Case Presentation: A 51- year old male with a past medical history of cirrhosis due to sarcoidosis, was admitted with worsening left lower extremity pain and swelling for two days. He remembered a pop in his left leg two days ago after performing squats followed by severe left lower extremity pain the morning after. Additionally, he was unable to bear weight. On arrival, he was hemodynamically unstable requiring pressor support and broad spectrum antibiotics. His physical exam was notable for an obese male with swelling, tenderness to palpation and crepitus in the left lower extremity. His abdomen was distended and he was not altered. His labs were remarkable for a leukocytosis of 35.7, lactic acidosis 8.48, and Cr 1.98 (baseline 1). A CT of his left lower extremity revealed nonspecific soft tissue edema without subcutaneous emphysema or fluid collection. Blood cultures were positive for Vibrio vulnificus. Upon further questioning, the patient that he had consumed oysters for dinner 10 days ago. He was started on piperacillin/tazobactam and doxycycline but continued to clinically decline. He required multiple debridements and ultimately due to severe myonecrosis with venous thrombosis needed an above-knee-amputation. His hospital course was complicated by kidney failure due to acute tubular necrosis necessitating dialysis. He clinically improved after the amputation and his antibiotics were narrowed to minocycline and doxycycline. He did not have complete renal recovery by time of discharge and required dialysis.
Discussion: Cirrhotic patients are well-known to suffer from unique medical complications. One that is readily well-known but may not be as recognized due to a low prevalence is a severe infection from Vibrio vulnificus. Over 90% of patients with primary septicemia from V. vulnificus report a recent history of eating raw oysters, which have increased concentrations of V. vulnificus compared to surrounding waters, especially in warm temperatures or with drops in salinity. When compared to other foodborne illnesses in the United States, V. vulnificus has the highest fatality at 39% of cases. Interestingly, 75% of infected patients present with bulbous lesions, which this patient did not have. However, V. vulnificus acutely leads to shock in one-third of patients with primary septicemia with mortality up to 90%, requiring urgent diagnosis. Fasciotomy within 24 hours of presentation may reduce mortality to 10-50%, with repeat debridements necessary to reduce bacterial load. Patients with MELD scores greater than 20 are associated with higher mortality compared to other cirrhotic patients.
Conclusions: This case is an example of the presentation of primary V. vulnificus bacteremia complicated by necrotizing myofasciites associated with the consumption of oysters. Early diagnosis and surgical intervention is crucial due to high risk of amputations and multiorgan failure. We need to be cognizant of seafood exposure in cirrhotics as prompt diagnosis could potentially be life-saving.