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
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)
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?
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 can occur with doses of less than 100
Vibrio vulnificus SepsisVibrio vulnificus Sepsis
Mode of TransmissionMode of Transmission Clinical ManifestationsClinical Manifestations DermatologicDermatologic
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.
(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
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
Develop within 36 hrsDevelop within 36 hrs
after ingestionafter ingestion
Bullous skin lesionsBullous skin lesions
Tender erythematous patches and plaques quickly
progress to vesicles and hemorrhagic bullae,
which may result in gangrene and necrotizing
Vibrio vulnificus PrimaryVibrio vulnificus Primary
High Risk Conditions Predisposing toHigh Risk Conditions Predisposing to Vibrio vulnificusVibrio vulnificus
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%)
Antacid use (high stomach pH)Antacid use (high stomach pH)
Immune disorders, including HIV infectionImmune disorders, including HIV infection
Long-term steroid useLong-term steroid use
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
Wound infections caused by Vibrio vulnificus and other marine
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
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]