eMedicine Specialties > Dermatology > Bacterial Infections

Vibrio Vulnificus Infection

Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Cris Jagar, MD, Staff Physician, Department of Psychiatry, Saint Vincent Catholic Medical Centers

Updated: Jul 16, 2009

Introduction

Background

Vibrio vulnificus is a gram-negative bacillus that only affects humans and other primates. It is in the same family as bacteria that cause cholera. The first documented case of disease caused by the organism was in 1979.

V vulnificus is usually found in warm, shallow, coastal salt water in temperate climates throughout most of the world. It can be found in the Gulf of Mexico, along most of the East Coast of the United States, and along all of the West Coast of the United States. V vulnificus can be found in water; sediment; plankton; and shellfish, such as oysters, clams, and crabs. This organism can survive in seawater and can produce wound infections, a potentially serious problem among Asian tsunami survivors.¹

Also see the eMedicine article Vibrio Infections.

Pathophysiology

Because the incidence of disease is relatively low, not all strains of V vulnificus may be equally virulent. Recent data are consistent with the existence of 2 genotypes of V vulnificus, with the C-type being a strong indicator of potential virulence.²

Frequency

United States

V vulnificus infections are rare but underreported. Most cases are found in the Gulf Coast states, and they are most common during warm weather months.

International

The frequency of V vulnificus infection, which is rare in Japan, was evaluated in 2008. Its prevalence varied in different districts.³

Mortality/Morbidity

Most V vulnificus infections are acute but have no long-term consequences; however, in patients who develop septic shock from infection with V vulnificus, the mortality rate is 50%. In rare instances, skin infection can result in necrotizing fasciitis.

Race

All races are affected equally.

Sex

Males and females are affected equally.

Age

All ages are affected equally.

Clinical

History

V vulnificus infection should be suspected in patients who give a history of ingestion of raw seafood or wound infection after exposure to seawater. Patients with V vulnificus infection report abrupt GI symptoms, such as vomiting, diarrhea, or abdominal pain, and may present with fever, chills, or shock. V vulnificus is normally found in warm estuarial and marine environments, lodging in filter feeders such as oysters. It occurs mainly in patients with chronic liver disease after the consumption of raw oysters. Partridge et al reported a case that was likely contracted from a thermal pool in Turkey, with no history of seawater or shellfish exposure.⁴

V vulnificus septicemia is the most common cause of death from seafood consumption in the United States.⁵ V vulnificus septicemia may first become evident in the skin as purpura fulminans, which can take a catastrophic course without immediate and intensive empirical antibiotic treatment.⁶

V vulnificus infection may be a rare cause of necrotizing fasciitis, which can be fatal.⁷

Physical

Most patients infected with V vulnificus have bullous skin lesions, which are found on the trunk and the lower extremities. Infection of the hand has been reported.⁸ These hemorrhagic bullae can progress to necrotic ulcerations, which require surgical debridement. Edema can be present.

A rapid onset of cellulitis may represent infection with V vulnificus, especially if the patient had contact with seawater or raw seafood. Patients can progress to necrotizing fasciitis.⁹

Causes

See Pathophysiology.

Workup

Laboratory Studies

Routine stool, wound, and blood cultures aid in the diagnosis of V vulnificus infection.

Imaging Studies

No imaging studies are necessary to help diagnose or treat V vulnificus infection.

Treatment

Medical Care

Antibiotics are necessary to eradicate the infection (see Medication below).

• In case of wound infection, aggressive debridement is necessary to remove necrotic tissue.
• If the patient is in shock, perform necessary interventions to resuscitate the patient.
• Available guidelines that may be helpful include the Practice guidelines for the diagnosis and management of skin and soft-tissue infections from the Infectious Diseases Society of America and the Diagnosis and management of foodborne illnesses: a primer for physicians and other health care professionals from the American Medical Association, American Nurses Association, American Nurses Foundation, Centers for Disease Control and Prevention, Center for Food Safety and Applied Nutrition, US Food and Drug Administration, Food Safety and Inspection Service, and US Department of Agriculture.^10,11

Consultations

• Because many patients with V vulnificus infection experience overwhelming sepsis, consultation with an infectious disease specialist is warranted.
• Consider consultation with an infectious disease specialist if the diagnosis is unclear or if the patient has atypical symptoms or does not respond to antibiotic treatment.

Activity

No restrictions are necessary.

Medication

The goals of therapy are to eradicate the infection, to reduce morbidity, and to prevent complications. A high index of suspicion is important, as doxycycline, the antibiotic of choice, is not usually a part of the empiric therapy for septicemia.

