Aeromonas hydrophila necrotizing fasciitis. A case report

Necrotizing fasciitis and gas gangrene due to Aeromonas hydrophila in an immunocompetent host: A rare entity

Aeromonas hydrophila, widely distributed in various aquatic environments, is recognized as emerging opportunistic pathogens mainly causing gastrointestinal and wound infections. Necrotizing fasciitis and gas gangrene attributable to A. hydrophila are believed to develop mainly in immunocompromised hosts and have required amputation as a life-saving measure in many of these individuals. The present case re-emphasizes the virulent nature of this organism requiring amputation even in an immunocompetent host and hence, the critical need for early recognition and appropriate targeted therapy, especially after minor traumatic injuries which usually tend to get neglected.

Aeromonas hydrophilia-infected nonunion of a closed tibial fracture in a healthy adolescent: A case report

Aeromonas hydrophilia can cause soft tissue infection in both immunocompromised and healthy persons. A healthy 15-year-old adolescent fell into a ditch after a scooter accident and sustained a right distal tibial shaft closed fracture, a right femoral shaft closed fracture, and a dirty laceration over the medial aspect of the distal thigh above the right knee. After empiric antibiotics and radical debridement of the contaminated wound, a femoral interlocking nail and tibial external fixator were applied. However, acute osteomyelitis later presented in his femur and tibia, and Aeromonas hydrophilia grew in cultures from the knee wound and the fracture sites. During the follow-up, his tibia became an infected nonunion, and was successfully treated with the induced membrane technique. In an otherwise healthy patient with a closed fracture, Aeromonas hydrophilia can cause acute osteomyelitis and necrotizing fasciitis by spreading from a nearby contaminated wound. Exposure to water is a risk factor for Aeromonas hydrophilia infection.

Cross-talk among flesh-eating Aeromonas hydrophila strains in mixed infection leading to necrotizing fasciitis

Necrotizing fasciitis (NF) caused by flesh-eating bacteria is associated with high case fatality. In an earlier study, we reported infection of an immunocompetent individual with multiple strains of Aeromonas hydrophila (NF1-NF4), the latter three constituted a clonal group whereas NF1 was phylogenetically distinct. To understand the complex interactions of these strains in NF pathophysiology, a mouse model was used, whereby either single or mixed A. hydrophila strains were injected intramuscularly. NF2, which harbors exotoxin A (exoA) gene, was highly virulent when injected alone, but its virulence was attenuated in the presence of NF1 (exoA-minus). NF1 alone, although not lethal to animals, became highly virulent when combined with NF2, its virulence augmented by cis-exoA expression when injected alone in mice. Based on metagenomics and microbiological analyses, it was found that, in mixed infection, NF1 selectively disseminated to mouse peripheral organs, whereas the other strains (NF2, NF3, and NF4) were confined to the injection site and eventually cleared. In vitro studies showed NF2 to be more effectively phagocytized and killed by macrophages than NF1. NF1 inhibited growth of NF2 on solid media, but ExoA of NF2 augmented virulence of NF1 and the presence of NF1 facilitated clearance of NF2 from animals either by enhanced priming of host immune system or direct killing via a contact-dependent mechanism.

Virulence diversity among bacteremic Aeromonas isolates: ex vivo, animal, and clinical evidences

Background

The objective of this study was to compare virulence among different Aeromonas species causing bloodstream infections.

Methodology/Principal Findings

Nine of four species of Aeromonas blood isolates, including A. dhakensis, A. hydrophila, A. veronii and A. caviae were randomly selected for analysis. The species was identified by the DNA sequence matching of rpoD. Clinically, the patients with A. dhakensis bacteremia had a higher sepsis-related mortality rate than those with other species (37.5% vs. 0%, P = 0.028). Virulence of different Aeromonas species were tested in C. elegans, mouse fibroblast C2C12 cell line and BALB/c mice models. C. elegans fed with A. dhakensis and A. caviae had the lowest and highest survival rates compared with other species, respectively (all P values <0.0001). A. dhakensis isolates also exhibited more cytotoxicity in C2C12 cell line (all P values <0.0001). Fourteen-day survival rate of mice intramuscularly inoculated with A. dhakensis was lower than that of other species (all P values <0.0001). Hemolytic activity and several virulence factor genes were rarely detected in the A. caviae isolates.

Conclusions/Significance

Clinical data, ex vivo experiments, and animal studies suggest there is virulence variation among clinically important Aeromonas species.

Functional genomic characterization of virulence factors from necrotizing fasciitis-causing strains of Aeromonas hydrophila

The genomes of 10 Aeromonas isolates identified and designated Aeromonas hydrophila WI, Riv3, and NF1 to NF4; A. dhakensis SSU; A. jandaei Riv2; and A. caviae NM22 and NM33 were sequenced and annotated. Isolates NF1 to NF4 were from a patient with necrotizing fasciitis (NF). Two environmental isolates (Riv2 and -3) were from the river water from which the NF patient acquired the infection. While isolates NF2 to NF4 were clonal, NF1 was genetically distinct. Outside the conserved core genomes of these 10 isolates, several unique genomic features were identified. The most virulent strains possessed one of the following four virulence factors or a combination of them: cytotoxic enterotoxin, exotoxin A, and type 3 and 6 secretion system effectors AexU and Hcp. In a septicemic-mouse model, SSU, NF1, and Riv2 were the most virulent, while NF2 was moderately virulent. These data correlated with high motility and biofilm formation by the former three isolates. Conversely, in a mouse model of intramuscular infection, NF2 was much more virulent than NF1. Isolates NF2, SSU, and Riv2 disseminated in high numbers from the muscular tissue to the visceral organs of mice, while NF1 reached the liver and spleen in relatively lower numbers on the basis of colony counting and tracking of bioluminescent strains in real time by in vivo imaging. Histopathologically, degeneration of myofibers with significant infiltration of polymorphonuclear cells due to the highly virulent strains was noted. Functional genomic analysis provided data that allowed us to correlate the highly infectious nature of Aeromonas pathotypes belonging to several different species with virulence signatures and their potential ability to cause NF.

