AUTHOR AND EDITOR INFORMATION

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INTRODUCTION

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Background

Infections caused by Vibrio species are largely classified into 2 distinct groups: Vibrio cholera infection and noncholera Vibrio infections. Historically, the noncholera Vibrio species were classified as halophilic or nonhalophilic, depending on their requirement of sodium chloride for growth.

Because most of these infections are associated with the consumption of contaminated food, Vibrio infections are often considered a foodborne disease. In recent years, the prevalence rate of noncholera Vibrio infections in the United States appears to be increasing. The combination of increased water temperature and salinity where shellfish are harvested may contribute to increased contamination rates of shellfish. Although many foodborne diseases are not reportable in the United States, the yearly estimate from the Centers for Disease Control and Prevention (CDC) is approximately 76 million illnesses and 5200 deaths.

Since 1988, the CDC has maintained a voluntary surveillance system for culture-confirmed Vibrio infections in Alabama, Florida, Louisiana, Mississippi, and Texas. Noncholera Vibrio species in the United States cause an estimated 8000 illnesses yearly. Cases of culture-confirmed noncholera infections from Alabama, Florida, Louisiana, Texas, and Mississippi accounted for 39% of the 462 cases reported to the CDC in 2003. Although Vibrio parahaemolyticus is the most common noncholera Vibrio species reported, Vibrio vulnificus is associated with 94% of reported deaths. Because clinical laboratories do not routinely use the selective medium thiosulfate-citrate-bile salts-sucrose (TCBS) for stool culture, many cases of Vibrio-associated gastroenteritis are not identified.

In the event of a natural disaster, the disturbance to the environment may increase the risk of infectious diseases such as Vibrio infections. During the 2 weeks following Hurricane Katrina in August 2005, the CDC reported 22 new cases of Vibrio infections in Louisiana and Mississippi. V vulnificus accounted for most (82%) of these wound-associated infections. The increased incidence of Vibrio wound infections in the residents of Gulf Coast states is most likely associated with the exposure of skin and soft tissue injuries to the contaminated floodwaters.

Pathophysiology

The Vibrionaceae family includes the genera Vibrio, Plesiomonas, and Aeromonas. Members of the family Vibrionaceae are natural inhabitants of seawater but can be found in fresh water. Vibrio species are oxidase-positive, gram-negative bacilli. With the exception of nonhalophilic Vibrio species, such as Vibrio cholerae and Vibrio mimicus, all Vibrio species require saline for growth.

Vibrio species can produce multiple extracellular cytotoxins and enzymes that are associated with extensive tissue damage and may play a major role in the development of sepsis (see Table 1).

Table 1. Noncholera Vibrio Species and Associated Clinical Presentations

V vulnificus lives in areas where the temperature exceeds 18°C. In the United States, it is found in the coastal waters of the Gulf of Mexico, New England, and the northern Pacific. Low-to-moderate salinity (15-25 parts per thousand) provides the most favorable growing condition for V vulnificus, and, conversely, high salinity (>25 parts per thousand) adversely affects its survival. Similar to the effect of high salinity, low seawater temperature (<10°C) significantly inhibits the growth of V vulnificus. V vulnificus is ingested by filter-feeding mollusks such as oysters, mussels, clams, and scallops. During the warmer months, the concentration of bacteria can be as high as 1 X 10⁶ bacteria per gram of oyster.

Several mechanisms contribute to the virulence of V vulnificus. Iron is an important growth factor. However, because free iron is virtually absent in humans, the organism produces siderophores that acquire iron from transferrin or lactoferrin and deliver it to the bacteria. Conversely, the inability to produce siderophores leads to reduction of virulence.

Clinical conditions that are associated with increased free iron, such as hemochromatosis or hemolytic anemia, represent a major risk factor for the development of disseminated Vibrio infections. Additionally, the organism produces several other virulence factors, including proteases, hemolysins, and cytolysins. One in particular, a thermolysinlike metalloprotease, activates the bradykinin pathway, causing an increase in vascular permeability. This metalloprotease is far more efficient at activating human enzymes than its counterpart in the other Vibrio species, which may explain why V vulnificus causes severe skin damage and necrotizing fasciitis.

