Infectious Diseases in Clinical Practice:
Concomitant Bacteremia Caused by Vibrio fluvialis and Vibrio alginolyticus in a Patient on Hemodialysis: A First Case Report and Review of Literature
Nadkarni, Abhijeet S. MD; Shah, Monika K. MD
Division of Infectious Diseases, Harlem Hospital Center and Columbia University College of Physicians and Surgeons, New York, NY.
Address correspondence and reprint requests to Abhijeet S. Nadkarni, MD, Harlem Hospital Center, 506 Lenox Ave, Division of Infectious Diseases, Room 3101A, New York, NY 10037. E-mail: firstname.lastname@example.org.
We describe a case of concomitant Vibrio fluvialis and V. alginolyticus bacteremia in a patient on hemodialysis via indwelling vascular catheter after swimming in seawater, with subsequent recurrences of V. alginolyticus bacteremia that resolved with catheter removal. This is, to our knowledge, the first report of this type of bacteremia.
Vibrio species are free-living bacteria that are commonly found in aquatic environments. A small subset of these species can cause disease in humans,1 including gastroenteritis, wound infections, and septicemia in susceptible hosts after exposure to seawater or ingestion of contaminated seafood, especially raw oysters.2 Vibrio fluvialis is a halophilic organism mainly associated with gastroenteritis,3-11 with only 2 documented cases of bacteremia reported previously.12,13 Vibrio alginolyticus is commonly associated with ear infections (otitis media and otitis externa) and superficial wounds, although cases of bacteremia have also been reported.14-19 We present the first case of concomitant V. fluvialis and V. alginolyticus bacteremia, and review relevant English literature.
A 40-year-old Mexican woman with type 2 diabetes mellitus, hypertension, and end-stage renal disease on hemodialysis for the past 2 years was admitted to the hospital with fevers and chills that developed during dialysis in July 2005. She was dialyzed via a right subclavian permanent catheter since April 2005 because of previous multiple failed arteriovenous grafts. She also complained of nausea, nonbilious vomiting containing ingested food, and diffuse abdominal pain for 4 days before admission. She denied having any diarrhea or having consumed raw oysters or uncooked seafood, but maintained that she swam in the Atlantic Ocean off Long Island 1 week earlier. There was no history of domestic or international travel since she moved to New York from Mexico in 2001. Family members were all in good health.
On admission, these measurements of vital signs were obtained: blood pressure, 83/43 mm Hg; pulse rate, 66 beats/min; and body temperature, 100.4°F. Physical examination revealed healthy conjunctiva, clear breath sounds, obese abdomen with normal bowel sounds, and diffuse tenderness-more tenderness in the left upper and lower quadrant, with genital examination revealing cervical motion tenderness with vaginal blood clots. The exit site of the right subclavian permanent catheter was not tender and was without discharge or warmth. There was no evidence of any other skin breaks or abrasions. The laboratory data were as follows: white blood cell count, 11,500 cells/μL, with 89% neutrophils, 6% lymphocytes, and 3% monocytes; hemoglobin level, 15.2 g/dL; serum albumin level, 4.1 g/dL; total protein level, 8.8 g/dL; alanine aminotransferase/aspartate aminotransferase levels, 18/24 U/L (reference range, 11-35 U/L); alkaline phosphatase, 64 U/L (reference range, 25-100 U/L); total bilirubin level, 0.9 mg/dL (reference range, 0.2-1.3 mg/dL); direct bilirubin level, 0.1 mg/dL (reference range, 0.0-0.2 mg/dL); serum urea nitrogen level, 26 mg/dL (reference range, 1-22 mg/dL); and serum creatinine level, 5.0 mg/dL (reference range, 0.1-1.1 mg/dL). The levels of serum electrolytes, the coagulation profile, and the urine analysis result were all within reference ranges. Two sets of blood cultures were drawn via the dialysis catheter on admission. Empirical antimicrobial therapy for possible catheter-related infection and pelvic inflammatory disease was initiated. This initial regimen consisted of a single dose of intravenous (IV) vancomycin, 1 g; ceftriaxone, 2 g IV once a day; and doxycycline, 100 mg IV twice a day.
The patient remained febrile during the first 2 days of admission, with reduced frequency of vomiting but with persistent abdominal pain and a complaint of dysuria. The ceftriaxone therapy was changed to gatifloxacin (dosage, 200 mg IV once a day). The abdominal and pelvic ultrasound result was negative; white blood cell count improved to 9000 cells/μL, with 70% neutrophils, 21% lymphocytes, and 7% monocytes. Isolates were recovered from 2 of 4 standard Aerobic/F and Anaerobic/F admission blood culture bottles (BD Biosciences, Sparks, MD) using Bactec 9240 blood culture system. Isolates grew on 5% sheep blood agar, producing nonhemolytic colonies. Colorless lactose-negative colonies developed on MacConkey agar. Morphologically, the organisms were curved Gram-negative bacilli that were highly motile in wet preparations. Biochemically, the isolates were rapidly oxidase positive and were subsequently identified as V. fluvialis and V. alginolyticus by the Vitek system using the Gram-negative identification test kit. Both isolates were susceptible to amikacin, gentamicin, chloramphenicol, and tetracycline, but resistant to ampicillin (by using Kirby-Bauer technique). Only V. alginolyticus was susceptible to carbenicillin, whereas only V. fluvialis was susceptible to cephalothin. Both isolates were forwarded to the New York City Department of Health and were further confirmed as V. fluvialis and V. alginolyticus.
