Five Cases of Vibrio vulnificus Necrotizing Fasciitis Outside Traditional Risk Areas

Researchers described 5 cases of Vibrio vulnificus necrotizing fasciitis that occurred after water or shellfish exposure in the Delaware Bay in a brief observation case report published in the Annals of Internal Medicine.¹

Traditionally, V vulnificus is found in brackish, high-salinity water with surface temperatures above 13°C. Mortality from wound and bloodstream infections is high, especially in patients with immunosuppression and patients with cirrhosis or other iron-overload states. While V vulnificus is endemic to the southeastern coast of the United States, it is rarely reported in areas farther north in areas with slightly cooler water temperatures, such as the Delaware Bay.

In the 8 years before 2017, researchers reported only 1 case of V vulnificus infection in the Delaware Bay area. However, between July 2017 and September 2018 there were 5 reported cases of V vulnificus infection.

All patients were men between age 38 and 64 years who presented with necrotizing fasciitis induced by V vulnificus after exposure/work involving marine life in the Delaware Bay (4 patients) and/or consumption of crabs from the Delaware Bay (1 patient). All patients received prompt medical and surgical management. After debridement, antibiotic treatment included 14 days of ceftriaxone and doxycycline (in 4 patients) or ceftriaxone and tigecycline (in 1 patient). Of note, 2 patients had untreated hepatitis C, 1 patient had untreated hepatitis B, 1 patient had Parkinson disease, and 1 had type 2 diabetes.

The patient with Parkinson disease, who was 60 years old, developed shock, respiratory failure, and disseminated intravascular coagulation, and subsequently all 4 distal limbs became necrotic and mummified and later required amputation.  The patient with type 2 diabetes developed significant and diffusely tender left leg edema with fluctuant bullae on the calf. One patient with untreated hepatitis C (aged 64 years) developed unstable ventricular tachycardia during the third debridement and subsequently died.

As a result of the rise in sea surface temperatures in many regions of the United States over the past 3 decades,² clinicians should be “aware of the possibility that V vulnificus infections are occurring more frequently outside traditional geographic areas,” concluded the researchers.¹

References

1. King M, Rose L, Fraimow H, Nagori M, Danish M, Doktor K. Vibrio vulnificus infections from a previously nonendemic area [published online June 18, 2019]. Ann Intern Med. doi:10.7326/L19-0133
2. Martinez-Urtaza J, Bowers JC, Trinanes J, DePaola A. Climate anomalies and the increasing risk of Vibrio parahaemolyticus and Vibrio vulnificus illnesses. Food Res Int. 2010;43(7):1780-1790.