Case Presentation: A 55-year old female with cirrhosis secondary to chronic hepatitis B infection non-adherent with Entecavir therapy presented with altered mental status, diarrhea, abdominal pain, and emesis. Vital signs revealed hypotension, tachycardia, and tachypnea. Exam revealed somnolence and significant abdominal distension without guarding, rebound, or rigidity. Laboratory evaluation was remarkable for a leukocytosis to 11.2, lactate 2.6, creatinine 1.3, INR 2.1, total bilirubin 2.2, ALT 328, AST 429, ALP 138. Right Upper Quadrant Ultrasound was negative for biliary pathology and CT abdomen and pelvis showed no acute abnormality. HBV DNA serum was 2,530,000. Patient was started on broad spectrum antibiotics; however, after blood cultures in two sets revealed vibrio Vulnificus growth after 7 hours, antibiotics were transitioned to IV cefepime, levofloxacin, and metronidazole. She gradually became more hypotensive, acedemic, and anuric that was refractory to vasopressors and continuous renal replacement therapy. The family made the decision to transition to comfort cares, and the patient soon subsequently expired. On further review, it was discovered that one week prior to presentation, the patient had dinner with boiled shrimp purchased locally and frozen Dungeness crab that was shipped from California. The timeline was consistent with the typical 1-7 day incubation period of Vibrio Vulnificus in a susceptible host, given the patient’s underlying chronic liver disease.
Discussion: Vibrio vulnificus is a gram negative bacteria that can cause diarrhea, wound infections, and sepsis. It is associated with the ingestion of raw or undercooked shellfish and is most common in patients with chronic, underlying illness, especially liver disease or hemochromatosis. Underlying liver disease is present in 24-31% of patients presenting with Vibrio vulnificus bacteremia. Vibrio vulnificus bacteremia has a fatality rate of 39%, which is the highest of all foodborne infections in the United States. Treatment for Vibrio vulnificus bacteremia entails combination therapy with doxycycline or minocycline plus either cefotaxime or ceftriaxone. Fluoroquinolines can be added for severe infections. Fatality rates for Vibrio vulnificus bacteremia have been shown to increase with delays in initiating bacteria-directed antibiotic therapy. Patients in high-risk groups, such as those with chronic liver disease, should avoid eating raw or undercooked shellfish.
Conclusions: Here we present a case of Vibrio vulnificus bacteremia in the setting of cirrhosis with associated mortality. It is important to recognize this disease entity for prompt diagnosis and management to help prevent associated morbidity and mortality as well as to recognize high risk patients and recommend that they avoid sources of disease.