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Vibrio Vulnificus 1 Vibrio Vulnificus 2 Vibrio Vulnificus 3
Vibrio Vulnificus 4

Vibrio Vulnificus
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Diagnosis Synopsis
Vibrio sepsis is due to a virulent, gram-negative rod infection caused by Vibrio vulnificus, a non-cholera vibrio. Infection is either through percutaneous inoculation via a small scratch, through the GI tract when swallowed by swimmers, or through ingestion of raw shellfish such as raw oysters (V. vulnificus is found in up to 10% of raw shellfish on the market in the United States). It is generally acquired in coastal areas (particularly the Gulf Coast) near warm water. V. vulnificus is part of the normal flora of seawater from warmer climates. Cutaneous lesions begin several days after a laceration in seawater or brackish lakes. It has been reported that 95% of patients with primary V. vulnificus bacteremia had pre-existing liver disease. One third of patients either present with shock or develop shock during the first 12 hours of hospitalization. There is also a worse prognosis with diabetes or immunosuppression. Mortality for primary V. vulnificus septicemia is greater than 50%.

Look For
Local infections can appear as pustular, lymphangitic, or cellulitic lesions that can be mild or rapidly progress into painful cellulitis with widespread necrosis. In primary bacteremic vibrio, tender erythematous patches and plaques quickly progress to vesicles and hemorrhagic bullae, which may result in gangrene and necrotizing fasciitis. DIC has been documented. Pustules have also been reported.

Diagnostic Pearls
Vibrio septicemia is characterized by the abrupt onset of chills, fever, headache, myalgias, vomiting, and diarrhea 24 to 48 hours after ingestion of raw oysters, and sometimes followed by hypotension. Cutaneous lesions develop within the first 36 hours of onset.

Differential Diagnosis & Pitfalls
Disseminated intravascular coagulation (DIC)
Purpura fulminans
Necrotizing fasciitis

Best Tests
Culture skin lesions and blood. TCBS agar is the best media. V. vulnificus appears as blue or blue-green colonies within 24 hours. Leukocytosis or leukopenia. Thrombocytopenia at later stages. Elevated liver enzymes.

Management Pearls
Admit to intensive care, treat with aggressive IV hydration, and involve an infectious disease specialist.

Therapy
Immediate antibiotic therapy for suspected cases is critical. Recommended regimens include a tetracycline and a third generation cephalosporin simultaneously. Examples include: doxycycline (100 mg q12h IV/PO) or minocycline (100 mg q12h PO) combined with cefotaxime (2g q8hrs IV) or ceftazidime (1g q8hrs IV). Ciprofloxacin (400 mg BID IV) may be substituted for the tetracycline. Necrotic lesions should be debrided and amputation may occasionally become necessary

Key Findings
Symptoms
Abdominal Pain
Chills
Diarrhea
Fatigue
Fever
Nausea
Painful Skin Lesions
Vomiting

Signs
Coma
Confusion
Hypotension
Lymphadenopathy
Stupor
Swelling

Appearance
Patient Appears Ill
Patient Appears Systemically Ill - Toxic

Exposures
Shellfish

Laboratory
Leukopenia
Thrombocytopenia

Medications
Glucocorticoid

Social
Alcohol Abuse
IVDA

Travel
Alabama
Central America
Florida
Louisiana
Mississippi
North Korea
South Korea
Taiwan
Texas

Distribution
Symmetric Extremities

Body Location
Lower Leg

Lesion
Tense Hemorrhagic Bullae
Tense Hemorrhagic Vesicle
Tense Serous Bullae
Tense Serous Vesicle

Medical History
Acquired Immune Deficiency Syndrome
Alcoholism
Bone Marrow Transplant
Cirrhosis
Diabetes Mellitus Type I
Diabetes Mellitus Type II
HIV Disease
Hepatitis NOS
Immunosuppression NOS
Renal Failure Chronic
S-P Organ Transplant NOS

Medical Disclaimer:
The information contained in this Web page is intended to be an adjunct to traditional medical information sources. It is not intended to be a substitute for professional medical judgment.

Authors and Editors:
Karen McKoy MD, MPH
Tara Mahar MD
Art Papier MD