 1</a>&#41; and peripheral pulmonary embolic lesions&#44; with no documentation of endocarditis in the transesophageal echocardiogram&#46; Also&#44; a magnetic resonance imaging &#40;MRI&#41; of the spine showed a posterior compression from L2 to S2&#44; which was suggestive of a subdural empyema in the sacral region extending to the lumbar spine&#46; A screening nasal swab for MRSA colonization was performed&#44; and blood was drawn&#46; Antimicrobial therapy began immediately&#46; Only in the eleventh day of hospitalization the infection was controlled&#44; with clinical improvement and serial negative blood cultures&#46; The patient received intravenous vancomycin &#40;15-20 mg&#47;kg&#47;day depending on serum levels of vancomycin&#41;&#44; followed by daptomycin &#40;10-12 mg&#47;kg&#47;day&#41;&#44; switching to oral sulfamethoxazole&#47;trimethoprim &#40;400&#47;80 mg&#47;q 6 h&#41; up to six months&#46;</p><elsevierMultimedia ident="fig0001"></elsevierMultimedia><p id="para0006" class="elsevierStylePara elsevierViewall">All blood cultures were processed using the automated BactAlert system &#40;BioMerieux&#44; Durham&#44; NC&#44; USA&#41;&#46; After determining positivity&#44; blood was cultured on sheep blood agar &#40;Plast Labor&#44; Rio de Janeiro&#44; Brazil&#41; for 24 hours with incubation at 37&#176; C&#44; in addition to abscess drainage collection&#46; Bacterial colonies were identified using the VITEK&#174;2 &#40;BioMerieux&#44; Durham&#44; NC&#44; USA&#41; automated identification and susceptibility testing system&#46; All isolates recovered &#40;blood&#44; psoas&#44; and epidural abscess&#41; revealed growth of MRSA&#46; Also&#44; the nasal swab was seeded on CHROMagar MRSA &#40;Plast Labor&#44; Rio de Janeiro&#44; Brazil&#41;&#44; and a MRSA isolate was confirmed by VITEK&#174;2 &#40;BioMerieux&#44; Durham&#44; NC&#44; USA&#41;&#46;</p><p id="para0007" class="elsevierStylePara elsevierViewall">Seven MRSA isolates were sent to a reference laboratory&#46; All were confirmed to be <span class="elsevierStyleItalic">S&#46; aureus</span> by MALDI-TOF MS &#40;matrix-assisted laser desorption&#47;ionization-time of flight mass spectrometry&#41; and methicillin-resistant by cefoxitin disk &#40;CLSI&#44; 2019&#41;&#46; The isolates were subjected to disk-diffusion and broth microdilution test to determine the Minimal Inhibitory Concentration &#40;MIC&#41; for common antimicrobials &#40;CLSI&#44; 2019&#41;&#46; In order to describe the SCC<span class="elsevierStyleItalic">mec</span> type&#44; the presence of <span class="elsevierStyleItalic">pvl</span>&#44; the pulsed field gel electrophoresis &#40;PFGE&#41; pattern&#44; and the Sequence Type &#40;ST&#41;&#44; all isolates were processed as described by Chamon et al&#46;<a class="elsevierStyleCrossRef" href="#bib0011"><span class="elsevierStyleSup">11</span></a> In addition&#44; the isolates were also characterized as for their SCC<span class="elsevierStyleItalic">mec</span> subtype and <span class="elsevierStyleItalic">spa</span> typing&#44; and the presence of ACME was determined by polymerase chain reaction &#40;PCR&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0012"><span class="elsevierStyleSup">12&#8211;14</span></a></p><p id="para0008" class="elsevierStylePara elsevierViewall">All MRSA isolates were susceptible to chloramphenicol&#44; ciprofloxacin&#44; clindamycin&#44; erythromycin&#44; gentamicin&#44; rifampicin&#44; sulfamethoxazole-trimethoprim and tetracycline&#46; All presented the same MIC values of 64 &#956;g&#47;mL&#44; 0&#46;5 &#956;g&#47;mL&#44; 1 &#956;g&#47;mL&#44; and 1 &#956;g&#47;mL for oxacillin&#44; daptomycin&#44; linezolid&#44; and vancomycin&#44; respectively&#46; All isolates presented the SCC<span class="elsevierStyleItalic">mec</span> type IVd and the <span class="elsevierStyleItalic">pvl</span> gene but were negative for ACME operon&#46; PFGE revealed that all isolates presented the same band patterns &#40;<a class="elsevierStyleCrossRef" href="#fig0002">Fig&#46; 2</a>&#41; and all were related to ST8&#47;CC8&#44; suggesting that all belonged to the USA300 lineage&#46; However&#44; the band pattern observed was different from those observed for a USA300 control strain &#40;526a&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0011"><span class="elsevierStyleSup">11&#44;21</span></a> and the <span class="elsevierStyleItalic">spa</span> type was thus determined as t008&#46; Therefore&#44; considering the data&#44; we could characterize all isolates as belonging to the CA-MRSA <span class="elsevierStyleItalic">pvl</span>-positive ACME-negative USA300-LV&#47;ST8&#47;SCC<span class="elsevierStyleItalic">mec</span>IVd lineage&#46;</p><elsevierMultimedia ident="fig0002"></elsevierMultimedia></span><span id="sec0003" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0005">Discussion</span><p id="para0009" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Staphylococcus aureus</span> is an important pathogen in hospital and community environments&#46; It is also a member of the skin microbiota of approximately 30&#37; of the population&#46; Its colonization is considered a risk factor for the development of invasive infections among hospitalized patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0001"><span class="elsevierStyleSup">1&#44;3</span></a> Kim et al&#46; conducted a meta-analysis and reported that subjects from community settings previously colonized with <span class="elsevierStyleItalic">S&#46; aureus</span>&#44; specially by MRSA isolates&#44; were also associated with a greater risk of having a <span class="elsevierStyleItalic">S&#46; aureus</span> infection&#46;<a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a> Also&#44; Neves et al&#46; suggested that children from a middle&#47;low socioeconomic status were more likely to be colonized by MRSA strains&#46;<a class="elsevierStyleCrossRef" href="#bib0002"><span class="elsevierStyleSup">2</span></a></p><p id="para0010" class="elsevierStylePara elsevierViewall">Although the incidence of CA-MRSA infections in Brazil is considered low &#40;&#60; 10&#37;&#41;&#44; recent studies have described an increase in the occurrence of CA-MRSA SSTI among pediatric patients&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">15</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0016"><span class="elsevierStyleSup">16</span></a> In the present report&#44; a 15-year-old boy from a low-income area of Rio de Janeiro without any known risk factor for MRSA infection was admitted at our university hospital presenting clinical signs and symptoms suggestive of a disseminate staphylococcal disease&#46; It is noteworthy that the boy&#44; besides being infected&#44; was also colonized by a MRSA isolate&#46;</p><p id="para0011" class="elsevierStylePara elsevierViewall">The microbiologic analysis showed that all seven MRSA isolates recovered presented the same PFGE pattern&#46; All belonged to the CA-MRSA <span class="elsevierStyleItalic">pvl</span>-positive ACME-negative USA300-LV&#47;ST8&#47;SCC<span class="elsevierStyleItalic">mec</span>IVd&#47;t008 lineage&#44; described here for the first time in Brazil&#46; The most important genetic distinction between the USA300-LV and North American USA300 lineages is the absence of the ACME island in USA300-LV&#44; which is replaced for a gene cluster-encoding proteins involved in the metabolism of copper and mercury&#46;<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0017"><span class="elsevierStyleSup">17</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0018"><span class="elsevierStyleSup">18</span></a> However&#44; similarly to the USA300 epidemic clone from North America&#44; USA300-LV variants can cause invasive infections in healthy individuals&#44; as shown in the present case report&#46;</p><p id="para0012" class="elsevierStylePara elsevierViewall">The USA300-LV lineage is a parallel USA300 epidemic clone that affects predominantly countries of the northern region of South America&#46; It is frequently associated with community-acquired SSTI but also with nosocomial BSI&#46;<a class="elsevierStyleCrossRefs" href="#bib0006"><span class="elsevierStyleSup">6&#8211;9</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0017"><span class="elsevierStyleSup">17</span></a> Recently&#44; Arias et al&#46; described that USA300-LV isolates can completely replace prevalent hospital-associated clones in Colombia and Ecuador&#46;<a class="elsevierStyleCrossRef" href="#bib0008"><span class="elsevierStyleSup">8</span></a> Moreover&#44; this lineage was already described in European countries&#44; such as Germany and Switzerland&#44; however isolated from patients traveling in or from South America&#46;<a class="elsevierStyleCrossRef" href="#bib0018"><span class="elsevierStyleSup">18</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0019"><span