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Frequently Asked Questions

• What is Vibrio vulnificus?
• What type of illness does V. vulnificus cause?
• How common is V. vulnificus infection?
• How do persons get infected with V. vulnificus?
• How can V. vulnificus be diagnosed?
• How is V. vulnificus infection treated?
• Are there long-term consequences of V. vulnificus infection?
• What can be done to improve the safety of oysters?
• How can I learn more about V. vulnificus?

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What is Vibrio vulnificus?

Vibrio vulnificus is a bacterium in the same family as those that cause cholera. It normally lives in warm seawater and is part of a group of vibrios that are called "halophilic" because they require salt.

What type of illness does V. vulnificus cause?

V. vulnificus can cause disease in those who eat eat contaminated seafood or have an open wound that is exposed to seawater. Among healthy people, ingestion of V. vulnificus can cause vomiting, diarrhea, and abdominal pain. In immunocompromised persons, particularly those with chronic liver disease, V. vulnificus can infect the bloodstream, causing a severe and life-threatening illness characterized by fever and chills, decreased blood pressure (septic shock), and blistering skin lesions. V. vulnificus bloodstream infections are fatal about 50% of the time.

V. vulnificus can also cause an infection of the skin when open wounds are exposed to warm seawater; these infections may lead to skin breakdown and ulceration. Persons who are immunocompromised are at higher risk for invasion of the organism into the bloodstream and potentially fatal complications.

 

How common is V. vulnificus infection?

V. vulnificus is a rare cause of disease, but it is also underreported. Between 1988 and 1995, CDC received reports of over 300 V. vulnificus infections from the Gulf Coast states, where the majority of cases occur. There is no national surveillance system for V. vulnificus, but CDC collaborates with the states of Alabama, Florida, Louisiana, Texas, and Mississippi to monitor the number of cases of V. vulnificus infection in the Gulf Coast region.

 

How do persons get infected with V. vulnificus?

Persons who are immunocompromised, especially those with chronic liver disease, are at risk for V. vulnificus when they eat raw seafood, particularly oysters. A recent study showed that people with these pre-existing medical conditions were 80 times more likely to develop V. vulnificus bloodstream infections than were healthy people. The bacterium is frequently isolated from oysters and other shellfish in warm coastal waters during the summer months. Since it is naturally found in warm marine waters, people with open wounds can be exposed to V. vulnificus through direct contact with seawater. There is no evidence for person-to-person transmission of V. vulnificus.

 

How can V. vulnificus infection be diagnosed?

V. vulnificus infection is diagnosed by routine stool, wound, or blood cultures; the laboratory should be notified when this infection is suspected by the physician, since a special growth medium can be used to increase the diagnostic yield. Doctors should have a high suspicion for this organism when patients present with gastrointestinal illness, fever, or shock following the ingestion of raw seafood, especially oysters, or with a wound infection after exposure to seawater.

How is V. vulnificus infection treated?

V. vulnificus infection is treated with antibiotics. Doxycycline or a third-generation cephalosporin (e.g., ceftazidime) is appropriate.

Are there long-term consequences of V. vulnificus infection?

V. vulnificus infection is an acute illness, and those who recover should not expect any long-term consequences.

 

What can be done to improve the safety of oysters?

Although oysters can be harvested legally only from waters free from fecal contamination, even legally harvested oysters can be contaminated with V. vulnificus because the bacterium is naturally present in marine environments. V. vulnificus does not alter the appearance, taste, or odor of oysters. Timely, voluntary reporting of V. vulnificus infections to CDC and to regional offices of the Food and Drug Administration (FDA) will help collaborative efforts to improve investigation of these infections. Regional FDA specialists with expert knowledge about shellfish assist state officials with tracebacks of shellfish and, when notified rapidly about cases, are able to sample harvest waters to discover possible sources of infection and to close oyster beds when problems are identified. Ongoing research may help us to predict environmental or other factors that increase the chance that oysters carry pathogens.

 

How can I learn more about V. vulnificus?

You can discuss your medical concerns with your doctor or other health care provider. Your local city or county health department can provide information about this and other public health problems that are occurring in your area. Information about the potential dangers of raw oyster consumption is available 24 hours a day from the FDA's Seafood Hotline (telephone 1-800-332-4010); FDA public affairs specialists are available at this number between 12 and 4 p.m. Monday through Friday. Information is also available on the world wide web at:
http://vm.cfsan.fda.gov.

Some tips for preventing V. vulnificus infections, particularly among immunocompromised patients, including those with underlying liver disease:

• Do not eat raw oysters or other raw shellfish.
• Cook shellfish (oysters, clams, mussels) thoroughly:
• For shellfish in the shell, either a) boil until the shells open and continue boiling for 5 more minutes, or b) steam until the shells open and then continue cooking for 9 more minutes. Do not eat those shellfish that do not open during cooking. Boil shucked oysters at least 3 minutes, or fry them in oil at least 10 minutes at 375°F.
• Avoid cross-contamination of cooked seafood and other foods with raw seafood and juices from raw seafood.
• Eat shellfish promptly after cooking and refrigerate leftovers.
• Avoid exposure of open wounds or broken skin to warm salt or brackish water, or to raw shellfish harvested from such waters.
• Wear protective clothing (e.g., gloves) when handling raw shellfish.

