Case Report Aeromonas hydrophila Infection

Chih-Kang Chou, MD

Chief Complain
A 45 y/o male came to the ER with erythematous swelling of the right leg and multiple large hemorrhagic bullae.

Past & Personal History

No job, smoking, drinking everyday Hypertension Type 2 diabetes mellitus Liver cirrhosis with ascites Atrial fibrillation Admission to GI due to fever, chillness & diarrhea on 100.8.19~8.21 Bladder cancer - TUR-BT on 85.5.25 Anal fistulectomy on 92.9.8 and anal fistectomy on 92.11.24

Present Illness
Right leg erythematous swelling and multiple bullae since one day ago. Fever, chillness and pain over right leg, so he came to our ER on 100.10.24. No known history of any sea food contact, trauma, or insect bites. Under the impression of right leg necrotizing fasciitis, he was admitted to our ward.

Course & Treatment

E3M5V2-3 K+ 2.6meq/L, Potassium replacement PLT 39000 Rocephin 1gm q12h Consult infection Dr. Leg wound care with uburn cream BP down, coma Transfer to ICU, On Endo & ventilator Dopamin & levophed NH3 88 - > Lactulose enema tid Rocephin 2gm q12h + Doxycycline 100mg bid Digoxin 1# qd for Af (consult CV) Albumin x3 days GI bleeding (Consult GI) NPO Losec 1 amp q12h FFP 2u, PLT 12u Lactulose enema tid Rocephin 2gm q12h + Minocin 100mg q12h Signed DNR Wound & blood culutre: Aermonas hydrophila Losec 1 amp q12h FFP 2u, PLT 12u Lactulose enema tid Rocephin 2gm q12h + Minocin 100mg q12h

10/24

10/25

10/26

10/27

10/24

10/25

Course & Treatment

Stop inotropes & antibiotics as requested by family Supportive treatment only E3M4VE NG: dark green BP: 121150/7090mmHg Consciousness improving E3-4M5-6VE Family accepted AK amputation Rocephin 2gm q12h + Minocin 100mg q12h E3M5VE BP more stable Start NG feeding

10/28

10/29

10/31

11/1

10/26

10/28

Course & Treatment

Under GA, AK amputation Keep antibiotics E3M3VE Consciousness downhill BP: 90/56 mmHg Af NH3: 37 (11/4) E1M1VE BP: 90/50 mmHg Signed DNR BP dropped Expired

11/3

11/6

11/7

11/8

11/07 11/01

Laboratory Data
data date WBC Hb Platelet Neutrophil Lymphocyte Bun Cr Na K CRP NH3 Alb GOT GPT Bil(T/D) Osm Digoxin

10/24 10/25 10/26 10/27 10/28 10/31 11/01

4500 5900 8200 8200 8500 9600 10200

14.5 11.5 11.9 10.6 9.6 12.1 11.2

39000 11000 29000 33000 38000 13000 43000

88.2 83.8 91.4 91.3 86.9 81.8

10.8 7.4 4.8 7.3 9.3 15.2

18

2.3

139

2.6 29.5 99.4 88 1.8

101

50

45

2.8

139

3.4

83 67 43 2.3 2.2 123 85

55

1.9

162 165

3.4 3.6

24

11/02
11/04 11/07

10400
8400 6200

11.0
9.1 7.2

25000
59000 25000 73.4 23.0 41 1.8

162
162 156 3.3 3.6 57.5 37 2.1 2.0 94

25.13/18 373
0.61

Bacterial Culture
Wound culture: Aeromonas hydrophila Blood culture: Aeromonas hydrophila/ caviae

Aeromonas hydrophila ()
Found in all freshwater environments as well as brackish, chlorinated, and unchlorinated water. Both a gram-negative rod and a facultative anaerobe. Can grow in temperatures as low as 4oC. These bacteria are motile by a polar flagella. Very toxic to many organisms. When it enters the body of its victim, it travels through the bloodstream to the first available organ. Produces Aerolysin Cytotoxic Enterotoxin (ACT), a toxin that can cause tissue damage. Considered to be opportunistic pathogens, meaning they rarely infect healthy individuals. Considered a major fish and amphibian pathogen, and its pathogenicity in humans has been recognized for decades.

Fish and Amphibians

Associated with diseases mainly found in fish and amphibians, because these organisms live in aquatic environments. It is linked to a disease found in frogs called red leg, which causes internal, sometimes fatal hemorrhage. When infected, fish develop ulcers, tail rot, fin rot, and hemorrhagic septicemia. Hemorrhagic septicemia causes lesions that lead to scale shedding, hemorrhages in the gills and anal area, ulcers, exophthalmia, and abdominal swelling.

Fish and Amphibians

Sites of infection in humans

GI: gastroenteritis/dysentery (children may be severe, adults less so or chronic), peritonitis (rare). Skin/soft tissue infection:
Cellulitis (may be fulminant with necrotizing features). Necrotizing fascitiis and mynoecrosis also may occur.

Sepsis: bacteremia often associated with malignancy, hepatobiliary disease such as cirrhosis, less commonly with diabetes. Bone: osteomyelitis, septic arthritis CNS: meningitis (rare) Cardiac: endocarditis (rare)

Gastroenteritis
Through oral contact with contaminated water, food, soil, feces, and/or ingestion of contaminated fish or reptiles. Two types of gastroenteritis.
1. Similar to cholera, which causes rice-water diarrhea. 2. Dysenteric gastroenteritis, which causes loose stools filled with blood and mucus. Dysenteric gastroenteritis is the most severe out of the two types, and can last for multiple weeks.

Soft tissue infection

Commonly acquired through an open wound that is exposed to contaminated water. Can cause severe skin/soft tissue infection and sepsis, often in the immunocompromised. Risk factors for severe infection: immunocompromise, diabetes, hepatobiliary disease (cirrhosis). Cellulitis can be severe and spread rapidly, often within hours following exposure. Infection into deeper tissues may cause necrotizing fasciitis or myonecrosis. Bullae and ecythma gangrenosum may be observed.

Antibiotics treatment
Resistant to penicillin, ampicillin, carbenicillin, and ticarcillin. Susceptible to broad-spectrum cephalosporins, aminoglycosides, carbapenems, chloramphenicol, tetracycline, trimethoprim-sulfamethoxazole, and quinolones.

Necrotizing Fasciitis (NF)

An insidiously advancing soft tissue infection characterized by widespread fascial necrosis. Increased risk in diabetics, elderly, infants, those with liver disease, or those taking immunosuppressive drugs such as chemotherapy for cancer.

Classification
Type I, or polymicrobial, after trauma or surgery.
A variant of NF type I is saltwater NF, a Vibrio species.

Type II, or group A Streptococcal. Type III gas gangrene, or clostridial myonecrosis.

Fourniers Gangrene

Vibrio Vulnificus

Vibrio Vulnificus

Streptococcal Necrotizing Fasciitis

Necrotizing Fasciitis with Mycotic Aneurysm Infected with Salmonella

Treatment of NF
Aggressive resuscitation to maintain hemodynamic stability. Broad-spectrum antibiotics to cover aerobic gram-positive & gram-negative organisms and anaerobes. Surgical debridement, early and aggressive, multiple and extensive. Following fluid resuscitation and nutritional support. Wound care, & wound reconstruction. Hyperbaric oxygen (HBO)

Conclusion
Aeromonas hydrophila infection is frequently the cause of necrotizing fasciitis in patients with suppressed immune systems, diabetes, burns, and trauma in an aquatic setting. These patients require aggressive antimicrobial therapy and debridement and the mortality rate is high. Individuals that fail to respond to these treatment measures may require amputation.