class="elsevierStyleSup">19</span></a> Interestingly&#44; Takadama et al&#46; suggested that a PVL-positive CA-MRSA USA300-LV clone has evolved and disseminated in Japan&#44; giving rise to a new clone called USA300-LV&#47;J&#46; This shows the adaptability capacity of such lineage to disseminate to distinct geographic regions&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">20</span></a> In the present study&#44; we have described a systemic infection caused by the USA300-LV lineage in a healthy boy with no previous history of travelling outside Brazil&#46; He was previously colonized by this CA-MRSA clone&#44; suggesting a community acquisition of this strain&#46; It is important to mention that the community transmission of the USA300-LV variant has already been reported in Germany&#46;<a class="elsevierStyleCrossRef" href="#bib0019"><span class="elsevierStyleSup">19</span></a></p></span><span id="sec0004" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0006">Conclusion</span><p id="para0013" class="elsevierStylePara elsevierViewall">As Brazil is a touristic route for many global travelers&#44; we emphasize the possibility of a community spread of a hypervirulent CA-MRSA lineage&#44; such as the USA300-LV&#44; which is widely adapted to and disseminated in some Latin American countries&#44; among them Brazil&#46; Therefore&#44; the improvement of surveillance programs and financial support for epidemiological studies on the community colonization by MRSA isolates&#44; together with antimicrobial resistance studies&#44; are urgent and necessary in order to prevent the dissemination of hypervirulent MRSA isolates into hospital and community environments in Brazil&#46;</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0007">Ethics approval and consent to participate</span><p id="para0014" class="elsevierStylePara elsevierViewall">The present case report was approved by the &#8220;Comit&#234; de &#201;tica em Pesquisa da Faculdade de Medicina da Universidade Federal Fluminense&#8221; under CAAE no&#46; 51559821&#46;3&#46;0000&#46;5243&#46; A written informed consent was obtained from the patient&#39;s mother&#44; who authorized the publication of this case report and all accompanying images&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:9 [
        0 => array:3 [
          "identificador" => "xres1877553"
          "titulo" => "Abstract"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abss0001"
            ]
          ]
        ]
        1 => array:2 [
          "identificador" => "xpalclavsec1628620"
          "titulo" => "Keywords"
        ]
        2 => array:2 [
          "identificador" => "xpalclavsec1628619"
          "titulo" => "Abbreviations"
        ]
        3 => array:2 [
          "identificador" => "sec0001"
          "titulo" => "Introduction"
        ]
        4 => array:2 [
          "identificador" => "sec0002"
          "titulo" => "Case report"
        ]
        5 => array:2 [
          "identificador" => "sec0003"
          "titulo" => "Discussion"
        ]
        6 => array:2 [
          "identificador" => "sec0004"
          "titulo" => "Conclusion"
        ]
        7 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Ethics approval and consent to participate"
        ]
        8 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2022-09-05"
    "fechaAceptado" => "2022-12-19"
    "PalabrasClave" => array:1 [
      "en" => array:2 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1628620"
          "palabras" => array:4 [
            0 => "MRSA"
            1 => "USA300-LV"
            2 => "Nasal colonization"
            3 => "Infection"
          ]
        ]
        1 => array:4 [
          "clase" => "abr"
          "titulo" => "Abbreviations"
          "identificador" => "xpalclavsec1628619"
          "palabras" => array:15 [
            0 => "ACME"
            1 => "BSI"
            2 => "CA-MRSA"
            3 => "CT"
            4 => "HA-MRSA"
            5 => "MALDI-TOF MS"
            6 => "MIC"
            7 => "MRI"
            8 => "MRSA"
            9 => "PCR"
            10 => "PFGE"
            11 => "PVL"
            12 => "SSTI"
            13 => "ST"
            14 => "USA300-LV"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:1 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abss0001" class="elsevierStyleSection elsevierViewall"><p id="spara003" class="elsevierStyleSimplePara elsevierViewall">The methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> &#40;MRSA&#41; USA300-Latin American variant &#40;USA300-LV&#41; lineage is well documented in northern Latin American countries&#46; It has replaced established clones in hospital environments&#46; We herein report a systemic infection caused by a USA300-LV isolate in a 15-year-old boy&#44; from a low-income area of Rio de Janeiro&#44; previously colonized by the same strain&#46; During hospital stay&#44; seven <span class="elsevierStyleItalic">pvl</span>-positive MRSA USA300-LV isolates were recovered by nasal swab&#44; blood and abscess secretion&#46; The patient underwent intravenous vancomycin&#44; daptomycin&#44; and oral sulfamethoxazole&#47;trimethoprim&#44; and was discharged after 45 days after full recovery&#46; This is the first documented case of a community-acquired MRSA infection caused by the USA300-LV variant in Brazil in a previously colonized adolescent with no history of recent travel outside of Rio de Janeiro&#46; The need for improved surveillance programs to detect MRSA colonization in order to control the spread of hypervirulent lineages among community and hospital settings is highlighted&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:3 [
        "etiqueta" => "1"
        "nota" => "<p class="elsevierStyleNotepara" id="notep0001">These authors contributed equally to this work&#46;</p>"
        "identificador" => "fn1"
      ]
    ]
    "multimedia" => array:2 [
      0 => array:8 [
        "identificador" => "fig0001"
        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1438
            "Ancho" => 1667
            "Tamanyo" => 216756
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "alt0001"
            "detalle" => "Fig "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spara001" class="elsevierStyleSimplePara elsevierViewall">Computed tomography &#40;CT&#41; of the abdomen&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "fig0002"
        "etiqueta" => "Fig&#46; 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 1474
            "Ancho" => 2477
            "Tamanyo" => 176462
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "alt0002"
            "detalle" => "Fig "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spara002" class="elsevierStyleSimplePara elsevierViewall">Dendrogram of PFGE patterns of <span class="elsevierStyleItalic">S&#46; aureus</span> isolates according to clinical source&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "cebibsec1"
          "bibliografiaReferencia" => array:21 [
            0 => array:3 [
              "identificador" => "bib0001"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span>"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "AS Lee"
                            1 => "H de Lencastre"
                            2 => "J Garau"
                            3 => "J Kluytmans"
                            4 => "S Malhotra-Kumar"
                            5 => "A Peschel"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1038/nrdp.2018.33"
                      "Revista" => array:5 [
                        "tituloSerie" => "Nat Rev Dis Primers"
                        "fecha" => "2018"
                        "volumen" => "4"
                        "paginaInicial" => "18033"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29849094"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0002"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Differences in gram-positive bacterial colonization and antimicrobial resistance among children in a high income inequality setting"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "FPG Neves"
                            1 => "MA Marlow"
                            2 => "G Rezende-Pereira"
                            3 => "MG Pinheiro"
                            4 => "AFM Dos Santos"
                            5 => "M de F&#225;tima Nogueira de Freitas"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/s12879-019-4104-2"
                      "Revista" => array:5 [
                        "tituloSerie" => "BMC Infect Dis"
                        "fecha" => "2019"
                        "volumen" => "19"
