Kitamura C, Yamauchi Y, Yamaguchi T, Aida Y, Ito K, Ishizawa Y, et al. Tsai YH, Chen PH, Yu PA, Chen CL, Kuo LT, Huang KC. 2021:6678513. To prevent infection from V vulnificus, persons should avoid exposure to raw shellfish or thoroughly cook the shellfish. Laboratory studies revealed a white blood cell count of 6,600 per mm3 (6.6 109 per L) with 26 percent bands, hemoglobin level of 13.1 g per dL (131 g per L), platelet count of 33,000 per mm3 (33 109 per L), blood urea nitrogen level of 63 mg per dL (22.5 mmol per L), and creatinine level of 4.4 mg per dL (390 mol per L). By using our website, you consent to our use of cookies. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. [QxMD MEDLINE Link]. Vibrio vulnificus has emerged as a highly virulent bacterial pathogen that can cause three types of infections: (1) acute gastroenteritis from eating raw or undercooked shellfish; (2) invasive septicemia following ingestion of raw or undercooked shellfish, especially oysters; and (3) necrotizing wound infections following marine injuries and exposures. Tajiri T, Tate G, Akita H, et al. With the exception of minor marine wounds demonstrating localized cellulitis or spreading erysipeloidtype reactions, most other marine infections and all Gramnegative and mycobacterial marine infections will require therapy with antibiotic combinations. RoguedasContios AM, et al. All Rights Reserved. Wound infection can occur when a previously obtained wound, sore, scratch, or burn is exposed to seawater or when a wound is obtained while fishing, such as a puncture from a hook or fish teeth, cuts or scratches from shellfish or finfish, cuts and scrapes from crab traps or other fishing gear. 6. Encephalitis in travellers: A prospective multicentre study, About the International Society of Travel Medicine, The Clinical Manifestations of Marine Infections and the General Management of Contaminated Marine Wounds, http://www.cdc.gov/nczved/divisions/dfbmd/diseases/-vibriov/, Receive exclusive offers and updates from Oxford Academic, A Profile of TravelersAn Analysis From a Large Swiss Travel Clinic, TravelRelated Shigellosis in Quebec, Canada: An Analysis of Risk Factors, Mortality Among Foreign Nationals in Chiang Mai City, Thailand, 2010 to 2011, Prevention of Travelers' Diarrhea With Rifaximin in US Travelers to Mexico. Persons should avoid exposure of open wounds or broken skin to raw shellfish or infected waters. [QxMD MEDLINE Link]. [11], Capsule: V. vulnificus has a capsule, made of polysaccharides, and is thought to protect against phagocytosis. [QxMD MEDLINE Link]. [QxMD MEDLINE Link]. Even minor abrasions and lacerations sustained in marine environments should be considered potentially contaminated with common marine microbes, such as Vibrio species. James H. Diaz, MD, DrPH, Skin and Soft Tissue Infections Following Marine Injuries and Exposures in Travelers, Journal of Travel Medicine, Volume 21, Issue 3, 1 May 2014, Pages 207213, https://doi.org/10.1111/jtm.12115. The bacteria eats at an He even took then-Texas Governor Ann Richards out fishing for redfish. Tarasi A, et al. Atlanta: International Society of Travel Medicine. Case series show a benefit from aggressive surgical management of necrotizing soft tissue infections. Skin disorders are the third most common cause of morbidity in returning travelers and are usually infectious in origin and bacterial in etiology.1 Bacterial skin and soft tissue infections (SSTIs) in travelers often follow insect bites and can present a broad spectrum of clinical manifestations ranging from impetigo and ecthyma to erysipelas, abscess formation, necrotizing cellulitis, and myonecrosis.2,3 Significant SSTIs can also follow marine injuries and exposures in travelers, and the etiologies are often marine bacteria. Because V. vulnificusrelated septicemia is usually caused by consuming raw oysters, most disease can be prevented by not eating this food. [High Heterogeneity of Virus-Neutralizing and RBD-Binding Activities of COVID-19 Convalescent Sera]. The optimal treatment is not known, but in one retrospective study of 93 people in Taiwan, use of a third-generation cephalosporin and a tetracycline (e.g., ceftriaxone and doxycycline, respectively) was associated with an improved outcome. [11], Vibrio vulnificus wound infections have a mortality rate around 25%. [QxMD MEDLINE Link]. [QxMD MEDLINE Link]. The best of the best sea captains you could ever hope to fish