Syndromes of Vibrio vulnificus infections. Clinical and epidemiologic features in Florida cases, 1981-1987

STUDY OBJECTIVE: To describe the clinical and epidemiologic features of Vibrio vulnificus infections. DESIGN: Case series based on notifiable disease report forms and patient medical records. SETTING: Cases reported to the Florida Department of Health and Rehabilitative Services from 1981 to 1987. Patients: Sixty-two patients with V. vulnificus infection. MEASUREMENTS AND MAIN RESULTS: The three clinical syndromes found were primary septicemia (38 patients), wound infections (17 patients), and gastrointestinal illness without septicemia or wound infections (7 patients). Mortality rate was highest for patients with primary septicemia (55%; 95% CI, 38 to 71) and intermediate for wound infections (24%; 95% CI, 8 to 51): no deaths occurred in those with gastrointestinal illness. Common characteristics and exposures in patients with these syndromes included recent history of raw oyster consumption for primary septicemia and gastrointestinal illness, liver disease for primary septicemia, and either having a preexisting wound or sustaining a wound in contact with seawater for wound infections. CONCLUSIONS: Clinicians should ask about marine exposures in patients with underlying medical conditions, especially liver disease, who present with unexplained febrile illness, and should start appropriate therapy promptly.     

Vibrio vulnificus septicemia in Spain

Vibrio vulnificus is a virulent marine organism, able to contaminate sea-food. It usually produces bacteremia associated with secondary skin lesions in patients with underlying conditions, such as hepatic cirrhosis. We report a case of septic shock and characteristic skin lesions, due to Vibrio vulnificus in a patient with cirrhosis, who had eaten raw oysters. The patient survived in spite of the severity of the clinical picture. We conclude that Vibrio vulnificus infection must be considered in the differential diagnosis of sepsis and skin lesions.     

Vibrio vulnificus infection after raw oyster ingestion in a patient with liver disease and acquired immune deficiency syndrome-related complex

Sepsis, peritonitis, and gastroenteritis developed in a 45-yr-old homosexual man 1 day after ingestion of raw oysters. The patient had chronic active hepatitis and cirrhosis with hepatitis B virus and delta-infection. He also had persistent generalized lymphadenopathy associated with HTLV-III antibody positivity. Vibrio vulnificus was isolated from the patient's blood and peritoneal fluid as well as from the same batch of oysters at the restaurant where the patient had visited. To our knowledge, this is the first report relating direct microbiologic and clinical evidence that the infection is acquired through the gastrointestinal tract by consuming raw seafood containing the pathogen. This is also the first reported case of peritonitis associated with sepsis and gastroenteritis from this organism. Patients with liver disease and other immunocompromised states should be warned about such life-threatening infections and complications associated with the consumption of raw oysters or other undercooked seafoods.     

Vibrio vulnificus Septicemia After Handling Tilapia Species Fish: A Canadian Case Report and Review.

BACKGROUND: Vibrio vulnificus can cause a necrotizing soft tissue infection or primary septicemia; these infections are collectively known as vibriosis. This bacterium is commonly found within molluscan shellfish. Primary septicemia is often fatal, principally affecting persons with chronic liver disease. CASE PRESENTATION: A fatal case of V vulnificus sepsis that developed in a patient with chronic hepatitis B and chronic renal failure is reported. Diagnosis was made by isolation of the pathogen by blood culture. Upon further questioning, the patient's family recounted that the patient had handled and ingested Tilapia species fish in the hours preceding the patient's presentation. Despite treatment with doxycycline and cefotaxime, in conjunction with supportive care in the intensive care unit, the patient died on day 7 from multiple organ dysfunction. CONCLUSION: The present case highlights the need to consider V vulnificus in the microbiological differential diagnosis when a person presents with sepsis and bullous cutaneous lesions. The importance of educating patients with liver disease (and certain other chronic diseases) about the need to be cautious when handling or consuming seafood is underscored.     

Rapid detection of Vibrio vulnificus using a loop-mediated isothermal amplification method

Vibrio vulnificus is found in marine waters near the coast around the world. Infection with this gram-negative rod, via ingestion of raw seafood or via a skin wound following contact with contaminated estuarine or marine water, can cause necrotizing fasciitis and sepsis. Most of patients with Vibrio vulnificus infection have underlying liver dysfunction or diabetes mellitus. Due to the high mortality and short latent periods, control of this infection depends on early identification of the bacterial species and prompt initiation of intensive care. Accordingly, the development of a technique that can identify this microbe quickly and accurately is of great importance. Loop-mediated isothermal amplification (LAMP) is a novel nucleic acid amplification method to detect specific genes with rapidity and high sensitivity. In this study, we developed LAMP for the detection of Vibrio vulnificus. Using 28 Vibrio vulnificus strains and 53 other bacterial strains, we confirmed the high specificity of this method. Moreover, our LAMP method also showed high sensitivity, with a minimum detection level of one colony-forming unit per test. Furthermore, we developed simplified and conventional pretreatments for the method using experimental animal models. All of these attempts have lod to our non being able to detect Vibrio vulnificus within 1 hour.     

