AUTHOR AND EDITOR INFORMATION

Section 1 of 9  

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 9  

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Vibrio vulnificus is a gram-negative bacillus that only affects humans and other primates. It is in the same family as bacteria that cause cholera. The first documented case of disease caused by the organism was in 1979.

V vulnificus is usually found in warm, shallow, coastal salt water in temperate climates throughout most of the world. It can be found in the Gulf of Mexico, along most of the East Coast of the United States, and along all of the West Coast of the United States. V vulnificus can be found in water; sediment; plankton; and shellfish, such as oysters, clams, and crabs. This organism can survive in seawater and can produce wound infections, a potentially serious problem among Asian tsunami survivors.¹

An eMedicine article of possible interest is Vibrio Infections. Additionally, a food-safety Medscape CME course is Hepatitis A & B Vaccines.

Pathophysiology

V vulnificus infects the body in 2 ways, either by exposure to contaminated seafood, such as raw oysters, or through an open wound exposed to contaminated seawater. Among healthy individuals, within 16 hours of ingestion, they experience vomiting, diarrhea, and abdominal pain. Many patients develop distinctive bullous skin lesions. In patients who are immunocompromised, particularly those with chronic liver disease (especially cirrhosis), immunosuppression, end-stage renal disease, and hematopoietic disorders, V vulnificus can cause life-threatening septic shock and blistering skin lesions. Those who are immunocompromised are at a much greater risk for contracting V vulnificus and dying from overwhelming sepsis.

Because the incidence of disease is relatively low, not all strains of V vulnificus may be equally virulent. Recent data are consistent with the existence of 2 genotypes of V vulnificus, with the C-type being a strong indicator of potential virulence.²

Frequency

United States

V vulnificus infections are rare but underreported. Most cases are found in the Gulf Coast states, and they are most common during warm weather months.

International

The frequency of V vulnificus infection, which is rare in Japan, was evaluated in 2008. Its prevalence varied in different districts.³

Mortality/Morbidity

Most V vulnificus infections are acute but have no long-term consequences; however, in patients who develop septic shock from infection with V vulnificus, the mortality rate is 50%. In rare instances, skin infection can result in necrotizing fasciitis.

Race

All races are affected equally.

Sex

Males and females are affected equally.

Age

All ages are affected equally.

CLINICAL

Section 3 of 9  

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

V vulnificus infection should be suspected in patients who give a history of ingestion of raw seafood or wound infection after exposure to seawater. Patients with V vulnificus infection report abrupt GI symptoms, such as vomiting, diarrhea, or abdominal pain, and may present with fever, chills, or shock. V vulnificus is normally found in warm estuarial and marine environments, lodging in filter feeders such as oysters. It occurs mainly in patients with chronic liver disease after the consumption of raw oysters.

V vulnificus septicemia is the most common cause of death from seafood consumption in the United States.⁴ V vulnificus septicemia may first become evident in the skin as purpura fulminans, which can take a catastrophic course without immediate and intensive empirical antibiotic treatment.⁵

V vulnificus infection may be a rare cause of necrotizing fasciitis, which can be fatal.⁶

Physical

• Most patients infected with V vulnificus have bullous skin lesions, which are found on the trunk and the lower extremities. These hemorrhagic bullae can progress to necrotic ulcerations, which require surgical debridement.
• Edema can be present.
• A rapid onset of cellulitis may represent infection with V vulnificus, especially if the patient had contact with seawater or raw seafood. Patients can progress to necrotizing fasciitis.⁷

Causes

See Pathophysiology.

WORKUP

Section 4 of 9  

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

Routine stool, wound, and blood cultures aid in the diagnosis of V vulnificus infection.

Imaging Studies

No imaging studies are necessary to help diagnose or treat V vulnificus infection.

TREATMENT

Section 5 of 9  

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

Antibiotics are necessary to eradicate the infection (see Medication below).

• In case of wound infection, aggressive debridement is necessary to remove necrotic tissue.
• If the patient is in shock, perform necessary interventions to resuscitate the patient.

Consultations

• Because many patients with V vulnificus infection experience overwhelming sepsis, consultation with an infectious disease specialist is warranted.
• Consider consultation with an infectious disease specialist if the diagnosis is unclear or if the patient has atypical symptoms or does not respond to antibiotic treatment.

Activity

No restrictions are necessary.

MEDICATION

Section 6 of 9  

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

The goals of therapy are to eradicate the infection, to reduce morbidity, and to prevent complications. A high index of suspicion is important, as doxycycline, the antibiotic of choice, is not usually a part of the empiric therapy for septicemia.

If necrotizing fasciitis is suspected, early fasciotomy and culture-directed antimicrobial therapy should be performed. These patients may develop hypotensive shock, leukopenia, severe hypoalbuminemia, and underlying chronic illness, especially a combination of hepatic dysfunction and diabetes mellitus.

Drug Category: Antibiotics

Antibiotics are necessary to eradicate V vulnificus infection. Effective antibiotics may include tetracycline, third-generation cephalosporins, and imipenem.

