A 70-Year-Old Man With Severe Hand Pain, Part 2

Correct Answer: C. The findings and demographics of the presented patient are most consistent with a vibriosis infection.

Discussion. The actual culprit and pathogen in this case is Vibrio vulnificus (V vulnificus; Answer C). This organism is a gram-negative rod, which has appeared more commonly in the recent medical literature likely due to global warming.^2,3

Indeed, V vulnificus have expanded their previous range and human contact ever northward to take advantage of the extension of their preferred habitat: warm, brackish waters. What was previously a literature dominated by studies from Southeast Asia (e.g. Mekong delta), is now being supplemented with studies from the United States coming from experiences in the Gulf of Mexico, the Chesapeake, and even the Delaware Bay.²

Although V vulnificus is a free-living bacterium, filter feeders such as oysters can concentrate these organisms and are considered a main vector of most human disease.³ Nonetheless, any wound sustained in an endemic inlet area such as marshes and river estuaries, can result in contamination and infection, which was the situation in the presented patient.

Infection with V vulnificus is serious and often lethal. Two syndromes are reported in the literature. First, is a primary septicemia due to the ingestion of filter-feeding oysters with no wound. Patients present profoundly ill, septic with shock, DIC, and often skin bullae with necrosis. There is a high mortality rate with this syndrome—40% baseline and approaching 90% when hypotensive.^4,5 

The other V vulnificus syndrome is wound infection as the entry point when an often-innocuous puncture or scratch wound occurs in the previously described "brackish water" environment and becomes infected by the free-living Vibrio. Thus, there are two avenues of human exposure and infection such that Answer D is incorrect. In some exposures, these wounds will devolve into a necrotizing fasciitis syndrome as discussed last month.¹ This, too, is a serious life and limb threatening syndrome.^5,6

There is an important relationship between the V vulnificus growth rate and iron. Vibrios are iron-loving organisms, which possess siderophores that utilize ambient iron to produce energy. Iron thus supercharges their growth rate exponentially in vitro.^6,7 And indeed, the in vivo "experiment" in humans confirms this relationship in that patients with increased iron stores such as in cirrhosis and hemochromatosis patients manifest increased incidence, severity and morbidity with vibriosis when exposed.⁸ In fact, a recent review of hemochromatosis cautions such patients not to eat raw oysters.⁸ This pathophysiology was the precise situation in the presented case. These facts of individual risk factors make Answer B incorrect.

Management of the wound-related syndrome consists of the prompt recognition of a necrotizing fasciitis with aggressive surgical debridement, appropriate antibiotics (specifically IV cephalosporins and doxycycline once vibriosis is the confirmed organism), and general ICU support with fluids, pressor, and narcotic analgesia as required. The sepsis syndrome does not require debridement of a wound but is an extremely life-threatening situation even with the best ICU care. Any delays in recognition that vibriosis if the potential pathogen can be catastrophic.

Patient Follow-Up. The local urgent care physicians were aware of the vibriosis risk in their region. They fluid-resuscitated the patient, initiated the broad-spectrum antibiotics (IV cephalosporin and doxycycline, a suggested regimen), and arranged transfer to a regional hospital.

In the operating room, the exploration and debridement revealed local findings of necrotizing fasciitis with significant areas of necrosis. Material was obtained for gram stain and culture, which yielded positivity for V vulnificus

The patient required several subsequent debridement surgeries but improved both systemically and locally. He was discharged with minimal tissue loss. A serum ferritin had been sent and returned at 519 ugm/dl (normal range: 20-200 ugm/dl), a level consistent with his cirrhosis diagnosis. He was cautioned to avoid eating raw oysters and exposure to brackish warm water environments in the future.

What’s the Take Home? Global warming is with us. Beyond the frequent heat waves and more violent hurricanes, we physicians can and will see it by changing demographics of infectious diseases. An example of this was presented here wherein a patient presented with what turned out to be a necrotizing fasciitis syndrome caused by wound exposure to an organism relatively new to the region where it was contracted, namely V vulnificus infection with exposure in the Chesapeake.

There are two vibriosis syndromes in humans. One is the situation described above, where the major presenting illness is necrotizing fasciitis in the setting of a wound or injury in brackish water. Just 30 or so years ago if one researched that situation essentially all the literature would be coming from Southeast Asia. Not anymore.

The other presenting syndrome is a fulminant overwhelming sepsis syndrome with a recent history of shellfish (especially oysters) ingestion from a similar environment. Both are significantly life and limb threatening. The key to good outcome is recognizing that these syndromes have a classical and characteristic warm water environment with food/wound connection in the patients in question.

Another interesting and important individual patient historical/demographic point is the siderophile nature of V vulnificus such that patients with increased iron stores (e.g. cirrhosis of liver, hemochromatosis) are at even higher risk as to incidence and pathogenicity of vibrioses.

A final comment is that these instances remain uncommon. Yet, the incidence and nature of once rare or uncommon infections from organisms are now increasing their breadth and range of occurrence. Dengue, malaria, the tick-borne infections are examples, to name but a few.

AUTHOR
Ronald N. Rubin MD^1,2

AFFILIATIONS
¹Lewis Katz School of Medicine at Temple University, Philadelphia, PA
²Department of Medicine, Temple University Hospital, Philadelphia, PA

CITATION
Rubin RN. A 70-year-old man with severe hand pain, part 2. Consultant. 2024;64(7):eXX. doi: 10.25270/con.2024.07.000004

DISCLOSURES
The author reports no relevant financial relationships.

CORRESPONDENCE:
Ronald N. Rubin, MD, Temple University Hospital, 3401 N. Broad Street, Philadelphia, PA 19140 (blooddocrnr@yahoo.com)

REFERENCES

1. Rubin RN. A 70-year-old man with severe hand pain. Consultant. 2024;64(6):e5. doi:10.25270/con.2024.06.000003
2. King M , Rose L, Fraimow H et al. Vibrio vulnificus infections from a previously non-endemic area. Ann Int Med. 2019;171:520-521
3. Blake PA, Merson MH, Weaver RE, et al. Disease caused by a marine vibrio: clinical characteristics and epidemiology. N Eng J Med. 1979; 300:1-5
4. Hoffman TJ, Nelson B, Rabin D, et al. Vibrio vulnificus septicemia. Arch Int Med. 1988;2019:520-
5. Liu JW, Lee JK, Tang HJ, et al. Prognostic factors and antibiotics in Vibrio Vulnificus septicemia. Arch Int Med. 2006;166: 2117-2123.
6. Stevens DL, Bryant A. Necrotizing soft tissue infections. N Eng J Med. 2017; 377:2253-2265
7. Bullen JJ, Spalding PB, Ward CG, et al. Hemochromatosis, iron and septicemia caused by Vibrio Vulnificus. Arch Int Med. 1991;151:1606-1609
8. Olynyk JK, Ramm GA. Hemochromatosis. N Eng J Med. 2022;387:2159-2170