Non-O1 Vibrio cholerae Epidural Brain Infection in a 12-Year-Old Boy After a Depressed Skull Fracture

Abstract

To the Editors: Non-01 Vibrio cholerae is ubiquitous in the marine environment. It is morphologically identical to Vibrio cholerae, the causative agent of epidemic cholera, but lacks the O1 antigen. Infection typically causes self-limited gastroenteritis after consumption of raw shellfish in adults. We present the first report of central nervous system (CNS) infection in a pediatric patient after trauma sustained in a marine habitat. A 12-year-old boy in the Marshall Islands (equatorial Pacific) was climbing a coconut tree directly over shallow water. He fell an estimated 10–30 feet, sustaining an 8 cm deep scalp laceration with underlying depressed skull fracture. The laceration was primarily closed with staples, and he was urgently evacuated to our tertiary healthcare facility in Hawaii. During air-evacuation, he had decreased movements of his left upper and lower extremities. Intravenous dexamethasone was administered for presumed cerebral edema. Upon arrival, 2 days after the injury, no antibiotics had been administered. Physical examination demonstrated lethargy and decreased movement of the left upper and lower extremities. Computed tomography revealed a depressed 6 cm × 1.5 cm right parietal skull fracture, air in brain parenchyma, cortical contusions, and mild mass effect. Emergent surgical debridement and bone fragment removal was performed. Aerobic cultures of bone fragments yielded pure growth of Gram negative rods identified by the Hawaii Department of Health as Vibrio cholerae non-O1, non-0139. The organism was susceptible to all beta-lactams and cephalosporins. The patient received cephalexin 250 mg QID for 15 days and phenytoin for seizure prophylaxis. Over the next 2 weeks, he received physical therapy and demonstrated increased movement of the left extremities. At discharge, he was able to walk. Six months later, the patient returned for cranioplasty without evidence of postinfectious sequelae. Vibrio species are motile Gram-negative rods that are ubiquitous in salt and brackish waters. Non-O1 V. cholerae is found worldwide, with documented infections in North America, Europe, Africa, and the Pacific. The organism rarely causes illness in humans but can be associated with a wide spectrum of presentations including wound infections, gastrointestinal tract infections, secondary septicemia, and CNS infections. We identified 5 pediatric cases of non-O1 V. cholerae CNS infections: all were in neonates.1–5 Sources of infection were not definitely established, but freshwater exposures, either primary or secondary, were identified. In 1 instance, a feeding bottle was stored in the same cooler as live crabs.3 In another, a family member cleaned fish in the sink where the neonate received daily baths.4 All previous cases of CNS infection caused by non-01 V. cholerae were also associated with septicemia. These infections have been successfully treated with cephalosporins (cefotaxime, cefazolin, ceftriaxone), and amoxicillin/clavulanate. The fluoroquinolones and tetracyclines may be useful in older children or adults. In summary, we present the first case of non-O1 V. cholerae CNS infection in a pediatric patient resulting from head trauma in a marine environment. Physicians who care for patients injured in or near sea water should consider the marine Vibrio organisms in the differential diagnosis of ensuing infections and administer empirical antibiotics with activity against Vibrio species. The views expressed in this letter are those of the authors and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the U.S. Government. Michael V. Arnett, MD Tripler Army Medical Center Honolulu, HI Susan L. Fraser, MD Walter Reed Army Medical Center Washington, DC Phyllis E. McFadden Tripler Army Medical Center Honolulu, HI