mortality aeromonas infection
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8/2/2019 Mortality Aeromonas Infection
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Morbidity & Mortality Aeromonas hydrophila Infection
8/2/2019 Mortality Aeromonas Infection
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Ch ief C omplain
A 45 y/o male came to t h e ER wit h eryt h ematous swelling of t h e rig h t leg andmultiple large h emorr h agic bullae.
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Past &
Personal History
No job, smoking, drinking everydayHypertension
Type 2 diabetes mellitusLiver cirr h osis wit h ascitesAtrial fibrillationAdmission to GI due to fever, c h illness & diarr h eaon 100.8.19~8.21Bladder cancer - TUR-BT on 85.5.25Anal fistulectomy on 92.9.8 and anal fistectomy on92.11.24
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Present Illness
Righ t leg eryt h ematous swelling and multiple bullae since one day ago.Fever, ch illness and pain over rig h t leg, so h ecame to our ER on 100.10.24.No known h istory of any sea food contact,
trauma, or insect bites.Under th e impression of rig h t leg necrotizingfasciitis, h e was admitted to our ward.
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C ourse & Treatment
1 0 / 2 4E3M5V2-3
K+ 2.6meq/L,P otassiumreplacementP LT 39000Rocep h in 1gmq12 h
C onsultinfection Dr.Leg wound carewit h uburncream
1 0 / 2 5BP down, coma
Transfer to I C U,On Endo &ventilator Dopamin &levop h ed
NH3 88 - >Lactuloseenema tidRocep h in 2gmq12 h +
Doxycycline100mg bidDigoxin 1# qdfor Af (consultC V)Albumin x3
days
1 0 / 2 6GI bleeding
(C onsult GI) NP OLosec 1 ampq12 h
FFP 2u, P LT12uLactuloseenema tidRocep h in 2gmq12 h + Minocin100mg q12 h
S igned DNR
1 0 / 2 7Wound & blood
culutre: Aermonashydrophil aLosec 1 amp
q12 hFFP 2u, P LT12uLactuloseenema tidRocep h in 2gm
q12 h + Minocin100mg q12 h
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10/24 10/25
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Course & Treatment
1 0 / 2 8S top inotropes
& antibioticsas requested byfamilyS upportivetreatment only
1 0 / 2 9E3M4VE
NG: dark green
BP : 121-150/70-90mmHg
1 0 / 3 1C onsciousness
improvingE3-4M5-6VE
Familyaccepted AK amputationRocep h in 2gmq12 h +Minocin
100mg q12h
1 1 / 1E3M5VE
BP more stableS tart NGfeeding
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10/26 10/28
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Course & Treatment
1 1 / 3Under GA, AK
amputationKeep
antibiotics
1 1 / 6E3M3VE
C onsciousnessdown h ill
BP : 90/56mmHgAf
NH3: 37 (11/4)
1 1 / 7E1M1VE
BP : 90/50mmHg
S igned DNR
1 1 / 8BP dropped
Expired
8/2/2019 Mortality Aeromonas Infection
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11/0111/07
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Laboratory Datadata
dateWBC Hb Platelet Neutrophil Lymphocyte Bun Cr Na K CRP NH3 Alb GOT GPT Bil(T/D) Osm Digoxin
10/24 4500 14.5 39000 88.2 10.8 18 2.3 139 2.6 29.5 101 50
10/25 5900 11.5 11000 83.8 7.4 99.4 88 1.8
10/26 8200 11.9 29000 91.4 4.8 45 2.8 139 3.4 83
10/27 8200 10.6 33000 91.3 7.3 67
10/28 8500 9.6 38000 86.9 9.3 43 2.3
10/31 9600 12.1 13000 81.8 15.2 55 1.9 162 3.4 24 2.2 123 85
11/01 10200 11.2 43000 165 3.6
11/02 10400 11.0 25000 162 25.13/18 373
11/04 8400 9.1 59000 41 1.8 162 3.3 37 2.1 0.61
11/07 6200 7.2 25000 73.4 23.0 156 3.6 57.5 2.0 94
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BacterialC
ultureWound culture: Aeromonas hydrophilaBlood culture: Aeromonas hydrophila/ caviae
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Aeromonas hydrophilaFound in all fres h water environments as well as brackis h ,ch lorinated, and unc h lorinated water.Both a gram-negative rod and a facultative anaerobe.