If necrotizing fasciitis is suspected, early fasciotomy and culture-directed antimicrobial therapy should be performed. These patients may develop hypotensive shock, leukopenia, severe hypoalbuminemia, and underlying chronic illness, especially a combination of hepatic dysfunction and diabetes mellitus.

Antibiotics

Antibiotics are necessary to eradicate V vulnificus infection. Effective antibiotics may include tetracycline, third-generation cephalosporins, and imipenem.

Doxycycline (Doryx, Vibramycin, Bio-Tab)

Synthetic antibiotic derived from tetracycline. Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. Effective against a large number of pathogens.

Dosing

Adult

100 mg PO bid for 7-14 d

Pediatric

<8 years: Not recommended
>8 years: Not established

Interactions

Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy

Contraindications

Documented hypersensitivity; severe hepatic dysfunction

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines

Follow-up

Deterrence/Prevention

• To prevent infection from V vulnificus, persons should avoid exposure to raw shellfish or thoroughly cook the shellfish. Persons should avoid cross-contamination of cooked shellfish with uncooked shellfish and eat shellfish promptly after cooking. Shellfish is best served hot.¹²
• Identifying oysters that are affected by V vulnificus is difficult because the appearance, taste, color, and odor of the oysters are not affected. Through improved reporting of affected oysters, oyster beds that are affected can be identified and closed.¹³
• Persons should avoid exposure of open wounds or broken skin to raw shellfish or infected waters. Patients who are immunocompromised should be especially careful to follow these guidelines because they are more susceptible to infection and complications.

Complications

• Patients who are immunocompromised are at risk of septic shock from the infection, which can be fatal. Otherwise, no complications from V vulnificus infection occur.

Prognosis

• V vulnificus infection is an acute illness that is quickly resolved with antibiotics and does not have any long-term consequences.
• The prognosis is often excellent with proper treatment.
• Retrospective analysis of 30 patients with necrotizing fasciitis and sepsis caused by Vibrio species and initially treated with surgical debridement or immediate limb amputation showed 11 (37%) died within several days of admission.¹⁴ A higher mortality rate was noted with the Vibrio cholerae non-O1 group (57%) compared with the V vulnificus group (30%). Other bad prognostic signs included a systolic blood pressure of less than or equal to 90 mm Hg, decreased platelet counts, and leukopenia. The combination of hepatic dysfunction and diabetes mellitus was also associated with a poor outcome.

Patient Education

• Counsel patients who are immunocompromised to prevent exposure to V vulnificus. The high mortality associated with this septicemia suggests susceptible individuals should be forewarned by signs displayed in restaurants; physicians should educate patients with chronic liver disease about the risk of raw oyster consumption. Additionally, harvesting methods that reduce contamination by V vulnificus should be used.⁵

Miscellaneous

Medicolegal Pitfalls

• Failure to diagnose the condition is a pitfall. Diagnosing V vulnificus infection with a culture and treating it appropriately are important because many medical problems can present with vomiting, diarrhea, and abdominal pain. If not diagnosed and treated properly, the patient may progress to septic shock, which has a high mortality rate.

References

1. Lim PL. Wound infections in tsunami survivors: a commentary. Ann Acad Med Singapore. Oct 2005;34(9):582-5. [Medline].

2. Rosche TM, Yano Y, Oliver JD. A rapid and simple PCR analysis indicates there are two subgroups of Vibrio vulnificus which correlate with clinical or environmental isolation. Microbiol Immunol. 2005;49(4):381-9. [Medline].

3. Inoue Y, Ono T, Matsui T, Miyasaka J, Kinoshita Y, Ihn H. Epidemiological survey of Vibrio vulnificus infection in Japan between 1999 and 2003. J Dermatol. Mar 2008;35(3):129-39. [Medline].

4. Partridge DG, Townsend R, Larkin S, Parsons HK. Vibrio vulnificus: an unusual mode of acquisition and novel use of rapid susceptibility testing. J Clin Pathol. Apr 2009;62(4):370-2. [Medline].

5. Haq SM, Dayal HH. Chronic liver disease and consumption of raw oysters: a potentially lethal combination--a review of Vibrio vulnificus septicemia. Am J Gastroenterol. May 2005;100(5):1195-9. [Medline].

6. Choi HJ, Lee DK, Lee MW, Choi JH, Moon KC, Koh JK. Vibrio vulnificus septicemia presenting as purpura fulminans. J Dermatol. Jan 2005;32(1):48-51. [Medline].

