Journal of the Louisiana State Medical Society
laboratory should be notified in advance that special culture media and stains will likely be required, such as sodium- enriched media for Vibrio species and acid-fast stains/cul- tures for marine aquatic mycobacteria. With the exception of minor marine wounds demonstrating localized cellulitis or spreading erysipeloid-type reactions, most other marine infections and all gram-negative and mycobacterial marine infections will require therapywith antibiotic combinations. 1 Streptococcus iniae infections are characterized by impetigo and cellulitis, and Erysipelothrix rhusthopathiae infections cause erysipeloid manifestations. These infections may be treated empirically with single antibiotics, specifically penicillins or macrolides in cases of penicillin allergy, until culture and antibiotic susceptibility results are reported. In all suspected cases of M. marinum infection, clini- cians will need to pursue confirmation by culture and begin combined antibiotic therapy with clarithromycin and ethambutol. 11,12 Persons who are immunosuppressed or have cirrhosis, hepatitis, uremia, hemosiderosis, or other iron-retaining conditions, are at higher risks for invasive Vibrio infections with the highest case fatality rates. They also should be empirically covered with combinations of third-generation cephalosporins (ceftazidime) and tetra- cyclines (doxycycline), fluoroquinolones and tetracyclines, or aminoglycosides and trimethroprim-sulfamethoxazole. The clinical microbiology laboratory should be consulted frequently, and all definitive antibiotic therapy should be based on precise pathogen identification by culture or molecular signature and antibiotic susceptibility testing. CONCLUSIONS AND RECOMMENDATIONS Clinicians should maintain a high index of suspicion regarding potentially catastrophic bacterial infections, especially Vibrio vulnificus and Chromobacterium violaceum infections, followingmarine injuries and exposures. Patients withwell-known risk factors for marine infections, including those with suppressed immune response mechanisms, liver disease, alcoholism, diabetes, chronic renal disease, AIDS, and cancer, should be cautioned about the risks of marine infections through exposures to marine animals, seawater, the preparation of freshly-killed seafood, and the ingestion of seawater or consumption of raw or undercooked seafood, especially oysters. All persons who handle strandedmarine mammals, such as bottle-nose dolphins common in the northern Gulf of Mexico, or who participate in necropsies on their carcasses should be educated as to the potential risks of marine mammal brucellosis and the use of personal protective equipment, including respirators. REFERENCES 1. United States Centers for Disease Control and Prevention (CDC). Human exposures to marine Brucella isolated from a harbor porpoise—Maine, 2012. Morb Mort Week Rep 61: 461-463. 2. Sohn AH, Probert WS, Glaser CA, et al. Human neurobrucellosis with intracerebral granuloma caused bymarine mammal Brucella
spp. Emerg Infect Dis 2003; 9: 485-488. 3. Maratea J, Ewalt DR, Frasca S, et al. Evidence of Brucella sp. infection inmarine mammals stranded along the coast of southern New England. J Zoo Wildlife Med 2003; 34: 256-261. 4. McDonaldWL, Jamaludin R, Mackereth G, et al. Characterization of Brucella sp. strain as a marine mammal type despite isolation from a patient with spinal osteomyelitis in New Zealand. J Clin Microbiol 2006; 44: 4363-4370. 5. United States Department of Commerce. National Oceanographic and Atmospheric Administration. NOAA finds bacterial infection as a cause of death for five northern Gulf dolphins; investigation continues. Available at www.noaanews.noaa.gov/ stories2011/20111027_dolphins.html 6. Petrillo VF, Severo V, Santos MM, Edelweiss EL. Recurrent infection with Chromobacterium violaceum: first case report from South America. J Infect 1984; 9: 167-169. 7. Yang CH. Nonpigmented Chromobacterium violaceum bacteremic cellulitis after a fish bite. J Microbiol Immunol Infect 2011; 44: 401-405. 8. Midani S, Rathore M. Chromobacterium violaceum infection. South Med J 1998; 91: 464-466. 9. Macher AM, Casale BT, Fauci AS. Chronic granulomatous disease of childhood and Chromobacterium violaceum infections in the South Eastern United States. Ann Intern Med 1982; 97: 51-52. 10. Smith MD, Gradon JD. Bacteremia due to Comamonas species associated with exposure to tropical fish. South Med J 2003; 96: 815-817. 11. Wagner N, Otto L, Podda M, et al. Travel-related chronic hemorrhagic leg ulcer infection by Shewanella algae. J Travel Med 2013; 20: 262-264. 12. Vignier N, Barreau M, Olive C, et al. Human infection with Shewanella putrefaciens and S. algae: Report of 16 cases in Martinique and review of the literature. Am J Trop Med Hyg 2013; 89: 151-156. 13. Poovorawan K, Chatsuwan T, Lakananurak N, et al. Shewanella haliotis associatedwith severe soft tissue infection, Thailand, 2012. Emerg Infect Dis 2013; 19: 1019-1021. 14. Pier GB, Madin SH. Streptococcus iniae sp. nov., a beta-hemolytic streptococcus isolated from an Amazon freshwater dolphin, Inia geoffrensis. Int J Syst Bacteriol 1976; 26:545-553. 15. Weinstein MR, Litt M, Kertesz DA, et al. Invasive infections due to a fish pathogen, Streptococcus iniae. N Engl J Med 1997; 337: 589-594.
Dr. Diaz is Professor and Head of Environmental and Occupational Health Sciences in the School of Public Health and Professor of Anesthesiology in the School of Medicine at Louisiana State University Health Sciences Center in New Orleans.
108 J La State Med Soc VOL 166 May/June 2014
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