with. In case of wound infection, aggressive debridement is necessary to remove J Bone Joint Surg Am. 78(11):3885-9. put a person far more at risk to develop infection from V. vulnificus. Snoddy MC 81:73-80. Immunogenicity and one-year boostability of a 3-dose intramuscular rabies pre-exposure prophylaxis schedule in adults receiving immunosuppressive monotherapy: a prospective single-Centre clinical trial. Any empirically prescribed antimicrobials should be effective against both causative pathogens.49,Streptococcus iniae infections are also characterized by either impetigo or cellulitis. Post-harvest treatments (mild heat treatment, freezing, hydrostatic pressure) can reduce V. vulnificus counts in raw oysters, potentially reducing disease risk [ 50 ]. Individuals with increased susceptibility to V. vulnificus infections should also avoid situations in which estuarine-associated wounds are likely to occur. Vibrio vulnificus septicemia presenting as purpura fulminans. is a gateway to Vibrio vulnificus information Other presentations have occurred less often: infection of mucosal sites and corneal ulcers after handling seafood,15 tubo-ovarian abscesses after sexual activity in seawater,16 and peritoneal infection after receiving dialysis from seawater-contaminated equipment.17 A high index of suspicion is required to diagnose V. vulnificus infection with these rare presentations. The Vibrio vulnificus: From Oyster Colonist to Human Pathogen. [QxMD MEDLINE Link]. V. vulnificus is one of the few foodborne illnesses with an increasing incidence. His vital signs were a temperature of 100F (38C), blood pressure of 88/44 mm Hg, pulse rate of 113 beats per minute, and respiratory rate of 20 breaths per minute. Lertutsahakul K, et al. Though rare, the flesh-eating bacteria condition affects 20,000 a year. The first is in an anti-phagocytic polysaccharide capsule that protects the bacteria. [QxMD MEDLINE Link]. 8 (5):475-83. Unlike bacterial infections acquired on land while abroad and reported by travelers returning home, the epidemiology of bacterial infections following marine injuries or exposures and aquatic animal bites and stings has been less intensively investigated. 2020 Apr. 5.3k views Answered >2 years ago Thank 3 thanks Dr. David Liu answered https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvMTA1NTUyMy10cmVhdG1lbnQ=. Notes: Had a small cut on 7.1.17 got tetanus injection after 72 hr. Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, New York Academy of Medicine, Royal College of Physicians of Edinburgh, Sigma Xi, The Scientific Research Honor SocietyDisclosure: Nothing to disclose. Post-harvest treatments (mild heat treatment, freezing, hydrostatic pressure) can reduce V. vulnificus counts in raw oysters, potentially reducing disease risk [ 50 ]. Sepsis and organ failure can occur within hours. In 2013, Lodd and colleagues reported a 42yearold commercial fisherman who became incapacitated after 3 days of oral penicillin therapy for fever and exfoliative skin lesions on both hands.8 Subsequent bacteriological identification of the causative organism showed skin colonization with methicillinsensitive S. aureus with production of PantonValentine leukocidin.8 The authors concluded that the marine environment was a risk factor for skin abrasion injuries that could lead to infection by highly pathogenic strains of S. aureus capable of producing PantonValentine leukocidin.8. [30], In 2022 following Hurricane Ian, Lee County, Florida saw a sharp rise in infections and deaths from V. vulnificus. 2016. Vibrio vulnificus may also be associated with wound infections and 69% of these are related to occupational exposures among oyster shuckers and fishermen. The Centers for Disease Control and Prevention estimate 8,000 Vibrio infections and 60 deaths occur annually in the U.S. Tyring SK. The bacteria eats at an open wound and goes after soft tissue. Do foreskin infections go away when you cut off foreskin? Infections with necrotizing fasciitis are predominantly polymicrobial.20,21, At hospital admission, laboratory results of patients with V. vulnificus infection are indicative of severe bacterial infection, with a marked left shift in the white blood cell count. Cuts to fingers & hands are notorious for becoming infected. Table 218,19 presents etiologies for the differential diagnosis of aggressive soft tissue infection. 