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Unknown #102


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  • 1. Unknown #102Unknown #102
  • 2. Galveston, TXGalveston, TX  48 yo male with a history of HTN, remote48 yo male with a history of HTN, remote pancreatitis and ETOH abuse, has beenpancreatitis and ETOH abuse, has been lost to follow-uplost to follow-up  Brought in by his landlord as he was foundBrought in by his landlord as he was found unresponsive in the hallway with a “rash”unresponsive in the hallway with a “rash”  His landlord noticed his belly has beenHis landlord noticed his belly has been swelling over the last few monthsswelling over the last few months
  • 3.  VS: Temp: 101.2 BP 88/40, Pulse 110,VS: Temp: 101.2 BP 88/40, Pulse 110, 02Sat 99% 2L, RR 2202Sat 99% 2L, RR 22  Exam: Unresponsive male with fetorExam: Unresponsive male with fetor hepatis. Distended abdomen, + fluid wave,hepatis. Distended abdomen, + fluid wave, + caput medusa+ caput medusa  Rash on lower extremities (next slide)Rash on lower extremities (next slide)
  • 4.  What’s the diagnosis?What’s the diagnosis?  How was it likely contracted?How was it likely contracted?  What antibiotics if any?What antibiotics if any?
  • 5. Vibrio vulnificusVibrio vulnificus Lactose-fermenting Gram negative rod Found in estuarine environments, associated with various marine species such as plankton, shellfish and finfish Cause soft tissue infections, gastroenteritis, or syndrome known as Primary Septicemia Septicemia can occur with doses of less than 100 total organisms
  • 6. Vibrio vulnificus SepsisVibrio vulnificus Sepsis Mode of TransmissionMode of Transmission Clinical ManifestationsClinical Manifestations DermatologicDermatologic ManifestationsManifestations Transmitted to humansTransmitted to humans through open wounds inthrough open wounds in contactcontact with seawaterwith seawater oror throughthrough consumptionconsumption ofof certain improperly cooked orcertain improperly cooked or raw shellfish.raw shellfish. V. vulnificusV. vulnificus is found in upis found in up to 10% of raw shellfish onto 10% of raw shellfish on the market in the Unitedthe market in the United States) and is part of theStates) and is part of the normal flora of seawaternormal flora of seawater from warmer climates.from warmer climates. -Gastroenteritis-Gastroenteritis (anyone can get this):(anyone can get this): usually developsusually develops within 16 hours ofwithin 16 hours of eating theeating the contaminated foodcontaminated food -Sepsis: 60% case-Sepsis: 60% case fatalityfatality Over 70 percent ofOver 70 percent of infected individualsinfected individuals have distinctivehave distinctive bullous skin lesions.bullous skin lesions. From hematogenousFrom hematogenous spread or from directspread or from direct innoculationinnoculation Develop within 36 hrsDevelop within 36 hrs after ingestionafter ingestion Bullous skin lesionsBullous skin lesions
  • 7. Tender erythematous patches and plaques quickly progress to vesicles and hemorrhagic bullae, which may result in gangrene and necrotizing fasciitis
  • 8. Vibrio vulnificus PrimaryVibrio vulnificus Primary SepticemiaSepticemia  High Risk Conditions Predisposing toHigh Risk Conditions Predisposing to Vibrio vulnificusVibrio vulnificus sepsis:sepsis:  Liver disease, either from excessive alcohol intake,Liver disease, either from excessive alcohol intake, viral hepatitis or other causes (95%)viral hepatitis or other causes (95%)  HemochromatosisHemochromatosis  DiabetesDiabetes  Antacid use (high stomach pH)Antacid use (high stomach pH)  CancerCancer  Immune disorders, including HIV infectionImmune disorders, including HIV infection  Long-term steroid useLong-term steroid use
  • 9. Diagnosis,TreatmentDiagnosis,Treatment  Culturing of the organism from wounds,Culturing of the organism from wounds, diarrheic stools, or blooddiarrheic stools, or blood  Treatment: 3Treatment: 3rdrd generation cephalosporingeneration cephalosporin and doxycycline (or antipseudomonaland doxycycline (or antipseudomonal penicillin), supportive care, oftenpenicillin), supportive care, often debridementdebridement
  • 10. ReferencesReferences  Oliver JD. Wound infections caused by Vibrio vulnificus and other marine bacteria. Epidemiol Infect. 2005 Jun;133(3):383-91. Review. PMID: 15962544 [PubMed - indexed for MEDLINE]  Chiang SR, Chuang YC. Vibrio vulnificus infection: clinical manifestations, pathogenesis, and antimicrobial therapy. J Microbiol Immunol Infect. 2003 Jun;36(2):81-8. Review. PMID: 12886957 [PubMed - indexed for MEDLINE]  Borenstein M, Kerdel F. Infections with Vibrio vulnificus. Dermatol Clin. 2003 Apr;21(2):245-8. Review. PMID: 12757246 [PubMed - indexed for MEDLINE]