One of the major virulence factors in pathogenic V haemolyticus strains is a thermostable direct hemolysin (TDH). This beta-hemolysin has both enterotoxic and cytotoxic effects; it is detoxified at 60-70°C but reactivated at 80°C (Arrhenius effect).

Frequency

United States

Between 1996 and 2001, Vibrio infections had substantially increased by more than 80%. More importantly, despite significant decline (30-45%) of most bacterial foodborne infections in the United States in 2004, Vibrio infections increased by 47%. The CDC estimates that 8000 Vibrio infections and approximately 60 deaths related to Vibrio infections may occur annually in the United States. Vibrio infections are acquired through consumption of contaminated raw or undercooked shellfish such as oysters, clams, mussels, or crabs. Exposure of wounds to contaminated seawater, injury caused by contaminated seashells, and shark and alligator bites are potential alternative sources of infection (see Table 2).

V parahaemolyticus is the leading cause of seafood-associated gastroenteritis in the United States. During a recent large outbreak of gastroenteritis in July 2004 in the Gulf of Alaska, V parahaemolyticus caused illness in almost one third of cruise ship passengers who consumed Vibrio-contaminated oysters.

Table 2. Clinical Presentation Rates of Pathogenic Vibrio Infections

International

Areas such as Japan, Taiwan, China, Hong Kong, Korea, Italy, and Israel frequently report noncholera Vibrio infections. The high prevalence of hepatitis B infections in areas such as China or Taiwan may also contribute to the high incidence of severe noncholera Vibrio infections.

Mortality/Morbidity

According to estimates of the CDC, foodborne diseases cause approximately 76 million illnesses, 325,000 hospitalizations, and 5200 deaths annually in the United States.

• Foodborne infections caused by noncholera Vibrio species may occur at rate of 0.2-0.3 per 100,000 population. Three thousand cases of V parahaemolyticus infection are estimated to occur annually, resulting in 40 hospitalizations and 7 deaths. Ninety-five cases of V vulnificus infection are estimated to occur annually, resulting in 85 hospitalizations and 35 deaths.
• Although Vibrio infections are not as common as Campylobacter, Salmonella, or Listeria infections, the septicemic form caused by V vulnificus is frequently fatal.
• Among all foodborne diseases, V vulnificus infection is associated with the highest case fatality rate (39%).
• Patients with cirrhosis who consumed raw oysters had 200 times greater risk of death than those without liver disease who ate raw oysters.

Race

No racial predilection in the development of Vibrio infections exists.

• Because Vibrio species are natural inhabitants of seawater, states or countries bordered by large bodies of seawater frequently report high incidence of Vibrio infections.
• Persons with underlying medical conditions, such as alcoholism, cirrhosis, malignancy, or organ transplant (recipients), are at increased risk of infections and serious complications.

Sex

Vibrio infections can occur in all persons regardless of sex. V vulnificus infections were reported in women who engaged in sexual intercourse in brackish water of the Gulf of Mexico. In general, V vulnificus infections occur more frequently in males (82%), according to most reports.

Age

• Persons of any age are at risk of developing Vibrio infection if they consume or are exposed to Vibrio-contaminated food or water, especially if they have underlying medical conditions such as advanced liver disease.
• Most patients with wound infections and septicemia are aged 50-60 years.

CLINICAL

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History

Most patients with noncholera Vibrio infections report a history of consumption raw seafood such as oysters, clams, crabs, or mussels. With the exception of a dramatic clinical progression in wound infection and septicemia, no characteristic signs and symptoms of noncholera Vibrio infection in the early stage exist (see Table 3).