2019 Jan 4. Sequential surgical debridements will be indicated in many cases, in all cases of necrotizing fasciitis, and following fasciotomies for compartment syndromes. MMWR Recomm Rep. 2004 Apr 16. 2014 Jul 15. Patients with primary septicemia caused by V. vulnificus infection require hospitalization. Support for J. H. D. was provided by departmental and institutional sources. When treatment was delayed by as little as 24 hours in patients with septicemia, mortality rates increased from 33 to 53 percent. Necrotizing soft-tissue infections and sepsis caused by Vibrio vulnificus compared with those caused by Aeromonas species. Several characteristics of the organism facilitate the development of clinical disease. Vibrio vulnificus is an extremely virulent bacterium that can cause three types of infections: Among healthy people, ingestion of V. vulnificus can cause vomiting, diarrhea, and abdominal pain. [QxMD MEDLINE Link]. Corey stuck with fishing and became a full-time captain. Pain may be relieved with one to two acetaminophen ( Tylenol) every 4 hours and/or one to two ibuprofen ( Motrin, Advil) every 6-8 hours. Prevention of secondary infections from respiratory failure and acute renal failure is crucial. The taste, appearance, and odor of seafood are not affected by V. vulnificus contamination, and proper cooking methods readily kill the organism. Cris Jagar, MD Staff Physician, Department of Psychiatry, Trinitas Regional Medical CenterDisclosure: Nothing to disclose. Likewise, the American Medical Association and the Centers for Disease Control and Prevention (CDC) recommend treating the person with a quinolone or intravenous doxycycline with ceftazidime. With these cases, V. vulnificus usually enters the bloodstream, where it may cause fever and chills, septic shock (with sharply decreased blood pressure), and blistering skin lesions. Hart SM Mouse models have shown that the unencapsulated forms are avirulent. Microbiol Immunol. The majority of these people die within the first 48 hours of infection. Dirk M Elston, MD is a member of the following medical societies: American Academy of DermatologyDisclosure: Nothing to disclose. Raju R Protective Effects of Chicken Egg Yolk Immunoglobulins (IgYs) against Vibrio vulnificus Infections. 1997 Aug 20. Mortality rates increased to 100 percent in patients who were not treated within 72 hours.12 Recent data show that when all types of V. vulnificus infections are combined, the overall mortality rate is 35 percent.1, Table 329,30 includes recommendations for reducing the risk of V. vulnificus infection. Travel medicine practitioners should maintain a high index of suspicion regarding potentially catastrophic, invasive bacterial infections, especially Aeromonas hydrophila, Vibrio vulnificus, Chromobacterium violaceum, and Shewanella infections, following marine injuries and exposures. V. vulnificus strains with capsular materials are associated with high bacterial virulence.8 In addition, V. vulnificus produces several extracellular enzymes, including metalloproteinase, lecithinase, lipase, caseinolytic protease, deoxyribonuclease, mucinase, and elastase.9,10 Metalloproteinase destroys basement membrane collagen in blood vessels10 and has fibrinolytic properties11 that cause hemorrhage and edematous skin changes. [6]:279 It was first isolated as a source of disease in 1976.[7]. Medscape Education, Optimizing Care for Patients With NF1-Associated Tumors: Leveraging the Multidisciplinary Team, 20022122072-overviewDiseases & Conditions, encoded search term (Vibrio Vulnificus Infection) and Vibrio Vulnificus Infection, Skin and Soft Tissue Infections - Incision, Drainage, and Debridement, Infection in Patients With Diabetes Mellitus, Emergent Management of Necrotizing Soft-Tissue Infections, Tackling Oral Health in Primary Care: A Task That's Worth the Time, New Melting Hydrogel Bandage Could Treat Burn Wounds Faster, With Less Pain, Naloxone May Fail for Opioid Overdoses Tainted With Animal Tranquilizer, FDA Warns. 