                        "paginaInicial" => "478"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/31142269"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0003"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The association between community-associated <span class="elsevierStyleItalic">Staphylococcus aureus</span> colonization and disease&#58; a meta-analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "MW Kim"
                            1 => "BK Greenfield"
                            2 => "RE Snyder"
                            3 => "CM Steinmaus"
                            4 => "LW&#46; Riley"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/s12879-018-2990-3"
                      "Revista" => array:5 [
                        "tituloSerie" => "BMC Infect Dis"
                        "fecha" => "2018"
                        "volumen" => "18"
                        "paginaInicial" => "86"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29466953"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0004"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Origin&#44; evolution&#44; and global transmission of community-acquired Staphylococcus aureus ST8"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "L Strau&#223;"
                            1 => "M Stegger"
                            2 => "PE Akpaka"
                            3 => "A Alabi"
                            4 => "S Breurec"
                            5 => "G Coombs"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Proc Natl Acad Sci USA"
                        "fecha" => "2017"
                        "volumen" => "114"
                        "paginaInicial" => "E10596"
                        "paginaFinal" => "E1E604"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Panton-Valentine leukocidin-positive <span class="elsevierStyleItalic">Staphylococcus aureus</span>&#58; a position statement from the International Society of Chemotherapy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "K Saeed"
                            1 => "I Gould"
                            2 => "S Esposito"
                            3 => "N Ahmad-Saeed"
                            4 => "SS Ahmed"
                            5 => "E Alp"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.ijantimicag.2017.11.002"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Antimicrob Agents"
                        "fecha" => "2018"
                        "volumen" => "51"
                        "paginaInicial" => "16"
                        "paginaFinal" => "25"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29174420"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0006"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "USA300 abroad&#58; global spread of a virulent strain of community-associated methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span>"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "GR&#46; Nimmo"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1469-0691.2012.03822.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Microbiol Infect"
                        "fecha" => "2012"
                        "volumen" => "18"
                        "paginaInicial" => "725"
                        "paginaFinal" => "734"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22448902"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0007"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Parallel epidemics of community-associated methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> USA300 Infection in North and South America"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "PJ Planet"
                            1 => "L Diaz"
                            2 => "SO Kolokotronis"
                            3 => "A Narechania"
                            4 => "J Reyes"
                            5 => "G Xing"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/infdis/jiv320"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Infect Dis"
                        "fecha" => "2015"
                        "volumen" => "212"
                        "paginaInicial" => "1874"
                        "paginaFinal" => "1882"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26048971"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0008"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A prospective cohort multicenter study of molecular epidemiology and phylogenomics of <span class="elsevierStyleItalic">Staphylococcus aureus</span> bacteremia in nine Latin American countries"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "CA Arias"
                            1 => "J Reyes"
                            2 => "LP Carvajal"
                            3 => "S Rincon"
                            4 => "L Diaz"
                            5 => "D Panesso"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Antimicrob Agents Chemother"
                        "fecha" => "2017"
                        "volumen" => "61"
                        "numero" => "10"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0009"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Dissemination of methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> USA300 sequence type 8 lineage in Latin America"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J Reyes"
                            1 => "S Rinc&#243;n"
                            2 => "L D&#237;az"
                            3 => "D Panesso"
                            4 => "GA Contreras"
                            5 => "J Zurita"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1086/648426"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Infect Dis"
                        "fecha" => "2009"
                        "volumen" => "49"
                        "paginaInicial" => "1861"
                        "paginaFinal" => "1867"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19911971"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical and microbiological characteristics of heteroresistant and vancomycin-Intermediate <span class="elsevierStyleItalic">Taphylococcus aureus</span> from bloodstream infections in a Brazilian teaching hospital"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "TM da Costa"
                            1 => "PG Morgado"
                            2 => "FS Cavalcante"
                            3 => "AP Damasco"
                            4 => "SA Nou&#233;r"
                            5 => "KR Dos Santos"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "PLoS One"
                        "fecha" => "2016"
                        "volumen" => "11"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0011"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Molecular characterization of <span class="elsevierStyleItalic">Staphylococcus aureus</span> isolates carrying the Panton-Valentine leukocidin genes from Rio de Janeiro hospitals"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "RC Chamon"
                            1 => "NL Iorio"
                            2 => "S da Silva Ribeiro"
                            3 => "FS Cavalcante"
                            4 => "KR Dos Santos"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.diagmicrobio.2015.09.004"
                      "Revista" => array:6 [
                        "tituloSerie" => "Diagn Microbiol Infect Dis"
                        "fecha" => "2015"
                        "volumen" => "83"
                        "paginaInicial" => "331"
                        "paginaFinal" => "334"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26431830"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0012"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Novel multiplex PCR assay for characterization and concomitant subtyping of staphylococcal cassette chromosome <span class="elsevierStyleItalic">mec</span> types I to V in methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span>"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "K Zhang"
                            1 => "JA McClure"
                            2 => "S Elsayed"
                            3 => "T Louie"
                            4 => "JM Conly"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1128/JCM.43.10.5026-5033.2005"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Clin Microbiol"
                        "fecha" => "2005"
                        "volumen" => "43"
                        "paginaInicial" => "5026"
                        "paginaFinal" => "5033"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16207957"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0013"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Typing of methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> in a university hospital setting by using novel software for spa repeat determination and database management"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "D Harmsen"
