On Damsels and Distress From a Vibrio Species
Abstract & Commentary
Synopsis: Halophilic Vibrio species (Vibrio vulnificus, alginolyticus, and damsela) are notorious for their propensity to cause gastroenteritis wound infections and sepsis in both compromised and apparently immunocompetent hosts. Despite a change in name, Photobacterium damsela (formerly Vibrio damsela) retains some fairly pathogenic characteristics that make it a dangerous organism acquired from salt-water environments. As the summer months with their increased water sports are upon us, the potential for injuries contaminated with these virulent pathogens should be kept in mind.
Source: Barber GR, Swygert JS. Necrotizing fasciitis due to Photobacterium damsela in a man lashed by a stingray. N Engl J Med 2000;342:824.
A 43-year-old man stepped off his sailboat in Tampa Bay, Fla, and sustained both a laceration and deep wound to his right anterior tibialis muscle from a stingray. He presented to the emergency department at Lakeland Regional Medical Center, where the wound was irrigated and sutured within six hours of admission. He received no antimicrobial therapy and was released, only to return after three days with fever, cellulitis around the margins of the wound, a 2.5 cm fluctuant, malodorous lesion, and leukocytosis, all indicating the presence of necrotizing fasciitis. The wound required deep surgical debridement on an emergency basis followed by additional surgery the following day. Cultures obtained from the wound site showed growth of Photobactium damsela, sensitive to the antibiotics administered (doxycycline, cefazolin, and tobramycin) but intermediately sensitive to the aminoglycoside, amikacin. He later required both physical therapy and a skin graft to the affected region in addition to two weeks of oral antibiotics.
Comment by Frank J. BIA, MD, MPH
By 1981, both skin ulcerations and death of saltwater damselfish had been attributed to Vibrio damsela and at least 16 cases of human infections with four fatalities had been reported. Contamination and serious infections of skin wounds by at least three notorious halophilic vibrios was well established by the 1980s. These included Vibrio vulnificus, Vibrio alginolyticus, and V. damsela. To review some clinical examples, in 1986, Coffey et al reported the amputation of an infected arm in order to control a severe and rapidly progressive necrotizing fasciitis occurring less than two days following a fish fin puncture wound to the finger acquired on the Gulf Coast of Texas.1 Early necrosis and cellulitis had rapidly progressed to necrotizing fasciitis and sepsis with a recorded rectal temperature of 108.6ºF on the first postoperative day following amputation of the right arm. The patient was subsequently found to be an insulin-requiring diabetic who also developed an acute peripheral neuropathy thought to be secondary to toxin(s) produced by V. damsela.
In 1989, Dryden et al reported both pure V. damsela and mixed vibrio infections, causing severe cases of cellulitis and tissue necrosis, each acquired in the waters around Sydney, Australia.2 In 1993, Yuen et al reported a fatality due to necrotizing fasciitis of the left arm, acquired from a rabbitfish puncture wound in Hong Kong, which did not respond to amputation and antibiotic therapy.3 By this time, the potent heat-labile protein toxin, damselysin, a phospholipase D with sphingomyelinase activity, had already been described by others; Yuen et al suggested it may have played an important role in the evolution of the severe necrotizing fasciitis observed in their patient. Although blood cultures had been negative in the former patient, Perez-Tirse et al documented a case of V. damsela sepsis in a 70-year-old man acquired from a knife cut sustained while filleting bluefish at the New Jersey shore.4 Progression of tissue invasion was rapid, occurring within hours, and resulted in both erythema and bullous lesions of the entire affected arm, elevated creatine kinase levels, septic shock, and disseminated intravascular coagulation. The patient had no history of diabetes mellitus or liver disease, yet he died despite aggressive therapy. However, in 1993 Shin et al reported a 63-year-old man from Korea with underlying diabetes mellitus and alcoholic liver disease who also died within 2.5 hours of admission to the hospital from V. damsela septicemia and no obvious wounds or history of exposure to seawater. The patient had eaten raw eel approximately 24 hours prior to presentation and this case was felt to represent primary septicemia secondary to ingestion of the organism harbored in eels. Shin et al also note that in experimental animals, iron overload, as might be present in cirrhotic patients, significantly reduced the LD50 for virulent strains of V. damsela in experimental animal models.
Since this organism may produce fulminant infections in apparently immunocompetent patients with minor contaminated injuries or occult ingestion of organisms, clues from the clinical microbiology lab can be important in alerting clinicians to the presence of V. damsela and related species. Fraser et al noted a double zone of beta-hemolysis between bacterial colonies on 5% sheep blood agar.5 This produces a honeycomb pattern on the surface of the blood agar, and the degree of hemolytic activity is felt to correlate with pathogenicity of V. damsela for mice.
Treatment of infections caused by halophilic Vibrio sp. should not rely solely upon aminoglycosides or ß-lactam antibiotics, to which they may be resistant. Even when appropriate therapy has been instituted, the rapidly progressive nature of these infections and toxin mediated tissue necrosis may overwhelm the patient’s immune defenses. The tetracyclines and fluoroquinolones are proven to be reliable agents but may have to be supplemented with judicious surgical intervention to eliminate sources for continued infection and sepsis. Both classes of agents are available as parenteral preparations and one should anticipate using them as part of initial coverage for patients with cellulitis and fasciitis-associated injuries contaminated with either salt or brackish water.
References
1. Coffey JA Jr, et al. Vibrio damsela: Another potentially virulent marine vibrio. J Infect Dis 1986;153:800-801.
2. Dryden M, et al. Vibrio damsela wound infections in Australia. Med J Aust 1989;151:540.
3. Yuen KY, et al. Fatal necrotizing fasciitis due to Vibrio damsela. Scand J Infect Dis 1993;25:659-661.
4. Perez-Tirse J, et al. Vibrio damsela: A cause of fulminant septicemia. Arch Intern Med 1993;153:1838-1840.
5. Shin JH, et al. Primary Vibrio damsela septicemia. Clin Infect Dis 1996;22:856-657.
6. Fraser SL, et al. Fatal infection due to Photobacterium (Vibrio) damsela. Clin Infect Dis 1997;25:935-936.
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