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ID Case Conference
January 23, 2008
Carlos M. Perez, MD, FACP
Associate Professor of Medicine
Pontificia Universidad Catolica de Chile
The Case
• HPI: ♂, 53 yo, Diabetic, otherwise healthy.
After returning from a 5 days business trip
to El Salvador (San Salvador, capital),
developed fever, generalized malaise and
severe burning pain on his right upper
extremity. He ate at Hotel and nearby
“safe” restaurants. No mosquito bites. No
contact with animals. No sexual contacts.
• PMH: Type 2 Diabetes mellitus insulin
dependent. Alcoholic liver disease ?
• PSH: Unremarkable
• Medications: Insulin NPH. Metformin
• NKDA
• SH: Married. Etoh abuse. No tobacco use.
• ROS: Fever, Malaise, RUE pain and
lesions.
Physical exam
• P: 120 x min. BP: 90/40. T: 37°C, RR: 24 x
min. Agitated.
• Skin:
- R arm: Edema, erythema, tenderness with
blue-gray patches and ecchymoses
- L forearm: Erythema, edema and bullae
- Both legs: Erytema and bullae
• HEENT, Lungs, Heart, abdomen
unremarkable on admission.
Clinical course
• Admitted to UCI. Persisted hypotensive despite
crystalloids/colloids, noradrenaline/adrenaline
infusion. Hemodynamics: PCWP 25 mm Hg. CI:
4.57 L/min/m2. SVR: 494 dyne.sec/cm-5.. Febrile
up to 39°C. Antibiotics started: Ceftazidime +
ciprofloxacin+ metronidazol+ cloxacilin. One
dose Amikacin. Hypoxic requiring mechanical
support. Bilateral infiltrates on CXR consistent
with ARDS. Anuric (Multiorgan system failure).
• Skin lesion progressed rapidly (hours)
Laboratory
• Hematocrit 42 %, leucocytes 6,700 (
10 % bands), Platelets: 103.000
60,000 Sed rate 21 mm. CRP 31 (NV
0-0.9). Creatinine 1.6. BUN 28. Na
131. K 3,0. Glucose 318. Bilirubin:
1.45. ALT 277 AST 119. AP 112. CPK
1258 (NV < 195), PT 48 % 26 %.
Lactate 6,9 mmol/L (NV < 2,4)
Discussion
Blood cultures
At 7 hours of incubation grew up a Lactose negative Gram negative rod
Blood cultures
Vibrio vulnificus
Clinical course
• Family said that patient had consumption of raw
oysters in El Salvador. Doxycyclin added after
identification of GNR (20 hours after admission).
• No improvement despite vasoactive drugs,
continuous hemofiltration, respiratory
mechanical support, antibiotics. Surgical
debridement not possible. Patient died 68 hours
after admission.
• See Abstract for Poblete R, Andresen M, Perez
C et al. Rev Med Chile 2002;130:787-91
Vibrio vulnificus infections
• Gram-negative bacterium in the Vibrio family,
which can cause serious wound infections and
septicemia.
• It is the leading cause of shellfish-associated
deaths in the United States. Infection due to V.
vulnificus is most common in individuals who
have chronic, underlying illness, with persons
with liver disease or hemochromatosis at
greatest risk.
Vibrio vulnificus infections
• Virulence of V. vulnificus has been associated
with the presence of a polysaccharide capsule.
• Certain carbotypes of V. vulnificus may be more
likely than others to cause human illness.
• V. vulnificus contains a lipopolysaccharide
(LPS) but, in contrast to Enterobacteriaceae, the
LPS of V. vulnificus is not a strong trigger for
release of tumor necrosis factor (TNF)-alpha
and other shock-related cytokines. Capsular
polysaccharide itself may directly trigger some
cytokine responses, contributing to the
development of the shock syndrome.
Vibrio vulnificus infections
• Growth of V. vulnificus is dependent in
part upon the availability of iron. Growth of
the organism in human serum is related
directly to the percentage saturation of
transferrin with iron. When transferrin iron
saturation exceeds 70 percent, growth of
the bacterium is nearly exponential.
Vibrio vulnificus infections
• Epidemiology: As with
other members of the
species Vibrio, V. vulnificus
exists as a free-living
bacterium inhabiting
estuarine or marine
environments. Filter-feeding
shellfish, such as oysters,
concentrate bacteria.V.
vulnificus can be isolated
from virtually all oysters
harvested in the
Chesapeake Bay () and the
United States Gulf Coast
when water temperatures
exceed 20ºC.
www.chesakpeakebaysampler.com
Vibrio vulnificus infections
• Epidemiology: Certain populations are at higher
risk for serious infection with V. vulnificus. These
include:
 Alcoholic cirrhosis: 31 to 43 percent
 Underlying liver disease including cirrhosis
(unspecified etiology) and chronic hepatitis: 24 to 31
percent
 Alcohol abuse without documented liver disease: 12
to 27 percent
 Hereditary hemochromatosis: 12 percent
 Chronic diseases such as diabetes mellitus,
rheumatoid arthritis, thalassemia major, chronic
renal failure, "preleukemia", and lymphoma:7 to 8
percent
Vibrio vulnificus infections
• Clinical manifestions :
 Wound infections:V. vulnificus may contaminate
wounds exposed to estuarine waters, shellfish, or fish.
Typical examples include hand injuries related to
opening oysters or leg lacerations related to entering,
exiting, or launching boats. The infections are usually
mild. However, in high-risk individuals, the infection may
spread rapidly, producing severe myositis and fasciitis
reminiscent of gas gangrene.
Vibrio vulnificus infections
• Clinical manifestions :
 Primary septicemia — Primary V. vulnificus septicemia
is associated with ingestion of raw or undercooked
shellfish, particularly raw oysters. Patients with primary
septicemia generally have underlying liver disease,
alcoholism, hereditary hemochromatosis, or a chronic
disease. Approximately one-third of patients with primary
septicemia present in shock or become hypotensive
within 12 hours of hospital admission. Three-fourths of
patients have distinctive bullous skin lesions
Thrombocytopenia is common, and often there is
evidence of DIC.
Vibrio vulnificus infections
• Mortality rates exceeding 40 percent have
been reported in other case series, with a
case fatality rate of more than 90 percent
among those who become hypotensive
Vibrio vulnificus infections
• Treatment:
 In vitro and in vivo studies in mice have demonstrated
an apparent synergism between minocycline and
cefotaxime in the treatment of serious V. vulnificus
infections. Subsequent studies showed comparable
survival in mice treated with "newer" quinolones.
 Recommended: Minocycline or doxycycline (100 mg PO
twice daily) plus either cefotaxime (2 gm IV every eight
hours) or ceftriaxone (1-2 g IV daily). A reasonable
alternative is levofloxacin (500 mg once daily).
Vibrio vulnificus infections
• Prevention: Persons in high-risk groups
should avoid eating raw or undercooked
shellfish, particularly oysters. Such
persons should also avoid situations in
which estuarine-associated wounds are
likely to occur.
Search PubMed
• Vibrio Vulnificus Infection
Case Reports
Review
Differential Diagnosis
Drug Therapy
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