|Year : 2016 | Volume
| Issue : 3 | Page : 384-386
A rare glimpse into the morbid world of necrotising fasciitis: Flesh-eating bacteria Vibrio vulnificus
M Madiyal1, VK Eshwara1, I Halim1, W Stanley2, M Prabhu2, C Mukhopadhyay1
1 Department of Microbiology, Kasturba Medical College, Manipal, Karnataka, India
2 Department of Medicine, Kasturba Medical College, Manipal, Karnataka, India
|Date of Submission||07-Jan-2016|
|Date of Acceptance||16-Jun-2016|
|Date of Web Publication||12-Aug-2016|
V K Eshwara
Department of Microbiology, Kasturba Medical College, Manipal, Karnataka
Source of Support: None, Conflict of Interest: None
Necrotising fasciitis is one of the fatal skin and soft tissue infections. Vibrio vulnificus is a rare cause of necrotising fasciitis; however, the disease is one of the major manifestations of the bacteria. Here, we report one such case in a middle-aged male patient. He presented with the signs of bilateral lower limb cellulitis and altered sensorium. V. vulnificus was isolated from blood culture and also from debrided tissue. Though the organism is well characterised, it is a rare causative agent of necrotising fasciitis. This case is a re-emphasis on active look out for this bacterium in patients presenting with necrotizsing fasciitis.
Keywords: Halophilic vibrio, necrotising fasciitis, septicemia, Vibrio vulnificus
|How to cite this article:|
Madiyal M, Eshwara V K, Halim I, Stanley W, Prabhu M, Mukhopadhyay C. A rare glimpse into the morbid world of necrotising fasciitis: Flesh-eating bacteria Vibrio vulnificus. Indian J Med Microbiol 2016;34:384-6
|How to cite this URL:|
Madiyal M, Eshwara V K, Halim I, Stanley W, Prabhu M, Mukhopadhyay C. A rare glimpse into the morbid world of necrotising fasciitis: Flesh-eating bacteria Vibrio vulnificus. Indian J Med Microbiol [serial online] 2016 [cited 2020 Feb 20];34:384-6. Available from: http://www.ijmm.org/text.asp?2016/34/3/384/188361
| ~ Introduction|| |
Necrotising fasciitis is a rare but potentially fatal condition with reported mortality up to 76%. Although Group A Streptococcus or polymicrobial etiologies are common, geographical variation may be observed in individuals residing in coastal regions.  Vibrio vulnificus is one such bacterium belonging to the group of halophilic vibrios that exist as a part of the natural flora of coastal marine environments, and it has been isolated from water, sediments and a variety of seafood. Infection with V. vulnificus can present either as primary bacteraemia or as wound infection.  Here, we report for the first time in India, a case of necrotising fasciitis by V. vulnificus in a middle-aged man with alcoholic liver disease.
| ~ Case Report|| |
A 52-year-old male auto rickshaw driver reported to emergency with sudden onset of giddiness along with history of redness and ulceration in both the legs, of 3 days' duration. He was known to have alcoholic liver disease. On examination, his sensorium was altered, blood pressure was 90/70 mm Hg and pulse rate was 128 beats/min. Local examination of the wound showed fluid-filled vesicles overlying diffuse, ill-defined, erythematous tender lesions on both thighs, suggestive of cellulitis. Patient was empirically treated with intravenous piperacillin-tazobactam 4.5 g and teicoplanin 400 mg 12 hourly. Initial laboratory investigations revealed haemoglobin to be 14.9 g/dL, low leukocyte count of 3800/μL and differential count of 31% neutrophils, 19% lymphocytes and monocytes each. Platelets were low, with a count of 73,000/μL. Liver enzymes were elevated, with a total bilirubin of 1.3 mg/dL, aspartate transaminase 181 U/L and alanine transaminase 110 U/L. A set of blood cultures was drawn in BacT/ALERT automated blood culture system. Both bottles flagged positive after 12 h of incubation.
Initial Gram stain of blood culture fluid showed thick curved Gram negative bacilli [Figure 1]. After 18 h of incubation, large mucoid non-haemolytic oxidase positive colonies were grown on 5% sheep blood agar [Figure 2], whereas faint growth was visible on MacConkey agar. Bacterium was presumptively identified as a member of Vibrionaceae family that was later confirmed by matrix-assisted laser desorption-ionisation time of flight mass spectrometry, Vitek MS system (bioMérieux, Inc., Durham, NC, USA) as V. vulnificus. Antibiotic susceptibility was performed in Vitek 2 system (bioMerieux).The isolate was sensitive to ceftazidime, cefepime, cefoperazone-sulbactum, amikacin, ciprofloxacin, minocycline and imipenem. The tissue from the debrided wound was also obtained, and it yielded the same isolate as in blood culture.
|Figure 1: Smear from positive blood culture bottle showing curved Gram negative bacilli|
Click here to view
Now, the treatment was changed to oral doxycycline 100 mg and intravenous ceftazidime 2 g 12 hourly. Patient's general conditions improved with this therapy and he became afebrile by 4 days. Total leukocyte count also was shown to be normal after 7 days of treatment. Locally, the cellulitis had progressed to necrotising fasciitis, and required debridement. But before complete recovery and completion of planned therapy, he was discharged from the hospital on request.