                            1 => "H Claus"
                            2 => "W Witte"
                            3 => "J Rothganger"
                            4 => "H Claus"
                            5 => "D Turnwald"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1128/JCM.41.12.5442-5448.2003"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Clin Microbiol"
                        "fecha" => "2003"
                        "volumen" => "41"
                        "paginaInicial" => "5442"
                        "paginaFinal" => "5448"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14662923"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0014"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Contribution of Panton-Valentine leukocidin in community-associated methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> pathogenesis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "BA Diep"
                            1 => "AM Palazzolo-Ballance"
                            2 => "P Tattevin"
                            3 => "L Basuino"
                            4 => "KR Braughton"
                            5 => "AR Whitney"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1371/journal.pone.0003198"
                      "Revista" => array:5 [
                        "tituloSerie" => "PLoS One"
                        "fecha" => "2008"
                        "volumen" => "3"
                        "paginaInicial" => "e3198"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18787708"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Is community-associated methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> &#40;CA-MRSA&#41; an emerging pathogen among children in Brazil&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "R Paternina-de la Ossa"
                            1 => "SID Prado"
                            2 => "MC Cervi"
                            3 => "DAFD Lima"
                            4 => "R Martinez"
                            5 => "F&#46; Bellissimo-Rodrigues"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.bjid.2018.10.276"
                      "Revista" => array:6 [
                        "tituloSerie" => "Braz J Infect Dis"
                        "fecha" => "2018"
                        "volumen" => "22"
                        "paginaInicial" => "371"
                        "paginaFinal" => "376"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30389351"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0016"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Frequency of community-acquired methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> in pediatric population in a general hospital in S&#227;o Paulo&#44; Brazil&#44; over 5 years"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "FD Penteado"
                            1 => "TZ Tubero"
                            2 => "N Hein"
                            3 => "AE&#46; Gilio"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/INF.0000000000002158"
                      "Revista" => array:6 [
                        "tituloSerie" => "Pediatr Infect Dis J"
                        "fecha" => "2019"
                        "volumen" => "38"
                        "paginaInicial" => "e87"
                        "paginaFinal" => "ee9"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30067601"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib0017"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Global spread of the community-associated methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> USA300 Latin American variant"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "PJ Planet"
                            1 => "L Diaz"
                            2 => "R Rios"
                            3 => "CA&#46; Arias"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/infdis/jiw418"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Infect Dis"
                        "fecha" => "2016"
                        "volumen" => "214"
                        "paginaInicial" => "1609"
                        "paginaFinal" => "1610"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27613776"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib0018"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Comparative genomics of community-associated methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> shows the emergence of clone ST8-USA300 in Geneva&#44; Switzerland"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "E Von Dach"
                            1 => "SM Diene"
                            2 => "C Fankhauser"
                            3 => "J Schrenzel"
                            4 => "S Harbarth"
                            5 => "P&#46; Fran&#231;ois"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/infdis/jiv489"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Infect Dis"
                        "fecha" => "2016"
                        "volumen" => "213"
                        "paginaInicial" => "1370"
                        "paginaFinal" => "1379"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26464204"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib0019"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Genomic structure of ST8-t008 USA300 and USA300-LV MRSA in the Rhine-Neckar Region&#44; Germany&#44; 2012-2018"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "S Klein"
                            1 => "S Boutin"
                            2 => "K Heeg"
                            3 => "P Zanger"
                            4 => "D&#46; Nurjadi"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "Int J Antimicrob Agents"
                        "fecha" => "2021"
                        "volumen" => "57"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A novel community-acquired MRSA clone&#44; USA300-LV&#47;J&#44; uniquely evolved in Japan"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "S Takadama"
                            1 => "H Nakaminami"
                            2 => "H Kaneko"
                            3 => "N&#46; Noguchi"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Antimicrob Chemother"
                        "fecha" => "2020"
                        "volumen" => "75"
                        "paginaInicial" => "3131"
                        "paginaFinal" => "3134"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib21"
              "etiqueta" => "21"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Polyclonal presence of non-multiresistant methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> isolates carrying SCC<span class="elsevierStyleItalic">mec</span> IV in health care-associated infections in a hospital in Rio de Janeiro&#44; Brazil"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:8 [
                            0 => "RP Schuenck"
                            1 => "SA Nou&#233;r"
                            2 => "CO Winter"
                            3 => "FS Cavalcante"
                            4 => "TD Scotti"
                            5 => "AL Ferreira"
                            6 => "M Giambiagi-de Marval"
                            7 => "KRN dos Santos"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.diagmicrobio.2009.04.007"
                      "Revista" => array:6 [
                        "tituloSerie" => "Diagn Microbiol Infect Dis"
                        "fecha" => "2009"
                        "volumen" => "64"
                        "paginaInicial" => "434"
                        "paginaFinal" => "441"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19631097"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
    "agradecimientos" => array:1 [
      0 => array:2 [
        "identificador" => "xack661109"
        "vista" => "all"
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/14138670/0000002700000002/v3_202304071918/S1413867022004305/v3_202304071918/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "10853"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "Case Reports"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/14138670/0000002700000002/v3_202304071918/S1413867022004305/v3_202304071918/en/main.pdf?idApp=UINPBA00003Y&text.app=https://www.bjid.org.br/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1413867022004305?idApp=UINPBA00003Y"
]
Share
Journal Information
Vol. 27. Issue 2.
(March - April 2023)
Share
Share
Download PDF
More article options
Visits
1971
Vol. 27. Issue 2.
(March - April 2023)
Case Report
Full text access
Systemic infection caused by the methicillin-resistant Staphylococcus aureus USA300-LV lineage in a Brazilian child previously colonized
Visits
1971
Carolina de Oliveira Whitakera,1, Raiane Cardoso Chamonb,c,1,
Corresponding author
raianechamon@id.uff.br

