Cluster of V Vulnificus Pops Up in Previously Non-Endemic Area

Vibrio vulnificus is a serious gram-negative pathogen that can lead to wound infections and intestinal infections. The pathogen can be found in brackish, high salinity waters and is endemic to the southeastern US coast. However, in the summer months of 2017 and 2018, 5 cases were detected in connection to the Delaware Bay, and 1 patient died.

A case report on the detection of the pathogen in the previously non-endemic area was published in Annals of Internal Medicine.

V vulnificus wound infections occur through breaks in the skin, and intestinal infections can occur following consumption of seafood. Either source of infection can then lead to bloodstream infections.

“People who have liver disease tend to carry a higher risk of developing an infection due to the mechanism by which the bacteria replicate,” the authors of the report told Contagion®. “People who are immunosuppressed or have diabetes are also at an increased risk of developing a V vulnificus infection if exposed.”

The investigators, led by Katherine Doktor, MD, of Cooper University Hospital, note that mortality of both wound and skin infections is high.

“Signs of necrotizing fasciitis (severe skin infection) would include a rapidly worsening, painful, red area near where any type of abrasion occurred, as well as fever and chills,” the authors continued.

The team of investigators, which also included Contagion® Editorial Advisory Board member Madeline King, PharmD, explained that the symptoms could begin up to a few days after exposure, with gastrointestinal infection symptoms likely to present earlier.

A summary of each of the 5 cases is included below:

• Patient 1: A 38-year-old man presented to the hospital with vomiting, a fever, and a left calf with erythema and induration. The man was found to have untreated hepatitis B. He experienced emergent debridement of necrotic skin, soft tissue, and fascia and later underwent skin grafting. Blood cultures from point-of-admission grew V vulnificus. The patient worked at seafood restaurant but denied exposure to crabs or the Delaware Bay. He recovered.
• Patient 2: A 64-year-old man presented to the hospital with erythema, pain, and swelling of his right hand. The man was admitted to the hospital 2 days after cleaning and eating crabs from Delaware Bay. He underwent fasciotomies for right arm compartment syndrome and during the third debridement developed unstable ventricular tachycardia and died. Blood cultures collected at point-of-admission grew V vulnificus.
• Patient 3: A morbidly obese 46-year-old man with type 2 diabetes and left leg lymphedema presented to the hospital with progressive left leg erythema, pain, swelling, and blistering 2 days after minor leg trauma while crabbing in Delaware Bay. He underwent debridement for necrotizing fasciitis, and wounds required skin and tissue grafting. Operative cultures grew V vulnificus. He recovered.
• Patient 4: A 60-year-old man with Parkinson’s disease presented to the hospital and developed progressively severe right leg swelling and pain that required fasciotomy. He later developed shock and respiratory failure and all 4 digital limbs became necrotic and mummified and required amputation. He reported that during the week prior to admission had multiple exposures to crabs in the Delaware Bay and on the day before admission ate a dozen crabs. He had no disposition for V vulnificus and later recovered.
• Patient 5: A 64-year-old man with untreated hepatitis C virus and a history of alcohol abuse and arthritis with long-term methylprednisolone use presented to the hospital. He was in shock and had hemorrhagic bullae on his right arm underwent emergent and extensive debridement of the right arm. He reported that a day earlier he ate crabs and lacerated his right leg with a crab trap in the Delaware Bay. Tissue cultures grew for V vulnificus. He recovered.

According to the authors, rising sea temperatures may lead to more cases of infection in non-endemic areas. “The biggest takeaway is that as sea temperatures are warming, non-endemic areas may start to see an increase in V vulnificus related infections,” the authors told Contagion®. “It is important for clinicians to keep this in mind when treating patients who may have been exposed to waters where V vulnificus lives.”

As infections can occur from being in the water or eating or handling infected seafood, the investigators offer some preventive measures. “One suggestion would be to keep areas that may be exposed to sea water (or other brackish, warm waters) covered. This would help limit abrasions that may occur, which would allow the bacteria to enter the skin. Eating cleaned and cooked seafood is a measure to reduce the risk of developing a gastrointestinal infection.”