IMAGES IN DERMATOLOGY Uma Paniker, MD, Section Editor
Danger on a Half Shell: Vibrio vulnificus Septicemia Benjamin Jones, MD,a Joshua Burkhart, MD,b Guru Sonpavde, MDa a
Division of Hematology and Oncology, Department of Medicine, bTinsley Harrison Internal Medicine Residency Program, University of Alabama at Birmingham, Birmingham.
PRESENTATION Patients with a compromised immune system should avoid certain gastronomic delights. A 69-year-old man became seriously ill 48 hours after consuming raw oysters. He presented with fever, confusion, tachycardia, hypotension, and patchy erythema of the bilateral lower extremities. Twelve hours later, he developed bullae in both lower extremities (Figure 1). His medical history included chronic lymphocytic leukemia with hypogammaglobulinemia, iron deficiency anemia, and gastric bypass surgery.
undergone gastric bypass surgery, food may pass through the gastrointestinal tract more quickly, and it may have less exposure to gastric acid. Theoretically, rapid transit may increase risk for infection from contaminated seafood. In addition, patients with hypogammaglobulinemia have an impaired ability to clear the more virulent encapsulated form of the bacterium.3 The prognosis for patients who present with distributive shock is worse than that of patients who present with preserved hemodynamics.
MANAGEMENT ASSESSMENT Despite initiation of vancomycin, cefazolin, and ampicillin/ sulbactam, the patient’s lesions worsened. On the third day of hospitalization, he underwent surgical debridement of both lower extremities, and pathological examination revealed a thrombotic microangiopathy. Gram staining of bullae fluid was negative, as was a culture of the sample. However, a Gram stain of blood cultures drawn on day 1 of hospitalization was positive for gram-negative rods. These were ultimately identified as Vibrio vulnificus on day 9.
The patient’s antibiotic regimen was switched to doxycycline and ceftazidime once the causative pathogen was identified. He also had additional wound debridement and
DIAGNOSIS V. vulnificus septicemia is a life-threatening infection with mortality exceeding 50%.1 Known risk factors include immunocompromised states, iron overload, liver disease, and hematologic malignancy.2 In patients who have
Funding: None. Conflict of Interest: None. Authorship: All authors meet criteria for authorship, including acceptance of responsibility for scientific content in the manuscript. Requests for reprints should be addressed to Benjamin Jones, MD, Department of Medicine, University of Alabama at Birmingham, 1720 2nd Avenue South, NP2540, Birmingham, AL, 35294-3000. E-mail address: [email protected] 0002-9343/$ -see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjmed.2014.11.039
Figure 1 Bullae appeared on the patient’s lower extremities 12 hours after presentation to the hospital.
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The American Journal of Medicine, Vol 128, No 5, May 2015 skin grafting, which fostered improvement (Figure 2). Antibiotics were continued for 14 days after the date of negative blood cultures. The patient was discharged 24 days after presentation, and he has remained infection free. Because of the associated high risk for mortality associated with V. vulnificus septicemia, physicians treating infection in high-risk patients with recent seafood or marine water exposure should prescribe antibiotics that cover Vibrio bacteremia.
References
Figure 2 Additional wound debridement and skin grafting led to further improvement.
1. Feldhusen F. The role of seafood in bacterial foodborne diseases. Microbes Infect. 2000;2:1651-1660. 2. Menon MP, Yu PA, Iwamoto M, Painter J. Pre-existing medical conditions associated with Vibrio vulnificus septicaemia. Epidemiol Infect. 2014;142:878-881. 3. Jones MK, Oliver JD. Vibrio vulnificus: disease and pathogenesis. Infect Immun. 2009;77:1723-1733.
Danger on a Half Shell: Vibrio vulnificus Septicemia Benjamin Jones, MD,a Joshua Burkhart, MD,b Guru Sonpavde, MDa a
Division of Hematology and Oncology, Department of Medicine, bTinsley Harrison Internal Medicine Residency Program, University of Alabama at Birmingham, Birmingham.
PRESENTATION Patients with a compromised immune system should avoid certain gastronomic delights. A 69-year-old man became seriously ill 48 hours after consuming raw oysters. He presented with fever, confusion, tachycardia, hypotension, and patchy erythema of the bilateral lower extremities. Twelve hours later, he developed bullae in both lower extremities (Figure 1). His medical history included chronic lymphocytic leukemia with hypogammaglobulinemia, iron deficiency anemia, and gastric bypass surgery.
undergone gastric bypass surgery, food may pass through the gastrointestinal tract more quickly, and it may have less exposure to gastric acid. Theoretically, rapid transit may increase risk for infection from contaminated seafood. In addition, patients with hypogammaglobulinemia have an impaired ability to clear the more virulent encapsulated form of the bacterium.3 The prognosis for patients who present with distributive shock is worse than that of patients who present with preserved hemodynamics.
MANAGEMENT ASSESSMENT Despite initiation of vancomycin, cefazolin, and ampicillin/ sulbactam, the patient’s lesions worsened. On the third day of hospitalization, he underwent surgical debridement of both lower extremities, and pathological examination revealed a thrombotic microangiopathy. Gram staining of bullae fluid was negative, as was a culture of the sample. However, a Gram stain of blood cultures drawn on day 1 of hospitalization was positive for gram-negative rods. These were ultimately identified as Vibrio vulnificus on day 9.
The patient’s antibiotic regimen was switched to doxycycline and ceftazidime once the causative pathogen was identified. He also had additional wound debridement and
DIAGNOSIS V. vulnificus septicemia is a life-threatening infection with mortality exceeding 50%.1 Known risk factors include immunocompromised states, iron overload, liver disease, and hematologic malignancy.2 In patients who have
Funding: None. Conflict of Interest: None. Authorship: All authors meet criteria for authorship, including acceptance of responsibility for scientific content in the manuscript. Requests for reprints should be addressed to Benjamin Jones, MD, Department of Medicine, University of Alabama at Birmingham, 1720 2nd Avenue South, NP2540, Birmingham, AL, 35294-3000. E-mail address: [email protected] 0002-9343/$ -see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjmed.2014.11.039
Figure 1 Bullae appeared on the patient’s lower extremities 12 hours after presentation to the hospital.
476
The American Journal of Medicine, Vol 128, No 5, May 2015 skin grafting, which fostered improvement (Figure 2). Antibiotics were continued for 14 days after the date of negative blood cultures. The patient was discharged 24 days after presentation, and he has remained infection free. Because of the associated high risk for mortality associated with V. vulnificus septicemia, physicians treating infection in high-risk patients with recent seafood or marine water exposure should prescribe antibiotics that cover Vibrio bacteremia.
References
Figure 2 Additional wound debridement and skin grafting led to further improvement.
1. Feldhusen F. The role of seafood in bacterial foodborne diseases. Microbes Infect. 2000;2:1651-1660. 2. Menon MP, Yu PA, Iwamoto M, Painter J. Pre-existing medical conditions associated with Vibrio vulnificus septicaemia. Epidemiol Infect. 2014;142:878-881. 3. Jones MK, Oliver JD. Vibrio vulnificus: disease and pathogenesis. Infect Immun. 2009;77:1723-1733.
