Necrotising fasciitis caused by Vibrio vulnificus

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.

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.

Necrotising fasciitis causing compartment syndrome of the forearm and septic shock due to Vibrio vulnificus: a case report

Compartment syndrome caused by necrotising fasciitis has rarely been described. We report a case of systemic Vibrio vulnificus necrotising fasciitis presented with compartmental syndrome of the forearm and septic shock. The patient was treated with systemic antibiotic treatment and urgent surgical decompression followed by multiple necrotic tissue debridements. The patient recovered with some limited motion of the hand function. Prompt recognition and immediate treatment with antibiotics and surgical intervention are essential.

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

A 9-year-old girl with nephrotic syndrome visited a local hospital after developing fever, chills, and edematous changes and multiple hemorrhagic bullae on both legs over 2 days. Cultures of blood and an aspirate from the bullae yielded Vibrio vulnificus. The patient was transferred to our hospital because of persistent fever, generalized edema, acute renal failure, and disseminated intravascular coagulopathy. We treated this patient as a V. vulnificus infection complicated with necrotizing fasciitis. With minocycline and ceftazidime combination therapy was instituted. Emergency fasciotomy and continuous peritoneal dialysis were performed. The patient developed acute respiratory distress syndrome (ARDS) during the hospitalization, requiring intubation and mechanical ventilation. She eventually died. The histopathological findings showed diffuse alveolar damage with lobular pneumonitis. Hyaline membranes, composed of proteinaceous exudate and cellular debris, covered the alveolar surfaces. Microscopic examinations of lung could not distinguish the effects of cytolysin from other insults to lungs that occur in ARDS. This report highlights the postmortem pathological findings in V. vulnificus infection in a child with nephrotic syndrome complicated by ARDS.

Necrotizing fasciitis caused by Vibrio vulnificus differs from that caused by streptococcal infection

We reviewed the clinical record of all patients admitted to Saga Medical School Hospital during the most recent 10 years and found that 17 (0.03%) were diagnosed as having necrotizing fasciitis. Bacteriological examination demonstrated that Vibrio vulnificus was the pathogen responsible in five patients (29%). The disease caused by V. vulnificus occurred in the warmer half of the year. All of the patients had underlying chronic liver dysfunction, and three of them had previously consumed raw seafood. In these patients, the predominant skin lesions were oedema and subcutaneous bleeding, such as ecchymosis and purpura, while superficial necrosis was not recognized. Three patients died of systemic complications. By contrast, all of the five patients with necrotizing fasciitis caused by Streptococcus pyogenes had the disorder in winter, and only one of them had chronic liver dysfunction. In skin lesions, subcutaneous bleeding was rare but necrosis was seen often. Despite the high incidence of systemic complications, no patients with streptococcal necrotizing fasciitis died. These findings suggest that the clinical features of necrotizing fasciitis caused by V. vulnificus are different from those of necrotizing fasciitis caused by classical pathogens, and that the two should be differentiated as early as possible to improve the prognosis.

In vitro synergism between cefotaxime and minocycline against Vibrio vulnificus

We conducted time-kill studies to evaluate the inhibitory activities of either cefotaxime or minocycline alone and the two drugs in combination against a clinical strain of Vibrio vulnificus. The MICs of cefotaxime and minocycline were 0.03 and 0.06 microg/ml, respectively. When approximately 5 x 10(5) CFU of V. vulnificus per ml was incubated with cefotaxime at 0.03 or 0.05 microg/ml, the bacterial growth was inhibited during the initial 2 and 8 h, respectively. Thereafter, V. vulnificus regrew and the level of growth reached that of the control. Within the dose range of less than five times the MIC, the duration of the inhibitory effect of cefotaxime was proportional to its concentration. When minocycline at 0.015, 0.03, 0.045, and 0.06 microg/ml was used to evaluate the inhibitory effect, a similar trend was observed. Either antibiotic at a concentration of five times the MIC or greater prevented the regrowth of V. vulnificus for at least 48 h. When cefotaxime at 0.05 microg/ml and minocycline at 0.045 microg/ml were combined in the same culture, the inhibitory effect against V. vulnificus persisted for more than 48 h, with no regrowth noted. The use of a combination of these two antibiotics resulted in the reduction of growth by 6 orders of magnitude compared to the use of either of the two antibiotics alone, and the number of surviving organisms in the presence of the antibiotics combined was approximately 3 orders of magnitude less than that in the starting inoculum. We conclude that cefotaxime and minocycline acted synergistically in inhibiting V. vulnificus in vitro.