7. Tajiri T, Tate G, Akita H, et al. Autopsy cases of fulminant-type bacterial infection with necrotizing fasciitis: group A (beta) hemolytic Streptococcus pyogenes versus Vibrio vulnificus infection. Pathol Int. Mar 2008;58(3):196-202. [Medline].

8. Inoue H. Vibrio vulnificus infection of the hand. J Orthop Sci. Jan 2006;11(1):85-7. [Medline].

9. Tsai YH, Hsu RW, Huang TJ, et al. Necrotizing soft-tissue infections and sepsis caused by Vibrio vulnificus compared with those caused by Aeromonas species. J Bone Joint Surg Am. Mar 2007;89(3):631-6. [Medline].

10. [Guideline] American Medical Association; American Nurses Association-American Nurses Foundation; Centers for Disease Control and Prevention; et al. Diagnosis and management of foodborne illnesses: a primer for physicians and other health care professionals. MMWR Recomm Rep. Apr 16 2004;53:1-33. [Medline].

11. [Guideline] Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis. Nov 15 2005;41(10):1373-406. [Medline].

12. Prutkin JM, Haq R. A dish best served hot. Am J Med. Apr 2006;119(4):307-9. [Medline].

13. Mouzin E, Mascola L, Tormey MP, Dassey DE. Prevention of Vibrio vulnificus infections. Assessment of regulatory educational strategies. JAMA. Aug 20 1997;278(7):576-8. [Medline].

14. Tsai YH, Huang TJ, Hsu RW, et al. Necrotizing soft-tissue infections and primary sepsis caused by Vibrio vulnificus and Vibrio cholerae non-O1. J Trauma. Mar 2009;66(3):899-905. [Medline].

15. Eastaugh J, Shepherd S. Infectious and toxic syndromes from fish and shellfish consumption. A review. Arch Intern Med. Aug 1989;149(8):1735-40. [Medline].

16. Koenig KL, Mueller J, Rose T. Vibrio vulnificus. Hazard on the half shell. West J Med. Oct 1991;155(4):400-3. [Medline].

17. Kumamoto KS, Vukich DJ. Clinical infections of Vibrio vulnificus: a case report and review of the literature. J Emerg Med. Jan-Feb 1998;16(1):61-6. [Medline].

18. Laughlin TJ, Lavery LA. Lower extremity manifestations of Vibrio vulnificus infection. J Foot Ankle Surg. Jul-Aug 1995;34(4):354-7. [Medline].

19. Lehane L, Rawlin GT. Topically acquired bacterial zoonoses from fish: a review. Med J Aust. Sep 2000;173(5):256-9. [Medline].

20. Linkous DA, Oliver JD. Pathogenesis of Vibrio vulnificus. FEMS Microbiol Lett. May 15 1999;174(2):207-14. [Medline].

21. Serrano-Jaen L, Vega-Lopez F. Fulminating septicaemia caused by Vibrio vulnificus. Br J Dermatol. Feb 2000;142(2):386-7. [Medline].

22. Strom MS, Paranjpye RN. Epidemiology and pathogenesis of Vibrio vulnificus. Microbes Infect. Feb 2000;2(2):177-88. [Medline].

Keywords

Vibrio vulnificus infection, Vibrio vulnificus, V vulnificus, consumption of raw shellfish, exposure to contaminated seawater

Contributor Information and Disclosures

Author

Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

Coauthor(s)

Cris Jagar, MD, Staff Physician, Department of Psychiatry, Saint Vincent Catholic Medical Centers
Disclosure: Nothing to disclose.

Medical Editor

Craig A Elmets, MD, Director of Dermatology, Departments of Dermatology, Pathology, and Environmental Health Sciences; Professor, The Kirklin Clinic, University of Alabama at Birmingham
Craig A Elmets, MD is a member of the following medical societies: American Academy of Dermatology, American Association of Immunologists, American College of Physicians, American Federation for Medical Research, and Society for Investigative Dermatology
Disclosure: Palomar Medical Technologies Stock None; Amgen Consulting fee Review panel membership; Astellas Consulting fee Review panel membership; Massachusetts Medical Society Salary Employment; Abbott Laboratories Grant/research funds Independent contractor

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Managing Editor

Jeffrey P Callen, MD, Professor of Medicine, Chief, Division of Dermatology, University of Louisville School of Medicine
Jeffrey P Callen, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and American College of Rheumatology
Disclosure: Amgen Honoraria Consulting; Abbott Honoraria Consulting; Electrical Optical Sciences Honoraria Consulting; Centocor Honoraria Consulting; Genetech Honoraria Consulting; Celgene Honoraria Consulting

CME Editor

Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University
Catherine Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

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