not every oyster has a pearl · diagnosis based upon the patients’ history & physical exam...
TRANSCRIPT
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Not Every Oyster Has a Pearl:A Case Study of Vibrio Vulnificus
Charlene Myers DNP, MSN, CNS, BC‐ACNP
Jennifer Miller DNP, ACNP‐BC, CVNP‐BC
The warm waters of the Gulf of Mexico and the surrounding waterways are a desirable destination for many locals and tourists.
This Photo by Unknown Author is licensed under CC BY
However, what may be lurking in the water could affect at risk individuals if proper precautions are not taken.
Case Vignette
The onset of pain is approximately one day ago. It is described initially as a “dull ache” which has progressed to an “intense pressure and burning sensation” over the past 4 hours. He rates the pain initially as a 10/10. One day prior to the onset, he was boating and swimming in the brackish water of the Alabama Gulfcoast.
He reports that the pain is worsened with walking, standing, and touch. The pain is alleviated with extremity elevation, heat application, and ibuprofen.
Additional symptoms include the following LLE swelling, redness, and heat; fever, N/V, malaise, and rigors developed the night before presentation.
The patient is a 55 y/o male who presented to the ED with a chief complaint of “Left lower
extremity pain”
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Subjective Data
PAST MEDICAL & SURGICAL HISTORY:Chicken Pox (age unknown) HypertensionBLE venous stasisDenies: DVT, Cellulitis, Phlebitis, or hx of other vascular problems
HOME MEDICATIONS:Losartan/HCTZ 50/12.5mg po dailyAtenolol 25mg po dailyAspirin 325mg po dailyMVI 1 tablet po daily
ALLERGIES: Denies food, medication, or environmental allergies
SOCIAL HISTORY:Drinks a 5th of Bourbon every 2 days and 2 cans of beer dailyDenies tobacco or illicit drug use
FAMILY HISTORY: Non‐contributory to the chief complaint
REVIEW OF SYSTEMS: Positive for fever, rigors, malaise, N/V; LLE pain with swelling, redness, and warmthDenies SOB, CP, palpitations
Physical ExaminationVS: T‐ 103.2 P‐132 R‐30 BP‐60/32 SaO2‐ 82% on RA
CONSTITUTIONAL: Ill appearing, obese male in acute distress
INTEGUMENT: Mucous membranes warm, pink, & dry. Well demarcated area of warmth, erythema, and bullae noted to the LLE from the mid‐calf area to the distal
THORAX/LUNGS: Respirations regular, even, and labored at 30 breaths per minute. Lungs clear to auscultation in all fields bilaterally.
CARDIOVASCULAR: Tachycardic RRR, S1 S2 auscultated without murmurs, rubs, or clicks. Peripheral pulses are weak
ABDOMEN/GI: Soft, non‐distended, non‐tender. Bowel sounds hypoactive.
NEUROLOGIC: Drowsy, oriented to person, place, time & situation. Answers questions appropriately
LYMPHATIC: Inguinal & popliteal lymph nodes non‐palpable
This Photo by Unknown Author is licensed under CC BY
Initial Management
Upon arrival to the ED, the patient was hypotensive, hyperthermic, & hypoxic.
The following initial management strategies were performed:
High‐flow O2 via non‐rebreather SaO2 96%
Aggressive IVF replacement BP 106/60mmHg
Dilaudid 2mg IV for pain
Acetaminophen 1 gram po for fever
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Pertinent Lab Results
WBC 17 x 10,000 µLWBC 17 x 10,000 µL
Hgb 12.7 g/dL
Hgb 12.7 g/dL
Na 132 mEq/LNa 132 mEq/L
Glucose 147 mg/dLGlucose
147 mg/dLCreatinine 2.4 mg/dLCreatinine 2.4 mg/dL
CRP 160 mg/dLCRP 160 mg/dL
Arterial pH 7.21
Arterial pH 7.21
Lactic acid 4.9 mmol/LLactic acid 4.9 mmol/L
CK 1,460 U/L
CK 1,460 U/L
Pertinent Diagnostic Data
Non‐contrast CT of the LLE revealed: Anterior and lateral soft tissue swelling Soft tissue gas Fluid collections across fascial planes
BLE Venous Doppler neg for DVT
Portable CXR neg for acute cardiopulmonary processes
Preliminary Bullous Fluid Gram Stain
Gram negative, motile, curved rods
“culture pending”
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Presumptive Diagnosis
Based upon the patients’ history & physical exam findings in conjunction with lab, diagnostic, &
gram stain results, the presumptive diagnosis is:
Necrotizing Fasciitis secondary to
V. Vulnificus infection
Necrotizing Fasciitis
Infection of the deep soft tissues that commonly spreads along fascial planes
Progressive destruction of the subcutaneous fat layer and muscular fascia
Most commonly due to Streptococcus spp.