Achilles tendinitis in Vibrio vulnificus sepsis: a rare presentation

Vibrio vulnificus infection commonly presents as sepsis or wound infection. A case of alcoholic liver cirrhosis developed acute left heel pain and swelling 2 days after ingesting raw fish. Two sets of blood cultures indicated V. vulnificus. HLA-B27 was negative. Ultrasonography revealed left Achilles tendinitis. Fluid aspirated from the left retrocalcaneal bursa was sterile. The patient recovered completely 3 weeks after treatment. To our knowledge, V. vulnificus septicaemia with Achilles tendinitis, which may be the only indication of reactive arthritis (ReA), has not been reported previously. Prompt recognition of this life-threatening infection and adequate treatment with antibiotics is vital.     

Vibrio vulnificus infection

We report 3 cases of Vibrio vulnificus infections from Taiwan. Patient 1, who manifested symptoms of primary septicemia, died after 2 days. Patient 2, who had a wound infection and signs and symptoms of sepsis but negative blood cultures, responded to tobramycin and chloramphenicol plus surgical debridement, and recovered after 26 days of hospitalization. Patient 3 had secondary septicemia originating from a wound inflicted by a shrimp. Originally, the patient seemed to respond to ceftazidime and amikacin treatment along with surgical debridement, but subsequently died from adult respiratory distress syndrome (ARDS) induced by several episodes of aspiration which occurred after initial clinical improvements. We conclude that, for patients with severe wounds and evidence of V. vulnificus infection, an appropriate, powerful antibiotic, such as one of the third generation cephalosporins should be used as initial therapy unless the nature of the infection indicates other treatment.     

Spontaneous Vibrio vulnificus Peritonitis and Primary Sepsis in Two Patients with Alcoholic Cirrhosis

Two patients with alcoholic cirrhosis were seen on two separate occasions for fever, swollen legs, petechial hemorrhage, purpura, and cutaneous bullae. One patient ate oysters 2 days before the onset of illness. Vibrio vulnificus, a lactose-positive halophilic vibrio, was isolated from the ascitic and cutaneous fluid in both cases, and from the blood in one of the two cases. Both isolated strains were sensitive to the antibiotics given to the patients from the beginning; however, both patients died, one from septicemic shock and the other from massive esophageal variceal hemorrhage. Autopsies in both patients revealed alcoholic cirrhosis, hemorrhagic necrosis of the terminal ileum, intraalveolar hemorrhage, petechial hemorrhage in the peritoneum, and nonspecific acute inflammation of the dermis with vasculitis. Physicians should consider V. vulnificus in the differential diagnosis of cirrhotic patients with sepsis, primary skin lesions, and spontaneous bacterial peritonitis with or without history of recent oyster ingestion.     

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 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.     

Mouse skin damage caused by cytolysin from Vibrio vulnificus and by V. vulnificus infection

Light and electron microscopy of mouse skin damage caused by intradermal infection with a virulent strain of Vibrio vulnificus and by a single intradermal injection of the cytolytic toxin produced by the bacterium revealed similar structural alterations. The epidermis was intact; however, the infection and toxin produced acute cellulitis characterized by extensive extracellular edema; disorganization of collagen bundles; large accumulations of cell debris and plasma proteins; damaged or necrotic fat cells, capillary endothelial cells, and muscle cells; and mild inflammatory cell infiltration. The virulent strain of V. vulnificus produced a capsule and was resistant to phagocytosis in vivo, whereas a weakly virulent strain of the bacterium did not produce a capsule and was readily phagocytized and digested. Factors that may be important in the pathogenesis of V. vulnificus wound infections include a capsule that inhibits phagocytosis and an extracellular cytolytic toxin that is responsible, at least in part, for the severe tissue damage characteristic of such wound infections.     

