A cirrhosis case killed by severe invasive Vibrio vulnificus infection after eating raw fish, June 2000 - Chiba
(IASR 2000; 21: 242-243)

Vibrio vulnificus (Vv) can cause severe invasive infections among those who have underlying diseases (e.g. liver cirrhosis) after eating raw seafood, or having open wound infection exposed to warm seawater. Here is a fatal case of Vv infection.

A 54 year-old man had been diagnosed as hepatitis C eight years ago. On June 17, 2000, after eating raw fish, he found painful swelling of the left elbow, followed by fever and chills. He was hospitalized at a nearby hospital on the same day. Because lesions suspecting insect bite were observed on the skin, the patient was initially treated for anaphylaxis due to insect bite. However, the swelling of his left elbow got worse, and he presented shock and was transferred to our emergency center. Upon admission, subcutaneous hemorrhage, vesicles, and swelling extended from the left arm to the left shoulder. Gas gangrene was ruled out by radiography. The patient developed hypotension, oliguria, and metabolic acidosis. Peripheral blood count and blood chemistry revealed pancytopenia, liver dysfunction, hypoproteinemia, and the elevation of creatine phosphokinase and C-reactive protein. Despite frequent drip infusion, the circulatory collapse was not controlled. While receiving catecholamines, he was connected with a mechanical ventilator. Metabolic acidosis was slightly corrected. Ampicillin was started with 2 g per day. Skin incision to reduce tension of the soft tissue was conducted expecting improvement of ischemia of the left upper extremity. Hemodialysis was started and a calcium agent given to correct hyperkalemia. The patient was once resuscitated from cardiac arrest due to hyperkalemia caused by muscle necrosis, however he died from multiple organ failure and septic shock on June 21.

Gram-negative rods were observed in the skin and the soft tissue specimens collected on June 20. A gray-colored, round-shaped, 4 mm diameter colonies were grown on chocolate agar, which were identfied as Vv. The bacteria was grown only in salinity of 3% sodium chloride. Vv gene was detected from the specimens by polymerase chain reaction (PCR). The clinical isolates were susceptible for ampicillin, cefazolin, imipenem/cilastatin sodium, gentamycin, and minocycline.

Until 1999 more than one hundred Vv infections had been reported mainly from the western part of Japan. Clinical courses of the Vv infections often become fulminant, and 40% of those cases die within 3 days after onset of illness. While Vv can cause life-threatening disease among patients who have underlying diseases such as liver cirrhosis or hemochromatosis, Vv rarely develops illness in healthy individuals. As a speculation, high levels of free iron and transferrin saturation in those patients' plasma were optimal for the growth of Vv. In order to facilitate diagnosis of Vv infections, 1) Gram-stained smears of the exudates from the skin lesions and 2) blood culture as early as possible, are highly needed.

Reported by: Shouichi Satoh, Masayuki Mikami, Hiroko Kikuchi, Megumi Kaneko, Sachiko Suzuki, Miyuki Tojo, Hideki Ogasawara, Takao Maru, Dept. of Clinical Laboratory, Chiba Emergency Medical Center; Ryouji Takahashi and Masahiko Araki, Clinical Care Medicine, Chiba Emergency Medical Center; Eiji Yokoyama and Kenji Koiwai, Public Health Laboratory of Chiba Prefecture

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