C an grow in temperatures as low as 4 oC . T h ese bacteria are motile by a polar flagella.Very toxic to many organisms. W h en it enters t h e body of its victim,it travels t h roug h th e bloodstream to t h e first available organ.P roduces Aerolysin C ytotoxic Enterotoxin (A C T), a toxin t h at cancause tissue damage.C
onsidered to be opportunistic path
ogens, meaning th
ey rarelyinfect h ealt h y individuals.C onsidered a major fis h and amp h ibian pat h ogen, and its
pat h ogenicity in h umans h as been recognized for decades.
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Fish
and Amph
ibiansAssociated wit h diseases mainly found in fis h and amp h ibians, because t h ese organisms live in
aquatic environments.It is linked to a disease found in frogs called red leg,wh ich causes internal, sometimes fatal h emorr h age.Wh en infected, fis h develop ulcers, tail rot, fin rot,and h emorr h agic septicemia.Hemorr h agic septicemia causes lesions t h at lead toscale s h edding, h emorr h ages in t h e gills and analarea, ulcers, exop h th almia, and abdominal swelling.
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Fish
and Amph
ibians
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Sites of infection in
humans
GI : gastroenteritis/dysentery (c h ildren may be severe, adults less so or ch ronic), peritonitis (rare).Skin/soft tissue infection : ± C ellulitis (may be fulminant wit h necrotizing features). ± Necrotizing fascitiis and mynoecrosis also may occur.
Sepsis : bacteremia often associated wit h malignancy, h epatobiliarydisease suc h as cirr h osis, less commonly wit h diabetes.Bone : osteomyelitis, septic art h ritis
CNS : meningitis (rare)Cardiac : endocarditis (rare)
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Gastroenteritis
Th roug h oral contact wit h contaminated water,food, soil, feces, and/or ingestion of
contaminated fis h or reptiles.Two types of gastroenteritis.1. S imilar to c h olera, w h ich causes rice-water diarr h ea.
2. Dysenteric gastroenteritis, wh
ich
causes loose stools filledwit h blood and mucus. Dysenteric gastroenteritis is t h emost severe out of t h e two types, and can last for multipleweeks.
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Soft tissue infection
C ommonly acquired t h roug h an open wound t h at isexposed to contaminated water.C an cause severe skin/soft tissue infection and sepsis,often in t h e immunocompromised.Risk factors for severe infection: immunocompromise,diabetes, h epatobiliary disease (cirr h osis).C ellulitis can be severe and spread rapidly, often wit h inh ours following exposure.Infection into deeper tissues may cause necrotizingfasciitis or myonecrosis. Bullae and ecyt h magangrenosum may be observed.
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Antibiotics treatmentResistant to penicillin, ampicillin,carbenicillin, and ticarcillin.S usceptible to broad-spectrumcep h alosporins, aminoglycosides,carbapenems, c h loramp h enicol, tetracycline,
trimet h oprim-sulfamet h oxazole, andquinolones.
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Necrotizing Fasciitis (NF)An insidiously advancing soft tissue infection c h aracterized
by widespread fascial necrosis.Increased risk in diabetics, elderly, infants, t h ose wit h liver disease, or t h ose taking immunosuppressive drugs suc h as
ch
emoth
erapy for cancer.
± ± ±
C lassification ± Type I, or polymicrobial, after trauma or surgery.
A variant of NF type I is saltwater NF, a V ibrio species. ± Type II, or group A Streptococcal. ± Type III gas gangrene, or clostridial myonecrosis.
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Fournier¶s Gangrene
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V ibrio
Vulnific
u s
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V ibrio Vu lnific u s
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Streptococcal Necrotizing Fasciitis
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Necrotizing Fasciitis wit h Mycotic Aneurysm
Infected wit h Salmonella
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Treatment of NFAggressive resuscitation to maintain h emodynamicstability.
Broad-spectrum antibiotics to cover aerobic gram-positive& gram-negative organisms and anaerobes.S urgical debridement, early and aggressive, multiple andextensive.Following fluid resuscitation and nutritional support.Wound care, & wound reconstruction.Hyperbaric oxygen (HBO)
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Conclusion
Aeromonas hydrophila infection is frequently t h ecause of necrotizing fasciitis in patients wit h
suppressed immune systems, diabetes, burns, andtrauma in an aquatic setting.Th ese patients require aggressive antimicrobialth erapy and debridement and t h e mortality rate ish igh .Individuals t h at fail to respond to t h ese treatmentmeasures may require amputation.