By day 9 of admission, her abdominal pain and vomiting resolved. A negative set of blood cultures was obtained and the patient was discharged on oral doxycycline (dosage, 100 mg twice a day) to complete the 2 weeks of treatment. The patient was followed up after discharge with no subsequent complaints of abdominal pain, diarrhea, or fever; 2 sets of blood cultures were negative after the completion of treatment.
However, the patient had recurrent fever (temperature, 101°F) with chills during a dialysis session in August 2005, with no associated abdominal pain, vomiting, or diarrhea. One aerobic bottle from each set of blood cultures drawn on 2 separate occasions via dialysis catheter revealed only V. alginolyticus. There was no history of ingestion of raw seafood or swimming in Atlantic Ocean before this episode. However, she was not admitted for this episode and, in view of symptom resolution and of a subsequent negative blood culture set, the patient was not treated with antibiotics by the dialysis team. In September 2005, a right arm arteriovenous graft was placed, whereas the right subclavian permanent catheter was maintained in place for interim dialysis until graft maturation. In October 2005, she was readmitted to the hospital, having fever (temperature, 103°F) with chills during dialysis. Again, no history of abdominal pain, diarrhea, vomiting, and seafood or seawater exposure was obtained on this occasion. Physical examination was notable for obvious tenderness, erythema, and warmth at the dialysis catheter exit site. One aerobic bottle from a set of blood cultures again revealed V. alginolyticus with an antimicrobial susceptibility pattern similar to her previous 2 episodes. Her subclavian dialysis catheter was removed on this occasion and the newly placed arteriovenous graft was used for dialysis. She was treated with amikacin (dose, 3 mg/kg IV) for 2 weeks with therapeutic level monitoring. Her fever resolved and 2 negative sets of blood cultures were obtained. Currently, she remains on dialysis via the right arm arteriovenous graft with no further episodes of Vibrio species bacteremia.
Vibrio fluvialis (formerly designated group F vibrios or group EF-6) was first isolated and identified in a patient with diarrhea by Furniss et al20 in 1977 and subsequently described and named by Lee et al21 in 1981. It is commonly implicated as a causative agent of gastroenteritis. Vibrio alginolyticus, on the other hand, is a species that is widely distributed in coastal waters of temperate and tropical regions. Most clinical isolates of V. alginolyticus are isolated from ear and skin infections. Our MEDLINE search of English literature revealed 2 previously described cases of V. fluvialis septicemia and 6 cases of bacteremia caused by V. alginolyticus, as summarized in Table 1.
The present case was the first involving concomitant bacteremia caused by 2 uncommon Vibrio species. To our knowledge, this is also the first case report of recurrent V. alginolyticus bacteremia in a patient with end-stage renal disease and indwelling vascular access for hemodialysis, thus raising the possibility of catheter-related Vibrio septicemia. In our patient's first episode, there was a clear history of seawater exposure. Although diarrhea is the most common presentation of V. fluvialis infections, it is possible that our patient's abdominal pain, nausea, and vomiting were an uncommon manifestation of V. fluvialis gastroenteritis, as opposed to the presumed diagnosis of pelvic inflammatory disease. We think that the Vibrio species invaded the bloodstream either from the intestinal tract or directly through the exit site of her subclavian hemodialysis catheter. The relative suppressed immunity due to underlying type 2 diabetes mellitus and chronic renal disease might have also increased her risk of the first episode of bacteremia after possible intestinal portal of entry. We postulate that the subsequent recurrences of V. alginolyticus bacteremia were due to contamination of the permanent subclavian catheter because her febrile episodes coincided with hemodialysis sessions and because complete clearing of bacteremia was noted after the removal of the indwelling catheter and administration of appropriate antibiotic therapy. As is evident from the table described in our report, various antibiotics have been used in the past for treatment of such infections. According to the reviewed literature and on the basis of the susceptibility patterns of our isolates, the antibiotics tetracycline, doxycycline, fluoroquinolones, aminoglycosides, trimethoprim-sulfamethoxazole, second/third generation cephalosporins, extended spectrum penicillins, and carbapenems may be the appropriate ones for treating V. fluvialis and V. alginolyticus infections.
In summary, V. fluvialis and V. alginolyticus are rarely implicated as causative agents of primary septicemia. However, exposure to seawater or ingestion of raw seafood is an important risk factor in acquiring these infections. As observed in our patient, concomitant bacteremia by 2 different Vibrio species has not been previously described. The possibility of indwelling catheter-related recurrent septicemia caused by Vibrio species needs further investigation.
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