FOLLOW-UP

Section 7 of 9  

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Deterrence/Prevention

• To prevent infection from V vulnificus, persons should avoid exposure to raw shellfish or thoroughly cook the shellfish. Persons should avoid cross-contamination of cooked shellfish with uncooked shellfish and eat shellfish promptly after cooking. Shellfish is best served hot.⁸
• Identifying oysters that are affected by V vulnificus is difficult because the appearance, taste, color, and odor of the oysters are not affected. Through improved reporting of affected oysters, oyster beds that are affected can be identified and closed.
• Persons should avoid exposure of open wounds or broken skin to raw shellfish or infected waters. Patients who are immunocompromised should be especially careful to follow these guidelines because they are more susceptible to infection and complications.

Complications

• Patients who are immunocompromised are at risk of septic shock from the infection, which can be fatal. Otherwise, no complications from V vulnificus infection occur.

Prognosis

• V vulnificus infection is an acute illness that is quickly resolved with antibiotics and does not have any long-term consequences.
• The prognosis is excellent with proper treatment.

Patient Education

• Counsel patients who are immunocompromised to prevent exposure to V vulnificus. The high mortality associated with this septicemia suggests susceptible individuals should be forewarned by signs displayed in restaurants; physicians should educate patients with chronic liver disease about the risk of raw oyster consumption. Additionally, harvesting methods that reduce contamination by V vulnificus should be used.⁴

MISCELLANEOUS

Section 8 of 9  

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failure to diagnose the condition is a pitfall. Diagnosing V vulnificus infection with a culture and treating it appropriately are important because many medical problems can present with vomiting, diarrhea, and abdominal pain. If not diagnosed and treated properly, the patient may progress to septic shock, which has a high mortality rate.

REFERENCES

Section 9 of 9

• Authors and Editors
• Introduction
• Clinical
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

1. Lim PL. Wound infections in tsunami survivors: a commentary. Ann Acad Med Singapore. Oct 2005;34(9):582-5. [Medline].
2. Rosche TM, Yano Y, Oliver JD. A rapid and simple PCR analysis indicates there are two subgroups of Vibrio vulnificus which correlate with clinical or environmental isolation. Microbiol Immunol. 2005;49(4):381-9. [Medline].
3. Inoue Y, Ono T, Matsui T, Miyasaka J, Kinoshita Y, Ihn H. Epidemiological survey of Vibrio vulnificus infection in Japan between 1999 and 2003. J Dermatol. Mar 2008;35(3):129-39. [Medline].
4. Haq SM, Dayal HH. Chronic liver disease and consumption of raw oysters: a potentially lethal combination--a review of Vibrio vulnificus septicemia. Am J Gastroenterol. May 2005;100(5):1195-9. [Medline].
5. Choi HJ, Lee DK, Lee MW, Choi JH, Moon KC, Koh JK. Vibrio vulnificus septicemia presenting as purpura fulminans. J Dermatol. Jan 2005;32(1):48-51. [Medline].
6. Tajiri T, Tate G, Akita H, Ohike N, Masunaga A, Kunimura T, et al. Autopsy cases of fulminant-type bacterial infection with necrotizing fasciitis: group A (beta) hemolytic Streptococcus pyogenes versus Vibrio vulnificus infection. Pathol Int. Mar 2008;58(3):196-202. [Medline].
7. Tsai YH, Hsu RW, Huang TJ, Hsu WH, Huang KC, Li YY, et al. Necrotizing soft-tissue infections and sepsis caused by Vibrio vulnificus compared with those caused by Aeromonas species. J Bone Joint Surg Am. Mar 2007;89(3):631-6. [Medline].
8. Prutkin JM, Haq R. A dish best served hot. Am J Med. Apr 2006;119(4):307-9. [Medline].
9. Eastaugh J, Shepherd S. Infectious and toxic syndromes from fish and shellfish consumption. A review. Arch Intern Med. Aug 1989;149(8):1735-40. [Medline].
10. Inoue H. Vibrio vulnificus infection of the hand. J Orthop Sci. Jan 2006;11(1):85-7. [Medline].
11. Koenig KL, Mueller J, Rose T. Vibrio vulnificus. Hazard on the half shell. West J Med. Oct 1991;155(4):400-3. [Medline].
12. Kumamoto KS, Vukich DJ. Clinical infections of Vibrio vulnificus: a case report and review of the literature. J Emerg Med. Jan-Feb 1998;16(1):61-6. [Medline].
13. Laughlin TJ, Lavery LA. Lower extremity manifestations of Vibrio vulnificus infection. J Foot Ankle Surg. Jul-Aug 1995;34(4):354-7. [Medline].
14. Lehane L, Rawlin GT. Topically acquired bacterial zoonoses from fish: a review. Med J Aust. Sep 2000;173(5):256-9. [Medline].
15. Linkous DA, Oliver JD. Pathogenesis of Vibrio vulnificus. FEMS Microbiol Lett. May 15 1999;174(2):207-14. [Medline].
16. Mouzin E, Mascola L, Tormey MP, Dassey DE. Prevention of Vibrio vulnificus infections. Assessment of regulatory educational strategies. JAMA. Aug 20 1997;278(7):576-8. [Medline].
17. Serrano-Jaen L, Vega-Lopez F. Fulminating septicaemia caused by Vibrio vulnificus. Br J Dermatol. Feb 2000;142(2):386-7. [Medline].
18. Strom MS, Paranjpye RN. Epidemiology and pathogenesis of Vibrio vulnificus. Microbes Infect. Feb 2000;2(2):177-88. [Medline].

Article Last Updated: Apr 23, 2008