Unusual portal of entry of Vibrio vulnificus: evidence of its prolonged survival on the skin

Vibrio Vulnificus Necrotizing Fasciitis Associated with Acupuncture

Necrotizing fasciitis is a severe life-threatening infection of the deep subcutaneous tissues and fascia. Infection with Vibrio vulnificus, a halophilic Gram-negative bacillus found worldwide in warm coastal waters, can lead to severe complications, particularly among patients with chronic liver diseases. We herein present an unusual case of necrotizing fasciitis caused by V. vulnificus triggered by acupuncture needle insertion. The patient, who suffered from diabetes mellitus and nonalcoholic fatty liver disease and worked at a fish hatchery, denied any injury prior to acupuncture. This is the first ever reported case of V. vulnificus infection triggered by acupuncture needle insertion, clearly emphasizing the potential hazards of the prolonged survival of V. vulnificus on the skin. The potential infectious complications of acupuncture needle insertion are discussed.

Comparative genomic analysis of clinical and environmental Vibrio vulnificus isolates revealed biotype 3 evolutionary relationships

In 1996 a common-source outbreak of severe soft tissue and bloodstream infections erupted among Israeli fish farmers and fish consumers due to changes in fish marketing policies. The causative pathogen was a new strain of Vibrio vulnificus, named biotype 3, which displayed a unique biochemical and genotypic profile. Initial observations suggested that the pathogen erupted as a result of genetic recombination between two distinct populations. We applied a whole genome shotgun sequencing approach using several V. vulnificus strains from Israel in order to study the pan genome of V. vulnificus and determine the phylogenetic relationship of biotype 3 with existing populations. The core genome of V. vulnificus based on 16 draft and complete genomes consisted of 3068 genes, representing between 59 and 78% of the whole genome of 16 strains. The accessory genome varied in size from 781 to 2044 kbp. Phylogenetic analysis based on whole, core, and accessory genomes displayed similar clustering patterns with two main clusters, clinical (C) and environmental (E), all biotype 3 strains formed a distinct group within the E cluster. Annotation of accessory genomic regions found in biotype 3 strains and absent from the core genome yielded 1732 genes, of which the vast majority encoded hypothetical proteins, phage-related proteins, and mobile element proteins. A total of 1916 proteins (including 713 hypothetical proteins) were present in all human pathogenic strains (both biotype 3 and non-biotype 3) and absent from the environmental strains. Clustering analysis of the non-hypothetical proteins revealed 148 protein clusters shared by all human pathogenic strains; these included transcriptional regulators, arylsulfatases, methyl-accepting chemotaxis proteins, acetyltransferases, GGDEF family proteins, transposases, type IV secretory system (T4SS) proteins, and integrases. Our study showed that V. vulnificus biotype 3 evolved from environmental populations and formed a genetically distinct group within the E-cluster. The unique epidemiological circumstances facilitated disease outbreak and brought this genotype to the attention of the scientific community.

Hemochromatosis and Vibrio vulnificus wound infections

There are several reports of persons with hemochromatosis and Vibrio vulnificus primary septicemia, but few accounts of persons with hemochromatosis and V. vulnificus wound infection. A 58-year-old white man developed infection of a forearm injury exposed to seawater in the Gulf of Mexico near the Alabama coast. At age 66, he was diagnosed to have hemochromatosis. Transferrin saturation was 89% and serum ferritin was 4761 pmol/L. HFE genotype was C282Y/C282Y. Serum levels of hepatic enzymes, glucose, IgG, IgA, and IgM, and blood levels of T, B, and natural killer cells were normal. We identified previous reports of only 2 similar cases: a woman from Alabama and a man from northern Australia. Mean age of the 3 subjects was 51 years at diagnosis of infection. Each had elevated serum iron measures or iron overload complications; both men were diagnosed to have hemochromatosis after they developed infection. Each of the 3 had recent exposure of a wound on an extremity to seawater, rapid development of a necrotizing soft tissue infection that required debridement and skin grafting, and positive wound or blood cultures. Each subject survived the infection. V. vulnificus wound infection occurs in some persons with hemochromatosis, but the risk of infection may be small. All patients with V. vulnificus infections should be evaluated for hemochromatosis, iron overload, and liver disorders.

Update in the Epidemiology, Prophylaxis, and Treatment of Fungal Infections in Patients with Hematologic Disorders

Invasive fungal infections contribute to the morbidity and mortality of immunosuppressed patients treated for hematologic malignancy and those undergoing hematopoietic cell transplantation. After years of limited advances, the management of fungal infections in these patients is now rapidly evolving. In this update, we will outline changes in the epidemiology of invasive fungal infections, discuss current issues in diagnosis and susceptibility testing, and review the current classes of antifungal drugs, focusing on newly licensed therapies. Data on antifungal prophylaxis, empiric therapy, and treatment of documented invasive fungal infections including single agents and combinations with newly licensed agents will be reviewed with emphasis on their impact on patients with hematologic malignancies.

