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Necrotizing fasciitis after a watercraft accident
Author(s)
Natsu Fukui, MD
Mark Delman, MD
Tuyethoa N. Vinh, MD
Svetolik Djurkovic, MD, FACCP

A 57-year-old man was transferred to our  hospital with leg pain and confusion. His family reported that he had injured his leg while launching a motorized personal watercraft at the North Carolina seashore 2 days before. He had a history of cirrhosis secondary to hepatitis C and alcohol abuse.

Figure 1. Left leg: bullous lesions from Vibrio vulnificus infection.
Figure 1. Left leg: bullous lesions from Vibrio vulnificus infection.
Physical examination revealed rashes on his legs with hemorrhagic bullous lesions and ecchymosis (Figure 1). He was hypotensive and had lactic acidosis, with blood lactate levels as high as 9.4 mmol/L (reference range 0.5–2.2 mmol/L). Despite aggressive hydration and broad-spectrum antibiotics provided at a previous hospital, he needed increasing vasopressor treatment.

Figure 2. Necrosis of deep dermis, subcutaneous fat, and fascial tissue with polymorphonuclear cell infiltration.
Figure 2. Necrosis of deep dermis, subcutaneous fat, and fascial tissue with polymorphonuclear cell infiltration (hematoxylin and eosin, × 200).
Given his septicemia and recent marine exposure, Vibrio vulnificus infection was suspected, and antibiotics were switched to doxycycline and ceftazidime. He underwent urgent surgical debridement, ultimately requiring above-the-knee amputation of his right leg. He also required additional surgeries on his left leg.

Blood and wound cultures eventually grew V vulnificus, and surgical pathology confirmed the diagnosis of necrotizing fasciitis (Figure 2).

RISE IN V VULNIFICUS INFECTIONS IS ATTRIBUTED TO GLOBAL WARMING

V vulnificus infection occurs most commonly from consuming raw shellfish, especially oysters, but it also occurs after exposure of an open wound to contaminated salt water. The pathogen is a gram-negative bacterium that resides in coastal waters worldwide, but in the United States it is usually seen on the Pacific and Gulf coasts1 during the summer.2

Although only 58 cases of V vulnificus infection were reported to the US Centers for Disease Control and Prevention in 1997, the number more than doubled to 124 in 2014.1 This rise is suspected to be due in part to warmer coastal waters associated with global warming.2

Various marine pathogens can cause wound infections, but V vulnificus is most commonly implicated in deaths and hospitalizations.2 Immunocompromised patients and those with liver disease are at particularly high risk of rapid progression to septic shock.

First-line antibiotics are doxycycline plus a third-generation cephalosporin.3 Studies have shown a direct correlation between delay of antibiotics and death,4 and early surgery is critical.5

Given the rising incidence of V vulnificus infection, it is increasingly important for providers across the United States to be aware of this infection.

References
  1. Centers for Disease Control and Prevention. National enteric disease surveillance: COVIS annual summary, 2014. US Department of Health and Human Services, Atlanta, GA. 2014. www.cdc.gov/nationalsurveillance/pdfs/covis-annual-summary-2014-508c.pdf. Accessed May 8, 2018.
  2. Newton A, Kendall M, Vugia DJ, Henao OL, Mahon BE. Increasing rates of vibriosis in the United States, 1996–2010: review of surveillance data from 2 systems. Clinl Infect Dis 2012; 54(suppl 5):S391–S395. doi:10.1093/cid/cis243
  3. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis 2014; 59(2):147-159. doi:10.1093/cid/ciu444
  4. Klontz KC, Lieb S, Schreiber M, Janowski HT, Baldy LM, Gunn RA. Syndromes of Vibrio vulnificus infections. Clinical and epidemiologic features in Florida cases, 1981-1987. Ann Intern Med 1988; 109:318–323. pmid:3260760
  5. Chao WN, Tsai CF, Chang HR, et al. Impact of timing of surgery on outcome of Vibrio vulnificus-related necrotizing fasciitis. Am J Surg 2013; 206(1):32–39. doi:10.1016/j.amjsurg.2012.08.008
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Author and Disclosure Information

Natsu Fukui, MD
Inova Fairfax Hospital, Falls Church, VA

Mark Delman, MD
Inova Fairfax Hospital, Falls Church, VA

Tuyethoa N. Vinh, MD
Inova Fairfax Hospital, Falls Church, VA

Svetolik Djurkovic, MD, FACCP
Inova Fairfax Hospital, Falls Church, VA

Address: Natsu Fukui, MD, Inova Fairfax Hospital, Department of Medicine, 3300 Gallows Road, Falls Church, VA 22042; [email protected]

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Cleveland Clinic Journal of Medicine - 85(6)
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Cleveland Clinic Journal of Medicine
Topics
Infectious Diseases
Page Number
448-449
Legacy Keywords
necrotizing fasciitis, Vibrio vulnificus, infection, Jet Ski, watercraft, North Carolina, global warming, amputation, debridement, Natsu Fukui, Mark Delman, Tuyethoa Vinh, Svetolik Djurkovic
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Author(s)
Natsu Fukui, MD
Mark Delman, MD
Tuyethoa N. Vinh, MD
Svetolik Djurkovic, MD, FACCP
Author(s)
Natsu Fukui, MD
Mark Delman, MD
Tuyethoa N. Vinh, MD
Svetolik Djurkovic, MD, FACCP
Author and Disclosure Information