Epidemiology
Affects M & F equally
More common in older adults
Incidence: 4.8 people/100,000 per year
Mortality rate is ≈35%
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Classification of Necrotizing Fasciitis Variants
Type Microorganism Risk Factors
I Polymicrobial bacterial (Streptococcus spp. and Bacteriodes most common)
Chronic disease states such as diabetes and hepatic failure; immunocompromised; peripheral vascular disease
II Monomicrobial bacterial (MRSA and GAS most common)
MRSA: intravenous drug useGAS: surgery, minor trauma in healthy individuals
III Vibrio vulnificus Exposure to brackish or seawater, especially with an open wound
IV Fungi Immunocompromised states, especially end‐stage acquired immunodeficiency syndrome
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Pathophysiology of Necrotizing
Fasciitis
The initial insult occurs when a break in the skin is exposed to contaminated water
Bacterial toxins and enzymes break down superficial tissues
The inflammatory process produces additional fascial destruction
The bacteria, toxins, and enzymes spread rapidly across the fascial planes
Thrombosis, ischemia, & tissue liquefication occurs enhancing tissue destruction
Vibrio Vulnificus is a gram‐negative rod that is commonly found in warm, brackish waters near the
Gulf of Mexico
Modes of Transmission
1. Exposure to contaminated seafood via the GI tract
2. Exposure to contaminated seawater via a break in the skin
Susceptible Individuals are
those with:
Chronic liver disease, cirrhosis
Peripheral vascular disease
Immunocompromised state
End‐stage renal disease
Open wounds
Diabetes
Hereditary hemochromatosis
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Microbiology
Produces powerful siderophores which scavenge iron from host transferrin and lactoferrin
Highly motile with a single flagella
Grow in both aerobic and anaerobic environments
Ideal water temp is 68°‐95°
Encapsulated and resistant to innate phagocytosis
Considered a moderate “halophile”, which is a salt requiring organism
V. Vulnificus Epidemiology
Vibriosis cases YTD as of August 2019 Florida‐ 110 Texas‐ 61 Alabama‐ 19 Louisiana‐ 3 Mississippi‐ 2
There were 38 reported cases in Alabama in 2018
Florida averages ≈31.8 cases per year with v. vulnificus accounting for the majority
Results in ≈80,000 illnesses, 500 hospital visits, and 100 deaths per year in the US
The #1 cause of shellfish associated deaths in the US
May‐October are the most susceptible times
This Photo by Unknown Author is licensed under CC BY‐SA
Emergent Specialty
Consultations
An interdisciplinary approach to care is recommended with V. Vulnificus
Intensivist: Patients with sepsis type symptoms should be admitted to the ICU for advanced care.
Infectious Disease: Recommended for patients with complicated cellulitis and suspected V. Vulnificus infection.
General & Orthopedic Surgery: Urgent surgical consultation is indicated with rapidly evolving necrotizing fasciitis in addition to monitoring for the development of compartment syndrome.
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Empiric Antibiotics
Ceftazidime 1 gm Q 12h: Ceftazidime is one of the antibiotics of choice in the treatment of V. Vulnificus. It is gram negative specific and provides a broad‐spectrum coverage while awaiting culture confirmation
Doxycycline 100mg IV BID: Doxycycline is the second antibiotic of choice in the treatment of V. Vulnificis in combination with Ceftazidime
Vancomycin 1 gm IV Daily: Vancomycin is utilized to cover for MRSA while final blood and fluid cultures are pending
Patient Outcomes
Admission Day 1:
The patient underwent emergent surgical wound exploration with debridement of a large area of tissue from the LLE at which time tissue cultures were collected and sent for analysis
Day 2:
The patient continued to deteriorate. The initial erythema & crepitus was noted to have spread to the proximal thigh and hip. He underwent emergent amputation of the LLE.
Day 3:
The patient developed ARDS for which he required intubation & mechanical ventilation.