Chronic liver disease and consumption of raw oysters: a potentially lethal combination--a review of Vibrio vulnificus septicemia

Vibrio vulnificus septicemia is the most common cause of fatality related to seafood consumption in the United States. It occurs predominantly in patients with chronic liver disease following consumption of raw oysters. V. vulnificus is a highly virulent human pathogen, normally found in warm estuarine and marine environment. It lodges in filter feeders like oysters. The onset of this illness is abrupt, rapidly progressing to septic shock with a high mortality. Clinicians managing patients with chronic liver disease need to educate their patients of the risk associated with the consumption of raw seafood, especially oysters. A high index of suspicion is necessary for appropriate treatments, as doxycycline, the antibiotic of choice, is not usually a part of the empiric therapy for septicemia. The high mortality associated with this septicemia demands aggressive preventive measures: susceptible individuals must be forewarned by signs displayed in restaurants; physicians must educate patients with chronic liver disease about the risk of raw oyster consumption; and harvesting methods which reduce contamination by V. vulnificus must be utilized.     

Vibrio vulnificus bacteremia associated with chronic lymphocytic leukemia, hypogammaglobulinemia, and hepatic cirrhosis: relation to host and exposure factors in 252 V. vulnificus infections reported in Louisiana

BACKGROUND: Vibrio vulnificus infection in persons with B-chronic lymphocytic leukemia (B-CLL) or hypogammaglobulinemia has been reported infrequently. PATIENT AND METHODS: A woman with B-CLL, hypogammaglobulinemia, and hepatic cirrhosis died of V. vulnificus bacteremia after eating cooked shrimp and crabs. We reviewed host and exposure data in 252 cases of V. vulnificus infection reported in Louisiana during the interval of 1980 through 2004. RESULTS: V. vulnificus was isolated from blood in 122 cases (48.8%). Preexisting conditions in 138 cases included liver disease (41.3%), malignancy (13.8%), and immunosuppression (9.4%). The prevalence of preexisting conditions was significantly greater in cases with positive blood cultures than in cases with positive wound or stool cultures. Exposure data in 116 cases revealed crab consumption without raw oyster consumption or seawater exposure in 3.4%. CONCLUSION: The present patient had several conditions associated with increased risk of V. vulnificus infection and bacteremia, especially hepatic cirrhosis, but her route of exposure to V. vulnificus was unusual.     

Deferasirox plus ciprofloxacin combination therapy after rapid diagnosis of Vibrio vulnificus sepsis using real-time polymerase chain reaction

We report a case of Vibrio vulnificus sepsis developed during deferoxamine therapy for transfusional iron overload due to secondary hemochromatosis of myelodysplastic syndrome. The patient was treated with adjuvant deferasirox in combination with ciprofloxacin, after rapid diagnosis of V. vulnificus sepsis using real-time polymerase chain reaction (PCR). This case suggests that since V. vulnificus DNA can be detected by real-time PCR for several days even after patients receive antibiotics, real-time PCR for V. vulnificus is a very useful test for establishing an early diagnosis, even if a patient has been treated with antibiotics prior to admission.     

Vibrio vulnificus infection: clinical and bacteriological analysis of four cases

Vibrio vulnificus (V. vulnificus) infection has recently been drawing attention as a high mortality disease especially in a patient with the preexisting chronic liver disease. The illness caused by V. vulnificus is divided into three groups such as primary septicemia, wound infection and gastrointestinal illness. Primary septicemia, which is the most common in Japan, is defined as a systemic illness presenting fever or hypotension with recovery of V. vulnificus from blood or tissue without the apparent primary focus of infection. We diagnosed four cases as infectious diseases of V. vulnificus by isolating it from each clinical material in Kurashiki Central Hospital from 1984 through 1997. We investigated clinical manifestations of the four cases including season of the onset, presence of drinking habit, underlying diseases, consumption of raw seafood, symptoms, presence of disseminated intravascular coagulation (DIC) or shock, laboratory data, administered antibiotics and the outcomes of the treatment. And for each strain, we also performed in vitro drug susceptibility tests. The age of the patients ranged from 49 to 61 years old (mean 56), and all of the patients were male. Each of them had a chronic liver disease as an underlying disease. Two of them had a history of raw seafood consumption prior to the onset of the illness. Skin manifestations appeared in two of the four patients. All the patients complicated septic shock and DIC. V. vulnificus was isolated from the venous blood cultures of them. Three of the four were given a diagnosis of primary septicemia and one was made a diagnosis of acute cholecystitis which has never been reported previously. Three of the four patients died and only the rest was alive as a result of antimicrobial therapy. In the sensitivity tests, the four strains were revealed to be very sensitive to the antimicrobials such as minocycline, cephalosporins of the third generation and carbapenems. Once patients with a chronic liver disease are infected with V. vulnificus, their prognosis is poor. Every effort should be made to advise not to have uncooked seafood. Physicians should be informed about the characteristics of the disease caused by this bacteria and treat any suspicious case promptly and appropriately.     