Necrotizing fasciitis of the foot caused by an unusual organism, Vibrio vulnificus

In modern medicine, there are very few infectious disease processes occurring in the foot that can cause death within 48 hr. and have an overall mortality rate of 50% despite appropriate antibiotic and surgical treatment. Such a condition must be regarded as being potentially deadly. The authors report a case of necrotizing fasciitis of the left foot resulting from an unusual organism of Vibrio vulnificus.

Contaminated marine wounds--the risk of acquiring acute bacterial infection from marine recreational beaches

An animal model was used to determine the potential for causing wound infections of bacteria isolated from marine recreational beaches in Hong Kong. Water samples were characterized physically, chemically and bacteriologically and used to inoculate artificially-induced wounds in rats. Morbidity and mortality correlated significantly (P < 0.01) with MacConkey plate counts and faecal coliform counts (membrane filtration) and inversely with salinity of the water. The majority of deaths were due to infection caused by marine and estuarine bacteria rather then enteric organisms. A total of 318 bacterial strains was isolated from the wounds and blood of animals inoculated with seawater, of which 242 were marine/estuarine (predominantly Vibrio spp., Aeromonas hydrophila and Pseudomonas putrefaciens) and 40 were enterobacteria. The virulence of the animal strains were comparable with those from clinical sources.

Vibrio vulnificus. Hazard on the half shell

Vibrio vulnificus is an extremely invasive gram-negative bacillus that causes bacteremia and shock. It should be suspected in any patient who is immunocompromised or has liver disease or hemochromatosis. Reduced gastric acidity may also increase the risk of infection if a patient presents with a history of ingesting raw shellfish (especially oysters) or trauma in brackish waters and skin lesions. Patients most commonly present with one of three clinical syndromes: primary septicemia, wound infection, or gastroenteritis. Treatment includes aggressive wound debridement, antibiotic therapy, and supportive care. Rapidly diagnosing and promptly initiating therapy are critical because V vulnificus infection is rapidly progressive and mortality approaches 100% if septic shock occurs.

Current hypotheses on synergistic microbial gangrene

We have reviewed spreading infections of the dermis, with special reference to the importance of synergy in their causation. Evidence for this is accumulating from both clinical studies and from studies in laboratory animals. Necrotizing fasciitis (rapid spread over 24 h) can be caused by beta-haemolytic streptococci, sometimes with Staphylococcus aureus, or by mixed infections of aerobes and anaerobes, often of gut origin. Animal studies provide good evidence that S. aureus can potentiate the beta-haemolytic streptococcal infection in necrotizing fasciitis. There is also evidence that mixtures of aerobes and anaerobes can act synergistically, but animal models for necrotizing fasciitis have not been developed. Anaerobic cellulitis (variable rate of spread from hours to days) can be caused by mixed aerobes and anaerobes or by mixed clostridia. Animal studies provide good evidence for synergy in the former. Meleney's synergistic postoperative gangrene (slow spread over weeks) may be cutaneous amoebiasis: the animal model of Brewer and Meleney relates to the more rapid infections of anaerobic cellulitis.

