History and exam

Key diagnostic factors

common

leg pain

May be present in up to 50% of patients with Vibrio vulnificus infection and antecedes the evolution to necrotizing cellulitis by as long as 24 hours.[4]​​[21]

cellulitis

Mild cellulitis results from a local inoculation injury.

Bilateral lower-extremity necrotizing cellulitis with bullae suggests Vibrio vulnificus infection.[4]​​[21]

diarrhea

Nonspecific. May occur as a gastroenteritis syndrome in the otherwise-normal host, or as concomitant symptoms with sepsis in a compromised host.[4]​​[21][28]

abdominal cramps

Highly likely to be present in gastroenteritis syndromes, although it may also occur during sepsis.

ear pain

Vibrio alginolyticus may cause otitis externa in swimmers and surfers.​[4]​

Typical symptom of external otitis, but nonspecific.

eye pain, redness

Non-cholera vibrios have been reported to cause conjunctivitis, keratitis, or endophthalmitis after eye injuries with shell fragments, seawater eye contamination, or penetrating eye wounds.[42]

Typical symptoms of eye infection, but nonspecific.

Other diagnostic factors

common

fever

Nonspecific finding associated with bacteremia and/or cellulitis.

altered mental status

Confusion may occur and is associated with sepsis, but is nonspecific for Vibrio infection.

nausea

Nonspecific. May occur as a gastroenteritis syndrome in the otherwise-normal host, or as concomitant symptoms with sepsis in a compromised host.[4]​​[21][28]

vomiting

Nonspecific. May occur as a gastroenteritis syndrome in the otherwise-normal host, or as concomitant symptoms with sepsis in a compromised host.[4]​​[21][28]

hypotension

Septic shock may be present on first evaluation in as many as 70% of patients bacteremic with Vibrio vulnificus and has a mortality of up to 75%.[4]​​[21][43]

Risk factors

strong

exposure to brackish or marine waters

Vibrios are a natural part of marine or brackish water bioflora. The concentration of vibrios varies seasonally with the water temperature and salinity, with high numbers occurring with water temperatures between 62.5°F (17°C) and 95°F (35°C) and with 5% to 25% saline content. When the water temperature drops below replication temperature, Vibrio vulnificus exists in the marine sediment in a viable but not culturable state.[21][28]

Contamination of an open wound (e.g., leg ulcer, abrasion, burn wound) with sea water provides an access for Vibrio penetration into deeper tissue. Approximately 30% of the reported cases of human V vulnificus infection have resulted from marine-water-contaminated wounds or marine-associated accidents.[4][12][21][28][29]

Vibrio alginolyticus is associated with superficial ear or eye diseases in otherwise healthy young people with swimming or surfing marine water exposure.[4][12]

handling and/or cleaning seafood

Injuries occurring during the handling or cleaning of shellfish (e.g., oyster shucking) have been reported to be a common occupational injury associated with Vibrio vulnificus infection.[4][21]

ingestion of raw or undercooked shellfish

Filter-feeding bivalves concentrate vibrios in their tissues, where they are capable of further replication. Concentrations in oysters can be as high as 10³-10⁶ bacteria per gram of tissue.[21] Shellfish stored at 39-46.5°F (4-8°C) can have a 2 log increase in Vibrio vulnificus infection in 1 week.[30]

Two Vibrio syndromes have been associated with the ingestion of raw or undercooked shellfish. In patients with underlying hepatic disorders or immunosuppression, V vulnificus and occasionally Vibrio parahaemolyticus can traverse the portal system and produce a primary septicemia with metastatic skin lesions.[4][21][28] In the otherwise-healthy host, vibrios can cause a gastroenteritis syndrome, occasionally with blood and mucus. This has most commonly been associated with V parahaemolyticus and appears related to the organism's ability to produce a thermostable hemolysin, which acts as an enterotoxin.[14][30]

underlying hepatic disease (cirrhosis, hepatitis B or C, hemochromatosis)

The presence of liver disease is a risk factor for V vulnificus infection and complications.[15]​ Patients with liver disease may have higher levels of circulating ferritin providing an iron growth factor source for vibrios.[31]

current corticosteroid use or other immunosuppression (HIV, chemotherapy, solid organ transplantation)

In the mouse model for Vibrio vulnificus, giving either cyclophosphamide or d-galactosamine was necessary for the animal to be susceptible to oral bacterial challenge.[32]

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