Natsu Fukui, MD
Inova Fairfax Hospital, Falls Church, VA

Mark Delman, MD
Inova Fairfax Hospital, Falls Church, VA

Tuyethoa N. Vinh, MD
Inova Fairfax Hospital, Falls Church, VA

Svetolik Djurkovic, MD, FACCP
Inova Fairfax Hospital, Falls Church, VA

Address: Natsu Fukui, MD, Inova Fairfax Hospital, Department of Medicine, 3300 Gallows Road, Falls Church, VA 22042; [email protected]

Author and Disclosure Information

Natsu Fukui, MD
Inova Fairfax Hospital, Falls Church, VA

Mark Delman, MD
Inova Fairfax Hospital, Falls Church, VA

Tuyethoa N. Vinh, MD
Inova Fairfax Hospital, Falls Church, VA

Svetolik Djurkovic, MD, FACCP
Inova Fairfax Hospital, Falls Church, VA

Address: Natsu Fukui, MD, Inova Fairfax Hospital, Department of Medicine, 3300 Gallows Road, Falls Church, VA 22042; [email protected]

Article PDF
fukui_necrotizingfasciitis.pdf
Article PDF
fukui_necrotizingfasciitis.pdf
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A 57-year-old man was transferred to our  hospital with leg pain and confusion. His family reported that he had injured his leg while launching a motorized personal watercraft at the North Carolina seashore 2 days before. He had a history of cirrhosis secondary to hepatitis C and alcohol abuse.

Figure 1. Left leg: bullous lesions from Vibrio vulnificus infection.
Figure 1. Left leg: bullous lesions from Vibrio vulnificus infection.
Physical examination revealed rashes on his legs with hemorrhagic bullous lesions and ecchymosis (Figure 1). He was hypotensive and had lactic acidosis, with blood lactate levels as high as 9.4 mmol/L (reference range 0.5–2.2 mmol/L). Despite aggressive hydration and broad-spectrum antibiotics provided at a previous hospital, he needed increasing vasopressor treatment.

Figure 2. Necrosis of deep dermis, subcutaneous fat, and fascial tissue with polymorphonuclear cell infiltration.
Figure 2. Necrosis of deep dermis, subcutaneous fat, and fascial tissue with polymorphonuclear cell infiltration (hematoxylin and eosin, × 200).
Given his septicemia and recent marine exposure, Vibrio vulnificus infection was suspected, and antibiotics were switched to doxycycline and ceftazidime. He underwent urgent surgical debridement, ultimately requiring above-the-knee amputation of his right leg. He also required additional surgeries on his left leg.

Blood and wound cultures eventually grew V vulnificus, and surgical pathology confirmed the diagnosis of necrotizing fasciitis (Figure 2).

RISE IN V VULNIFICUS INFECTIONS IS ATTRIBUTED TO GLOBAL WARMING

V vulnificus infection occurs most commonly from consuming raw shellfish, especially oysters, but it also occurs after exposure of an open wound to contaminated salt water. The pathogen is a gram-negative bacterium that resides in coastal waters worldwide, but in the United States it is usually seen on the Pacific and Gulf coasts1 during the summer.2

Although only 58 cases of V vulnificus infection were reported to the US Centers for Disease Control and Prevention in 1997, the number more than doubled to 124 in 2014.1 This rise is suspected to be due in part to warmer coastal waters associated with global warming.2

Various marine pathogens can cause wound infections, but V vulnificus is most commonly implicated in deaths and hospitalizations.2 Immunocompromised patients and those with liver disease are at particularly high risk of rapid progression to septic shock.

First-line antibiotics are doxycycline plus a third-generation cephalosporin.3 Studies have shown a direct correlation between delay of antibiotics and death,4 and early surgery is critical.5

Given the rising incidence of V vulnificus infection, it is increasingly important for providers across the United States to be aware of this infection.

A 57-year-old man was transferred to our  hospital with leg pain and confusion. His family reported that he had injured his leg while launching a motorized personal watercraft at the North Carolina seashore 2 days before. He had a history of cirrhosis secondary to hepatitis C and alcohol abuse.

Figure 1. Left leg: bullous lesions from Vibrio vulnificus infection.
Figure 1. Left leg: bullous lesions from Vibrio vulnificus infection.
Physical examination revealed rashes on his legs with hemorrhagic bullous lesions and ecchymosis (Figure 1). He was hypotensive and had lactic acidosis, with blood lactate levels as high as 9.4 mmol/L (reference range 0.5–2.2 mmol/L). Despite aggressive hydration and broad-spectrum antibiotics provided at a previous hospital, he needed increasing vasopressor treatment.