The human pathogenic vibrios--a public health update with environmental perspectives

Pathogenic Vibrio species are naturally-occurring bacteria in freshwater and saline aquatic environments. Counts of free-living bacteria in water are generally less than required to induce disease. Increases in number of organisms towards an infective dose can occur as water temperatures rise seasonally followed by growth and concentration of bacteria on higher animals, such as chitinous plankton, or accumulation by shellfish and seafood. Pathogenic Vibrio species must elaborate a series of virulence factors to elicit disease in humans. Activities which predispose diarrhoeal and extraintestinal infections include ingestion of seafood and shellfish and occupational or recreational exposure to natural aquatic environments, especially those above 20 degrees C. Travel to areas endemic for diseases due to pathogenic Vibrio species may be associated with infections. Host risk factors strongly associated with infections are lack of gastric acid and liver disorders. Involvement of pathogenic Vibrio species in cases of diarrhoea should be suspected especially if infection is associated with ingestion of seafood or shellfish, raw or undercooked, in the previous 72 h. Vibrio species should be suspected in any acute infection associated with wounds sustained or exposed in the marine or estuarine environment. Laboratories serving coastal areas where infection due to pathogenic Vibrio species are most likely to occur should consider routine use of TCBS agar and other detection regimens for culture of Vibrio species from faeces, blood and samples from wound and ear infections.

Vibrio vulnificus infection in Hawaii

A life-threatening Vibrio vulnificus infection occurred in a 52-year-old Korean woman with hepatic cirrhosis. Four days after ingesting raw crab, the patient presented to the hospital with nausea, vomiting, fever, hypotension, and hemorrhagic blistering of the left foot. Vibrio vulnificus was recovered from both her blood and a foot wound.

Detection of piluslike structures on clinical and environmental isolates of Vibrio vulnificus

Twenty clinical isolates of Vibrio vulnificus were compared with 10 environmental strains by using electron microscopy and agglutination assays with human erythrocytes, guinea pig erythrocytes, and Saccharomyces cerevisiae. In addition, the isolates were tested for ability to adhere to the human epithelial cell lines HEp-2 and A549. When examined by electron microscopy, 16 (80%) of the 20 clinical isolates demonstrated the presence of piluslike structures; the composition of the bacterial populations ranged from 0 to 68% piliated cells. In contrast, only 3 (30%) of the 10 environmental isolates were piliated, with a range from 0 to 16% piliated cells. A significant association between the presence of piliated cells and the isolate source was found (P less than 0.05). None of the 30 strains agglutinated erythrocytes or yeast cells. V. vulnificus adherence results obtained with HEp-2 cells showed 10 (50%) of 20 clinical isolates and 0 (0%) of 10 environmental isolates with averages of greater than 10 adherent bacteria per cell, demonstrating a correlation between attachment and the isolate source (P less than 0.05). Selected strains were tested to determine whether methyl alpha-D-mannopyranoside, fructose, or alpha-L-(-)-fucose would inhibit bacterial adherence to HEp-2 cells. Multiple patterns of adherence inhibition were observed. Adherence to A549 cells showed 8 (40%) of 20 clinical isolates and 0 (0%) of 10 environmental strains with averages of greater than 10 adherent bacteria per cell. A statistical association between attachment and the isolate source was demonstrated (P less than 0.05). These data suggest that the presence of piluslike structures and the ability to adhere to human epithelial cell lines may be more closely associated with V. vulnificus isolates from clinical specimens than with environmental strains.

Vibrio vulnificus infection

We report 3 cases of Vibrio vulnificus infections from Taiwan. Patient 1, who manifested symptoms of primary septicemia, died after 2 days. Patient 2, who had a wound infection and signs and symptoms of sepsis but negative blood cultures, responded to tobramycin and chloramphenicol plus surgical debridement, and recovered after 26 days of hospitalization. Patient 3 had secondary septicemia originating from a wound inflicted by a shrimp. Originally, the patient seemed to respond to ceftazidime and amikacin treatment along with surgical debridement, but subsequently died from adult respiratory distress syndrome (ARDS) induced by several episodes of aspiration which occurred after initial clinical improvements. We conclude that, for patients with severe wounds and evidence of V. vulnificus infection, an appropriate, powerful antibiotic, such as one of the third generation cephalosporins should be used as initial therapy unless the nature of the infection indicates other treatment.

