Vibrio vulnificus infection complicated by acute respiratory distress syndrome in a child with nephrotic syndrome

Biomimetic Nanosponges Enable the Detoxification of Vibrio vulnificus Hemolysin

Vibrio vulnificus (V. vulnificus) infection-associated multiple antibiotic resistance has raised serious public health concerns. Recently, nanosponges (NSs) have been expected to provide innovative platforms for addressing antibacterial and drug-resistant challenges by targeting various pore-forming toxins (PFTs). In the present study, we constructed NSs to explore the effects and possible mechanism of recombinant V. vulnificus hemolysin (rVvhA)-induced injuries. In vitro, NSs significantly reversed rVvhA-induced apoptosis and necrosis, and improved toxin-induced intracellular reactive oxygen species (ROS) production, adenosine triphosphate (ATP) depletion, and apoptosis signaling pathway disruption. To explore the clinical translation potential of NSs, we established VvhA-induced septicemia and wound infection mouse models, respectively, and further found NSs could notably attenuate rVvhA-induced acute toxicity and septicemia-associated inflammation, as well as local tissue damage. In a conclusion, NSs showed excellent protective effects against rVvhA-induced toxicity, thus providing useful insights into addressing the rising threats of severe V. vulnificus infections.

A systematic review of necrotising fasciitis in children from its first description in 1930 to 2018

BACKGROUND

Necrotising fasciitis is a rapidly progressing soft-tissue infection with a low incidence that carries a relevant risk of morbidity and mortality. Although necrotising fasciitis is often fatal in adults, its case fatality rate seems to be lower in children. A highly variable clinical presentation makes the diagnosis challenging, which often results in misdiagnosis and time-delay to therapy.

METHODS

We conducted a protocol-based systematic review to identify specific features of necrotising fasciitis in children aged one month to 17 years. We searched 'PubMed', 'Web of Science' and 'SCOPUS' for relevant literature. Primary outcomes were incidence and case fatality rates in population-based studies, and skin symptoms on presentation. We also assessed signs of systemic illness, causative organisms, predisposing factors, and reconstructive procedures as secondary outcomes.

RESULTS

We included five studies reporting incidence and case fatality rates, two case-control studies, and 298 cases from 195 reports. Incidence rates varied between 0.022 and 0.843 per 100,000 children per year with a case-fatality rate ranging from 0% to 14.3%. The most frequent skin symptoms were erythema (58.7%; 175/298) and swelling (48%; 143/298), whereas all other symptoms occurred in less than 50% of cases. The majority of cases had fever (76.7%; 188/245), but other signs of systemic illness were present in less than half of the cohort. Group-A streptococci accounted for 44.8% (132/298) followed by Gram-negative rods in 29.8% (88/295), while polymicrobial infections occurred in 17.3% (51/295). Extremities were affected in 45.6% (136/298), of which 73.5% (100/136) occurred in the lower extremities. Skin grafts were necessary in 51.6% (84/162) of the pooled cases, while flaps were seldom used (10.5%; 17/162). The vast majority of included reports originate from developed countries.

CONCLUSIONS

Clinical suspicion remains the key to diagnose necrotising fasciitis. A combination of swelling, pain, erythema, and a systemic inflammatory response syndrome might indicate necrotising fasciitis. Incidence and case-fatality rates in children are much smaller than in adults, although there seems to be a relevant risk of morbidity indicated by the high percentage of skin grafts. Systematic multi-institutional research efforts are necessary to improve early diagnosis on necrotising fasciits.

Tigecycline salvage therapy for necrotizing fasciitis caused by Vibrio vulnificus: Case report in a child

Necrotizing fasciitis caused by Vibrio vulnificus is rarely reported in children. We describe a 12-year-old immunocompetent boy with necrotizing fasciitis caused by V. vulnificus. He was cured by radical and serial debridement and salvage therapy with intravenous cefpirome plus tigecycline. The in vitro antibacterial activity of combination regimens and a literature review of pediatric V. vulnificus infection are described.

A comprehensive review of Vibrio vulnificus: an important cause of severe sepsis and skin and soft-tissue infection

Vibrio vulnificus is a halophilic Gram-negative bacillus found worldwide in warm coastal waters. The pathogen has the ability to cause primary sepsis in certain high-risk populations, including patients with chronic liver disease, immunodeficiency, iron storage disorders, end-stage renal disease, and diabetes mellitus. Most reported cases of primary sepsis in the USA are associated with the ingestion of raw or undercooked oysters harvested from the Gulf Coast. The mortality rate for patients with severe sepsis is high, exceeding 50% in most reported series. Other clinical presentations include wound infection and gastroenteritis. Mild to moderate wound infection and gastroenteritis may occur in patients without obvious risk factors. Severe wound infection is often characterized by necrotizing skin and soft-tissue infection, including fasciitis and gangrene. V. vulnificus possesses several virulence factors, including the ability to evade destruction by stomach acid, capsular polysaccharide, lipopolysaccharide, cytotoxins, pili, and flagellum. The preferred antimicrobial therapy is doxycycline in combination with ceftazidime and surgery for necrotizing soft-tissue infection.

Septic arthritis as the initial manifestation of fatal Vibrio vulnificus septicemia in a patient with thalassemia and iron overload

Vibrio vulnificus infection is an uncommon but potentially fatal disease in children such that prompt recognition has prognostic implications. We describe here the case of a 9-year-old female with thalassemia and iron overload who presented with septic arthritis as an atypical initial manifestation of fatal V. vulnificus septicemia. This report underscores the possibility of septic arthritis as an early manifestation of V. vulnificus septicemia. Pediatricians should be alert to this extremely invasive disease, especially in children with iron overload.

