A 57‐year‐old presented with 1 week of worsening right lower‐extremity swelling and tendemess. He reported initially injuring his leg or a metal pot during a seafood boil. He did not seek medical care as he thought he could self treat with topical antibiotics and analgesics. His past history included hypertension and significant alcohol abuse. On presentation, he was alert only to person, hypotensive, tachycardic, and tacbypneic. The cardiac, pulmonary, and abdominal examinations were normal. He had an edematous, tender right leg with erythema extending from The knee to The foot. There was significant skin breakdown with gangrenous changes and hemorrhagic bullae surrounding the site of his initial injury. Chemistry demonstrated a gap metabolic acidosis and acute renal failure; Ihe remaining electrolytes were normal. Imaging of the extremity demonstrated significant soft tissue swelling but no osteomyelitis. He underwent massive debridement with a fasciotomy from the right knee to the foot. Blood cultures obtained prior To the initiation of antibiotics revealed Vibrio vulnificus. Doxycycline was added to his antibiotic regimen. He required supportive care including norepinephrine for blood pressure support and treatment for alcohol withdrawal. He later underwent further debridement, with an autograft reconstruction of the right lower leg. His renal failure resolved, and he was subsequently discharged home with follow‐up.
Cellulitis is a commonly encountered presentation by the hospitalist. Although most cases of cellulitis respond to antibiotics alone, the hospitalist must be adept at identifying signs and symptoms that herald more serious infections. The key factors for diagnosis of V. vulnificus infection in our patient relied on a Thorough history, covering alcohol use and seafood exposure, as well as detailed physical examination. The history of alcohol abuse and the water‐based exposure were risk factors that raised the pretest probability of V. vulnificus. The presence of gangrenous changes and hemorrhagic bulla suggested an infection lhat was sub‐dermal with signs of hypotension and delirium also suggesting a systemic infection. V. vulnificus is a Gram‐negative, motile, curved bacterium that thrives in warm seawater. Most infections are attributed to consuming raw oysters harvested during summer months. However, the hospitalist should recognize, as with our patient, that inoculation can occur with direct wound exposure to warm seawater or handling of raw seafood.
Patients typically present with nonspecific findings including fever, diarrhea, and nausea with vomiting. However, most will proceed to the typical skin findings of severe cellulitis with bullae. Doxycycline and ceftazidime along with supportive care and surgical debridement is the recommended treatment. Early treatment with appropriate antibiotics is the only chance for survival of this infection; for those with hypotension, the mortality rate is as high as 90%.
R. Drennan, none; L. Richey, none.