A 64–year–old man presented with fatigue, fever, and bilateral lower extremity pain. He had a history of Laennec’s cirrhosis and was awaiting liver transplant. He noted no recent travel, ill contacts or occupational exposures. He had no headache, chest pain or abdominal pain. His blood pressure was 62/35 mmHg, heart rate was 114 bt/min, and temperature was 98.1°F. He was drowsy, jaundiced, had significant abdominal distension. His lungs were clear, and heart sounds were soft but normal. Neurologic examination was normal. There were tender ecchymotic lesions on both ankles. Two hours later, ecchymotic lesions appeared on his calves and medial thighs. Later it was learned that he had consumed raw oysters four days earlier. Intravenous ceftazidime and doxycycline were started emergently. Three hours later hemorrhagic bullae had formed and he lost pain sensation in his legs. He underwent emergent surgical exploration that revealed significant necrotizing fasciitis with characteristic “dish–water” fluid expressed from his wounds. Blood cultures confirmed Vibrio vulnificus sepsis. He expired on the second hospital day.
The hospitalist is frequently charged with the initial management and care of septic patients. The surviving sepsis campaign has stressed the importance of early goal directed therapy and initiation of antibiotics to improve survival. Identifying the source of infection is of equal importance, especially in patients who may be at risk for virulent forms of sepsis. Vibrio vulnificus is a gram–negative bacterium that’s found in seawater when the water temperature is above 20°C. Filter–feeding shellfish concentrate the bacteria and typically have levels up to twice that of surrounding water. Most cases of Vibrio infection are acquired from direct recreational or occupational exposure to sea water. Direct ingestion of the bacteria, especially for patients without an immune system to fight the infection, is of equal importance. Oysters harvested in the United States are identified as the vector of infection in 90% of people with no occupational exposures. Individuals with alcoholic cirrhosis, chronic hepatitis, hereditary hemochromatosis, diabetes mellitus, rheumatoid arthritis, chronic renal failure, thalassemia major and lymphoma are at increased risk for serious infection with V. vulnificus.
Sepsis due to V. vulnificus carries a high mortality rate. Ninety percent of patients who are hypotensive when they arrive won’t survive. Skin manifestations include rapidly progressive, painful cellulites with extensive skin necrosis, myositis, and necrotizing fasciitis with large hemorrhagic bullae. Antibiotic coverage should be started immediately in anyone with a fever, hypotension, predisposing diagnoses, and characteristic skin lesions. Preferred antibiotic regimen includes combination of doxycyline and ceftazidime. Surgical debridement is urgent for rapidly progressing rashes with necrotic appearing lesions.