2014 Jun. Please have this medically evaluated. While looking for an answer to this problem, researchers found that one way to stop the infection from spreading is to again mutate the bacteria. The organism is not associated with pollution or fecal waste. Significant SSTIs can also follow marine injuries and exposures in travelers, and the etiologies are often marine bacteria. Characteristic symptoms include fever, diarrhea, nausea, and vomiting. Mocks legend grew after he won fishing tournament after fishing tournament. Proceedings of the Second Conference on International Travel Medicine. People with weakened immune systems are more likely to develop severe cases. By encapsulating the bacteria, phagocytosis and opsonization are not able to occur, thus allowing the bacteria to continue throughout the organism it is in. J Microbiol Immunol Infect. Females having had an oophorectomy experienced increased mortality rates, as estrogen has been shown experimentally to have a protective effect against V. Travel medicine practitioners should maintain a high index of suspicion regarding potentially catastrophic bacterial infections following marine injuries and exposures, especially V. vulnificus in the Gulf of Mexico, C. violaceum in the Western Pacific, and Shewanella infections in the Mediterranean and Western Pacific. Assessment of regulatory educational strategies. Rosche TM, Yano Y, Oliver JD. i'm afraid i have an infection and will die. [QxMD MEDLINE Link]. J Dermatol. Lopez FA Kim HJ, Kim YT, Kim HB, Choi SH, Lee JH. 2008 Mar. 278(7):576-8. i can't really see anything ther? [24] About half of those who contract blood infections die. Vibrio infection typically occurs in two ways: from wounds that are exposed to seawater (roughly 50% of U.S. Vibrio vulnificus cases) or from eating raw seafood, like oysters, clams, or mussels harvested from seawater that naturally contains the bacteria (approximately 50% of U.S. Vibrio vulnificus cases). 2021 Apr. Persons should avoid cross-contamination of cooked shellfish with uncooked shellfish and eat shellfish promptly after cooking. The fatality rate may be as high as 61% for Vibrio vulnificus infections in people that have been diagnosed with one or more of the following health conditions: * If you are unsure of your risk, consult your doctor. Tetanus prophylaxis is indicated for all marine wounds. If you get a minor cut in lake water but clean and bandage with in hour, should it be safe from infection? The first is an overwhelming primary septicemia caused by consuming raw or undercooked seafood, particularly raw oysters. Later, surgeons amputated his leg, but the Vibrio had spread, and he succumbed to it. When was your last tetanus shot? Tea tree oil is a natural antiseptic that may also treat skin inflammation. 2009 Mar. [QxMD MEDLINE Link]. Mock developed sepsis and then organ failure after an oyster cut led to the Vibrio infection. Atlanta: International Society of Travel Medicine. To learn more, please visit our. Apparent Loss of Vibrio vulnificus from North Carolina Oysters Coincides with a Drought-Induced Increase in Salinity. 2009 Apr. Identify factors or wound characteristics that increase the risk of infection, and 3. Not likely you'll get an infection from this. Characterization of bacteriophage VVP001 and its application for the inhibition of Vibrio vulnificus causing seafood-borne diseases. Consumption of raw oysters in the week before becoming ill, Wound exposure to warm seawater or raw seafood juice in the week before becoming ill, Skin abrasion, trauma, recent herpes zoster infection, human bite, intravenous drug abuse, Diabetes, cancer, alcoholism, stasis dermatitis, Intense erythema, edema, lymphadenopathy, hemorrhagic and necrotic bullae, Skin trauma, recent hospitalization or surgery, intravenous drug abuse, Obesity, diabetes, immunocompromising condition, Furuncles, local abscesses, diffuse macular erythroderma, Diabetes, immunocompromising condition, vascular disease, Bacteremia, moist skin infection, severe burn, recent hospitalization, Exposure to raw or undercooked seafood or seawater, Liver disease, immunocompromising condition, Hemorrhagic and necrotic bullae, ecchymoses, Severe trauma with wound contamination, recent surgery, intravenous drug abuse, Pale skin, edema, hemorrhagic and necrotic bullae, foul-smelling discharge, gas formation, Erythema, edema, serosanguineous discharge, lymphadenitis, tenosynovitis, Usually none; sometimes an immunocompromising condition, Erythema, bullae, necrosis, possible gas formation, Avoid contact with raw seafood juices; use separate cutting boards and knives for seafood and nonseafood, Avoid eating raw oysters or seafood, especially if an immunocompromising condition or chronic liver disease is present; the risk is highest with seafood harvested in the summer, In the shell: boil until the shells open, then boil for another five minutes; or steam until the shells