- Case report
- Open Access
- Open Peer Review
Vibrio parahemolyticus septicaemia in a liver transplant patient: a case report
- Rajeev R Fernando1Email author,
- Sujatha Krishnan1,
- Morgan G Fairweather1 and
- Charles D Ericsson1
https://doi.org/10.1186/1752-1947-5-171
© Fernando et al; licensee BioMed Central Ltd. 2011
- Received: 22 March 2010
- Accepted: 6 May 2011
- Published: 6 May 2011
Abstract
Introduction
Vibrio parahemolyticus is the leading cause of vibrio-associated gastroenteritis in the United States of America, usually related to poor food handling; only rarely has it been reported to cause serious infections including sepsis and soft tissue infections. In contrast, Vibrio vulnificus is a well-known cause of septicaemia, especially in patients with cirrhosis. We present a patient with V. parahemolyticus sepsis who had an orthotic liver transplant in 2007 and was on immunosuppression for chronic rejection. Clinical suspicion driven by patient presentation, travel to Gulf of Mexico and soft tissue infection resulted in early diagnosis and institution of appropriate antibiotic therapy.
Case presentation
A 48 year old Latin American man with a history of chronic kidney disease, orthotic liver transplant in 2007 secondary to alcoholic end stage liver disease on immunosuppressants, and chronic rejection presented to the emergency department with fever, vomiting, abdominal pain, left lower extremity swelling and fluid filled blisters after a fishing trip in the Gulf of Mexico. Samples from the blister and blood grew V. parahemolyticus. The patient was successfully treated with ceftriaxone and ciprofloxacin.
Conclusion
Febrile patients with underlying liver disease and/or immunosuppression should be interviewed regarding recent travel to a coastal area and seafood ingestion. If this history is obtained, appropriate empiric antibiotics must be chosen. Patients with liver disease and/or immunosuppresion should be counselled to avoid eating raw or undercooked molluscan shellfish. People can prevent Vibrio sepsis and wound infections by proper cooking of seafood and avoiding exposure of open wounds to seawater or raw shellfish products.
Keywords
- Chronic Kidney Disease
- Soft Tissue Infection
- Necrotizing Fasciitis
- Chronic Rejection
- Fishing Trip
Introduction
Vibrio parahaemolyticus is a facultative anaerobic gram-negative, flagellated, halophilic, asporogenous, bacterium that inhabits marine and estuarine environments [1]. Despite its broad distribution, V. parahemolyticus infections in the United States of America are most common in individuals living in the states bordering the Gulf of Mexico [2–4]. Water temperature, salinity and turbidity correlate with increased densities of pathogenic V. parahemolyticus[2, 5]. Filter feeding animals such as shellfish, blue crabs, finfish and planktonic copepods concentrate V. parahemolyticus. Consumption of raw or undercooked seafood or exposure of wounds to warm seawater may lead to vibrio infections. The most common clinical presentation is self-limited gastroenteritis (59%), but wound infections (34%), primary septicaemia (5%) and other infection sites (2%) may also occur [3]. Persons who are immunocompromised or who have liver disease are at particularly high risk for severe vibrio infections. Necrotizing soft tissue infections are exceptional and may cause significant morbidity and mortality from invasion and destruction of fascial planes as well as the release of cytokines [6, 7].
Case presentation
Vibrio parahemolyticus cellulitis. A. Large hemorrhagic bulla of left lower extremity. B. Blistering cellulitis of the left foot. Bedside debridement excluded necrotizing fasciitis.