Table 3. Clinical Signs and Symptoms of Vibrio Infections

*ARDS

• Gastroenteritis: After an average incubation period of 19 hours (12-52 h), patients with gastroenteritis report diarrhea, abdominal cramps, nausea, and vomiting.
• • Patients frequently pass several watery stools (10-15/d).
  • Bloody diarrhea is variable. It is reported in 25% of patients with V parahaemolyticus infection but can be present in as many as 75% of patients with V fluvialis infection.
  • Low-grade fever may be observed in patients with gastroenteritis.
  • Most patients remain alert on admission. However, elderly patients may have decreased mental status because of dehydration or sepsis.
• Noncholera Vibrio wound infection: Patients frequently report injury caused by fish hooks; preparation of St Peter's fish (Tilapia zillii); preparation of crabs, lobsters, or mussels; or stepping on seashells.
• • Initially, patients almost always report severe pain of the involved limb or body part.
  • Numbness of the wound and the surrounding area may predominate if patients delay seeking medical attention.
• Noncholera Vibrio septicemia: Patients frequently exhibit a dramatic clinical presentation characterized by the following:
• • High fever
  • Shaking chills
  • Generalized myalgia
  • Exquisite pain in the lower extremities (most characteristic) or, rarely, pain in the lower trunk

Physical

The physical findings vary according to clinical presentations.

• Acute gastroenteritis
• • Patients are acutely ill with diarrhea, nausea, vomiting, abdominal pain, and fever (50%).
  • The vital signs, such as blood pressure and heart rate, vary with the level of dehydration.
  • Unless the patient has underlying disease, no specific physical findings for this form of Vibrio infection exist.
• Wound infection
• • After a short incubation period (3-24 h), patients frequently present with rapidly progressing swelling of the wound and severe pain.
  • Wounds usually involve the fingers, palms, or soles of the feet.
  • In milder cases, erythema, edema, and pain are localized to the initial wound, without signs of compartment syndrome, necrosis, gangrene, or necrotizing fasciitis.
  • In patients with medical conditions such as cirrhosis or malignancies, the wound infection may progress very rapidly, with formation of hemorrhagic bullae and extensive soft tissue necrosis.
• Septicemia
• • After a short incubation period (12-48 h) following consumption of raw seafood or exposure of broken skin to warm seawater, patients frequently develop fever, shaking chills, generalized myalgia, edema, and severe pain in the lower extremities.
  • Within 3-24 hours, edema of the lower extremities worsens.
  • Multiple hemorrhagic bullae and extensive ecchymoses distributed predominantly over the lower extremities form rapidly (see Images 1-3).
  • Patients frequently become hypotensive despite aggressive intravenous fluid therapy.
  • Patients become lethargic, obtunded, and, finally, unconscious as the disease progresses.
  • Oliguria
  • Noncardiogenic pulmonary edema

Causes

• Noncholera Vibrio infections are foodborne diseases and are largely associated with the following:
• • Consumption of raw or undercooked seafood such as oysters, clams, crabs, or mussels
  • Exposure of wound to contaminated water
• The acute gastroenteritis associated with noncholera Vibrio infection is frequently self-limited, although persons with certain underlying medical conditions may develop fulminant infections. These underlying medical conditions include the following:
• • Advanced liver diseases, such as cirrhosis, hepatitis B virus (HBV) infection, hepatitis C virus (HCV) infection, alcoholism, hemochromatosis, and liver transplant
  • Hematologic diseases, such as acute leukemia, aplastic anemia, hemolytic anemia, and thalassemia
  • Immunosuppressive therapy, including cytotoxic chemotherapy, corticosteroids, and tacrolimus
  • Kidney disease involving kidney transplant or hemodialysis
  • Miscellaneous conditions, including splenectomy and diabetes mellitus

DIFFERENTIALS

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Other Problems to be Considered

