Case Presentation: 40 year-old male with history of alcoholic liver cirrhosis presented with acute onset of fever with severe left lower extremity pain with no history of local wound or trauma. Exam revealed a patient in moderate distress with temperature of 38.6 °C, heart rate of 104 bpm, and BP of 123/74 mmHg. Abdomen was mildly tender and his left lateral lower extremity was non-blanching, ecchymotic, tender to palpation, but had intact sensation and strength with no crepitus. On laboratory evaluation, patient was noted to have an elevated creatinine (1.6 mg/dl, baseline: 0.7mg/dl), bicarbonate 16.2 meq/l and hyperlactatemia (5.4 meq/l, normal 0.5-2.2 meq/l). Patient was started on IV ceftriaxone and Vancomycin for cellulitis and empiric coverage for spontaneous bacterial peritonitis. Despite antibiotics, the patient continued to decline, with progression of leg pain and multiple fever spikes. Repeat exams showed increased tension on lower leg compartments, including pain with passive range of motion prompting concern for compartment syndrome. Four-compartment fasciotomy was performed by surgery the following day, and both blood and tissue cultures returned positive for Vibrio Vulnificus. Later history revealed that the patient had eaten raw oysters two days prior to presentation. Prior iron studies revealed an 85% iron saturation and ferritin of 305 ng/ml (normal: 27-300 ng/ml), consistent with iron overload due to cirrhosis. The patient recovered slowly over the next two weeks with the addition of Doxycycline to ceftriaxone and surgical wound care.

Discussion: Vibrio Vulnificus is a marine gram-negative bacterium that can cause serious wound infections, primary septicemia and diarrhea. Septicemia usually follows ingestion of raw or poorly cooked seafood and can be fatal in up to 50% of chronically ill patients. It is especially virulent in those with liver cirrhosis and iron overload, due to the necessity of iron for Vibrio’s survival. Wound infections are seen after injury to the skin in a marine environment or from exposure of preexisting wounds to seawater. Vibrio Vulnificus infection should be suspected in patients with cirrhosis presenting with febrile illness and soft tissue infection, especially if temporally related to exposure to eating seafood or exposure of preexisting wounds to seawater. Soft tissue infections in the absence of wound are rare, which highlights the importance of this case.

Conclusions: This unusual cause of skin and soft tissue infection is important for hospitalists, as skin infections are very common causes for admission to hospitals, and this diagnosis requires a high index of suspicion as it will not respond to antibiotics typically used to treat skin flora.