| ~ Discussion|| |
V. vulnificus is a halophilic Gram negative bacillus found worldwide, primarily in warm coastal waters. Infection by V. vulnificus essentially manifests in three syndromes, namely gastroenteritis, sepsis and skin and soft tissue infection. It is one of the important causes of seafood-related infections mostly seen in tropical and subtropical region. , Clinical disease by this bacterium is often reported from Gulf of Mexico, South America, South and Eastern Asia and Australia.  Despite being endowed with vast coastal land, reports of V. vulnificus infection are rare from India; there is only one case of diarrhoea in a child by this bacterium.  Our case is the first report of sepsis following necrotising fasciitis by V. vulnificus from the Indian subcontinent. Prominent risk factors for V. vulnificus infection are chronic liver disease, immunodeficiency disorders, diabetes mellitus, cancer chemotherapy and late stage renal diseases. ,,, The patient presented here suffered from alcoholic liver disease, although exact duration could not be assessed. Consumption of contaminated sea food is the usual mode of infection in case of V. vulnificus gastroenteritis and primary septicaemia. An infected wound as a presenting feature usually carries a history of exposure of a prior injury to the sea water. Cases of spontaneous cellulitis have also been reported, suggesting that the organism is capable of invading through micro-injury.  Our patient neither had any gastrointestinal disturbances nor recollected wound exposed to marine water. Moreover, he did not reveal the consumption of raw seafood. However, coastal habitation was the most probable prime factor in exposing him to the marine bacterium, likely through micro-injuries, and subsequent development of necrotising fasciitis. Underlying liver disease may have contributed to rapid disease progression and sepsis.
Primary septicaemia usually presents as fever, diarrhoea and nausea, followed by skin involvement. Severe wound infection is often characterised by necrotising fasciitis and gangrene. Wound infections differ from primary septicaemia in being confined to affected area. However, secondary septicaemia is common in such cases and can be severe.  According to a study done in Israel, 92% of wound infections caused by V. vulnificus presented as cellulitis and only 7% of cases presented as necrotising fasciitis. 
V. vulnificus infections are associated with high morbidity and mortality, and the prognosis is directly linked to the speed and accuracy of diagnosis and treatment. 
Various combinational therapies have been used in the treatment of V. vulnificus infection. Doxycycline and a third-generation cephalosporin such as ceftazidime is the recommended treatment by Centre for Disease Control. Minocycline has also been used in place of doxycycline.  Combination of third-generation cephalosporin with minocycline or doxycycline has been shown to more effective than monotherapy using any of those drugs.  Early suspicion and identification of causative agent has helped initiation of right therapy that led to survival of our patient although we failed to document complete therapeutic success.
| ~ Conclusion|| |
Infection by V. vulnificus is fatal if diagnosis and management is delayed as a result of its rarity. Use of newer diagnostic techniques will help in early and accurate diagnosis, thereby helping in early initiation of treatment. Laboratory should be aware of the clinical manifestation and preliminary findings of the organism in patients residing near the coastal regions to facilitate early diagnosis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| ~ References|| |
Park KH, Jung SI, Jung YS, Shin JH, Hwang JH. Marine bacteria as a leading cause of necrotizing fasciitis in coastal areas of South Korea. Am J Trop Med Hyg 2009;80:646-50.
Horseman MA, Surani S. A comprehensive review of Vibrio vulnificus
: An important cause of severe sepsis and skin and soft-tissue infection. Int J Infect Dis 2011;15:e157-66.
Jones MK, Oliver JD. Vibrio vulnificus
: Disease and pathogenesis. Infect Immun 2009;77:1723-33.
Kuo YL, Shieh SJ, Chiu HY, Lee JW. Necrotizing fasciitis caused by Vibrio vulnificus
: Epidemiology, clinical findings, treatment and prevention. Eur J Clin Microbiol Infect Dis 2007;26:785-92.
De A, Mathur M. Vibrio vulnificus
diarrhea in a child with respiratory infection. J Glob Infect Dis 2011;3:300-2.
Hsueh PR, Lin CY, Tang HJ, Lee HC, Liu JW, Liu YC, et al. Vibrio vulnificus
in Taiwan. Emerg Infect Dis 2004;10:1363-8.
Bisharat N, Agmon V, Finkelstein R, Raz R, Ben-Dror G, Lerner L, et al.
Clinical, epidemiological, and microbiological features of Vibrio vulnificus
biogroup 3 causing outbreaks of wound infection and bacteraemia in Israel. Israel Vibrio Study Group. Lancet 1999;354:1421-4.
Bross MH, Soch K, Morales R, Mitchell RB. Vibrio vulnificus
infection: Diagnosis and treatment. Am Fam Physician 2007;76:539-44.
Chen SC, Lee YT, Tsai SJ, Chan KS, Chao WN, Wang PH, et al.
Antibiotic therapy for necrotizing fasciitis caused by Vibrio vulnificus
: Retrospective analysis of an 8 year period. J Antimicrob Chemother 2012;67:488-93.
[Figure 1], [Figure 2]