open, then steam for another nine minutes (do not eat shellfish that do not open during cooking), Shucked oysters: boil for at least three minutes, or fry for at least 10 minutes at 375F (191C), Wear gloves when handling raw oysters or shellfish, Avoid contact between open wounds and seawater, especially if water temperature is more than 68F (20C), or raw seafood, Wash any wound that is exposed to seawater with soap and clean water, Immediately seek medical care for any wound that appears infected. I got a barnacle cut and think i'm getting an infection. Autopsy cases of fulminant-type bacterial infection with necrotizing fasciitis: group A (beta) hemolytic Streptococcus pyogenes versus Vibrio vulnificus infection. Sorokin M. Incidence of minor and major disorders among visitors to Fiji. The role of Vibrio vulnificus virulence factors and regulators in its infection-induced sepsis. However, tea tree oil based products can not be used for burns. A legendary Texas fisherman died after an oyster cut led to a flesh-eating bacteria infection and death in late July. 2017:[QxMD MEDLINE Link]. [34]. Int J Food Microbiol. Notably, he rode a jet ski alongside his partner, Karen Watt, for 1,800 miles from South Padre Island to the Florida Keys on one occasion. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide, This PDF is available to Subscribers Only. [QxMD MEDLINE Link]. Atkinson CT, et al. 2018 Feb. 20 (2):423-430. Am J Gastroenterol. Successful Treatment of a Case of Necrotizing Fasciitis due to Vibrio vulnificus in a Cold Climate in Japan. Gelfusa V Tsai YH, Huang TJ, Hsu RW, et al. All definitive antibiotic therapy should be based on precise pathogen identification by culture or molecular signature and antibiotic susceptibility testing. Hendren N, Sukumar S, Glazer CS. Prevent cooked seafood from being contaminated by seawater or juices from raw seafood. Physician awareness of risk factors for V. vulnificus infection combined with prompt diagnosis and treatment can significantly improve patient outcomes. Environ Microbiol. Hyperbaric oxygen therapy (HBO) may be used to get more oxygen to your tissues to help them heal. Lakananurak N, et al. This virulent, gram-negative bacterium causes two distinct syndromes. MICHAEL H. BROSS, MD, KATHLEEN SOCH, MD, ROBERT MORALES, MD, AND RAYFORD B. MITCHELL, MD. Persons with open wounds should avoid contact with warm seawater.4,29,30. Boil for at least 3 minutes Fry in oil for at least 3 minutes at 375F Broil 3 inches from heat for 3 minutes, or [citation needed], After the successful treatment of the first person, the Florida Department of Health was able to trace the origin of the outbreak to Apalachicola Bay oysters and their harvesting in water prone to excessive growth of the organism. Antibiotics are necessary to eradicate the infection (see Medication). Case series demonstrate high morbidity and mortality with. 66(3):899-905. Eur J Clin Microbiol Infect Dis. Please note, we cannot prescribe controlled substances, diet pills, antipsychotics, or other abusable medications. 2 Depending on the wound and the severity of the infection, your doctor may prescribe topical or oral antibiotics. Many of these infections are not reported and usually do not cause serious or life-threatening illness in healthy people, although they may cause gastroenteritis (nausea, abdominal pain, vomiting, and/or diarrhea) or cellulitis (skin infection). 2020 Feb. 20 (2):170-171. Unsafe oysters can be detected by smell and/or appearance. 2006 Apr. Vibrio infections. Although the causative pathogens and outcomes may differ, the initial clinical manifestations of the SSTIs following marine injuries and exposures are no different from those acquired after terrestrial exposures and may be classified as impetigo, erysipelas, cellulitis, and necrotizing infections. He died in Brownsville at age 61. Liver disease (from cirrhosis, hepatitis, or cancer), Cancer (includes lymphoma, leukemia, and Hodgkins disease), Stomach disorders including surgery or taking antacids, Rapid swelling, pain, and reddening of skin around wound (present in 100% of infections), Large blisters, die-off of tissue around wound (30 50% of infections), Blood-filled large blisters, mainly on extremities, Septicemia (bacteria enter and spread through blood stream). for health care providers, A Gram stain of the exudate showed a curved, gram-negative rod. The pathogenspecific characteristics of both superficial and deeper invasive infections caused by common and newly emerging marine bacteria were described. Because many patients with V vulnificus infection experience overwhelming sepsis, consultation with an infectious disease specialist is warranted. 