A rare case of Aeromonas hydrophila catheter related sepsis in a patient with chronic kidney disease receiving steroids and dialysis: a case report and review of Aeromonas infections in chronic kidney disease patients

Aeromonas hydrophila (AH) is an aquatic bacterium. We present a case of fifty-five-year-old gentleman with chronic kidney disease (CKD) due to crescentic IgA nephropathy who presented to us with fever. He was recently pulsed with methyl prednisolone followed by oral prednisolone and discharged on maintenance dialysis through a double lumen dialysis catheter. Blood culture from peripheral vein and double lumen dialysis catheter grew AH. We speculate low immunity due to steroids and uremia along with touch contamination of dialysis catheter by the patient or dialysis nurse could have led to this rare infection. Dialysis catheter related infection by AH is rare. We present our case here and take the opportunity to give a brief review of AH infections in CKD patients.

Actin cross-linking domain of Aeromonas hydrophila repeat in toxin A (RtxA) induces host cell rounding and apoptosis

The repeat in toxin (Rtx) of an environmental isolate ATCC 7966 of Aeromonas hydrophila consists of six genes (rtxACHBDE) organized in an operon similar to the gene organization found for the Rtx of the Vibrio species. The first gene in this operon (rtxA) encodes an exotoxin in vibrios, while other genes code for proteins needed for proper activation of RtxA and in secretion of this toxin from Vibrio cholerae. However, the RtxA of ATCC 7966, as well as from the clinical isolate SSU of A. hydrophila, was exclusively expressed and produced during co-infection of this pathogen with the host, e.g., HeLa cells, indicating that rtxA gene expression required host cell contact. Within the RtxA, an actin cross-linking domain (ACD) exists and to investigate the functionality of this domain, several truncated versions of ACD were generated to discern its minimal biological active region. Such genetically modified genes encoding ACD, which were truncated on either the NH(2) or the COOH terminal, as well as on both ends, were expressed from a bidirectional promoter of the pBI-enhanced green fluorescent protein (EGFP) vector in a HeLa-Tet-Off cell system. We demonstrated that only the full-length ACD of RtxA from A. hydrophila catalyzed the covalent cross-linking of the host cellular actin, whereas the ACD truncated on the NH(2), COOH or both ends did not exhibit such actin cross-linking characteristics. Further, we showed that the full-length ACD of A. hydrophila RtxA disrupted the actin cytoskeleton of HeLa cells, resulting in their rounding phenotype. Finally, our data provided evidence that the full-length ACD of RtxA induced host cell apoptosis. Our study is the first to report that A. hydrophila possesses a functional RtxA having an ACD that contributes to the host cell apoptosis, and hence could represent a potential virulence factor of this emerging human pathogen.

Enterobacter asburiae and Aeromonas hydrophila: soft tissue infection requiring debridement

Enterobacter asburiae and Aeromonas hydrophila are gram-negative bacilli that have been isolated in soil and water. Enterobacter asburiae can cause an array of diseases, and exposure to A hydrophila can cause soft tissue infections, including necrotizing faciitis.A healthy-appearing 22-year-old man presented with an innocuous soft tissue injury to his leg due to an all-terrain vehicle crash. He received intravenous antibiotics and was discharged with prophylactic oral antibiotics. After the rapid onset of high fevers (102°F-103°F) <24 hours postinjury, he returned to the emergency department. Emergent surgical debridement was performed, and broad-spectrum intravenous antibiotics were started. Fevers persisted, and the patient underwent repeat extensive surgical debridement and antibiotic bead placement <30 hours after the initial surgical debridement and broad-spectrum antibiotics. Intraoperative cultures found E asburiae and A hydrophila in the wound. Following a long course of antibiotics and a skin graft, he fully recovered and had no functional deficits 1 year postoperatively.Extensive research revealed that these organisms are rare in soft tissue infections. E asburiae is opportunistic but has not been reported as a primary wound organism, and A hydrophila infections have been reported following motor vehicle crashes involving wound contamination. At presentation, it is challenging to determine rare organisms in a timely fashion; however, emergent extensive surgical intervention of an accelerated aberrant disease process should be considered to avoid catastrophic outcomes.

Necrotizing Fasciitis Caused by Inconspicuous Infection of Aeromonas hydrophila in an Immunocompromised Host

We present a case of serious necrotizing fasciitis due to Aeromonas hydrophila without a suggestive history of routes of pathogen invasion in a 60-year-old male. Despite prompt broad-spectrum antibiotic and extensive surgical therapies, the patient died within 72 hours following initial presentation. Our experience suggests clinicians be highly alert to the disease when an immunocompromised patient featured fulminant soft-tissue infection in the endemic area.

Necrotizing fasciitis and sepsis caused by Aeromonas hydrophila after crush injury of the lower extremity

BACKGROUND

Aeromonas hydrophila is a motile gram-negative bacillus found in water sources that typically causes minor skin infections or gastroenteritis in humans. There are sporadic reports of cases of sepsis or necrotizing fasciitis caused by A. hydrophila but no other cases of severe infection secondary to trauma. The mortality rate of septic shock caused by A. hydrophila approaches 100%.

METHODS

Case report and review of pertinent literature.

RESULTS AND CONCLUSIONS

A patient recently seen at our institution illustrates the features of necrotizing fasciitis and sepsis caused by A. hydrophila after an open femur fracture. We describe the aggressive multi-modality treatment necessary to maximize the likelihood of survival.