Vibrio Vulnificus Infection
Necrotizing fasciitis may be caused by a variety of organism . The progression of the disease may be gradual or have a fulminant course. We report a case of septicaemia, gangrene and fulminant necrotizing fasciitis caused by Vibrio Vulnificus with fatal outcome. The patient expired inspite of I.V antibiotics and amputation of the affected limb. Transmission to men is through contact with skin, mucosa or wounds exposed to sea water, and/or consumption of certain undercooked fish or raw shell, especially during the summer months. Significant risk factors for fulminant course of the disease include pre-existing liver disease and immunocompromised states. This infection should be clinically suspected and recognized from its typical history of exposure to sea water and fulminant clinical progress as a delay in diagnosis and treatment may result in considerable mortality.
Vibrio Vulnificus infection is an acute illness, and those who recover should not expect any long-term consequences. The organism rapidly crosses the gut mucosa and invades the bloodstream without causing any significant gastrointestinal symptoms.
Vibrio Vulnificus is an opportunistic halophilic (those which require salt), lactose fermenting, highly motile gram-negative bacillus in the same genus as that cause cholera. It is found in marine or brackish waters in the costal areas. It grows best in warmer waters (temperature >20°C) with salt level ranging from 0.7%-1.6%. Most cases of Vibrio Vulnificus infections occur during the warm summer months between May and October. In some epidemiologic studies, greater than 50% of shellfish and 11% of crabs were found to harbor the organism during warmer months when the incidence of the infection also shows a significant rise.
Virulence of Vibrio Vulnificus in humans is associated with the availability of iron. Patients with increased iron stores, such as seen in hemochromatosis, alcoholic liver disease, or hemolytic anemia, are susceptible to septicemia with Vibrio Vulnificus. The organism is unable to use transferrin-bound iron for growth; however, in patients with iron overload and transferrin saturation of 75% or higher, free iron is available for use by the organism. Therefore, transferrin saturation is a more important growth variable for Vibrio Vulnificus than total iron stores. Appropriate antibiotics should be administered without delay for soft tissue infections and septicemia and include doxycycline in combination with a third generation cephalosporin such as ceftazidime, an aminoglycoside or possibly chloramphenicol. Surgical debridement of soft tissue infections is indicated early if the disease progression is rapid, surgical amputation of gangrenous limbs is often required . The course of illness is often rapid and about 50% of cases are fatal.
Vibrio Vulnificus secretes a variety of toxins that have been instrumental in bacterial virulence and pathogenesis of severe manifestations. Iron has been shown to play a significant role in the pathogenesis of virulent infection as has been immunocompromised states. It has been postulated that the bacterium recruits iron to accelerate its growth and can quickly reach concentrations where the tumor necrosis factor–alpha released by its overwhelms the immune system.
The histopathology of Vibrio Vulnificus is usually revealed as an intense cellulitis involving the skin and subcutaneous tissues in a septal distribution. Numerous bacteria are found in the superficial dermis, and bullae that form at the dermal-epidermal interface are devoid of inflammatory cells. The infiltrate is usually neutrophilic, which makes our case unusual in that the infiltrate was composed of mostly mononuclear cells.
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