Figure 2. Necrosis of deep dermis, subcutaneous fat, and fascial tissue with polymorphonuclear cell infiltration.
Figure 2. Necrosis of deep dermis, subcutaneous fat, and fascial tissue with polymorphonuclear cell infiltration (hematoxylin and eosin, × 200).
Given his septicemia and recent marine exposure, Vibrio vulnificus infection was suspected, and antibiotics were switched to doxycycline and ceftazidime. He underwent urgent surgical debridement, ultimately requiring above-the-knee amputation of his right leg. He also required additional surgeries on his left leg.

Blood and wound cultures eventually grew V vulnificus, and surgical pathology confirmed the diagnosis of necrotizing fasciitis (Figure 2).

RISE IN V VULNIFICUS INFECTIONS IS ATTRIBUTED TO GLOBAL WARMING

V vulnificus infection occurs most commonly from consuming raw shellfish, especially oysters, but it also occurs after exposure of an open wound to contaminated salt water. The pathogen is a gram-negative bacterium that resides in coastal waters worldwide, but in the United States it is usually seen on the Pacific and Gulf coasts1 during the summer.2

Although only 58 cases of V vulnificus infection were reported to the US Centers for Disease Control and Prevention in 1997, the number more than doubled to 124 in 2014.1 This rise is suspected to be due in part to warmer coastal waters associated with global warming.2

Various marine pathogens can cause wound infections, but V vulnificus is most commonly implicated in deaths and hospitalizations.2 Immunocompromised patients and those with liver disease are at particularly high risk of rapid progression to septic shock.

First-line antibiotics are doxycycline plus a third-generation cephalosporin.3 Studies have shown a direct correlation between delay of antibiotics and death,4 and early surgery is critical.5

Given the rising incidence of V vulnificus infection, it is increasingly important for providers across the United States to be aware of this infection.

References
  1. Centers for Disease Control and Prevention. National enteric disease surveillance: COVIS annual summary, 2014. US Department of Health and Human Services, Atlanta, GA. 2014. www.cdc.gov/nationalsurveillance/pdfs/covis-annual-summary-2014-508c.pdf. Accessed May 8, 2018.
  2. Newton A, Kendall M, Vugia DJ, Henao OL, Mahon BE. Increasing rates of vibriosis in the United States, 1996–2010: review of surveillance data from 2 systems. Clinl Infect Dis 2012; 54(suppl 5):S391–S395. doi:10.1093/cid/cis243
  3. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis 2014; 59(2):147-159. doi:10.1093/cid/ciu444
  4. Klontz KC, Lieb S, Schreiber M, Janowski HT, Baldy LM, Gunn RA. Syndromes of Vibrio vulnificus infections. Clinical and epidemiologic features in Florida cases, 1981-1987. Ann Intern Med 1988; 109:318–323. pmid:3260760
  5. Chao WN, Tsai CF, Chang HR, et al. Impact of timing of surgery on outcome of Vibrio vulnificus-related necrotizing fasciitis. Am J Surg 2013; 206(1):32–39. doi:10.1016/j.amjsurg.2012.08.008
References
  1. Centers for Disease Control and Prevention. National enteric disease surveillance: COVIS annual summary, 2014. US Department of Health and Human Services, Atlanta, GA. 2014. www.cdc.gov/nationalsurveillance/pdfs/covis-annual-summary-2014-508c.pdf. Accessed May 8, 2018.
  2. Newton A, Kendall M, Vugia DJ, Henao OL, Mahon BE. Increasing rates of vibriosis in the United States, 1996–2010: review of surveillance data from 2 systems. Clinl Infect Dis 2012; 54(suppl 5):S391–S395. doi:10.1093/cid/cis243
  3. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis 2014; 59(2):147-159. doi:10.1093/cid/ciu444
  4. Klontz KC, Lieb S, Schreiber M, Janowski HT, Baldy LM, Gunn RA. Syndromes of Vibrio vulnificus infections. Clinical and epidemiologic features in Florida cases, 1981-1987. Ann Intern Med 1988; 109:318–323. pmid:3260760
  5. Chao WN, Tsai CF, Chang HR, et al. Impact of timing of surgery on outcome of Vibrio vulnificus-related necrotizing fasciitis. Am J Surg 2013; 206(1):32–39. doi:10.1016/j.amjsurg.2012.08.008
Issue
Cleveland Clinic Journal of Medicine - 85(6)
Issue
Cleveland Clinic Journal of Medicine - 85(6)
Page Number
448-449
Page Number
448-449
Publications
Cleveland Clinic Journal of Medicine
Publications
Cleveland Clinic Journal of Medicine
Topics
Infectious Diseases
Article Type
Article
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Necrotizing fasciitis after a watercraft accident
Display Headline
Necrotizing fasciitis after a watercraft accident
Legacy Keywords
necrotizing fasciitis, Vibrio vulnificus, infection, Jet Ski, watercraft, North Carolina, global warming, amputation, debridement, Natsu Fukui, Mark Delman, Tuyethoa Vinh, Svetolik Djurkovic
Legacy Keywords
necrotizing fasciitis, Vibrio vulnificus, infection, Jet Ski, watercraft, North Carolina, global warming, amputation, debridement, Natsu Fukui, Mark Delman, Tuyethoa Vinh, Svetolik Djurkovic
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