Title

Dog Scratch Disease? A Rare Case of Vibrio Vulnificus in a Liver Transplant Patient

Authors

Emily Kim MS, Courtney Mack BS, Andrea Covington MD, Daniel Stanton MD

Introduction

Vibrio vulnificus causes disease via primary septicemia, gastroenteritis, or wound infection. This bacterium can present along the Texas coastline, where water temperatures rise during late spring-summer months. Risk factors for severe infection include liver disease, immunocompromised state, iron overload disorders, and increased age, with mortality rates ranging from 50-60% in high-risk patients. Given the varying presentations of this bacteria, the need for aggressive intervention poses a decision-making challenge.

Case Presentation

A 58-year-old male presented to the emergency department with severe left lower extremity pain, tachycardia, and a leg wound with severe swelling and erythema. His medical history was notable for type 2 diabetes, and chronic kidney disease stage 3, and alcoholic cirrhosis status post liver transplantation 4 years prior actively maintained with immunosuppressants. Twenty-six hours prior, he had sustained a scratch from his dog who had swam on the coast in warm saltwater. Given the tense, erythematous appearance of the wound, there was high clinical suspicion for necrotizing fasciitis. Patient underwent incision and drainage within 4 hours of admission. However, given rapidly worsening necrosis of the skin with bullae formation, decision was made to perform a left- sided above the knee amputation. Blood cultures on admission confirmed pan- susceptible vibrio vulnificus bacteremia with matching wound cultures collected intra- operatively. empiric antibiotics of vancomycin and meropenem started on admission were narrowed to ceftriaxone and doxycycline. Post operatively, patient became hemodynamically unstable, requiring ICU admission for vasopressors and intubation. The ICU course was complicated by acute renal failure requiring continuous renal replacement therapy and development of a tachyarrhythmia, atrial fibrillation with rapid ventricular response with associated troponin elevation. Given the severity of the infection, his immunosuppressants were held and he was started on stress dose steroids. On day 3 of hospitalization, he cleared blood cultures. By day 7, patient’s hemodynamics and clinical status improved significantly, and he was weaned from vasopressors and extubated. He completed 14 days of ceftriaxone and 21 days of doxycycline for his vibrio vulnificus bacteremia and subsequently lab values stabilized. Patient was discharged on hospital day 23.

Discussion

This case illustrates an unusual and interesting method of infection transmission, from water source to dog to human. With the patient’s immunocompromised state and his dog’s recent saltwater exposure, the patient became an ideal host for the pathogen. Given the severity of the patient’s presentation and the patient’s history of liver transplantation, prognosis was extremely guarded. However, the patient made a miraculous recovery with prompt source control, surgical intervention, empiric and targeted antibiotic therapy, and strict monitoring in the ICU. As ocean water temperature increases with climate change, the seasonal growth and geographic reach of vibrio is likely to increase. To prevent high mortality and promote favorable outcomes, vigilant surveillance, increased understanding of this pathogen, and cognizance of need for immediate initiation of treatment is crucial.

References

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