VIOLACEOUS BULLAE: A CASE OF VIBRIO VULNIFICUS (V. VULNIFICUS) NECROTIZING FASCIITIS Zui Keat Ng DO, Heath Scott DO, Youseff Bou-Mikael MD, Joseph Hennig MD, Amit Rajkarnikar MD, Jacob Cunningham MD, Benjamin Pickard MD, Erica Jones MD, George Cary Guidry MD; Department of Medicine, LSU Health, Lafayette, LA.
Introduction: Vibrio vulnificus is a gram-negative bacteria that lives in the water and is commonly found in warmer areas. It infects a wide range of hosts, from humans to different types of fish species. Case: A 71-year-old male with type 2 diabetes and coronary artery disease presented with complaints of weakness, shortness of breath, fever, and chills. Reportedly, he was fishing with a net a day ago and accidentally lacerated the dorsal aspect of his left hand, resulting in a small wound measuring 1cm. The wound circumference increased to 7cm x 5cm accompanied by violaceous erythema and local edema in less than 24 hours. His initial labs were significant for WBC 19,200, creatinine 3.7, AST 1112, ALT 693, BNP 3000, troponin 86,000; an arterial blood gas showed a pH 7.29, pCO2 80, pO2 65, HCO3 36. Significant imaging included an X-Ray of the left hand showing severe generalized edema and osteoarthritic changes; transthoracic echocardiogram showing an ejection fraction of 25% with severe left ventricular global hypokinesis; and chest X-Ray showing bilateral pleural effusion. He developed hypotension, altered mental status, and severe breathing difficulties requiring vasopressors, broad spectrum antibiotics, and intubation. Wound debridement was performed immediately due to high suspicion for necrotizing fasciitis with wound
cultures showing growth of Vibrio vulnificus. His clinical course deteriorated rapidly, and his family ultimately decided to withdraw medical therapy. Discussion: The pathogenesis of Vibrio vulnificus remains largely unknown, but some studies have suggested it is an opportunistic pathogen that possesses several unique virulence factors. It rarely causes severe infection in healthy individuals. However, those with weakened immunity caused by diabetes, hemochromatosis, malignancy, or AIDS, are at a much higher risk of sepsis and severe wound infection. V. vulnificus causes several distinct syndromes: sepsis caused by the consumption of contaminated seafood, wound infections acquired from exposing open wounds to contaminated seawater, or gastroenteritis. In those with severe sepsis and/or necrotizing fasciitis, death usually occurs within 72 hours of hospitalization. While the differential for skin infection and septic shock are broad, V. vulnificus infection should always be considered when patients present with bullous skin lesions and symptoms suggestive of septic shock. A combination of thorough history taking and clinical features may point clinicians toward this infection. Early diagnosis expedites treatments and improves prognostic outcomes.
WHAT THE H! IS IN MY EAR? Trac Le MD, Edison Tenezaca Quizhpi MD; Department of Medicine, Leonard J Chabert Medical Center, Houma, LA.
Introduction: Bacterial meningitis is a rare but severe and life-threatening illness requiring prompt diagnosis and treatment. Due to the widespread usage of routine vaccines and development of more effective vaccination programs, meningitis due to Haemophilus influenza has decreased in prevalence—although it remains a potential culprit for those who were born prior to these vaccinations. Case: A 75-year-old female with smoldering multiple myeloma, hypertension, and gastroesophageal reflux disease presents with altered mental status. Four days prior to admission, the family found the patient to be paranoid and somnolent. The temperature on arrival
was 103.2oF and the patient was hypertensive on admit. The physical examination showed 2/5 strength in all extremities, decreased lower extremity reflexes, spontaneous lower extremity movement and cranial nerve reflexes intact. Initial Computed Tomography (CT) of the head did not reveal an acute abnormality. Meningitis was suspected; however, the initial lumbar puncture was unsuccessful. Regardless, the patient was started on broad spectrum antibiotics due to high suspicion for infection. An lumbar puncture was subsequently performed by interventional radiology two days later. Spinal fluid was found to be cloudy and purulent. Following broad treatment, the patient began to slowly recover and provided 35
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