Culture-Confirmed Severe Methicillin-Susceptible Staphylococcus aureus Pneumonia with Lung Abscess, Bacteremia, and Hydropneumothorax Managed without ECMO: A Case Report.

Abstract

Background: Methicillin-susceptible Staphylococcus aureus (MSSA) can cause rapidly destructive pneumonia complicated by lung abscess, bacteremia, empyema, and hydropneumothorax. Extracorporeal membrane oxygenation (ECMO) may be considered for refractory hypoxemia but is not always feasible. We report a young adult with severe MSSA pneumonia who recovered with optimized conventional support without ECMO.

Case presentation: A 36-year-old man presented with fever, melena, hemoptysis, and progressive dyspnea. He developed severe hypoxemic respiratory failure with a PaO₂/FiO₂ ratio of 75 mmHg, septic shock requiring high-dose vasopressors, and extensive purulent airway secretions. ECMO was considered but declined for financial reasons. Immediate modified prone positioning was initiated through a rapid emergency-to-ICU workflow, and bronchoscopy performed in the prone position removed large volumes of purulent secretions. Computed tomography later showed right hydropneumothorax with approximately 60% lung compression and partial right lung destruction, as well as left pneumothorax with approximately 30% compression. Bilateral chest tubes were inserted with continuous negative-pressure drainage. Repeated early blood and sputum cultures grew Staphylococcus aureus, and oxacillin susceptibility with negative cefoxitin screening confirmed MSSA bacteremia and pneumonia. Antimicrobial therapy was dynamically adjusted according to microbiological results, including later isolation of carbapenem-resistant Acinetobacter baumannii and Klebsiella pneumoniae. Lesion-guided multi-segmental postural drainage was individualized according to imaging findings, air leakage, and drainage characteristics. The patient gradually improved, was weaned from mechanical ventilation, decannulated, and discharged on hospital day 80 with good functional recovery at follow-up.

Conclusion: Fulminant MSSA pneumonia with lung abscess, bacteremia, and bilateral hydropneumothorax may be managed without ECMO in selected patients when rapid, coordinated conventional support and source-control measures are feasible. Early prone positioning, timely pleural drainage, individualized postural drainage, dynamic antimicrobial adjustment, and stepwise rehabilitation may provide a feasible multimodal approach when advanced support is unavailable.