Corresponding author.
, Tamara Lopes Rocha de Oliveiraa, Simone Aranha Nouérd, Kátia Regina Netto dos Santosa
a Universidade Federal do Rio de Janeiro, Instituto de Microbiologia Paulo de Góes, Departamento de Microbiologia Médica, Laboratório de Infecção Hospitalar, Rio de Janeiro, RJ, Brazil
b Universidade Federal Fluminense, Faculdade de Medicina, Departamento de Patologia, Niterói, RJ, Brazil
c Universidade Federal Fluminense, Hospital Universitário Antônio Pedro, Unidade de Pesquisa Clínica, Laboratório de Microbiologia, Niterói, RJ, Brazil
d Universidade Federal do Rio de Janeiro, Hospital Universitário Clementino Fraga Filho, Faculdade de Medicina, Rio de Janeiro, RJ, Brazil
This item has received
Article information
Abstract
Full Text
Bibliography
Download PDF
Statistics
Figures (2)
Abstract

The methicillin-resistant Staphylococcus aureus (MRSA) USA300-Latin American variant (USA300-LV) lineage is well documented in northern Latin American countries. It has replaced established clones in hospital environments. We herein report a systemic infection caused by a USA300-LV isolate in a 15-year-old boy, from a low-income area of Rio de Janeiro, previously colonized by the same strain. During hospital stay, seven pvl-positive MRSA USA300-LV isolates were recovered by nasal swab, blood and abscess secretion. The patient underwent intravenous vancomycin, daptomycin, and oral sulfamethoxazole/trimethoprim, and was discharged after 45 days after full recovery. This is the first documented case of a community-acquired MRSA infection caused by the USA300-LV variant in Brazil in a previously colonized adolescent with no history of recent travel outside of Rio de Janeiro. The need for improved surveillance programs to detect MRSA colonization in order to control the spread of hypervirulent lineages among community and hospital settings is highlighted.

