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International Society for Infectious Diseases <http://www.isid.org>

Date: Wed 20 Jun 2012
Source: Hong Kong Department of Health

The Centre for Health Protection (CHP) of the Department of Health is investigating 2 fatal cases of _Vibrio vulnificus_ infection, with one of them causing necrotising fasciitis (flesh-eating disease).

The case of necrotising fasciitis caused by _V. vulnificus_ affected a 48-year-old man who lived in Shenzhen with underlying medical conditions. He presented with fever, pain and swelling in both legs since 16 Jun 2012. He attended the Accident and Emergency Department of Pok Oi Hospital on 17 Jun 2012 and was transferred to Tuen Mun Hospital on the same day. His clinical diagnosis is necrotising fasciitis and bilateral above knee amputations were performed. His condition continued to deteriorate and he died on 19 Jun 2012. The patient's blood culture grew _V. vulnificus_ and his tissue and wound swabs also detected _V. vulnificus_. His home contact was asymptomatic. Investigation continues.

The 2nd case of _V. vulnificus_ infection involved a 61-year-old man who lived in Yuen Long, with chronic illness. He developed fever since
16 Jun 2012 and loss of consciousness on 17 Jun 2012. He was admitted to Pok Oi Hospital on the same day. His condition deteriorated and he died on 18 Jun 2012. His blood specimen taken during his admission yielded _V. vulnificus_. CHP's investigation revealed that the patient had consumed raw mantis shrimp. His home contact was asymptomatic.
Investigation continues.

The cases have been referred to the Coroner for further investigation.

People are reminded to adopt the following measures to prevent necrotising fasciitis and Vibrio vulnificus infection:
- Avoid exposure of open wounds or broken skin to seawater or salty water;
- Wounds should be thoroughly cleaned and properly covered;
- Wear thick rubber gloves when handling raw shellfish;
- Cook seafood, especially shellfish (e.g., oysters, clams, mussels) thoroughly; and
- For shellfish, boil until the shells open and avoid cross-contamination of ready-to-eat food with raw seafood.

Patients should seek medical advice promptly if they develop symptoms and signs of infection such as increasing redness, pain and swelling.

Communicated by:

[_Vibrio vulnificus_, a lactose-fermenting, halophilic [salt-loving], Gram negative, opportunistic pathogen, is found in estuarine environments and associated with various marine species such as plankton, shellfish (oysters, clams, and crabs), and finfish. It is usually found in the warmer waters. Cases of illness have also been associated with brackish lakes. Environmental factors responsible for controlling members of _V. vulnificus_ in seafood and in the environment include temperature, pH, salinity, and increased dissolved organics.

Wound infections result either from contaminating an open wound with seawater harboring the organism, or by lacerating part of the body on coral, fish, etc., followed by contamination with the organism. The ingestion of _V. vulnificus_ by healthy individuals can result in gastroenteritis. The "primary septicemic" form of the disease follows consumption of raw seafood containing the organism by individuals with underlying chronic disease, particularly liver disease. The organism can also enter through damaged skin. In these individuals, the microorganism enters the blood stream, resulting in septic shock, rapidly followed by death in many cases (about 50 percent). Over 70 percent of infected individuals have distinctive bulbous skin lesions (shown at http://safeoysters.org/images/sym_2_photo.jpg).

A discussion of the disease in humans can be found in ProMED-mail posting "Vibrio vulnificus, salt water exposure - USA (TX) 20070719.2317." There are 2 points to be emphasized: that vibrios are normal flora in warm saltwater (not indicative of any sewage
contamination) and that most of the life-threatening illnesses occur in individuals with underlying medical illnesses, including immunocompromised states, chronic liver disease, and diabetes.
So-called normal individuals often just get gastroenteritis. The range of disease due to _V. vulnificus_ can involve more northern geographical areas if the area is affected by a substantial heat wave.
- Mod.LL

A HealthMap/ProMED-mail map can be accessed at:

[see also:
Vibrio vulnificus, fatal - China: (HK) 20120531.1150595 Necrotizing fasciitis - USA: (HI), Vibrio vulnificus suspected 20120317.1072640
Vibrio vulnificus, fatal - Taiwan: (TW) raw oyster 20110914.2804
Vibrio vulnificus - USA: Gulf oyster ban planned 20091030.3756 Necrotizing fasciitis, fatal - Canada: (MB) 20090118.0222
Vibrio vulnificus, salt water exposure - USA (LA) 20070724.2376 Vibrio vulnificus, salt water exposure - USA (TX) 20070719.2317 Vibrio vulnificus, shellfish - USA (FL) 20070427.1376 Vibrio vulnificus, 2000-2005 - Australia (NT) 20070302.0742
Vibrio vulnificus, oysters - USA (GA) 20060930.2805 Vibrio vulnificus - Germany (Mecklenburg-Vorpommern) 20060819.2319 Vibrio vulnificus - USA: RI 20060805.2173
Vibrio vulnificus, post-hurricane - USA (04): Additional Vibrio species 20050915.2723 Vibrio vulnificus, post-hurricane - USA 20050906.2642 Vibrio vulnificus, salt water exposure - USA (MD) 20050905.2622
Vibrio vulnificus, oysters - USA (FL) 20041120.3117 Vibrio vulnificus - USA (TX) 20040816.2274
Vibrio vulnificus, fatal - Israel (03) 20031230.3173 Vibrio vulnificus, fatal - Israel 20031229.3159] .................................................ll/ejp/dk
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