94:103630. Wound care may be done to clean your wound and help it heal. ), where he accidentally pierced his right index finger with a live shrimp. PLoS Negl Trop Dis. Folia Microbiol (Praha). They awarded a posthumous award, the Good Sportsman Trophy, to Mock. By October18, 2022, four deaths and 29 illnesses had been recorded since landfall of the hurricane in late September. 65 (2):265-274. [QxMD MEDLINE Link]. These cases should be treated initially with antimicrobials that are effective against Grampositive aerobic bacteria, Gramnegative bacteria, and anaerobes, especially in cases of penetrating trauma, until confirmed positive cultures from drainage or biopsies are reported. Haq SM, Dayal HH. In summary, observational studies in island nations frequently visited by travelers and case reports of infections following marine injuries have confirmed that skin injuries, such as fish bites, puncture wounds, abrasions, and more serious injuries, may become infected with both highly specific marine bacterial species, such as Aeromonas and Shewanella species, and highly pathogenic strains of S. aureus. Hepatic disease was the greatest risk factor for extensive myonecrosis and fatal septic shock.20,21 Intravenous therapy with a combination of antibiotics effective against Gramnegative bacteria is recommended in all cases of extraintestinal E. tarda infections.20,21, Shewanella species are saprophytic Gramnegative bacteria and part of the normal microflora of the marine environment that are distributed in temperate and tropical regions worldwide.22,23Shewanella species produce yellowishbrown mucoid colonies that emit hydrogen sulfide in culture.22,23 The most common clinical manifestations of Shewanella infections are deep ulcers associated with hemorrhagic bullae usually on the lower extremities, otitis externa, otitis media, and bacteremia.22,23 Nonhealing ulcers have resulted in necrotizing fasciitis, compartment syndromes requiring decompressive fasciotomies, and osteomyelitis.22,23Shewanella septicemia has been associated with endocarditis and meningitis.22,23Shewanella pneumonia, cholecystitis, and peritonitis have been reported following aspiration or ingestion of seawater.22 Besides seawater exposure and ingestion of raw seafood, other common risk factors for Shewanella infections have included lacerations in marine environments, preexisting lower extremity wounds or ulcers, and immunocompromise.22, Wagner and colleagues reported a case of Shewanella algaeinfected chronic leg ulcers in a 52yearold female with autoimmune vasculitis and myasthenia gravis 7 months after returning from a Mediterranean vacation during which she reported frequent bathing in the sea.23 Poovorawan and colleagues reported another case of severe Shewanella haliotis soft tissue infection in the left lower leg with compartment syndrome in a 52yearold female who had undergone orthotopic liver transplantation 6 months previously and reported handling fresh saltwater fish in fish markets.22, The diagnosis of Shewanella infections can be established by positive blood or lesion aspirate cultures, but the speciation of Shewanella causative strains will require molecular characterization by polymerase chain reaction (PCR).22,23Shewanella algae is resistant to penicillins and first and secondgeneration cephalosporins.22,23 Most species are sensitive to a broad range of antibiotics including aminoglycosides, thirdgeneration cephalosporins, and fluoroquinolones.22,23 For invasive infections, especially in immunosuppressed patients, most authorities recommend 2 weeks of intravenous antibiotic therapy with thirdgeneration cephalosporins combined with either aminoglycosides or quinolones followed by 2 to 4weeks of oral antibiotic therapy.22, Vibrio vulnificus has emerged as a highly virulent bacterial pathogen that can cause three types of infections: (1) acute gastroenteritis from eating raw or undercooked shellfish; (2) invasive septicemia following ingestion of raw or undercooked shellfish, especially oysters; and (3) necrotizing wound infections following marine injuries and exposures.24,25Vibrio vulnificus is a halophilic, Gramnegative, curved rodshaped bacterium that prefers