Clostridial necrotizing fasciitis

WORKUP

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Lab Studies

• CBC count with differential and platelet count
• • Findings on blood count initially are nondiagnostic.
  • In patients with underlying medical conditions, such as cirrhosis, the presence of thrombocytopenia and/or schistocytes is an early indicator of disseminated intravascular coagulation (DIC).
• Serum chemistries (comprehensive metabolic panel)
• • Serum electrolytes, BUN, and creatinine levels can become abnormal with dehydration, hypotension, and severe sepsis.
  • Monitoring serum electrolytes is essential in the treatment of severe gastroenteritis.
• Stool examination for occult blood and fecal leukocytes: The presence of either fecal occult blood or fecal leukocytes is a reliable marker for invasive infectious diarrhea.
• Stool examination for ova and parasites and stool cultures for Salmonella, Shigella, Campylobacter, Yersinia, and Vibrio
• • Stool examination for parasites and stool culture are indicated in patients who present with diarrhea and who have a history of recent travel and/or consumption of contaminated food or water.
  • Perform these tests in patients with gastroenteritis, especially upon suspicion of foodborne illness.
  • The physician may alert the public health department if a specific pathogen is identified in a group of people.
• Prothrombin time and activated partial thromboplastin time
• • Prothrombin time (PT) and activated partial thromboplastin time (aPTT) may be prolonged in patients with DIC.
  • Coagulation tests are indicated in patients who require extensive surgical debridement.
• Gram stain and culture of the bulla aspirate
• • Gram stain and culture are indicated in patients with wound infections.
  • Test results may reveal gram-negative rods on Gram stain, or these studies may be used to isolate a specific pathogen for antibiotic sensitivity testing.
• Blood cultures
• • Patients with certain medical conditions, such as advanced liver disease, may develop bacteremia and serious complications.
  • Findings on blood culture frequently are positive in patients with V vulnificus infections.
• Arterial blood gas
• • Arterial blood gas (ABG) is indicated in patients with severe sepsis, septic shock, multiple organ dysfunction, DIC, or ARDS.
  • Findings on ABG may show severe metabolic acidosis because of tissue hypoperfusion and/or hypoxia.

Imaging Studies

• Chest radiograph may show fluffy bilateral pulmonary infiltrates compatible with ARDS.
• Radiographic examination of the injured anatomical parts, such as fingers, hand, foot, or trunk
• • Examination may reveal foreign objects, such as fragments of fishhooks or seashells.
  • The presence of gas feathering in the soft tissue may help identify other potential diagnoses, such as gas gangrene.
• CT scan of the injured body parts may be indicated if the patient develops signs and symptoms of compartment syndrome or necrotizing fasciitis.

Other Tests

• Other tests may not be necessary on admission but may help identify the underlying medical conditions that predispose the patient to serious Vibrio infection and/or complications.
• Serology for HBV and HCV and serum iron studies are used to identify the etiology of advanced liver disease.

Procedures

• Wound debridement
• • Early wound debridement is indicated in patients with wound infection or septicemia. Delay of wound debridement may lead to amputation.
  • Debridement must be performed urgently if the patient develops compartment syndrome.

Histologic Findings

Findings on histologic examination of the skin and/or soft tissue in patients with noncholera Vibrio wound infection frequently demonstrate gram-negative bacilli, acute inflammatory reaction with extensive tissue necrosis, and fat infarction. In patients with rapidly progressing illness, examination of biopsy specimens of the skin may demonstrate an absence of cellular response.

TREATMENT

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Medical Care

Medical care depends on the clinical presentation and the presence of underlying medical conditions.

• Gastroenteritis
• • Because the illness is self-limited in most patients with gastroenteritis, no specific medical therapy is required. Patients who cannot tolerate oral fluid replacement may require intravenous fluid therapy.
  • Although most Vibrio species are sensitive to antibiotics, such as doxycycline or quinolones, antibiotic therapy does not shorten the course of the illness or the duration of pathogen excretion. However, if the patient is ill and has a high fever or has an underlying medical condition, oral antibiotic therapy with doxycycline or quinolone can be initiated.
• Patients with noncholera Vibrio-associated wound infection or septicemia are much sicker and frequently have other medical conditions. Medical therapy consists of the following:
• • Prompt initiation of effective antibiotic therapy
  • Intensive medical therapy with aggressive fluid replacement and vasopressors for hypotension and septic shock to correct acid-base and electrolytes abnormalities that may be associated with severe sepsis

Surgical Care

• Early debridement of the infected wound has an important role in successful therapy and is especially indicated to avoid amputation of fingers, toes, or limbs.
• Because the physical condition of patients with wound infection or septicemia may deteriorate rapidly, with development of necrotizing fasciitis or compartment syndrome, expeditious and serial surgical evaluation and intervention are required.
• Reconstructive surgery, such as skin graft, is indicated in the recovery phase.