Despite aggressive medial and nursing management, the patient did not survive.
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https://commons.m.wikimedia.org/wiki/File:Necrotizing_fasciitis_left_leg.JPEG#m
w‐jump‐to‐license
This case illustrates an aggressive presentation of NF, however the symptoms may be highly variable
V. Vulnificus exposure must first occur in a susceptible
patient with a portal of entry
The incubation period is 16 hours, during
which time prodromal symptoms develop:
Unexplained fever
+
pain disproportionate to assessment findings
At 16‐36 hours earlycutaneous
manifestations develop:
Dark, red epidermal induration with fluid‐filled purple
bullae
Late cutaneous manifestations:
Necrotic skin that is friable with palpable
crepitus
Dermal papillae thrombosis
If untreated with deep fascial involvement, septic shock will ensue as the bacteria is quickly via the
venous & lymphatic channels:
Organ failure, Hypotension, tachcardia,
hypoxemia, etc.
DEATH
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Diagnosis
The “typical” clinical manifestations are present in less than half of patients
Gold Standard Open surgical evaluation with tissue/fluid cultures
Laboratory testing CBC CMP
Blood Cultures
Diagnostic Testing CT MRI
US
Common Diagnostic
Abnormalities
Leukocytosis with a left shift
Elevated BUN and creatinine
Elevated creatinine kinase
Thrombocytopenia
Elevated fibrin split products
Gram negative curved rods on Gram stain
Positive cutaneous lesion and blood cultures for V. Vulnificus
CT or MRI of the affected area often demonstrates soft tissue swelling or gas production if severe
Laboratory Risk Indicator for Necrotizing Fasciitis (LRINC) Scoring Tool
Utilized to differentiate NF from more benign STI’s
A score of >6 should raise suspicion
A score of >8 is highly predictive
*The patient presented in this case had a LRINC = 10
LRINEC Score
Variable Result Score
C‐reactive protein (mg/dL) <15
≥15
0
4
White blood cell count (x 10,000/µL) <15
15‐25
>25
0
1
2
Hemoglobin (g/dL) >13.5
11‐13.5
<11
0
1
2
Glucose (mg/dL) ≤180
>180
0
1
Sodium (mEq/L) ≥135
<135
0
2
Creatinine (mg/dL) ≤1.6
>1.6
0
2
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Differential Diagnosis of Necrotizing Fasciitis
Differential Diagnosis of Necrotizing Fasciitis
CellulitisCellulitis
ErysipelasErysipelas
AbscessAbscess
DVTDVT
Venous StasisVenous Stasis
Pyoderma GangrenosumPyoderma
Gangrenosum
Gas GangreneGas Gangrene
PyomyositisPyomyositis
Management
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Rapid surgical debridement within 24h is first line therapy and should not be delayed due to imaging
Serial debridement may be required
Fasciotomy may be required for the development of compartment syndrome
Amputation may be necessary in severe cases involving extremities
Adjuvant broad‐spectrum antibiotics
Initial agents should encompass activity against gram negatives, gram positives, & anaerobes while cultures are pending
Exposures suggestive of a causative organism should be provided agents with activity against that organism
Once culture data is available, antimicrobials tailored to the gram stain & culture results are indicated
Tailored antibiotics should be continued until the following are met:
Completion of all surgical debridement
Hemodynamic stability
Afebrile for at least 48h
Supportive care
Fluid resuscitation
Vasopressors
ICU Monitoring/Care
Complications & Prognosis
The most common complication of V. vulnificus is septicemia which progresses to septic shock
Patients who develop necrotizing fasciitis and require amputation are at high risk for death within the first week of admission
The mortality rate is 50% for most patients, however it can reach 100% in patients with severe immunocompromised states
Additional indicators of poor prognosis: Persistent hypotension with SBP < 90mmHg
Thrombocytopenia
Leukopenia
Pre‐existing DM or hepatic dysfunction
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Closing Points
NF is a rapidly progressing bacterial infection of the ST, fascia, and muscle
If unrecognized, NF can lead to sepsis, MOSF, and death
The initial diagnosis is based on clinical findings with supportive lab and diagnostic imaging
A thorough history and clinical exam is essential for rapid diagnosis
At risk patients who have been swimming at the Gulfcoast should have a high index of suspicion for V. Vulnificus as the causative organism
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