Vibrio vulnificus: halophilic (salt-requiring) gram-negative motile bacillus commonly found in estuaries and coastal areas 1. History a.

5th century B.C. Hippocrates describes a fatal foot wound infection described as black bullous skin lesions leading to sepsis and death within 48 hours b. 1970 patient with leg wound infection with gangrene that required below-the-knee amputation and endotoxin-related septic shock after exposure to New England coastal waters 2. Pathology a. Lodges in tissues of filter-feeding mollusks b. Possesses a chitinase digestive enzyme that breaks down glycosidic bonds in chitin which allows Vibrio to embed themselves in the exoskeleton of most arthropods c. Produces extracellular toxins destroys tissue and basement membranes in blood vessels d. Possess bacterial capsule that imbeds immune response 3. Clinical Characteristics a. Wound infection (45%) b. Primary septicemia (43%) c. Gastrointestinal tract-limited infection (5%) d. Atypical manifestations: i. Meningitis, peritonitis, corneal ulcers, osteomyelitis, otitis, urinary tract infection, myositis, and rhabdomyolysis e. Isolated from blood cultures, aspiration, or stool cultures (requires thiosulfate-citrate-bile salts-sucrose agar for isolation) 4. Epidemiology a. Though infections can occur throughout the year, most occur during the warmer months (May October) b. Grows best in warm waters (over 22 C), has been isolated from all coastal regions (Gulf of Mexico in particular) c. Considered an opportunistic human pathogen, most commonly affecting immune-compromised individuals i. Kidney disease, diabetes, cancer, hemochromatosis, achlorhydria ii. Especially susceptible are in cirrhosis, alcoholic liver disease or chronic hepatitis B or C 1. Reduced immune response 2. In presence of portal hypertension, directly enters portal system (bypassing hepatic reticuloendothelial system) 3. Bacterial growth bolstered by high iron stores (seen in liver disease) 5. Source a. eating seafood (especially raw oysters)

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i. in 96% of primary septicemia cases, patient reported consumption of raw oysters during the 7 days preceding the illness (89% men) ii. With chronic liver disease: x80 more likely to develop infection and x200 more likely to die from infection compared to those without chronic liver disease b. entry through open wounds during swimming or wading in infected waters i. often necrotizing c. puncture wounds from the spins of fish (e.g. tilapia) Signs and symptoms a. Vomiting b. Diarrhea c. Abdominal pain d. Blistering dermatitis (similar to pemphigus or pemphigoid) e. Dissemination into bloodstream in immune compromised (chronic liver disease) Prognosis a. Cutaneous wounds have 25% mortality b. Septicemia has 50% mortality (most patients die within 48 hours of infection c. Total mortality in treated patients (ingestion and wound) approx. 33% Incidence a. 100 persons in the United States every year with approximately 50 deaths per year Treatment a. Doxycycline 100 mg IV or Ceftazidime 1-2 g IV Q8H b. Supportive therapy c. Surgical debridement, fasciotomy or limb amputation