Consultations

A team effort is required to ensure successful therapy for patients with noncholera Vibrio-associated wound infection or septicemia.

• Urgent consultation with an infectious diseases specialist for diagnosis and possible investigation of foodborne illness
• Urgent consultation with a general surgeon or orthopedist for debridement
• Critical care medicine consultation - Because the patient may develop severe sepsis, septic shock, and multiple organ dysfunction (eg, ARDS, renal failure)
• Gastroenterology consultation - Most patients may have advanced liver disease, and they may develop serious complications such as gastrointestinal bleeding.

Diet

• Patients with gastroenteritis are permitted oral intake if tolerated.
• Patients with wound infection and septicemia frequently are too sick to tolerate oral intake during the acute phase.
• Some patients with advanced liver disease may develop hepatic encephalopathy and may require oral or parenteral hepatic nutrition.

MEDICATION

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For noncholera Vibrio infections other than gastroenteritis, the combination of ceftazidime and doxycycline or an antipseudomonal penicillin (eg, ticarcillin and clavulanate, piperacillin and tazobactam) is the therapy of choice. Alternative antibiotics are cefotaxime or fluoroquinolones. Although in vitro testing demonstrates that Vibrio species are sensitive to aminoglycosides, the use of aminoglycosides may be associated with toxicities above those observed with other agents.

Adjuvant therapy: Recombinant human activated protein C (drotrecogin alfa activated) has been used as an adjuvant therapy for patients with severe sepsis who scored 25 or more on the Acute Physiology and Chronic Health Evaluation (APACHE II). A few patients with V vulnificus sepsis who were successfully treated with antibiotics, surgical debridement, and recombinant human activated protein C were reported. In view of serious bleeding associated with the continuous infusion of recombinant human activated protein C and the potential requirement for repeated surgical debridement in patients with V vulnificus sepsis, routine use of this adjuvant therapy is not recommended.

Drug Category: Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting. Antibiotic combinations are usually recommended for serious gram-negative bacillary infections. This approach ensures coverage for a broad range of organisms and polymicrobial infections. In addition, resistance from bacterial subpopulations is prevented, and additive or synergistic effects are provided. Once organisms and sensitivities are known, the use of antibiotic monotherapy is recommended.

Drug Name	Piperacillin and tazobactam (Zosyn)
Description	Antipseudomonal penicillin plus beta-lactamase inhibitor. Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active multiplication.
Adult Dose	4.5 g IV q8h
Pediatric Dose	<6 months: Not established >6 months: 75 mg/kg IV q6h
Contraindications	Documented hypersensitivity
Interactions	Tetracyclines may decrease effects of piperacillin; high concentrations in vivo or in vitro of piperacillin may chemically inactivate aminoglycosides; synergistic effect occurs when administered concurrently with aminoglycosides; probenecid may increase penicillin levels
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Perform CBC prior to initiation of therapy and at least weekly during therapy; adjust dose in renal dysfunction; monitor for liver and renal function abnormalities

Drug Name	Ticarcillin and clavulanate (Timentin)
Description	Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active growth. Antipseudomonal penicillin plus beta-lactamase inhibitor provides coverage against most gram-positive, gram-negative, and anaerobic bacteria.
Adult Dose	3.1 g IV q4-6h
Pediatric Dose	75 mg/kg IV q6h
Contraindications	Documented hypersensitivity
Interactions	Tetracyclines may decrease effects of ticarcillin; high concentrations of ticarcillin in vivo or in vitro may chemically inactivate aminoglycosides; synergistic effect occurs when administered concurrently with aminoglycosides; probenecid may increase penicillin levels
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Perform CBC prior to initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT during therapy; exercise caution in patients diagnosed with hepatic insufficiencies; perform urinalysis, BUN, and creatinine determinations during therapy and adjust dose if values become elevated

