Case Presentation: A 61-year-old man presented for a pre-transplant evaluation and complaint of dyspnea on exertion. He also complained of bilateral lower extremity edema and worsening abdominal distension. Past medical history was significant for alcoholic cirrhosis, hypothyroidism, and hypertension. His vital signs were within normal limits and findings on physical exam included diffuse anasarca with a non-tender distended abdomen. The initial laboratory results were notable for a sodium of 122, creatinine of 1.30, mildly elevated alkaline phosphatase and aspartate aminotransferase, total bilirubin of 6.3 and leukocytosis of 34,000. His bedside paracentesis fluid tested negative for spontaneous bacterial peritonitis. A chest X-ray revealed a possible infiltrate. The patient was given Cefepime for possible hospital-acquired pneumonia. On hospital day two, the admission blood culture grew gram-negative rods and the patient abruptly developed a non-tender, erythematous maculopapular rash extending from his right buttock to his right lateral thigh. He became hypotensive and was unresponsive to fluid resuscitation. He was started on broad-spectrum antibiotics. CT of his right lower extremity and an emergent exploratory dissection did not reveal signs of necrotizing fasciitis. His admission blood culture returned positive for Vibrio vulnificus. Upon further questioning, the patient recalled consuming large portions of raw oysters in the last week. He was treated with ceftriaxone and doxycycline for fourteen days and his rash improved significantly throughout his course. He was discharged with strict counseling regarding raw seafood.
Discussion: This case highlights the importance of educating patients with chronic liver disease or any immunocompromised state on avoiding consumption and handling of raw seafood or swimming in Vibrio infested waters to prevent fatal complications. It also illustrates the importance of prompt imaging and surgical evaluation for necrotizing fasciitis. While this patient had a favorable outcome, delayed differential diagnosis can result in significant morbidity and mortality.
Vibrio vulnficus is a gram-negative bacillus typically found in coastal environments such as the Gulf of Mexico. Consumption of raw or undercooked shellfish, handling of contaminated seafood or exposure of open wounds to water in which the organism lives may result in vibriosis. Manifestations range from mild gastroenteritis to primary septicemia, which has a mortality rate of nearly 50%. Patients with underlying chronic illnesses such as chronic liver disease, hemochromatosis, AIDS, malignancy or any immunocompromised state are particularly vulnerable to Vibrio vulnificus infections.
Conclusions: This patient was unaware of the dangers of consuming raw seafood with his underlying cirrhosis. It is important for internists to be aware of the clinical manifestations associated with Vibrio vulnificus. Finally, education is vital to preventing infection from this deadly bacterium.