Vibrio parahaemolyticus and other halophilic vibrios associated with seafood in Hong Kong

The summer prevalence of Vibrio parahaemolyticus and other halophilic vibrios in seafood from Hong Kong markets was investigated. Halophilic vibrios were isolated from all seven types of seafood examined, and comprised 9.1%, 8% and 6.1% of contaminating aerobic heterotrophic bacteria from mussels, clams and oysters respectively. Sucrose-positive vibrios were more common than sucrose-negative varieties. Vibrio alginolyticus was the most frequently isolated species, followed by V. parahaemolyticus, V. harveyi, V. fluvialis, V. vulnificus, V. pelagius, V. campbellii, V. spendidus and V. marinus. Mussels contained the highest concentration of V. parahaemolyticus (4.6 x 10(4)/g); oysters and clams contained 3.4 x 10(4)/g and 6.5 x 10(3)/g respectively. The ubiquity and relatively high concentrations of V. parahaemolyticus and other pathogenic vibrios in shellfish is a potential public health hazard in Hong Kong and other subtropical Asian countries.

Vibrio vulnificus septicaemia presenting as spontaneous necrotising cellulitis in a woman with hepatic cirrhosis

Vibrio vulnificus is a virulent marine organism commonly found in Hong Kong coastal waters which contaminates local sea-food. It may produce a primary septicaemia, often associated with secondary skin lesions, following ingestion of raw shell fish. We report a rapidly fatal case of primary V. vulnificus septicaemia in a 50-year-old housewife with post-hepatitic cirrhosis presenting as spontaneous necrotising cellulitis of the legs. V. vulnificus infection should be considered in patients with a history of liver disease with acute septicaemia and characteristic skin lesions.

Current perspectives on the epidemiology and pathogenesis of clinically significant Vibrio spp

Recent taxonomic advances have now implicated several different Vibrio species as human pathogens. While the most common clinical presentation of Vibrio infection continues to be gastroenteritis, an increasing number of extraintestinal infections are being reported, particularly in immunocompromised individuals. Detection of Vibrio infections requires a good clinical history and the use of appropriate isolation and identification procedures by the laboratory to confirm illnesses attributed to Vibrio species. Except for Vibrio cholerae O1 and Vibrio parahaemolyticus, there is little direct evidence linking the production of a myriad of cell-associated or extracellular factors produced by each species with human disease and pathogenesis. Many questions regarding pathogenic Vibrio species remain unanswered, including their frequency and distribution in environmental specimens (water, shellfish), infective doses, virulence potential of individual isolates, and markers associated with such strains.

Vibrio Vulnificus Necrotizing Fasciitis Presenting with Compartmental Syndrome of the Hand

Vibrio vulnificus necrotizing fasciitis is an unusual clinical problem. When it presented as a compartment syndrome, the picture was obscured. We report a rare case of such a presentation. A below-elbow amputation was performed and the patient recovered.

Acute hepatic failure precipitated in a patient with subclinical liver disease by vibrionic and clostridial septicemia

A case of fatal septicemia caused by Vibrio vulnificus and Clostridium bifermentans in a patient with subclinical liver disease is described. The patient appeared to recover from the infection initially after antibiotic therapy but finally succumbed to rapidly developing hepatic failure. Postmortem examination revealed hemochromatosis. The pathogenesis of the polymicrobial septicemia and hepatic failure is discussed in the light of the published literature.

Occurrence and distribution of halophilic vibrios in subtropical coastal waters of Hong Kong

The summer occurrence and distribution of halophilic vibrios in the subtropical coastal waters of Hong Kong were investigated. The density of vibrios in six sample sites ranged from 90 to 6,700 per ml, which made up 0.41 to 40% of the total bacterial populations of these sample sites. The sucrose-positive vibrios were found to be much more common (88% of total vibrios) than the sucrose-negative ones. A total of 48 strains belonging to six Vibrio species were fully characterized. Among these, Vibrio alginolyticus was the most frequently isolated, followed by V. parahaemolyticus, V. harveyi, V. vulnificus, V. campbellii, and V. fluvialis. The finding that eight of the nine strains of V. harveyi showed a positive Kanagawa reaction warrants further study.