 

 

A 37 year old man with multiple, erythematous, tender nodules on the legs and left hand.
A 37 year old man with Vibrio vulnificus septicemia

By Kelley Pagliai, MSIV Johns Hopkins School of Medicine

 

Diagnosis:
Upon further questioning, the patient reported eating raw oysters from the Chesapeake Bay 24 hours prior to the onset of symptoms. Blood cultures grew oxidase positive, gram-negative rods that were specifically identified as Vibrio vulnificus. Vibrio vulnificus is an opportunistic human pathogen and halophilic marine organism. Infection is acquired by exposure to organisms in contaminated, undercooked, or raw crustaceans or shellfish or by exposure of wounds to warm ocean waters or estuaries(1). Infections are more common during the summer months from regions along the Atlantic coast and the Gulf of Mexico and from tropical waters around the world(3,10). Nearly all oysters isolated during the summer months from the Chesapeake Bay contain this pathogen as do 10% crabs(3). Vibrio vulnificus is a rare yet severe cause of septicemia and wound infections(10). The most common clinical presentation of Vibrio infection is self-limited gastroenteritis (59%), but wound infections (34%), primary septicemia (5%), and other infection sites (3%) also occur(3,4). Initial skin lesions begin as erythematous subcutaneous nodules that spread to the dermis and muscle. Overlying hemorrhagic vesicles or bullae and then necrotic ulcers frequently develop(9). Vibrio vulnificus accounts for 90% of all seafood-related deaths in the United States and has been fatal in over 50% of patients(1,2,3). Persons who are immunocompromised or who have liver disease, iron overload states, diabetes mellitus, hemolytic anemia, or chronic renal failure are at particular high risk for severe Vibrio infections and should be warned to avoid consumption of raw or undercooked shellfish(1,2). Pathogenesis of Vibrio infections involves the presence of a capsule, virulence factors, and the availability of iron in the host(5,10) Following exposure, the bacteria use proteases to penetrate the mucosal layer of the proximal small bowel and enter the enterohepatic circulation. Vascular permeability is increased and edematous plaques and nodules develop(10). Saturated transferrin uses the iron for bacterial growth and hematological dissemination occurs(6). Other putative virulence factors include metalloprotease, hemolysin-cytolysin, polysaccharide capsules, mechanisms for iron acquisition, lecithinase, lipase, hyaluronidase, DNAse, mucinase, and elastase(7,10).
	Tender, erythematous nodules, some with necrosis and ulceration, on the right lower extremity with edema. The lesions never progressed to hemorrhagic bullae or necrotic ulcers.
Lab Tests:
The initial blood cultures grew oxidase positive, gram-negative rods identified as Vibrio vulnificus. The wound cultures were negative. Metabolic panel and CBC were within normal limits with the exception of a mild hemolytic anemia. Liver enzymes were mildly elevated with AST at 88, ALT at 103 and bilirubin at 6.9.
Differential:
The differiential diagnosis of the nodules at these stes includes erythema nodosum, acute febrile neutrophilic dermatosis(Sweet syndrome), leukemia cutis, infectious panniculitis, most likely bacteria, disseminated candida, or mycobacteria, and vasculitis. Biopsy results show a lobular panniculitis, which is not consistent with erythema nodosum. The differiential diagnosis of lobular panniculitis includes pancreatic fat necrosis, alpha-1-antitrypsin deficiency, and infection.
Treatment:
The patient was initially treated with piperacillin and tobramycin, but discharged on tetracycline and ceftazidime. The lesions never progressed to hemorrhagic bullae or necrotic ulcers. Rapid diagnosis and treatment of Vibrio vulnificus is life saving. Tetracycline is the mainstay of antibiotic treatment and can be used in combination with fluoroquinolones, gentamicin, ceftaxidime, or chloroamphenicol(8,9). Incision and drainage or aggressive debridement is sometimes warranted(9). Practitioners should inform patients with underlying liver disease and other chronic illnesses of the hazards of eating raw oysters. However, the only effective means of prevention is thorough cooking of seafood.
Summary:
Vibrio vulnificus is an opportunistic human pathogen and halophilic marine organism. Infection is acquired by exposure to organisms in contaminated, undercooked, or raw crustaceans or shellfish or by exposure of wounds to warm ocean waters or estuaries. Vibrio is a rare yet severe cause of septicemia and wound infections. The initial skin lesions begin as tender, erythematous, subcutaneous nodules that spread to the dermis and muscle and can progress to hemorrhagic bullae and necrotic ulcers. Risk factors for septicemia include liver disease, iron overload states, hemolytic anemia, chronic renal failure, malignancy, Human immunodeficiency virus infection, and immunosuppressive medications. Such patients are at paticular high risk for severe infections and should be warned to avoid consumption of raw or undercooked shellfish. Rapid diagnosis and treatment is life saving. Tetracycline is the mainstay of antibiotic therapy and can be used in combination with fluoroquinolones, gentamicin, ceftaxidime, or chloroamphenicol. The only effective means of prevention is thorough cooking of seafood.
References
1. Morris JG, Black RE. Cholera and other vibrioses in the United States. N Engl J Med. 1985;312:343-350.
2. Hlday WG, Klontz KC. The epidemiology of Vibrio infections in Florida, 1981-1993. J Infect Dis. 1996;173:1176-1183.
3. Wright AC, et al. Distribution of Vibrio vulnificus in the Chesapeake Bay. App and Envir Micro. 1996; 62(2):717-724.
4. Daniels NA, et al. Emergence of a new Vibrio parahaemolyticus serotype in raw oysters. JAMA. 2000;284(12):1541-1545.
5. Oliver JD, Wear JE, Thomas MB et al. Production of extracellular enzymes and cytotoxicity by Vibrio vulnificus. Diagn Microbiol Infect Dis. 1986;5:99-111.
6. Serrano-Jaen L, Vega-Lopez F. Fulminating septicaemia caused by Vibrio vulnficus. Bri J Derm. 1999;142(2):386-387.
7. Strom MS, Paranjpye RN. Epidemiology and pathogenesis of Vi brio vulnificus. Microbes Infect. 2000;2:177-188.
8. Fang FC. Use of tetracycline for treatment of Vibrio vulnificus infections. Clin Infect Dis. 1992;15(6):1071-1072.
9. Hill MK, Sanders CV. Skin and soft tissue infections in critical care. Crit Car Clin. 1998;14(2):251-262.
10. Kumamoto KS, Vukich DJ. Clinical infections of Vibrio vulnificus: a case report and review of the literature. J Emerg Med. 1998; 16(1):61-66.

