Thomas Jefferson University Hospital Philadelphia, Pennsylvania
Introduction: Infection with Vibrio vulnificus is the leading cause of death related to seafood consumption in the United States. The consumption of raw or undercooked seafood can cause bacteremia and sepsis with fatality rates >50%. Approximately 80% of patients who die from V. vulnificus infections have underlying liver disease.1
Case Description/Methods:
The patient is a 51-year-old female with a history of decompensated alcoholic cirrhosis complicated by ascites and esophageal varices with a baseline MELD score of 17. She presented with one day of altered mental status, increased abdominal distension and lower extremity edema, skin bruising, and fever.
On hospital presentation, she was afebrile, tachycardic, and normotensive. Labs revealed a Na 122 mmol/L, Cr 1.5 mg/dL, WBC 9,000 /mL, Total Bilirubin 6.8 mg/dL, INR 13, pH 7.17, lactate 13 mmol/L. Shortly after arrival, the patient had a cardiac arrest and return of spontaneous circulation was achieved after 1 round of chest compressions.
She was admitted to the ICU on three vasopressors, bicarbonate, pantoprazole, and octreotide infusions, and broad-spectrum antibiotics with vancomycin and piperacillin/tazobactam. After two days she was transferred to our hospital where her exam revealed hemorrhagic bullae over abdomen and extremities (Figure 1).
Her admission blood cultures eventually grew V. vulnificus. Upon questioning, the patient had eaten oysters and sushi three days prior to admission. Antibiotics were transitioned to doxycycline and cefepime though the patient had progressive shock and died four days after admission.
Discussion: This case demonstrates the severity and rapid progression of V. vulnificus infection in patients with underlying liver disease. The prognosis is linked to time to treatment. Studies have shown that patients who have treatment delayed for 72 hours have a mortality of 100%.2
V. vulnificus is not covered by typical broad-spectrum antibiotics and delay in onset of treatment by enough time for a blood culture to speciate dramatically increases mortality. V. vulnificus is important to keep on the differential in any patient with gram-negative sepsis, skin wounds, and a history of liver disease. Questions about raw seafood and swimming in sea water should be routinely asked to guide clinicians to an early diagnosis. This case demonstrates a classic presentation of an uncommon infection and suggests that the clinician should consider empiric treatment for a V. vulnificus if there is a high index of suspicion.
