(566) Hidden Marine Hazards: Disseminated Vibrio vulnificus Infection With Noncontiguous Skin Lesions

Monday, January 22, 2024

9:00 AM – 10:00 AM MT

Location: Connections Central - RST 09

First Author(s)

AS

Alyscia C. Severance, MD

Resident
University of Mississippi Medical Center, United States

Co-Author(s)

RB

Riley H. Brown, n/a

Medical Student
University of Mississippi Medical Center, United States
HS

Hanna Sams, MD

Fellow
University of Mississippi Medical Center, United States
MG

Matthew L. Graves, MD

Attending Surgeon
University of Mississippi Medical Center, United States
PB

Patrick F. Bergin, MD

Attending Surgeon
University of Mississippi Medical Center, United States
Ashlee M. Griffin, MD

University of Mississippi Medical Center
Jackson, MS
MZ

Mouayyad Zaza, MD

Attending Surgeon
University of Mississippi Medical Center, United States
MK

Matthew E. Kutcher, MD, MS

Attending Surgeon
University of Mississippi Medical Center
Jackson, Mississippi, United States

Introduction: Vibrio vulnificus is a gram negative bacilli known to cause septicemia and rapidly progressive necrotizing soft tissue infections. Exposure usually occurs via raw shellfish ingestion or saltwater exposure of broken skin. Optimal management requires a high index of suspicion, targeted antibiotic therapy, and aggressive debridement.

Description: A 65-year-old non-insulin-dependent diabetic male (A1c 6.8%) presented to a rural hospital with right flank pain, left foot mottling, vomiting, and diarrhea for 3 days. On arrival, he was hypotensive (systolic blood pressure < 60) and leukopenic (white blood cell count 3.9). Blood cultures were obtained and vancomycin and piperacillin-tazobactam administered. Despite fluid resuscitation, he required vasopressor support and was transferred to a tertiary care facility. Within 12 hours of presentation, blistering lesions appeared on his left flank, left knee, left thigh, and right elbow with progression to hemorrhagic bullae. CT imaging showed soft tissue edema without emphysema, with an incidental finding of previously undiagnosed cirrhosis. He was taken emergently for surgical debridement, with findings of extensive soft tissue edema without fascial necrosis or abscess. Further targeted history revealed a recent trip to the coast with consumption of raw oysters the day before symptom onset. Empiric doxycycline was added. He underwent further aggressive debridement of devascularized fascia from the right arm, right flank, and left leg. His initial blood and intraoperative cultures resulted with growth of V. vulnificus. Despite multiple aggressive debridements including left below-knee amputation, appropriately targeted antibiotics, and empiric IVIG, he had persistent lactic acidosis, hepatic failure, and developed acute anuric renal failure with refractory hyperkalemia. His family elected transition to comfort care and he died on hospital day 3. Death occurred within 6 days of symptom onset.

Discussion: This case of V. vulnificus necrotizing soft tissue infection with septicemia highlights the potential rapid evolution of these infections, including the manifestation of multiple discrete cutaneous lesions. A high index of suspicion, careful history, and urgent aggressive debridement are required to arrest rapidly fatal disease progression.