 

 

Vibro vulnificus

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• At least 11 species of Vibrio bacteria are known to cause diseases in man, but Vibrio vulnificus accounts for most of the deaths associated with raw oyster consumption during the past 15 years.
  The presence of Vibrio vulnificus is not associated with pollution. The bacteria is a naturally occurring marine organism that thrives in shallow, coastal waters in temperate climates throughout most of the world.
  The first documented case of human illness caused by the organism occurred in 1979.
  Vulnificus may concentrate in clams, oysters, scallops and in finfish.
  More than 100 strains of vulnificus have been identified, and not all are disease-causing.
  Healthy individuals are rarely susceptible to vulnificus illness through the consumption of raw oysters. However, individuals with pre-existing liver disease are 80 times more likely to get sick and more than 200 times more likely to die from eating raw oysters infected with vulnificus than a person with no such disease.
  Seventy-two cases of vulnificus infection from raw oysters were reported in Florida from 1981 to 1992, and 36 (50 percent) patients died, making this infection the leading cause of reported deaths from foodborne illness in Florida.
  Of the 45 deaths from foodborne illness reported in Florida from 1981 to 1992, 36 were attributed to consumption of raw oysters containing Vibrio vulnificus and eight others were attributed to raw oyster consumption involving three other Vibrio species.
  Consumers of raw oysters are considered at risk for vulnificus illness if they have hepatitis or other liver disease, are alcoholics, are under immunosuppression treatment for cancer or any other disease, are HIV- positive, are diabetic, have chronic kidney disease or have achlorohydria, a condition where the normal acidity of the stomach is low.
  In 1992, an estimated 71,000 Floridians with liver damage consumed raw oysters and nine died from vulnificus infections. Four of the victims suffered from cirrhosis and a fifth had a history of heavy drinking.
  Of the known sources of oysters associated with vulnificus infection in Florida, 83 percent were purchased at restaurants. None were from self- harvested sources.
  Most commonly, a vulnificus infection results in acute septicemia, or blood poisoning. Symptoms include vomiting, diarrhea, and abdominal pain, rapidly followed by fever and chills.
  Treatment of vulnificus septicemia is with such antibiotics as tetracycline, chloramphenicol and penicillin.
  Warm weather months--typically from June to October--are when vulnificus concentrations in seawater are highest. From December through March, the organism is almost indetectable in samples collected from Apalachicola Bay, Florida, where most of FloridaÕs oyster production is based.
  The organism can't be seen, tasted or smelled. Only a laboratory test can detect its presence.

• The organism is easily killed by cooking. Recommended cooking times for oysters and clams are three to five minutes (if boiled); four to nine minutes (if steamed); 10 minutes at 375oF (fried) and 10 minutes at 450oF (baked).

  Source: The Florida Department of Health and Rehabilitative Services; The University of Florida Institute of Food and Agricultural Sciences; The U.S. Food & Drug Administration

 

 

 

 

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