Keywords:
MRSA
USA300-LV
Nasal colonization
Infection
Abbreviations:
ACME
BSI
CA-MRSA
CT
HA-MRSA
MALDI-TOF MS
MIC
MRI
MRSA
PCR
PFGE
PVL
SSTI
ST
USA300-LV
Full Text
Introduction

Staphylococcus aureus colonizes about 30% of human nares. Such colonization is an important source of person-to-person bacterial transmission, especially in low socioeconomic status communities, characterized by a large number of subnormal agglomerates.1,2 Recent studies have proposed that previous nasal colonization with methicillin-resistant S. aureus (MRSA) strains could increase the risk of a subsequent staphylococcal infection, such as skin and soft tissue infections (SSTI), pneumonia, osteomyelitis, bloodstream infections (BSI) and endocarditis.1,3

Community-associated MRSA (CA-MRSA) USA300/ST8/SCCmecIVa strains are considered epidemic and widely disseminated in North America as a causative agent of SSTI.4 In general, CA-MRSA strains are known for their ability to carry a wide range of virulence determinants, such as the Panton-Valentine leucocidin (PVL) gene (pvl), which has been associated with invasive and severe diseases, particularly in children.5 However, differently from North America, a USA300-related genetic lineage (designated USA300 Latin American variant [USA300-LV]) emerged and has become epidemic in countries of the northern region of South America, such as Colombia, Venezuela, and Ecuador, as the causative agents of bloodstream infections. It has replaced the hospital-associated MRSA clone designated “Chilean/Cordobes”.6–9 The first description of USA300-LV was in 2009 in a prospective multicenter study that aimed to evaluate the molecular epidemiology of MRSA isolates recovered from 32 high-level care hospitals distributed in four Latin American countries in 2006 and 2008.9 Similarly to other CA-MRSA strains, USA300-LV isolates can harbor the PVL gene; however, unlikely USA300/ST8/SCCmecIVa, the USA300-LV lacks the arginine catabolic mobile island element (ACME), and most USA300-LV isolates carry different variants of type IV methicillin resistance cassette.6,9

In Rio de Janeiro, Brazil, hospital-associated MRSA (HA-MRSA) USA100/ST5/SCCmecII and CA-MRSA USA1100/ST30/SCCmecIV lineages are frequently associated with BSI and SSTI, respectively.10,11 However, in this study, we aimed to describe for the first time in Brazil the occurrence of a systemic infection caused by a CA-MRSA isolate belonging to the pvl-positive USA300-LV/SCCmecIVd/t008 lineage in the nares of a Brazilian 15-year-old boy colonized by the same MRSA strain.

Case report

On October 19th, 2019, a 15-year-old boy from a low-income neighborhood of Rio de Janeiro, with no previous history of travel outside Brazil and with no comorbidity, entered a Brazilian university hospital with a two-week history of lumbar pain and polyarthralgia after a body trauma during a soccer game. Upon admission, the patient was febrile and presented edema, redness, and heat in right elbow and left shoulder, suggesting a disseminated and complicated S. aureus SSTI. Computed tomography (CT) of the abdomen evidenced an extensive abscess in left psoas (Fig. 1) and peripheral pulmonary embolic lesions, with no documentation of endocarditis in the transesophageal echocardiogram. Also, a magnetic resonance imaging (MRI) of the spine showed a posterior compression from L2 to S2, which was suggestive of a subdural empyema in the sacral region extending to the lumbar spine. A screening nasal swab for MRSA colonization was performed, and blood was drawn. Antimicrobial therapy began immediately. Only in the eleventh day of hospitalization the infection was controlled, with clinical improvement and serial negative blood cultures. The patient received intravenous vancomycin (15-20 mg/kg/day depending on serum levels of vancomycin), followed by daptomycin (10-12 mg/kg/day), switching to oral sulfamethoxazole/trimethoprim (400/80 mg/q 6 h) up to six months.

Fig. 1.

Computed tomography (CT) of the abdomen.

(0.21MB).

All blood cultures were processed using the automated BactAlert system (BioMerieux, Durham, NC, USA). After determining positivity, blood was cultured on sheep blood agar (Plast Labor, Rio de Janeiro, Brazil) for 24 hours with incubation at 37° C, in addition to abscess drainage collection. Bacterial colonies were identified using the VITEK®2 (BioMerieux, Durham, NC, USA) automated identification and susceptibility testing system. All isolates recovered (blood, psoas, and epidural abscess) revealed growth of MRSA. Also, the nasal swab was seeded on CHROMagar MRSA (Plast Labor, Rio de Janeiro, Brazil), and a MRSA isolate was confirmed by VITEK®2 (BioMerieux, Durham, NC, USA).

