FATAL RASH

Abstract

SESSION TITLE: Critical Care cases 2 SESSION TYPE: Fellow Case Reports PRESENTED ON: 10/08/2018 03:15 PM - 04:15 PM INTRODUCTION: Vibrio vulnificus is a Gram-negative bacillus found in warm coastal waters. There are three clinical syndromes: primary septicemia, wound infections and gastrointestinal disease. Mortality rates of >50% have been reported in patients who present with primary septicemia. We describe a case of V. vulnificus presenting with septic shock and a violaceous annular rash with hemorrhagic bullae. CASE PRESENTATION: A 52 year old male with chronic alcoholism presented with fever, dyspnea and rash over upper and lower limbs for 2 days. He was febrile, tachypneic, and had a tachycardia of 140 beats/minute, hypotension with a blood pressure of 90/61mmHg, and pulse oximetry of 100% on room air. A violaceous annular rash over face, trunk, and upper limbs and hemorrhagic bullae over lower limbs was observed. There was no overlying cellulitis or necrotizing fasciitis. He was jaundiced, and laboratory data revealed a depressed white cell count, thrombocytopenia, high anion gap metabolic acidosis with hyperlactemia, acute renal failure and disseminated intravascular coagulation. He was intubated and mechanically ventilated and required dual vasopressor support following aggressive fluid resuscitation. Intravenous meropenem and doxycycline were promptly administered. Chest radiograph was normal and computed tomography of the abdomen and pelvis revealed ascites and hepatomegaly. Further history revealed no recent seawater exposure or seafood ingestion. A Gram-negative bacillus which later identified as V. vulnificus was isolated from the initial blood cultures and antibiotics were changed to IV ceftriaxone and doxycycline. Despite appropriate antibiotics and supportive management, he died 20 hours after. DISCUSSION: V. vulnificus infection can have an aggressive clinical course with significant morbidity and mortality. In this case, the patient died of multi-organ failure despite timely and appropriate antibiotics, and maximal supportive treatment. High-risk patients include those with chronic liver disease and chronic alcoholism; usually with a positive history of shellfish consumption or seawater exposure. Hypotension in the first 12 hours of presentation and leukopenia predicts for poorer outcomes. High bacterial densities of V vulnificus are seen with higher water temperatures of tropical seawater. CONCLUSIONS: High clinical suspicion of V. vulnificus infection is warranted in tropical coastline areas for patients presenting with severe sepsis and widespread violaceous annular rash with hemorrhagic bullae. Reference #1: Horseman MA, Surani S. A comprehensive review of Vibrio vulnificus: an important cause of severe sepsis and skin and soft-tissue infection. Int J Infect Dis. 2011 Mar;15(3):e157-66. Reference #2: Klontz KC, Lieb S, Schreiber M, Janowski HT, Baldy LM, Gunn RA. Syndromes of Vibrio vulnificus infections. Clinical and epidemiologic features in Florida cases, 1981-1987. Ann Intern Med. 1988 Aug 15;109(4):318-23. DISCLOSURES: No relevant relationships by Liesel Fong, source=Web Response No relevant relationships by Pyng Lee, source=Web Response No relevant relationships by Sui An Lie, source=Web Response