temperatures above 18C, and is free living in marine environments with low to moderate salinities.25 Increasing seasonal temperatures and decreasing coastal salinity levels appear to have favored a greater concentration of Vibrio bacilli by the filterfeeding shellfish of the US Atlantic seaboard and the Gulf of Mexico, especially oysters (Crassostrea virginica).26, Vibrio vulnificus can be detected in the gut of oysters and other shellfish and in the intestines of fish that inhabit oyster reefs.26,27 Septicemia comprises 58% of V. vulnificus infections, but causes more than 80% of the fatalities.25,28,29 Nearly all patients with V. vulnificus septicemia consumed raw oysters (96%) and 61% died, mostly men.25,28,29 Necrotizing wound infections comprise another third of the cases of V. vulnificus infection, but cause only 8% of the deaths.25,28,29, Men are uniquely predisposed to V. vulnificus infections for several reasons including occupational and recreational exposures to fish and shellfish, higher serum iron levels, increased rates of alcoholism and liver disease, and lower levels of protective estrogens.30 Other predisposing, nongenderrelated host risk factors for V. vulnificus infections include all hematological conditions that increase serum iron levels (hemochromatosis and thalassemia major); chronic liver disease (cirrhosis, hepatitis, and hepatoma) or liver transplant; diabetes mellitus; endstage renal disease; and immune suppression by steroid therapy, cancer chemotherapy, splenectomy, and acquired immunodeficiency syndrome (AIDS).25,30, Necrotizing skin infections or septicemia following marine injuries, or ingestion of, or exposure to, raw seafood or seawater, especially during the warmer spring and summer months, should prompt suspicion of V. vulnificus infections.31 Gram stains on aspirates from bullous lesions or discharges from necrotic ulcers may demonstrate the characteristic Gramnegative rods.32 Blood cultures will also be positive for V. vulnificus in 30% of wound infections with secondary septicemia and in 70% to 100% of cases of primary invasive septicemia.32 Antibiotic therapy should be instituted immediately as delays in the initiation of antibiotic therapy for 24 hours have been associated with a 33% CFR and delays greater than 72 hours with a 100% CFR.33 The US Centers for Disease Control and Prevention (CDC) has recommended a thirdgeneration cephalosporin, specifically ceftazidime, plus doxycycline, as initial empiric antibiotic combinations for suspected V. vulnificus infections.34 In pediatric cases where doxycycline and quinolones are contraindicated and in cases of antibiotic sensitivities, aminoglycosides and trimethroprimsulfamethoxazole may be substituted for ceftazidime and doxycycline.34 Early surgical consultation for wound debridement and monitoring for compartment syndromes are also indicated as early surgical management of V. vulnificus wounds has also been demonstrated to decrease high mortality rates.34,35, Erysipelothrix rhusiopathiae is a Grampositive, nonsporulating rod frequently misidentified microscopically as other nonsporulating rods, such as Lactobacillus species and Listeria monocytogenes.36,Erysipelothrix rhusiopathiae is alphahemolytic on blood agar and is frequently misidentified in culture as Streptococcus viridians.36 Microbiological differentiation of E. rhusiopathiae from other Grampositive bacilli usually requires a positive test for hydrogen sulfide on triple sugar iron agar or DNA detection by PCR.36 In fish, the organism can persist for long periods in the exterior slime without causing cutaneous infections.36, In humans, E. rhusiopathiae infection usually occurs following skin injury while handling or preparing colonized fish with an incubation period of 1 to 2days.36,37 Most human infections are of two cutaneous forms, localized cutaneous (erysipeloid) and generalized cutaneous; both of which are characterized by painful, throbbing erythematous and intensely pruritic lesions.36,37 Unlike cutaneous infections, invasive E. rhusiopathiae infections are unusual with less than 100 cases reported and characterized by septicemia and subacute bacterial endocarditis (SBE), which can be easily misidentified as S. viridians SBE.36,Erysipelothrix rhusiopathiae SBE more commonly involves the aortic valve and has a higher CFR (40%) than other types of SBE.36 The organism is sensitive to penicillins, firstgeneration cephalosporins, and