Vibrio vulnificus septicaemia presenting as spontaneous necrotising cellulitis in a woman with hepatic cirrhosis

Vibrio vulnificus is a virulent marine organism commonly found in Hong Kong coastal waters which contaminates local sea-food. It may produce a primary septicaemia, often associated with secondary skin lesions, following ingestion of raw shell fish. We report a rapidly fatal case of primary V. vulnificus septicaemia in a 50-year-old housewife with post-hepatitic cirrhosis presenting as spontaneous necrotising cellulitis of the legs. V. vulnificus infection should be considered in patients with a history of liver disease with acute septicaemia and characteristic skin lesions.     

Basic studies on Vibrio vulnificus infection: isolation of V. vulnificus from sea water,sea mud,and oysters

To clarify the environmental distribution of Vibrio vulnificus, sea water, sea mud, and oysters were examined at 13 sites, i.e. 4 sites in the Tokyo Bay (eastern Japan) and 9 sites (5 sites for oysters) in Tokushima Prefecture (western Japan). 1. V. vulnificus was isolated from 80 (54.8%) of the 146 samples of sea water examined. It was isolated from 19 (41.3%) of the 46 samples from western Japan and 61 (61.0%) of the 100 samples from eastern Japan. 2. It was isolated from 40 (40.8%) of the 98 samples of sea mud obtained in eastern Japan. 3. It was isolated from 655 (30.3%) of the 2,165 samples of oysters. They were 30 (9.7%) of 309 samples from western Japan and 625 (33.7%) of 1,856 samples from eastern Japan. 4. The density of V. vulnificus was 0.3-1.1 x 10(6) MPN/L in seawater, 0.3-1.1 x 10(5) MPN/100 g in sea mud, and 0.3-1.1 x 10(7) MPN/100 g in oysters. 5. Seasonally, V. vulnificus was isolated from 44 (6.2%) of the 713 samples in spring, 450 (72.6%) of the 620 samples in summer, 264 (51.8%) of the 510 samples in fall, and 17 (3.0%) of the 56 samples in winter. Thus, the isolation rates of V. vulnificus from sea water and oysters tended to be higher in eastern Japan than in western Japan and to be highest in summer, then, in fall.     

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.     

Vibrio vulnificus infection in Taiwan: report of 28 cases and review of clinical manifestations and treatment.

From May 1985 through July 1990, 28 episodes of Vibrio vulnificus infection in 27 patients were encountered in five major hospitals in Taiwan. The ages of patients ranged from 19 to 76 years; the ratio of male to female patients was 2:1. Eighteen episodes manifested as bacteremia and eight as wound infections alone. One patient each developed gastroenteritis and pneumonia after nearly drowning. Twenty-three patients exhibited skin manifestations. Twenty patients had underlying diseases. All patients were treated with antibiotics, and 14 also underwent some form of surgical treatment (incision and drainage, fasciotomy, debridement, or amputation). Thirteen of the 28 episodes were preceded by precipitating factors; most were due to ingestion of seafood or exposure of abraded skin to salt water. Ten of the 18 septicemic patients died--most within 48 hours of hospitalization. One patient without bacteremia who had a wound infection died. Results of in vitro susceptibility studies suggested that ampicillin or a third-generation cephalosporin would be effective. Susceptibility to aminoglycosides was observed for greater than 90% of isolates. We recommend combined therapy with a third-generation cephalosporin or ampicillin and an aminoglycoside along with appropriate surgical therapy for the treatment of V. vulnificus infection.     

Vibrio vulnificus as a health hazard for shrimp consumers.

Over the last 30 years, a number of Vibrio species found in the aquatic environment have been indicated as cause of disease in human beings. Vibrio vulnificus is an emergent pathogen, an invasive and lethal marine bacterium related to wound infection and held accountable for gastroenteritis and primary septicemia. It occurs quite frequently in marine organisms, mainly in mollusks. This study aimed at isolating and identifying strains of V. vulnificus based upon the analysis of twenty samples of seabob shrimp, Xiphopenaeus kroyeri (Heller), purchased at the Mucuripe fish market (Fortaleza, Brazil). TCBS agar was used to isolate suspect strains. Seven of twenty-nine strains isolated from six different samples were confirmed as such by means of biochemical evidence and thus submitted to biological assays to determine their virulence. The susceptibility of the V. vulnificus strains to a number of antibiotics was tested. None of the V. vulnificus strains showed signs of virulence during a 24-hour observation period, possibly due to the shedding of the capsules by the cells. As to the results of the antimicrobial susceptibility tests, the seven above-mentioned V. vulnificus strains were found to be sensitive to nitrofurantoin (NT), ciprofloxacin (CIP), gentamicin (GN) and chloramphenicol (CO) and resistant to clindamycin (CI), penicillin (PN) and ampicillin (AP).