Case Presentation: A 51-year-old male with a history of alcoholic liver cirrhosis presented with severe bilateral leg pain associated with nausea, vomiting, and diarrhea, after consuming raw oysters 36 hours prior to admission. Physical exam revealed an encephalopathic obese man with a temperature of 38.2oC, heart rate of 102 bpm, and BP of 85/50 mmHg. His lower extremities were non-blanching, ecchymotic, and tender to palpation with hemorrhagic bullae extending from both feet to the ankles, with proximal extension to the right knee compared to the left. His labs revealed leukocytosis, thrombocytopenia, acute renal failure, lactic acidosis, and hyperbilirubinemia. He was initiated on vasopressors for septic shock and started on broad spectrum antibiotics with vancomycin, clindamycin, doxycycline, and cefepime. His LRINEC score was 7 and he underwent emergent surgical debridement with RLE guillotine amputation for suspected necrotizing fasciitis and formalization of right AKA. Blood and wound cultures grew V. vulnificus. His antimicrobial regimen was then de-escalated to doxycycline and ceftriaxone based on susceptibility.

Discussion: Vibrio vulnificus is a halophilic, curved, gram negative bacillus found worldwide in marine environments. Infections result from consuming or handling contaminated seafood or exposing open wounds or broken skin to salt or brackish water. Vibrio infections can manifest as three syndromes – primary septicemia, skin and soft tissue infections (SSTI), and gastroenteritis. Vibrio necrotizing fasciitis should be considered in immunocompromised patients who have recently been exposed to seawater or consumed raw seafood.According to literature review, the incidence of V. vulnificus infections is estimated to be 0.05 per 100,000 per year in the US [2]. In 2014, 124 cases of V. vulnificus were reported to the CDC; among these individuals, 97 (79%) were hospitalized and 21 (18%) died. Predisposing factors for Vibrio infections include chronic liver disease, immunodeficiencies, and diabetes mellitus. A 2017 study [4] recommended initial therapy with cefepime combined with doxycycline or ciprofloxacin to cover gram-negative-resistant organisms and V. vulnificus while awaiting a microbiological diagnosis; once a diagnosis of V. vulnificus septicemia is confirmed, treatment can be changed to ceftriaxone combined with doxycycline or ciprofloxacin. The high mortality rate associated with primary septicemia demands aggressive preventative measures [1]. Physicians must educate patients with chronic liver disease to avoid eating raw oysters or shellfish especially those harvested from warm salt and brackish water and utilize protective clothing (gloves) when handling raw shellfish. Persons with open wounds should avoid contact with warm seawater.

Conclusions: Necrotizing fasciitis caused by V. vulnificus is a life-threatening SSTI with rapid progression to multiorgan failure within 24 hours and its case-fatality rate is reported to exceed 50% in primary septicemia [3]. Early recognition of V. vulnificus infections with prompt systemic antibiotics and surgical debridement can significantly improve patient outcomes.

IMAGE 1: Figure 1. Identification of V. vulnificus. (A) Green colonies on selective culture media containing thiosulfate citrate bile-salts sucrose (TCBS). (B) Blood agar from surgical wound cultures.

IMAGE 2: Figure 2. Identification of V. vulnificus. (C) Blood agar from blood cultures. (D) Curved, gram negative bacilli on gram stain under microscope.