1/ 55M, h/o psoriatic arthritis on adalimumab, cut hand cleaning🐟after fishing in coastal🌊
~12h later,⬆️finger erythema/edema
Admit: T101, rigors,⬆️HR,⬇️BP
On Ceftriaxone w/o improvement, now finger w/purple hue, blistering. How would you modify abxs?
#IDTwitter #MedTwitter
~12h later,⬆️finger erythema/edema
Admit: T101, rigors,⬆️HR,⬇️BP
On Ceftriaxone w/o improvement, now finger w/purple hue, blistering. How would you modify abxs?
#IDTwitter #MedTwitter
2/
Did you ID the🦠? Vibrio vulnificus!
🔹GNR
🔹In coastal water, saltwater marsh/wetlands, river estuaries
🔹Peak summer/late fall (water temp⬆️)
Filter feeding shellfish (🦪/clam/mussel/🦀) conc bact more than in water ▶️in virtually all oysters Chesapeake Bay, US gulf coast
Did you ID the🦠? Vibrio vulnificus!
🔹GNR
🔹In coastal water, saltwater marsh/wetlands, river estuaries
🔹Peak summer/late fall (water temp⬆️)
Filter feeding shellfish (🦪/clam/mussel/🦀) conc bact more than in water ▶️in virtually all oysters Chesapeake Bay, US gulf coast
3/
Leading cause of seafood-related deaths in US
CDC: ~100 persons in US are infected with V.vulnificus/yr
cdc.gov/nationalsurvei…
Leading cause of seafood-related deaths in US
CDC: ~100 persons in US are infected with V.vulnificus/yr
cdc.gov/nationalsurvei…
4/
Pathogenesis? Likely due to:
✳️Produce polysaccharide capsule (protects against phagocytosis/opsonization)
✳️Toxins, such as MARTX
✳️Iron availability (although can grow in nl iron saturation, likely has ⬆️proliferation if transferrin iron sat % >70%)
pubmed.ncbi.nlm.nih.gov/1940460/
Pathogenesis? Likely due to:
✳️Produce polysaccharide capsule (protects against phagocytosis/opsonization)
✳️Toxins, such as MARTX
✳️Iron availability (although can grow in nl iron saturation, likely has ⬆️proliferation if transferrin iron sat % >70%)
pubmed.ncbi.nlm.nih.gov/1940460/
5/
There are two major clinical syndromes for V.vulnificus to know:
🦶Wound infection +/- necrotizing fasciitis
🤒Primary septicemia (w/o clearly defined source of infection)
We’ll discuss these more 👇
🤮Can cause diarrhea/gastroenteritis sxs too, but this is less common
There are two major clinical syndromes for V.vulnificus to know:
🦶Wound infection +/- necrotizing fasciitis
🤒Primary septicemia (w/o clearly defined source of infection)
We’ll discuss these more 👇
🤮Can cause diarrhea/gastroenteritis sxs too, but this is less common
6/
Wound inf can occur:
🦪Handling shellfish/🐟
🌊Expose wound to brackish water (eg known wound; new leg lac enter/exiting 🛥️) or perhaps flood waters as seen after Katrina (cdc.gov/mmwr/preview/m…)
🚨Even minor skin penetration can ➡️serious inf, esp if predisposing condition
Wound inf can occur:
🦪Handling shellfish/🐟
🌊Expose wound to brackish water (eg known wound; new leg lac enter/exiting 🛥️) or perhaps flood waters as seen after Katrina (cdc.gov/mmwr/preview/m…)
🚨Even minor skin penetration can ➡️serious inf, esp if predisposing condition
7/
1ary septicemia:
🔸often seen after ingestion raw/undercooked shellfish, classic = raw oysters
🔸~⅓ have shock w/i 12h of admission
🔸~¾ have bullous skin lesions
🔸⬇️plts, DIC
🚨Very⬆️fatality rate ~50%, vs.~15% w/ wound inf
🔸 ~10% req'd amputation pubmed.ncbi.nlm.nih.gov/18444811/
1ary septicemia:
🔸often seen after ingestion raw/undercooked shellfish, classic = raw oysters
🔸~⅓ have shock w/i 12h of admission
🔸~¾ have bullous skin lesions
🔸⬇️plts, DIC
🚨Very⬆️fatality rate ~50%, vs.~15% w/ wound inf
🔸 ~10% req'd amputation pubmed.ncbi.nlm.nih.gov/18444811/
8/
Who is at ⬆️risk?
🔹Underlying liver disease, such as alcoholic cirrhosis (present in ~1/3 pts with 1ary septicemia) or chronic hepatitis
🔹Hemochromatosis
🔹Chronic dz or immunosuppression (DM, RA, thal major, chronic renal failure, lymphoma)
🔹⬆️cases in men
Who is at ⬆️risk?
🔹Underlying liver disease, such as alcoholic cirrhosis (present in ~1/3 pts with 1ary septicemia) or chronic hepatitis
🔹Hemochromatosis
🔹Chronic dz or immunosuppression (DM, RA, thal major, chronic renal failure, lymphoma)
🔹⬆️cases in men
9/
Dx:
📑Often presumptive based on clinical syndrome ( fever, hypotension, sx suggestive of septic shock, characteristic bullous skin lesions) + risk factors
🧫V.vulnificus will grow in standard blood or wound cultures. From stool, often needs selective cx (TCBS)
Dx:
📑Often presumptive based on clinical syndrome ( fever, hypotension, sx suggestive of septic shock, characteristic bullous skin lesions) + risk factors
🧫V.vulnificus will grow in standard blood or wound cultures. From stool, often needs selective cx (TCBS)
10/
🔪Surgical eval/tx
💊Combo abx for severe septicemia or wound inf:
Minocycline or doxycycline
➕
Cefotax or Ceftriaxone
Combo therapy ⬇️mortality comp'd to monotherapy, other regimens (such as with AG):
pubmed.ncbi.nlm.nih.gov/17060542/
pubmed.ncbi.nlm.nih.gov/22117030/
🔪Surgical eval/tx
💊Combo abx for severe septicemia or wound inf:
Minocycline or doxycycline
➕
Cefotax or Ceftriaxone
Combo therapy ⬇️mortality comp'd to monotherapy, other regimens (such as with AG):
pubmed.ncbi.nlm.nih.gov/17060542/
pubmed.ncbi.nlm.nih.gov/22117030/
11/
An important pathogen given its ability to cause fulminant disease!!
Here are two cases from NEJM to look at:
nejm.org/doi/10.1056/NE…
nejm.org/doi/full/10.10…
And a paper on "pearls and perils" from CID: pubmed.ncbi.nlm.nih.gov/21367733/
#idmedEd
An important pathogen given its ability to cause fulminant disease!!
Here are two cases from NEJM to look at:
nejm.org/doi/10.1056/NE…
nejm.org/doi/full/10.10…
And a paper on "pearls and perils" from CID: pubmed.ncbi.nlm.nih.gov/21367733/
#idmedEd