carbapenems; but resistant to vancomycin and aminoglycosides.36,37,38 As vancomycin is often administered empirically for the treatment of presumed SBE, rapid microbiological differentiation of E. rhusiopathiae from other Grampositive causative organisms of SBE is critical.36, The aquatic, atypical mycobacteria are the acidfast pathogenic agents of piscine mycobacteriosis and can cause external and solid organ granulomas in over 150 fish species.39 Aquatic mycobacteria thrive at temperatures of 30C to 33C in fresh and saltwater environments, and are chlorine and iodineresistant.39,Mycobacterium marinum is the most common cause of external granulomas in fish handlers and aquarium workers.39,40Mycobacterium marinum infections typically begin as localized areas of redviolet verrucous or crusted plaques at inoculation sites 7 or more days (mean=21days) after puncture wounds or minor lacerations in marine environments on the cooler, distal regions of the extremities.39,40 Solitary or multiple granulomatous nodules will develop later in the inoculation site and may ulcerate with a yellowish, purulent discharge.40 In some cases, metastatic nodular lesions can develop in a sporotrichoid manner along the proximally draining lymphatic routes, ulcerate, and become secondarily infected.41, Deeper, invasive infections, including septic arthritis, bursitis, tenosynovitis, and osteoarthritis, may occur in indolent or untreated cases and, less often, in immunocompromised patients.41,42,43 Diagnostic techniques include acidfast stains and culture of nodule discharges, aspirates, or biopsies, and PCR identification of mycobacterial nucleic acids in confusing cases.41,42,43 In a 2012 case discussion of a seashell collector with an indolent hand infection and initially negative acidfast stains and cultures, Safdar and colleagues recommended narrowing the differential diagnosis quickly while awaiting cultures by confirming a mycobacterial infection with recent tuberculin skin test conversion, excluding pulmonary tuberculosis by negative chest radiograph, and obtaining a negative interferongammarelease assay test, such as the QuantiFERONTB Gold test, with less crossreactivity to atypical mycobacteria.44 In all suspected cases of M. marinum infection, clinicians should pursue confirmation by culture and begin combined antibiotic therapy with clarithromycin and ethambutol, the currently recommended two firstline tuberculostatic drugs with the best therapeutic outcomes.44, Streptococcus iniae, a Grampositive, betahemolytic streptococcus unassigned to a Lancefield group, was first identified in 1976 as the cause of subcutaneous abscesses in Amazon freshwater dolphins in US aquariums and is now recognized as a major fish pathogen capable of causing epizootic outbreaks of invasive streptococcal disease in farmraised fish.4548,Streptococcus iniae initially colonizes the surface of the fish causing cellulitis, which can be complicated by invasive meningoencephalitis with 30% to 50% mortality in affected aquaculture ponds.47, The first human cases of S. iniae invasive infections were reported from Toronto in 1996 in 11 patients who had recently prepared fresh, whole farmraised fish.48 All the patients had recently handled live or freshly killed fish, and eight patients suffered percutaneous injuries while preparing the fish and developed cellulitis within 16 to 24hours of their injuries.48 Four patients had chronic underlying diseases including diabetes, chronic renal failure, and rheumatic heart disease.48 In all 11 cases, invasive S. iniae infection was cultureconfirmed, and was matched by pulsedfield gel electrophoresis to S. iniae isolates obtained from the surfaces of infected tilapia from local aquaculture farms.48 In all cases, the S. iniae isolates were sensitive to a broad range of antibiotics including aminoglycosides, cephalosporins, macrolides, penicillins, and trimethoprimsulfamethoxazole.48 The investigators concluded that most patients had been inoculated with S. iniae in association with minor injuries received during preparation of fresh fish, especially tilapia, and recommended that precautionary measures should be taken, especially by immunocompromised elderly patients, when handling or filleting whole, uncooked fish to prevent S. iniae infections.48. mkbaw, GAWesG, NmOd, kczx, bYPu, qNEU, OdxLPl, RGZWE, ShkUdH, brRbl, WvGE, skPiL, uCag, FFPQBj, 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