Seven MRSA isolates were sent to a reference laboratory. All were confirmed to be S. aureus by MALDI-TOF MS (matrix-assisted laser desorption/ionization-time of flight mass spectrometry) and methicillin-resistant by cefoxitin disk (CLSI, 2019). The isolates were subjected to disk-diffusion and broth microdilution test to determine the Minimal Inhibitory Concentration (MIC) for common antimicrobials (CLSI, 2019). In order to describe the SCCmec type, the presence of pvl, the pulsed field gel electrophoresis (PFGE) pattern, and the Sequence Type (ST), all isolates were processed as described by Chamon et al.11 In addition, the isolates were also characterized as for their SCCmec subtype and spa typing, and the presence of ACME was determined by polymerase chain reaction (PCR).12–14

All MRSA isolates were susceptible to chloramphenicol, ciprofloxacin, clindamycin, erythromycin, gentamicin, rifampicin, sulfamethoxazole-trimethoprim and tetracycline. All presented the same MIC values of 64 μg/mL, 0.5 μg/mL, 1 μg/mL, and 1 μg/mL for oxacillin, daptomycin, linezolid, and vancomycin, respectively. All isolates presented the SCCmec type IVd and the pvl gene but were negative for ACME operon. PFGE revealed that all isolates presented the same band patterns (Fig. 2) and all were related to ST8/CC8, suggesting that all belonged to the USA300 lineage. However, the band pattern observed was different from those observed for a USA300 control strain (526a),11,21 and the spa type was thus determined as t008. Therefore, considering the data, we could characterize all isolates as belonging to the CA-MRSA pvl-positive ACME-negative USA300-LV/ST8/SCCmecIVd lineage.

Fig. 2.

Dendrogram of PFGE patterns of S. aureus isolates according to clinical source.

(0.17MB).
Discussion

Staphylococcus aureus is an important pathogen in hospital and community environments. It is also a member of the skin microbiota of approximately 30% of the population. Its colonization is considered a risk factor for the development of invasive infections among hospitalized patients.1,3 Kim et al. conducted a meta-analysis and reported that subjects from community settings previously colonized with S. aureus, specially by MRSA isolates, were also associated with a greater risk of having a S. aureus infection.3 Also, Neves et al. suggested that children from a middle/low socioeconomic status were more likely to be colonized by MRSA strains.2

Although the incidence of CA-MRSA infections in Brazil is considered low (< 10%), recent studies have described an increase in the occurrence of CA-MRSA SSTI among pediatric patients.15,16 In the present report, a 15-year-old boy from a low-income area of Rio de Janeiro without any known risk factor for MRSA infection was admitted at our university hospital presenting clinical signs and symptoms suggestive of a disseminate staphylococcal disease. It is noteworthy that the boy, besides being infected, was also colonized by a MRSA isolate.

The microbiologic analysis showed that all seven MRSA isolates recovered presented the same PFGE pattern. All belonged to the CA-MRSA pvl-positive ACME-negative USA300-LV/ST8/SCCmecIVd/t008 lineage, described here for the first time in Brazil. The most important genetic distinction between the USA300-LV and North American USA300 lineages is the absence of the ACME island in USA300-LV, which is replaced for a gene cluster-encoding proteins involved in the metabolism of copper and mercury.6,17,18 However, similarly to the USA300 epidemic clone from North America, USA300-LV variants can cause invasive infections in healthy individuals, as shown in the present case report.

The USA300-LV lineage is a parallel USA300 epidemic clone that affects predominantly countries of the northern region of South America. It is frequently associated with community-acquired SSTI but also with nosocomial BSI.6–9,17 Recently, Arias et al. described that USA300-LV isolates can completely replace prevalent hospital-associated clones in Colombia and Ecuador.8 Moreover, this lineage was already described in European countries, such as Germany and Switzerland, however isolated from patients traveling in or from South America.18,19 Interestingly, Takadama et al. suggested that a PVL-positive CA-MRSA USA300-LV clone has evolved and disseminated in Japan, giving rise to a new clone called USA300-LV/J. This shows the adaptability capacity of such lineage to disseminate to distinct geographic regions.20 In the present study, we have described a systemic infection caused by the USA300-LV lineage in a healthy boy with no previous history of travelling outside Brazil. He was previously colonized by this CA-MRSA clone, suggesting a community acquisition of this strain. It is important to mention that the community transmission of the USA300-LV variant has already been reported in Germany.19

Conclusion

As Brazil is a touristic route for many global travelers, we emphasize the possibility of a community spread of a hypervirulent CA-MRSA lineage, such as the USA300-LV, which is widely adapted to and disseminated in some Latin American countries, among them Brazil. Therefore, the improvement of surveillance programs and financial support for epidemiological studies on the community colonization by MRSA isolates, together with antimicrobial resistance studies, are urgent and necessary in order to prevent the dissemination of hypervirulent MRSA isolates into hospital and community environments in Brazil.

Ethics approval and consent to participate

The present case report was approved by the “Comitê de Ética em Pesquisa da Faculdade de Medicina da Universidade Federal Fluminense” under CAAE no. 51559821.3.0000.5243. A written informed consent was obtained from the patient's mother, who authorized the publication of this case report and all accompanying images.

