A fatal case of Vibrio vulnificus presenting as septic arthritis.

Vibrio vulnificus is an invasive gram-negative bacillus that may cause necrotizing cellulitis, bacteremia, and/or sepsis. Although V vulnificus infection is uncommon, it is frequently fatal and is usually attributed to ingestion of raw shellfish or traumatic exposure to a marine environment; patients are also often found to have a hepatic disorder (cirrhosis, alcohol abuse, or hemochromatosis) or an immunocompromised health status, and most commonly present with septicemia or a wound infection. We describe a patient who presented with septic arthritis as the first clinical manifestation of a V vulnificus infection. The organism was subsequently identified in a synovial fluid aspirate.     

Two case reports of septic shock due to Vibrio vulnificus with liver cirrhosis

We have recently experienced a case of Vibrio vulnificus septicemia which occurred in a patient with hepatic cirrhosis, and as we were able to give early antibiotic treatment, the patient survived. We would like to report this case here together with another case experienced 2 years ago. Case 1 was a 58-year-old male who was attending our hospital as an outpatient for hepatic cirrhosis. At 5:30 pm on August 8, 1987, he consumed abalone and giant clam and at 9 pm complained of high fever with shaking chills. He was admitted to our department as an emergency case. Cefoperazone was administered resulting in a decline of fever on the following day. During the course of treatment he fell transiently into pre-DIC, but due mainly to the administration of antibiotics his condition was subsided. Case 2 was a 53-year-old male who was under medical care in our hospital for grave hepatic cirrhosis. On October 11, 1985, he consumed sushi and two days later suffered chills and pyrexia. A blood culture revealed Vibrio vulnificus. His condition improved transiently with administration of Cefazolin, but oliguria, hypotension and ascites occurred subsequently, and finally the patient died on the 22nd day.     

A case of fatal sepsis due to Vibrio vulnificus

A 66-year-old male with chronic alcoholic liver injury was admitted on July 27, 1986 to our hospital with complaints of high fever, convulsion and skin erythema. He had consumed raw fish 3 days before, and had a scratch wound over the right arm and left leg because he had slipped in a small stream in the woods the day before admission. He was already in shock state with sepsis of V. vulnificus and DIC on admission. Although the treatment with ABPC, CP, CAZ, MINO for sepsis, and Heparin & Antithrombin III for DIC was immediately begun, he died only 10 hours after admission. On autopsy, the skin lesion revealed phlegmon with necrotizing angitis and the liver showed fatty changes with Mallory's body. The causative organism was detected from the blood and on autopsy from the skin wound, bile juice, liver, spleen, kidney and bone marrow, and its type was determined as a V. vulnificus serovar 4. It was suspected that the route of infection in this case was the raw fish rather than via the wound because the water in which he had been wounded was fresh water and the bacterium was not detected from the water, shells, nor moss existing there.     

A case of septicemia type Vibrio vulnificus infection with necrotizing fasciitis rescued by lower extremity amputation]

We report a case of septicemia type Vibrio vulnificus infection. The patient was a 74-year-old man who had liver cirrhosis and hepatocelluler carcinoma. He felt a pain in the right femoral lesion after eating raw shellfish (Japanese "Umitake") two days ago. He was admitted to our emergency center due to his shock status and thrombocytopenia two days after the onset. We diagnosed necrotizing fasciitis due to Vibrio vulnificus infection, his life was saved by emergency amputation of the right lower extremity. The culture of the blood and vesicle fluid showed Vibrio vulnificus. There are some reports that the debridement was effective to necrotizing fasciitis due to Vibrio vulnificus infection, but these reports are all about single upper extremity lesion. As far as we know, this is the second report of lower extremity necrotiaong fasciitis due to septicemia type Vibrio vulnificus infection rescued by extremity amputation in Japan. The mortality of septicemia type Vibrio vulnificus infection with necrotizing fasciitis is very high, this is quite a valuable report in making a decision for therapy of septicemia type Vibrio vulnificus infection.     

An autopsied case of septicemia due to Vibrio vulnificus

A 63-year-old male with liver cirrhosis due to type-C hepatitis virus was admitted on June 14, 1999 to our hospital with complaints of dyspnea, and blisters, swelling and purpuras on his legs. He had consumed raw fish one or two days before. He was already in a state of shock with sepsis and disseminated intravascular coagulation shortly after the admission. Although treatment with MEPM and MINO for sepsis, and daltepalin sodium, antithrombin III and gabexate mesilate for disseminated intravascular coagulation was begun within 12 hours, he died only 30 hours after admission. The causative organism was detected from the blood and the contents of blisters, and was determined as Vibrio vulnificus. On autopsy, Vibrio vulnificus was also detected from skin and muscular tissue of his legs, but necrotizing fasciitis were not apparently revealed. Coagulating necrosis and acute tubular necrosis were verified in intestine and kidneys respectively probably due to ischemic changes. Pseudolobuli were formed and a small hepatocellular carcinoma was detected in the liver. Vibrio vulnificus has two infection channels; one is oral intake and the other is an external wound. The former is said to become serious. It has a rather short period from the starting of the symptom to death, and is highly fatal. If this bacteria is suspected by the clinical coarse of the patients or the laboratory examinations, it is necessary to dose effective antibiotics in its early stage. And for prevention, susceptible patients must be informed of the existence of this disease and the necessity of adequately heating raw seafood.     