Drug Name	Ciprofloxacin (Cipro, Ciloxan)
Description	Fluoroquinolone with activity against pseudomonads, streptococci, MRSA, Staphylococcus epidermidis, and most gram-negative organisms but no activity against anaerobes. Inhibits bacterial DNA synthesis and, consequently, growth.
Adult Dose	400 mg IV bid for 7-14 d, may switch to 500 mg PO to complete therapy when oral intake is normalized
Pediatric Dose	<18 years: Not recommended >18 years: Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; ciprofloxacin reduces therapeutic effects of phenytoin; probenecid may increase ciprofloxacin serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy; CNS and GI disturbances have been observed

Drug Name	Cefotaxime (Claforan)
Description	For septicemia and treatment of gynecologic infections caused by susceptible organisms. Arrests bacterial cell wall synthesis, which in turn inhibits bacterial growth. Third-generation cephalosporin with gram-negative spectrum. Lower efficacy against gram-positive organisms.
Adult Dose	2 g IV q6h
Pediatric Dose	Infants to <12 years: 50-180 mg/kg/d IV divided q4-6h >12 years: Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	Probenecid may increase cefotaxime levels; coadministration with furosemide and aminoglycosides may increase nephrotoxicity
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Adjust dose in severe renal impairment; has been associated with severe colitis

FOLLOW-UP

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Further Inpatient Care

• Daily or repeated surgical debridement may be necessary.
• Continue intensive medical care for fluid, electrolytes, and acid-base abnormalities.
• Blood transfusion or infusion of platelet or clotting factors is necessary for the treatment of DIC.
• Perform hemodialysis for renal failure, if indicated.
• Medically monitor and treat other underlying medical conditions such as advanced liver disease, diabetes mellitus, or leukemia.

Further Outpatient Care

• Patients with noncholera Vibrio-associated gastroenteritis have self-limited illness and do not require further outpatient care.
• Patients who survive devastating halophilic Vibrio infections may sustain finger, toe, or limb amputation and massive destruction of skin and soft tissue. These patients require extensive reconstructive surgery and physical rehabilitation.

Transfer

• Patients with serious noncholera Vibrio infections may require transfer to a facility where intensive monitoring and surgical expertise are available.
• In contrast to the treatment of gas gangrene, hyperbaric oxygen therapy (HBO) has not been studied or proven effective in the treatment of serious halophilic Vibrio infections. Therefore, transfer to an HBO facility is not recommended.

Deterrence/Prevention

• Avoid eating raw or undercooked seafood. Contaminated seafood cannot be distinguished by smell or taste. This is especially important for individuals with conditions predisposing to invasive disease with Vibrio species.
• • Fry, bake, steam, or boil oysters, clams, and mussels 4-9 minutes or until plump.
  • Boil shrimp or crab until shells turn pink and the meat is cooked in the middle.
  • Fish is cooked until the thickest part is opaque.
• Avoid exposure to seawater in summer months or along the coastal regions in the southeastern United States.
• Promptly seek medical attention if fever, nausea, abdominal cramps, diarrhea, myalgia, or severe pain in the lower extremities develops.

Complications

• Although reactive arthritis may occur, other complications are rare in patients who are immunocompetent and have noncholera Vibrio-associated gastroenteritis.
• Patients with advanced liver disease or other underlying medical conditions are prone to developing serious complications, including the following:
• • Hypotension, shock
  • Compartment syndrome
  • Multiple organ dysfunction
  • DIC
  • ARDS
  • Hemolysis
• Delay in debridement of Vibrio-associated wound infection may result in rapid disease progression and may lead to amputation.
• Avoid admitting patients with noncholera Vibrio-associated wound infection or septicemia to the regular ward. Hypotension or shock can develop very quickly.
• Frequent surgical evaluation is necessary to detect the rapid development of compartment syndrome.

