A 62-year-old man is brought to the emergency department because of watery diarrhea, skin rash, and confusion. He has had diarrhea for the past 1-2 days and took some over-the-counter medicines. He returned from a cruise to Mexico 4 days ago. He ate shellfish and raw oysters with fried rice at a local restaurant 2 days ago.
His other medical problems include alcoholic liver cirrhosis, type 2 diabetes mellitus, hypertension, and mild chronic kidney disease. His medications include spironolactone, long-acting insulin, and propranolol. He is an ex-smoker and drinks 1-2 cans of beer on weekends. He occasionally smokes crack cocaine and marijuana.
His temperature is 38.9 C (102 F), blood pressure is 70/30 mm Hg, pulse is 124/min, and respirations are 22/min. Examination shows bilateral basal crackles. The abdomen is distended and non-tender. His skin shows multiple bullous lesions.
Laboratory results are as follows:
Despite aggressive fluid resuscitation and antibiotics, the patient dies in the emergency department.
Which of the following is most likely responsible for this patient's initial presentation?

Question

A 62-year-old man is brought to the emergency department because of watery diarrhea, skin rash, and confusion.  He has had diarrhea for the past 1-2 days and took some over-the-counter medicines.  He returned from a cruise to Mexico 4 days ago.  He ate shellfish and raw oysters with fried rice at a local restaurant 2 days ago.
His other medical problems include alcoholic liver cirrhosis, type 2 diabetes mellitus, hypertension, and mild chronic kidney disease.  His medications include spironolactone, long-acting insulin, and propranolol.  He is an ex-smoker and drinks 1-2 cans of beer on weekends.  He occasionally smokes crack cocaine and marijuana.
His temperature is 38.9 C (102 F), blood pressure is 70/30 mm Hg, pulse is 124/min, and respirations are 22/min.  Examination shows bilateral basal crackles.  The abdomen is distended and non-tender.  His skin shows multiple bullous lesions.
Laboratory results are as follows:
 Despite aggressive fluid resuscitation and antibiotics, the patient dies in the emergency department.
Which of the following is most likely responsible for this patient's initial presentation?

Quizplus · Accepted Answer

This patient's presentation is consistent with Vibrio vulnificus infection, a gram-negative bacterium that causes serious wound infections and sepsis. The organism is most virulent in patients with cirrhosis, hemochromatosis, and chronic diseases (e.g., diabetes mellitus, chronic kidney disease, hepatitis). Vibrio vulnificus is associated with undercooked or raw shellfish, especially raw oysters. Since the infection can be fatal, high-risk patients should avoid eating, or even handling, raw shellfish. Patients typically present with wound infections, sepsis without a clearly defined infectious source, and/or gastroenteritis with characteristic bullous skin lesions. Diagnosis is confirmed with culture (wound, stool, blood), and suspected patients should receive immediate antibiotics (e.g., tetracycline) with close ICU monitoring. Patients can rapidly decompensate (within 12 hours) and develop bullous lesions, DIC, and even death. (Choice A) Crack cocaine use is usually associated with decreased gastric motility, euphoria, chest pain, shortness of breath, and occasional vasculitis in the skin. This patient's diarrhea, sepsis, and bullous lesions make this less likely. (Choice B) Norwalk virus is associated with cruise ships and can survive chlorination and other forms of disinfection. The virus usually presents with self-limited diarrhea (2-3 days) without the skin lesions seen in this patient. (Choice C) Toxins in fried rice are typically associated with Bacillus cereus food poisoning. Patients usually present with a self-limited and rapid onset of nausea and vomiting, usually within 1-6 hours of ingestion. Diarrhea may occur later in the disease, but it rarely causes sepsis as seen in this patient. (Choice D) Although a visit to Mexico can expose the patient to multiple organisms that cause diarrhea or acute gastroenteritis, it is not a significant risk factor for V. vulnificus infection. Educational objective: Vibrio vulnificus is found in shellfish and can cause potentially fatal infections in patients with chronic liver disease and cirrhosis. Suspected patients should be treated promptly with antibiotics and ICU monitoring. High risk groups (i.e., hepatitis, hemochromatosis, cirrhosis) should avoid consumption or contact with raw shellfish. __________ References: Vibrio vulnificus oysters: pearls and perils (http://www.ncbi.nlm.nih.gov/pubmed/21367733) Vibrio vulnificus infection: an important cause of septicemia in patients with cirrhosis. (http://www.ncbi.nlm.nih.gov/pubmed/9347818) Spontaneous Vibrio vulnificus peritonitis and primary sepsis in two patients with alcoholic cirrhosis. (http://www.ncbi.nlm.nih.gov/pubmed/3898820)

A 62-Year-Old Man Is Brought to the Emergency Department Because