References
[1]
AS Lee, H de Lencastre, J Garau, J Kluytmans, S Malhotra-Kumar, A Peschel, et al.
Methicillin-resistant Staphylococcus aureus.
Nat Rev Dis Primers, 4 (2018), pp. 18033
[2]
FPG Neves, MA Marlow, G Rezende-Pereira, MG Pinheiro, AFM Dos Santos, M de Fátima Nogueira de Freitas, et al.
Differences in gram-positive bacterial colonization and antimicrobial resistance among children in a high income inequality setting.
BMC Infect Dis, 19 (2019), pp. 478
[3]
MW Kim, BK Greenfield, RE Snyder, CM Steinmaus, LW. Riley.
The association between community-associated Staphylococcus aureus colonization and disease: a meta-analysis.
BMC Infect Dis, 18 (2018), pp. 86
[4]
L Strauß, M Stegger, PE Akpaka, A Alabi, S Breurec, G Coombs, et al.
Origin, evolution, and global transmission of community-acquired Staphylococcus aureus ST8.
Proc Natl Acad Sci USA, 114 (2017), pp. E10596-E1E604
[5]
K Saeed, I Gould, S Esposito, N Ahmad-Saeed, SS Ahmed, E Alp, et al.
Panton-Valentine leukocidin-positive Staphylococcus aureus: a position statement from the International Society of Chemotherapy.
Int J Antimicrob Agents, 51 (2018), pp. 16-25
[6]
GR. Nimmo.
USA300 abroad: global spread of a virulent strain of community-associated methicillin-resistant Staphylococcus aureus.
Clin Microbiol Infect, 18 (2012), pp. 725-734
[7]
PJ Planet, L Diaz, SO Kolokotronis, A Narechania, J Reyes, G Xing, et al.
Parallel epidemics of community-associated methicillin-resistant Staphylococcus aureus USA300 Infection in North and South America.
J Infect Dis, 212 (2015), pp. 1874-1882
[8]
CA Arias, J Reyes, LP Carvajal, S Rincon, L Diaz, D Panesso, et al.
A prospective cohort multicenter study of molecular epidemiology and phylogenomics of Staphylococcus aureus bacteremia in nine Latin American countries.
Antimicrob Agents Chemother, 61 (2017),
[9]
J Reyes, S Rincón, L Díaz, D Panesso, GA Contreras, J Zurita, et al.
Dissemination of methicillin-resistant Staphylococcus aureus USA300 sequence type 8 lineage in Latin America.
Clin Infect Dis, 49 (2009), pp. 1861-1867
[10]
TM da Costa, PG Morgado, FS Cavalcante, AP Damasco, SA Nouér, KR Dos Santos.
Clinical and microbiological characteristics of heteroresistant and vancomycin-Intermediate Taphylococcus aureus from bloodstream infections in a Brazilian teaching hospital.
PLoS One, 11 (2016),
[11]
RC Chamon, NL Iorio, S da Silva Ribeiro, FS Cavalcante, KR Dos Santos.
Molecular characterization of Staphylococcus aureus isolates carrying the Panton-Valentine leukocidin genes from Rio de Janeiro hospitals.
Diagn Microbiol Infect Dis, 83 (2015), pp. 331-334
[12]
K Zhang, JA McClure, S Elsayed, T Louie, JM Conly.
Novel multiplex PCR assay for characterization and concomitant subtyping of staphylococcal cassette chromosome mec types I to V in methicillin-resistant Staphylococcus aureus.
J Clin Microbiol, 43 (2005), pp. 5026-5033
[13]
D Harmsen, H Claus, W Witte, J Rothganger, H Claus, D Turnwald, et al.
Typing of methicillin-resistant Staphylococcus aureus in a university hospital setting by using novel software for spa repeat determination and database management.
J Clin Microbiol, 41 (2003), pp. 5442-5448
[14]
BA Diep, AM Palazzolo-Ballance, P Tattevin, L Basuino, KR Braughton, AR Whitney, et al.
Contribution of Panton-Valentine leukocidin in community-associated methicillin-resistant Staphylococcus aureus pathogenesis.
[15]
R Paternina-de la Ossa, SID Prado, MC Cervi, DAFD Lima, R Martinez, F. Bellissimo-Rodrigues.
Is community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) an emerging pathogen among children in Brazil?.
Braz J Infect Dis, 22 (2018), pp. 371-376
[16]
FD Penteado, TZ Tubero, N Hein, AE. Gilio.
Frequency of community-acquired methicillin-resistant Staphylococcus aureus in pediatric population in a general hospital in São Paulo, Brazil, over 5 years.
Pediatr Infect Dis J, 38 (2019), pp. e87-ee9
[17]
PJ Planet, L Diaz, R Rios, CA. Arias.
Global spread of the community-associated methicillin-resistant Staphylococcus aureus USA300 Latin American variant.
J Infect Dis, 214 (2016), pp. 1609-1610
[18]
E Von Dach, SM Diene, C Fankhauser, J Schrenzel, S Harbarth, P. François.
Comparative genomics of community-associated methicillin-resistant Staphylococcus aureus shows the emergence of clone ST8-USA300 in Geneva, Switzerland.
J Infect Dis, 213 (2016), pp. 1370-1379
[19]
S Klein, S Boutin, K Heeg, P Zanger, D. Nurjadi.
Genomic structure of ST8-t008 USA300 and USA300-LV MRSA in the Rhine-Neckar Region, Germany, 2012-2018.
Int J Antimicrob Agents, 57 (2021),
[20]
S Takadama, H Nakaminami, H Kaneko, N. Noguchi.
A novel community-acquired MRSA clone, USA300-LV/J, uniquely evolved in Japan.
J Antimicrob Chemother, 75 (2020), pp. 3131-3134
[21]
RP Schuenck, SA Nouér, CO Winter, FS Cavalcante, TD Scotti, AL Ferreira, M Giambiagi-de Marval, KRN dos Santos.
Polyclonal presence of non-multiresistant methicillin-resistant Staphylococcus aureus isolates carrying SCCmec IV in health care-associated infections in a hospital in Rio de Janeiro, Brazil.
Diagn Microbiol Infect Dis, 64 (2009), pp. 434-441

These authors contributed equally to this work.

Copyright © 2023. Sociedade Brasileira de Infectologia
The Brazilian Journal of Infectious Diseases
Article options
Tools