Prognosis

• Prognosis is excellent in patients who are immunocompetent and have acute gastroenteritis.
• In patients with wound infection or septicemia, the prognosis is very grave and depends on the following:
• • Underlying medical conditions such as cirrhosis or leukemia
  • Pathogen (V vulnificus is associated with a 50% mortality rate.)
  • Prompt initiation of effective antibiotic therapy
  • Early debridement
  • Availability of intensive monitoring and medical care for serious complications
  • Availability of reconstructive surgery and physical rehabilitation

Patient Education

• Educate patients with appropriate underlying medical conditions about the serious medical illness that may be associated with consumption of raw or undercooked seafood.
• Educate patients to seek medical attention promptly if fever, nausea, abdominal cramps, diarrhea, myalgia, or severe pain in the lower extremities develops.

MISCELLANEOUS

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Medical/Legal Pitfalls

• Failure to suspect or to make an early diagnosis of noncholera Vibrio infection in a patient who ate raw seafood and who has advanced liver disease is a potential pitfall.
• Delay in the debridement of noncholera Vibrio-associated wound infection can lead to limb amputation.
• Failure to warn a patient with advanced liver disease about the possibility of developing a life-threatening illness after eating raw or undercooked shellfish is a potential pitfall.
• Failure to warn a patient with advanced liver disease about the possibility of developing a life-threatening illness after exposure to contaminated warm seawater is a potential pitfall.
• Failure to educate a patient with advanced liver disease about properly cooking or preparing seafood is a potential pitfall.
• Failure of the owner of a seafood restaurant to display a warning about the association between consumption of raw seafood and the development of life-threatening illness in patients with advanced liver disease is a potential legal pitfall.

MULTIMEDIA

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Media file 1:  Vibrio infections. Early bullous lesions appear over the dorsum of the foot of a patient with cirrhosis.
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Media file 2:  Vibrio infections. In a patient with cirrhosis, skin lesion rapidly becomes necrotic.
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Media type:  Photo

Media file 3:  Vibrio infections. Bullous lesions in a patient with cirrhosis continue to progress, and the patient rapidly develops hypotension and shock despite aggressive medical therapy.
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Media type:  Photo

REFERENCES

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• Brennt CE, Wright AC, Dutta SK. Growth of Vibrio vulnificus in serum from alcoholics: association with high transferrin iron saturation. J Infect Dis. Nov 1991;164(5):1030-2. [Medline].
• Centers for Disease Control and Prevention (CDC). Vibrio illnesses after Hurricane Katrina--multiple states, August-September 2005. MMWR Morb Mortal Wkly Rep. Sep 23 2005;54(37):928-31.
• Centers for Disease Control and Prevention (CDC). Preliminary FoodNet data on the incidence of infection with pathogens transmitted commonly through food--selected sites, United States, 2003. MMWR Morb Mortal Wkly Rep. Apr 30 2004;53(16):338-43.
• Dadisman TA Jr, Nelson R, Molenda JR. Vibrio parahaemolyticus gastroenteritis in Maryland. I. Clinical and epidemiologic aspects. Am J Epidemiol. Dec 1972;96(6):414-26. [Medline].
• Daniels NA, MacKinnon L, Bishop R. Vibrio parahaemolyticus infections in the United States, 1973-1998. J Infect Dis. May 2000;181(5):1661-6. [Medline].
• Hlady WG, Klontz KC. The epidemiology of Vibrio infections in Florida, 1981-1993. J Infect Dis. May 1996;173(5):1176-83. [Medline].
• Hollis DG, Weaver RE, Baker CN. Halophilic Vibrio species isolated from blood cultures. J Clin Microbiol. Apr 1976;3(4):425-31. [Medline].
• Hor LI, Chang TT, Wang ST. Survival of Vibrio vulnificus in whole blood from patients with chronic liver diseases: association with phagocytosis by neutrophils and serum ferritin levels. J Infect Dis. Jan 1999;179(1):275-8. [Medline].
• Howard RJ, Lieb S. Soft-tissue infections caused by halophilic marine vibrios. Arch Surg. Feb 1988;123(2):245-9. [Medline].
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Article Last Updated: Jan 4, 2007