Skin Manifestations of Primary Vibrio vulnificus Septicemia

A 55-year-old man from the southwest United States (Tucson, AZ) presented with altered sensorium. He has a history of alcohol-induced liver cirrhosis. Family members reported thepatient had complainedof abdominal discomfort, watery nonbloody diarrhea, malaise, and leg discoloration earlier that day. He had not traveled outside of the United States for more than 20 years. Vitals were significant for hypotension, tachycardia, tachypnea, and hypothermia (35.4 C). Pertinent physical examination findings revealed scleral icterus, abdominal distension, and cutaneous ecchymosiswith scatteredhemorrhagic appearingbullae locatedonboth lower extremities (Figure 1A and 1B). Laboratory investigations uncovered a white blood cell count 1.2 × 10 cells/mL, platelet count 31×10 cells/mL, international normalized ratio 2.1, total bilirubin 5.1 mg/dL, serum bicarbonate 7 mMol/L, blood urea nitrogen 66 mg/dL, creatinine 6.6 mg/dL, and lactic acid 13.0 mMol/L. The Gram stain of the bullae aspirate (Figure 1C) and blood (Figure 1D) revealedGram-negative bacilli with a curved appearance. Growth from all sampled sources identified the culprit microorganism as Vibrio vulnificus. Despite aggressive supportive care in the medical intensive care unit and broadspectrum antibiotics, the patient unfortunately died from multiorgan failure. Vibrio vulnificus is a Gram-negative halophilic bacilli endemic to coastal regions of warm temperate climates. Gram staining will often reveal a short, slim, and curved Gramnegative bacillus under light microscopy. Vibrio vulnificus is a potentially lethal pathogen and the leading cause of seafoodrelated death in the United States. High rates of infection are reported in Taiwan, South Korea, Japan, andGulf ofMexico of the United States. Exposure to V. vulnificus occurs either through direct contact with a contaminated water source or seafood (handling or ingestion) which can lead to gastroenteritis, skin and soft tissue infection (often necrotizing), or septicemia. Our patient was lacking any contact with a salt FIGURE 1. (A) Cutaneous bullae with hemorrhagic appearing fluid of bilateral lower extremities. (B) Cutaneous ecchymosis appearing prior to developing bullae. (C) Bullae aspirate (as seen in syringe) under lightmicroscopy revealingGram-negative bacilli (red arrow) after Gram staining. (D) Innumerable Gram-negative bacilli with some exhibiting curved appearance as seen on Gram stain of blood sample.