The Aftermath of Hurricane Ian: A Rise in Cases of Lower Extremity Vibrio vulnificus Infections in Southwest Florida

Hurricane Ian wreaked havoc on southwest Florida, with the resulting storm surge leading to a rise in seawater levels around coastal areas. In the following days after hurricane Ian, many found themselves wading in knee-level water or with other seawater exposures.
 
This is problematic given that Vibrio vulnificus, a gram-negative, alkaliphilic marine bacterial pathogen grows favorably in warmer and low-salinity waters, often in areas near coastal regions.^1,2Vibrio vulnificus infections develop rapidly and are associated with a high mortality rate. The rates of diagnosis and treatment are directly associated with mortality.³ Podiatric physicians, as experts in pathology of the lower extremities, have been at the forefront in southwest Florida in the medical triage following Ian.
 
According to the Florida Department of Health, there have been 66 cases of Vibrio vulnificus infections and 11 confirmed deaths from complications of said infections following hurricane Ian.⁴ Forty-seven percent of all of these cases occurred in Lee and Collier counties alone, where hurricane Ian made landfall.⁴
 
Anyone with a break in skin and exposure to seawater can develop a Vibrio infection. However, a high index of suspicion should arise particularly in those with a predisposition to infection, including those with diabetes, liver disease, or immunocompromise.^5,6
 
Often first-line treatments are empiric antibiotics and surgical debridement. Deep wound microbiological culture and sensitivity should be attained in a timely manner. The Centers for Disease Control and Prevention recommend doxycycline 100 mg intravenously or orally twice a day plus ceftazidime (or any other third-generation cephalosporin) 1 to 2 g intravenously every 8 hours for the treatment of V vulnificus infection.⁷ The authors highly recommend infectious disease consultation when Vibrio infection is suspected or confirmed given the high mortality rate.
 
The authors present a case of necrotizing fasciitis/myofasciitis secondary to Vibrio vulnificus infection. The patient is a 71-year-old male, seasonal visitor, with prior skin grafting to lower extremities secondary to burns about 20 years ago. While cleaning up storm damage 1 day after the hurricane, a cabinet door exposed to seawater fell, resulting in a glancing injury to the left medial pretibial region with a subsequent soft tissue defect (Figure 1).
 
Within 24 hours the patient went to the hospital with signs and symptoms of hemodynamic instability including: chest pain, confused behavior, tachycardia with elevated troponins, as well as marked inflammatory changes to the lower extremity (Figure 2). Upon admission the patient was febrile with a leukemoid reaction; empiric IV antibiotic therapy was started along with fluid resuscitation. Computed tomography of the lower extremity revealed multiple foci of gas within the intramuscular planes in all 3 compartments of the leg with proximal reaches to the upper third of the leg. Cardiology consultation was suggestive that arrhythmia and elevated troponins were likely secondary to sepsis.
 
The patient was taken urgently to the operating room and underwent a 3-compartment fasciotomy of the leg and debridement of wound (Figure 3 and Figure 4).The fasciotomies revealed sero-purulent discharge in all 3 compartments of the leg, which was sent for culture and sensitivity. Both blood cultures and surgical deep wound cultures revealed Vibrio vulnificus as the offending organism. The patient remained hemodynamically stable for the remainder of admission and underwent subsequent debridement 2 days after the initial intervention and then another subsequent debridement with closure of fasciotomy incisions as well as xenografting for an anterior ankle soft tissue deficit.
 
This patient is currently being followed as an outpatient and has made a marked improvement in pain levels, functionality, and overall global picture of his health. The authors hope that by presenting this case and related information, DPMs can become more aware of the unique, but important nature of such infections. 
 
Dr. Furmanek is a Fellow at Associates in Medicine and Surgery Sports Medicine and Reconstructive Surgery Fellowship in Fort Myers, FL.
 
 

Dr. Barbounis is an Attending Physician at Associates in Medicine and Surgery in Naples, FL.
 
References

1.    Chuang YC, Young CD, Chen CW. Vibrio vulnificus infection. Scand J Infect Dis. 1989;21(6):721–6.
2.    Motes ML, DePaola A, Cook DW, Veazey JE, Hunsucker JC, Garthright WE, et al. Influence of water temperature and salinity on Vibrio vulnificus in Northern Gulf and Atlantic Coast oysters (Crassostrea virginica). Appl Environ Microbiol. 1998;64(4):1459–65.
3.    Di W, Cui J, Yu H, et al. Vibrio vulnificus necrotizing fasciitis with sepsis presenting with pain in the lower legs in winter: a case report. BMC Infect Dis. 2022; 22(1):670. https://doi.org/10.1186/s12879-022-07655-1
4.    Florida Department of Health. Vibrio infections. https://www.floridahealth.gov/diseases-and-conditions/vibrio-infections/vibrio-vulnificus/index.html
5.    Menon MP, Yu PA, Iwamoto M, Painter J. Pre-existing medical conditions associated with Vibrio vulnificus septicaemia. Epidemiol Infect. 2014;142(4):878–81.
6.    Shapiro RL, Altekruse S, Hutwagner L, Bishop R, Hammond R, Wilson S, et al. The role of Gulf Coast oysters harvested in warmer months in Vibrio vulnificus infections in the United States, 1988–1996. Vibrio Working Group. J Infect Dis. 1998;178(3):752–9
7.    Centers for Disease Control and Prevention. Atlanta (GA): CDC; 2018. Vibrio vulnificus: general information [Internet] [cited 2018 May 21]. Available from: https://www.cdc.gov.

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