Discussion
Vibrio species are a rare cause of soft tissue infections. Exceedingly rare is soft tissue infection with V. parahemolyticus, which can occur in patients with underlying co-morbidities such as cancer, liver disease, kidney disease, heart disease, recent gastric surgery, or antacid use [4, 6]. Wound infection may occur after contamination of skin laceration with warm seawater, after direct trauma with pieces of shellfish, fishhooks or utensils contaminated with seawater or translocation from the gastrointestinal tract [6]. Bacteraemia and septicaemia occur in three to five percent of Vibrio infections and is a concern in immunocompromised patients especially those with liver disease [3]. Superficial infection can extend to deeper soft tissue causing cellulitis or necrotizing fasciitis and may require radical surgical debridement [6]. The diagnosis of V. parahemolyticus soft tissue infection is difficult. Clinical suspicion must be high in people returning from coastal areas such as the Gulf of Mexico especially with a history of raw seafood consumption or extremity wounds. Soft tissue infections are hard to recognize and difficult to differentiate from necrotizing fasciitis. Our patient underwent a bedside exploration and then debridement to definitively exclude necrotizing fasciitis. V. parahemolyticus causes skin and soft tissue necrosis which can further confound the clinical picture. Recognition of necrotizing soft-tissue infections is critical for survival because they may carry a high mortality rate. Surgical debridement must be complemented with broad spectrum antibiotic therapy. V. parahemolyticus demonstrates beta-lactamase activity in as many as 50% of isolates [8]. The vibrios are susceptible most notably to fluoroquinolones, third generation cephalosporins and doxycycline, Septicaemia and serious soft tissue infections can be treated with the synergistic combination of ceftazidime plus doxycycline or ceftazidime plus a fluoroquinolone with the latter combination being more potent in vitro[9]. There is evidence that patients with cirrhosis and end stage liver disease are susceptible to Vibrio infections [10]. This is the first case, however, in which a Vibrio parahemolyticus species infection has been reported in a liver transplant patient. It is imperative to educate patients with compromised liver function of the necessity of avoiding uncooked salt water foods and exposure to brine.
Conclusion
Preventing contamination of seafood is impossible since several shellfish and finfish filter and concentrate the organism. Raw seafood consumption must be discouraged, particularly for individuals at high risk for development of septicaemia, especially in people with compromised liver function or immunosuppression. Special attention should be paid to possible cross-contamination during the preparation of seafood.
Consent
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Declarations
Authors’ Affiliations
References
- Yeung PS, Boor KJ: Epidemiology, pathogenesis, and prevention of foodborne Vibrio parahaemolyticus infections. Foodborne Pathog Dis. 2004, 1 (2): 74-88. 10.1089/153531404323143594.View ArticlePubMedGoogle Scholar
- Zimmerman M, DePaola A, Bowers JC, Krantz JA, Nordstrom JL, Johnson CN, Grimes DJ: Variability of Total and Pathogenic Vibrio parahaemolyticus Densities in Northern Gulf of Mexico Water and Oysters. Applied and Environmental Microbiology. 2007, 739 (23): 7589-7596.View ArticleGoogle Scholar
- Daniels NA, MacKinnon L, Bishop R, Altekruse S, Ray B, Hammond RM, Thompson S, Wilson S, Bean NH, Griffin PM, Slutsker L: Vibrio parahaemolyticus infections in the United States, 1973-1998. J Infect Dis. 2000, 181 (5): 1661-6. 10.1086/315459.View ArticlePubMedGoogle Scholar
- Daniels NA, Ray B, Easton A, Marano N, Kahn E, McShan AL, Del Rosario L, Baldwin T, Kingsley MA: Emergence of a new Vibrio parahaemolyticus serotype in raw oysters: A prevention quandary. JAMA. 2000, 284: 1541-1545. 10.1001/jama.284.12.1541.View ArticlePubMedGoogle Scholar
- Kelly MT, Stroh EM: Temporal relationship of Vibrio parahaemolyticus in patients and the environment. J Clin Microbiol. 1988, 26: 1754-PubMedPubMed CentralGoogle Scholar
- Payinda G: Necrotizing fasciitis due to Vibrio parahaemolyticus. N Z Med J. 2008, 121 (1283): 99-101.PubMedGoogle Scholar
- Lim TK, Stebbings AE: Fulminant necrotising fasciitis caused by Vibrio parahaemolyticus. Singapore Med J. 1999, 40 (9): 596-7.PubMedGoogle Scholar
- Tena D, Arias M, Alvarez BT, Mauleón C, Jiménez MP, Bisquert J: Fulminant necrotizing fasciitis due to Vibrio parahaemolyticus. J Med Microbiol. 2010, 59: 235-8. 10.1099/jmm.0.014654-0.View ArticlePubMedGoogle Scholar
- Ottaviani D, Bacchiocchi I, Masini L, Leoni F, Carraturo A, Giammarioli M, Sbaraglia G: Antimicrobial susceptibility of potentially pathogenic halophilic vibrios isolated from seafood. Int J Antimicrob Agents. 2001, 18: 135-140. 10.1016/S0924-8579(01)00358-2.View ArticlePubMedGoogle Scholar
- Hlady WG, Klontz KC: The epidemiology of Vibrio infections in Florida, 1981-1993. J Infect Dis. 1996, 173 (5): 1176-83. 10.1093/infdis/173.5.1176.View ArticlePubMedGoogle Scholar
Copyright
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.