A successful treatment of Vibrio vulnificus infection

A 65-year-old male patient with a history of alcoholism visited our outpatient clinic complaining of nausea and diarrhea followed by dizziness. Erythema and swelling with partial exfoliation on the right forearm to hand and right thigh were noticed. Vibrio vulnificus was isolated from the purulent discharge of the skin. Due to urgent and intensive treatment of bacterial shock and antimicrobial drugs, the patient fully recovered three months later. We believe that the patient survived from this fatal infection because; 1) the isolates were highly sensitive to a wide variety of antibiotics, 2) the antibiotic therapy was started immediately, with an alternative usage of different antibiotics, and 3) the liver dysfunction of the patient had not been severely damaged by alcohol before the infection.     

A collective review of Vibrio vulnificus infection in Japan

Vibrio vulnificus is found globally in marine coastal waters. Infection with this organism, via ingestion of raw shellfish or exposure to marine water, can cause necrotizing fasciitis and sepsis, which have high mortality and short latency. In Japan, many cases have been reported since 1980, mainly from hospitals in western prefectures. However, because of the sporadic nature of infection outbreaks, a thorough epidemiologic survey has not been done. We studied the epidemiological and clinical characteristics of Vibrio vulnificus infections reported in Japan from 1975 to 2005. We identified 185 cases using the medical article search engines Ichushi (Japan Medical Abstracts Society), CiNii (Citation Information by National Institute of Informatics), and PubMed over 30 years. The median age of patients was 59. The number of male patients was eight times the number of female patients; however, no significant difference in mortality was found between genders. In yearly distributions of patients, 20 cases were reported in 2001, a year in which we experienced more rainfall and a longer rainy season in Northern Kyushu. In monthly distribution, about 80% of cases were reported from July to September when sea water temperatures rise. About 40% of cases were reported in four prefectures around the Ariake Sea. The underlying disease indicated liver dysfunction in 90% of patients, but mortality was the same regardless of the infection pathway (oral ingestion or wound). Because of its rapid aggravation and high mortality rate, public education is important to prevent new cases. It is also highly recommended that patients with preexisting liver dysfunction avoid raw fish and limit exposure to marine water during the summer.     

创伤弧菌的药物敏感性

目的创伤弧菌(Vibrio vulnificus)是"人鱼共患病"的重要致病菌,从患"腐皮病"卵形鲳鲹(Trachinotus ovatus)鱼中分离到创伤弧菌TO-3,以阿莫西林等44种药物进行敏感性试验。结果对青霉素类抗菌药物不敏感,对头孢菌素类等抗菌药物很强的耐药性,而对氟哌酸、头孢氯氨苄、氟嗪酸、米诺环素、呋喃妥因、复达欣、萘啶酸、四环素、庆大霉素等抗菌药物高度敏感。在17味中草药中对五倍子、诃子、黄连、石榴皮等中草药极为敏感。     

A case of a sudden death from Vibrio vulnificus septicemia in a patient with liver cirrhosis

A 46-year-old male patient with alcoholic cirrhosis of the liver was carried to our out-patient clinic as he had developed shock while under routine follow-up, and died on the way to the hospital. He had been admitted several times since the diagnosis eight years ago, and was finally discharged from the hospital six weeks ago with improved physical condition and laboratory findings. A vesicle and bulla formation with phlegmon on the skin of right leg and sole of foot was noticed. Vibrio vulnificus was detected from the purulent discharge of the skin on culture. We conclude that the patient developed V. vulnificus-septicemia which resulted in sudden death. Since V. vulnificus infection may frequently take a fulminant course in patients with liver cirrhosis, adequate measures should be taken for early diagnosis and treatment to prevent the fatal outcome.     

创伤弧菌基因组学研究进展

创伤弧菌是人类三大致病弧菌之一,能够通过食源性传播或者伤口感染导致发病,近年来全球发病率逐步升高。随着新一代测序技术的发展,已有上百株创伤弧菌全基因组序列在国际公共数据库公布。这些数据为创伤弧菌基因组学研究提供了重要基础,并促进了对该病原菌遗传多样性、传播和致病机制的认识。本文从基因分型、种群结构和重要毒力因子3个方面对创伤弧菌基因组学研究进展进行归纳总结,以期为创伤弧菌感染、进化和防控研究提供借鉴。     

Quantitative detection of Vibrio vulnificus in seafood

To quantify the number of Vibrio vulnificus in shellfish, we compared the most probable number (MPN) combined with a culture (MPN-culture) or polymerase-chain reaction (PCR) assay (MPN-PCR) to a quantitative PCR assay. Enrichment in alkaline peptone water by MPN was conducted at 25 and 35 degrees C. Enrichment at 35 degrees C was superior or similar to enrichment at 25 degrees C in over 65% of samples by MPNculture and in more than 75% of samples by MPN-PCR assay. V. vulnificus was more easily isolated on chromogenic agar medium during culture, MPN-PCR assay was superior or similar to MPNculture in over 90% of samples by enrichment at 25 degrees C and to over 88% of samples by enrichment at 35 degrees C. The number of V. vulnificus by quantitative PCR assay was similar to that of MPN-PCR assay in 6 of 8 samples but not from MPNculture. V. vulnificus contamination was frequently detected in samples from Kyushu Island.     

A resected case of fibrolamellar hepatocellular carcinoma with chronic hepatitis (type B)]

We report a case of a 34-year-old woman who tested positive for HBs Ag with fibrolamellar hepatocellular carcinoma of the liver. The sister of this patient, who was also positive for HBs Ag, died of hepatocellular carcinoma (HCC). The patient showed elevation of alpha-fetoprotein. Abdominal CT scan showed a tumor in the posterior segment of the liver and hepatic angiography revealed marked neovascularity in the tumor. Partial resection of the liver was performed, and the histological diagnosis was fibrolamellar hepatocellular carcinoma. The patient is now tumor free and doing well 20 months after the operation.