{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,16]],"date-time":"2026-09-16T19:21:14Z","timestamp":1789586474249,"version":"build-2803163510"},"reference-count":26,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,1,16]],"date-time":"2026-01-16T00:00:00Z","timestamp":1768521600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Med."],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>\n                      Panton-Valentine leukocidin (PVL)-positive\n                      <jats:italic>Staphylococcus aureus<\/jats:italic>\n                      strains are associated with severe necrotising infections and may be linked to fulminant systemic inflammatory presentations. We report an exceptionally fulminant and rapidly fatal case of PVL-positive\n                      <jats:italic>S. aureus<\/jats:italic>\n                      sepsis with toxic shock-like features and early deterioration despite escalation to veno-arterial extracorporeal membrane oxygenation (VA-ECMO).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Case presentation<\/jats:title>\n                    <jats:p>\n                      A previously healthy 16-year-old boy presented with chest pain, dyspnoea and circulatory collapse. Initial evaluation demonstrated massive bilateral pulmonary embolism, severe biventricular systolic dysfunction, acute kidney injury and marked systemic inflammation. He received prompt haemodynamic support, systemic thrombolysis for high-risk pulmonary embolism and empirical broad-spectrum antibiotics. Echocardiography confirmed profound myocardial dysfunction and VA-ECMO was instituted as salvage support.\n                      <jats:italic>S. aureus<\/jats:italic>\n                      grew from respiratory samples and blood cultures, with susceptibility consistent with meticillin-susceptible\n                      <jats:italic>S. aureus<\/jats:italic>\n                      . Virulence gene profiling by multiplex PCR detected\n                      <jats:italic>lukS-PV and LukF-PV<\/jats:italic>\n                      , while\n                      <jats:italic>tst<\/jats:italic>\n                      ,\n                      <jats:italic>eta<\/jats:italic>\n                      and\n                      <jats:italic>etb<\/jats:italic>\n                      were not detected. Antimicrobial therapy was shifted to include antitoxin agents (clindamycin and linezolid). Intravenous immunoglobulin was not administered. Despite maximal supportive care, he developed refractory multi-organ failure and died within 24\u202fh of ICU admission.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>\n                      PVL-positive\n                      <jats:italic>S. aureus<\/jats:italic>\n                      can, albeit rarely, be associated with an extreme toxic shock-like phenotype even when classical toxin genes are not detected. This case highlights the diagnostic and management challenges posed by atypical presentations and mixed shock physiology, and underscores the need for early recognition and rapid escalation of supportive care.\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fmed.2026.1729510","type":"journal-article","created":{"date-parts":[[2026,1,16]],"date-time":"2026-01-16T13:14:31Z","timestamp":1768569271000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":2,"title":["Case Report: Fulminant shock due to PVL-positive Staphylococcus aureus in an adolescent\u2014superantigen-negative sepsis with toxic shock-like features"],"prefix":"10.3389","volume":"13","author":[{"given":"Rachid","family":"Attou","sequence":"first","affiliation":[{"name":"Intensive Care Department, CHU Brugmann","place":["Brussel, Belgium"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Soha\u00efb","family":"Mansour","sequence":"additional","affiliation":[{"name":"Intensive Care Department, CHU Brugmann","place":["Brussel, Belgium"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Evelyne","family":"Maillart","sequence":"additional","affiliation":[{"name":"Infectious Disease Department, CHU Brugmann","place":["Brussel, Belgium"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Leonel Barreto","family":"Gutierrez","sequence":"additional","affiliation":[{"name":"Intensive Care Department, CHU Brugmann","place":["Brussel, Belgium"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ayoub","family":"Jaafari","sequence":"additional","affiliation":[{"name":"Intensive Care Department, CHU Brugmann","place":["Brussel, Belgium"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,1,16]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"77","DOI":"10.1146\/annurev.micro.55.1.77","article-title":"Toxic shock syndrome and bacterial superantigens: an update","volume":"55","author":"McCormick","year":"2001","journal-title":"Ann Rev Microbiol"},{"key":"ref2","volume-title":"Toxic shock syndrome (other than streptococcal) 2011 case definition","year":"2011"},{"key":"ref3","doi-asserted-by":"publisher","first-page":"651","DOI":"10.1016\/j.ccc.2013.03.012","article-title":"Toxic shock syndrome: major advances in pathogenesis, but not treatment","volume":"29","author":"Low","year":"2013","journal-title":"Crit Care Clin"},{"key":"ref4","doi-asserted-by":"publisher","first-page":"1077","DOI":"10.3201\/eid2606.190783","article-title":"Manifestations of toxic shock syndrome in children, Columbus, Ohio, USA, 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enterotoxin C producing Staphylococcus aureus","volume":"97","author":"Mushtaq","year":"2008","journal-title":"Acta Paediatr"},{"key":"ref23","doi-asserted-by":"publisher","first-page":"e27246","DOI":"10.1371\/journal.pone.0027246","article-title":"Fatal S. aureus hemorrhagic pneumonia: genetic analysis of a unique clinical isolate producing both PVL and TSST-1","volume":"6","author":"Li","year":"2011","journal-title":"PLoS One"},{"key":"ref24","doi-asserted-by":"publisher","first-page":"2921","DOI":"10.2147\/IDR.S262123","article-title":"Two cases of intrafamilial transmission of community-acquired methicillin-resistant Staphylococcus aureus producing both PVL and TSST-1 causing fatal necrotizing pneumonia and sepsis","volume":"13","author":"Hayakawa","year":"2020","journal-title":"Infect Drug Resist"},{"key":"ref25","doi-asserted-by":"publisher","first-page":"181","DOI":"10.1086\/498901","article-title":"A clinical and microbiological comparison of Staphylococcus aureus toxic shock 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