Necrotizing fasciitis caused by Vibrio vulnificus: epidemiology, clinical findings, treatment and prevention

Necrotizing fasciitis is a soft-tissue infection with a high risk of fatality. Infection with Vibrio vulnificus can lead to development of necrotizing fasciitis and primary septicemia, and occurs mostly in immunocompromised host-associated diseases such as hepatic disease, diabetes mellitus, chronic renal insufficiency, and adrenal insufficiency. Early recognition and treatment of the infection, which are unclear, are vital to patient welfare. We studied the disease epidemiology and reviewed the prognosis and clinical features of patients treated using our developed protocol. Clinical manifestations and outcomes were retrospectively analyzed for 67 patients with V. vulnificus-mediated necrotizing fasciitis and sepsis. All patients who had contacted seawater or raw seafood with positive culture for vibrio were included. Patients were divided into two groups based on the timing of first fasciotomy and injury; within 24 h (group A) and beyond 24 h (group B). Twenty-three of the 67 patients (40%) had hepatic disease, 17 (25.4%) had chronic renal insufficiency, and 12 (17.9%) exhibited adrenal insufficiency. The most common site of infection was the upper extremity (74.7%). Group B presented with more clinical symptoms including fever (p = 0.02), hemorrhagic bullae (p < 0.0001), and shock (p = 0.007). Group A patients exhibited enhanced survival compared to group B (in hospital mortality: 4.9% vs. 23%; p = 0.005). We conclude that early and appropriate diagnosis for V. vulnificus infection should be made, especially in patients presenting with atypical clinical findings. Early fasciotomy within 24 h remains the highest priority and decreases the mortality rate.

Vibrio vulnificus Bacteremia Associated with Chronic Lymphocytic Leukemia, Hypogammaglobulinemia, and Hepatic Cirrhosis: Relation to Host and Exposure Factors in 252 V. Vulnificus Infections Reported in Louisiana

BACKGROUND

Vibrio vulnificus infection in persons with B-chronic lymphocytic leukemia (B-CLL) or hypogammaglobulinemia has been reported infrequently.

PATIENT AND METHODS

A woman with B-CLL, hypogammaglobulinemia, and hepatic cirrhosis died of V. vulnificus bacteremia after eating cooked shrimp and crabs. We reviewed host and exposure data in 252 cases of V. vulnificus infection reported in Louisiana during the interval of 1980 through 2004.

RESULTS

V. vulnificus was isolated from blood in 122 cases (48.8%). Preexisting conditions in 138 cases included liver disease (41.3%), malignancy (13.8%), and immunosuppression (9.4%). The prevalence of preexisting conditions was significantly greater in cases with positive blood cultures than in cases with positive wound or stool cultures. Exposure data in 116 cases revealed crab consumption without raw oyster consumption or seawater exposure in 3.4%.

CONCLUSION

The present patient had several conditions associated with increased risk of V. vulnificus infection and bacteremia, especially hepatic cirrhosis, but her route of exposure to V. vulnificus was unusual.

Vibrio vulnificus in Taiwan

Residents in Taiwan are often exposed to marine microorganisms through seafood and occupational exposure. The number of reported cases of infection attributable to this organism has increased since the first case was reported in 1985. The increasing number of cases may be caused by greater disease activity or improved recognition by clinicians or laboratory workers. We analyze a clinical-case series of 84 patients with Vibrio vulnificus infection from 1995 to 2000 and describe the molecular epidemiologic features of pathogens isolated from these patients. The spectrum of clinical manifestations and outcomes, options of antimicrobial therapy, and virulence mechanisms were investigated. Results of molecular typing of isolates from humans and marine environment in this country had a high genetic divergence among these isolates. Education and measures are needed to prevent this emerging disease.

Vibrio vulnificus infection in a hemodialysis patient receiving intravenous iron therapy

A 73-year-old man treated with long-term hemodialysis, erythropoietin, and intravenous iron sucrose infusions developed Vibrio vulnificus infection after eating raw oysters harvested from the Alabama coast. Five of the 31 persons with cases of V. vulnificus infection reported to the Alabama Department of Public Health (Montgomery) during 1996-2002 (including the patient described here) also had renal disease. Persons with renal disease, especially those treated with long-term hemodialysis and intravenous iron infusions, may have an increased risk of infection with V. vulnificus.

Cytotoxic mechanism of Vibrio vulnificus cytolysin in CPAE cells

Vibrio vulnificus is an estuarian bacterium that causes septicemia and serious wound infection. The cytolysin, one of the important virulence determinants in V. vulnificus infection, has been reported to have lethal activity primarily by increasing pulmonary vascular permeability. In the present study, we investigated the cytotoxic mechanism of V. vulnificus cytolysin in cultured pulmonary artery endothelial (CPAE) cells, which are possible target cells of cytolysin in vivo. V. vulnificus cytolysin caused the CPAE cell damages with elevation of the cytosolic free Ca2+, DNA fragmentation, and decrease of the cellular NAD+ and ATP level. These cytotoxic effects of V. vulnificus cytolysin were prevented by EGTA and aminobenzamide, but were not affected by verapamil or catalase. These results indicate that the elevation of cytosolic free Ca2+ induced by V. vulnificus cytolysin causes the increase of DNA fragmentation and the damaged DNA activates nuclear poly(ADP-ribose) synthetase, which depletes the cellular NAD+ and ATP, resulting in cell death.