Septicaemia presenting in the backdrop of MRSA osteomyelitis
The present case has been reported in BMJ. A 14-year-old boy presented with tenderness on the right knee after minor trauma while playing football the previous day. On physical examination, there were minor inflammatory signs, with no penetrating wound and he was sent home.

Two days later, due to worsening symptoms, MRI of the lower limb was performed and revealed multiple tibial lytic lesions, intraosseous abscesses and diffuse soft tissue oedema.

Surgical debridement was performed and flucloxacillin and amikacin were initiated. The following day, his clinical status deteriorated with septic shock and respiratory failure. He was admitted in the paediatric intensive care unit.

Preoperatory blood cultures identified a methicillin-resistant Staphylococcus aureus (MRSA) Panton-Valentine leucocidin (PVL) positive and antimicrobial therapy was changed to ceftriaxone and vancomycin. Fasciotomy of the four leg fascial compartments was performed, with skin closure using a shoelace technique.

Eight days later, due persistent fever, the antimicrobial therapy was changed to clindamycin and vacuum systems were placed on the fasciotomies with instillation system every 4 hours. There was a favourable clinical evolution and he completed 8 weeks of antibiotic therapy.

After infection control was achieved, he started daily physiotherapy for a total of 6 months after discharge. He recovered with no functional limitation. On follow-up, there were no signs of recurrent musculoskeletal or other form of staphylococcal infection.

Learning points
• Methicillin-resistant Staphylococcus aureus (MRSA) infections are becoming an emerging problem in the community and Panton-Valentine leucocidin is associated with increased virulence of MRSA strains.

• There should be a high level of suspicion for this pathogen even in children without any risk factor, in order to avoid delays in diagnosis and treatment, with potentially worse prognosis.

• The diagnosis of osteomyelitis needs to be considered in the setting of trauma with bony point tenderness on examination. Blood testing with C reactive protein/erythrocyte sedimentation rate and imaging may assist the diagnosis. Prompt clinical follow-up should be secured if symptoms do not resolve.

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