Evaluation of genotypic and phenotypic methods to distinguish clinical from environmental Vibrio vulnificus strains

Vibrio vulnificus is a heterogeneous bacterial species that comprises virulent and avirulent strains from environmental and clinical sources that have been grouped into three biotypes. To validate the typing methods proposed to distinguish clinical from environmental isolates, we performed phenotypic (API 20E, API 20NE, and BIOLOG tests) and genetic (ribotyping and DNA polymorphism at several loci) studies with a large strain collection representing different biotypes, origins, and host ranges. No phenotypic method was useful for biotyping or grouping strains with regard to the origin of an isolate, and only the BIOLOG system was reliable for identifying the strains at the species level. DNA polymorphisms divided the population into three major profiles. Profile 1 strains were vcg type C, 16S rRNA type B, and vvh type 1 and included most of the biotype 1 human septicemic isolates; profile 2 strains were vcg type E, 16S rRNA type A, and vvh type 2 and included all biotype 2 isolates together with biotype 1 isolates from fish and water and some human isolates; and profile 3 strains were vcg type E, 16S rRNA type AB, and vvh type 2 and included biotype 3 strains. Ribotyping divided the species into two groups: one group that included profile 1 biotype 1 isolates and one group that included isolates of all three biotypes with the three profiles described above. In conclusion, no genotyping system was able to distinguish either clinical strains from environmental strains or biogroups within the species V. vulnificus, which suggests that new typing methodologies useful for public health have to be developed for this species.

New and emerging infectious diseases

New and emerging diseases present a constant challenge. Globalization of business, international adoption, immigration, and tourism have contributed to the rapid spread of diseases, such as severe acute respiratory syndrome (SARS). Infectious diseases that emerge in Africa or Asia may arrive on US shores within days. This article reviews the new and emerging pathogens important to dermatologists.

Vibrio vulnificus Peritonitis After Handling of Seafood in a Patient Receiving CAPD

Vibrio vulnificus is a marine bacterium and opportunistic human pathogen. Associated infections have contributed to the majority of seafood-related deaths in the United States. In patients with such predisposed clinical conditions as chronic liver disease, immunocompromised state, and end-stage renal disease, this organism has been associated with the development of life-threatening primary septicemia and severe wound infection. However, continuous ambulatory peritonitis dialysis (CAPD)-related peritonitis caused by V vulnificus has not been reported. We describe a patient receiving CAPD who developed peritonitis caused by V vulnificus after handling seafood. This case highlights the importance of strict aseptic technique during CAPD exchanges and calls for an effort in educating our dialysis patients on precautions about seafood handling.

Two cases of severe sepsis due to Vibrio vulnificus wound infection acquired in the Baltic Sea

Two severe cases of Vibrio vulnificus wound infection with secondary septicemia occurred during 1 week in August 2003 on the German island of Usedom in the southwestern Baltic Sea. In both cases, pre-existing wounds were inoculated by wading in contaminated sea water. One of the patients died from septic multiorgan failure. To the best of our knowledge, this is the first fatality due to a V. vulnificus infection to have occurred in Germany. Microbiological analysis revealed high concentrations of V. vulnificus in sea water along the coastline, following a period when water temperature exceeded 20 degrees C for more than 2 weeks.

Identification of the emerging pathogen Vibrio vulnificus biotype 3 by commercially available phenotypic methods

Identification of the emerging pathogen Vibrio vulnificus biotype 3 has become a challenge for clinical laboratories in the last few years. In this study, the abilities of five commercial systems to identify this new species have been evaluated for the first time, using a unique collection of strains. Fifty-one well-documented wild strains of V. vulnificus biotype 3 were processed using API 20 NE, GNI+ Vitek 1 cards, ID-GNB Vitek 2 cards, Neg Combo 20 Microscan panels, and NMIC/ID-5 BD Phoenix panels. The numbers of strains identified as V. vulnificus by ID-GNB, NMIC/ID-5, and GNI+ were 50 (98.0%), 46 (90.2%), and 7 (13.7%), respectively. Neg Combo 20 Microscan panels and API 20 NE were unable to identify any of the strains of this emerging pathogen to the species level and mostly misidentifies them as other species of the Vibrionaceae family. Data on the phenotypic pattern of V. vulnificus biotype 3 when processed in all five systems as presented here could help clinical laboratories in identifying this new pathogen.

Cutaneous manifestations of waterborne infections

Although waterborne pathogens are relatively uncommon causes of cutaneous infections, these agents are being recognized with increasing frequency. Humans are exposed to water through a variety of recreational and occupational activities. Poor sanitary conditions in developing nations place the human populations at constant risk. Some aquatically acquired skin infections respond well to therapy, whereas other diseases do not require a specific treatment. However, many of these infections are rare, and effective therapy has not been defined. Gram-negative bacilli constitute the largest group of aquatic pathogens that cause skin infections. Other agents include mycobacteria, fungi, viruses, and amoeba and other parasites. Toxins from aquatic animals and parasites are associated with cutaneous diseases. Because waterborne skin infections, which are caused by a wide variety of pathogens, occur infrequently, most of the literature on the topic are case reports. This paper reviews the aquatic pathogens associated with cutaneous infections in humans and the available treatments.

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.