Infections hit Texas coast fishermen

August 17, 2004

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http://www.chron.com/cs/CDA/ssistory.mpl/health/2735560

Man loses battle with Gulf bacteria

--

A Houston dentist has lost his month long battle with a bacterium that

invaded a cut on his leg while he was fishing near Port O'Connor, officials

said on Fri 13 Aug 2004. The man, 52, died late on Thu 12 Aug in a Victoria

hospital, where he had been undergoing treatment since 17 Jul, 2 days after

he was exposed to the saltwater bacteria _Vibrio vulnificus_. His is the

7th vibrio-related death in Texas in 2004, officials said. At least 12

Texans have been injured by the cholera-like bacteria as well, according to

the Texas Department of Health.

Another man on the fishing-contest outing was infected by a different

strain of the bacterium. He was released from the Victoria hospital on Mon

9 Aug 2004, after more than 3 weeks of treatment, including several

surgical procedures to remove tainted flesh. Officials attributed his

survival to swift medical treatment after exposure. The dentist apparently

got a minor cut on his leg, on 15 Jul, when he slipped on a dock. The

following day, the leg became swollen, and he sought treatment in Port

Lavaca. By the 2nd day he was critically ill, a spokesman at Citizens

Medical Center in Victoria said.

" By the time he got here, vibrios had already infiltrated his blood system,

and he was in shock, which itself can be deadly, " CMC spokeswoman Melissa

Purl said. Within days, both legs were amputated, and he sank into a coma,

she said. The dentist was one of several Houston-area residents stricken by

the bacteria in Gulf waters this summer [2004]. A Bay City man, who went

fishing in the Laguna Madre, and a Dayton man, who vacationed in Freeport,

were successfully treated, in late July 2004, for infection with the bacteria.

Health experts said the bacteria are common in the Gulf, and, most

prevalent in coastal and bay waters in warmer months. The bacteria can be

ingested via contaminated seafood, such as oysters, or absorbed through

skin wounds, but don't penetrate healthy skin. The Centers for Disease

Control and Prevention (CDC), which has recorded vibrio-related illnesses

and deaths since 1988, said cases are rare, but underreported. A typical

year brings 16 deaths along the Gulf Coast states, CDC said.

The Texas Department of Health reported on Fri 13 Aug that, so far this

year, there have been 31 illnesses caused by vibriosis, including the 7

deaths, 4 of which were attributed to eating contaminated oysters. Experts

say those who enter coastal waters should make note of skin cuts and check

them later for redness or swelling. If caught quickly, illness caused by

the bacteria is controllable with antibiotics.

[byline: John W Gonzalez]

http://www.chron.com/cs/CDA/ssistory.mpl/sports/2707587

Infections hit Texas coast fishermen

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A recent outbreak of rare, but potentially dangerous, bacterial infections

has some coastal fishermen scared to go near the water. Experts say there

is reason for concern, and opportunity to increase awareness, but no cause

for panic. _Vibrio vulnificus_, and its many relatives, are naturally

occurring bacteria found in warm saltwater throughout much of the world.

CDC's Division of Bacterial and Mycotic Diseases notes that " an average of

50 culture-confirmed cases, 45 hospitalizations, and 16 deaths " occur

annually along the Gulf Coast. Nationally, the numbers roughly double

across the board. These bacteria are most often responsible for illnesses

and deaths from consumption of contaminated seafood, but fishermen often

contract the bacteria through open wounds.

The Texas Department of Health issued a release, on 22 Jul 2004, that

documented 20 confirmed cases of these infections this year [2004],

including 3 deaths. " At least 2 (of the infections) were associated with

exposure of cuts, or open wounds, to coastal saltwater, " according to the

release.

TDH spokeswoman Emily Palmer amended that report on Wed 28 Jul 2004, noting

that 11 cases of wound-related Vibrio infections in Texas have now been

confirmed since June 2004. In 2003, there were 14 wound-related infections

statewide among 43 total cases, 7 of which were fatal.

Among the latest to make the unfortunate list of infected patients are 3

fishing guides. The man most recently stricken was on high personal alert

for the disease, after word of earlier diagnoses hit the coastal community.

He, therefore, knew to seek medical attention at the 1st serious hint of

infection. A Port O'Connor guide, he had worked for 10 consecutive days.

When he got home, his left ankle felt tender, " like a slight sprain. " The

next morning, he felt queasy and skipped breakfast. Wading with clients a

few hours later, he became light-headed and passed out. A face full of bay

water brought him quickly back to consciousness, and the fishing guide knew

that he was in trouble.

Back in the boat, he summoned other guides to retrieve his customers, then

called for a family member to meet him at the dock. When he removed his

wading boots, he noticed a black spot " about the size of a quarter " below

the sore ankle. " In the time it took us to get from the dock to the

emergency room (about an hour), " he said, " that dot about doubled in size. "

The patient was met at DeTar Hospital Navarro by Dr Brian F Burns, a

plastic surgeon who also is treating 2 other victims of V. vulnificus_

infection at Citizens Medical Center in Victoria, TX. " While Dr Burns drew

a circle around (the infected area), and explained what he was going to

do, " the guide said, " I could see a redness going up my leg. " The infected

tissue was removed, the patient was administered antibiotics, and he

improved. This man is luckiest, thus far, of Texas waders stricken this

summer [2004] by the bacteria. Burns said that early detection, and

treatment, saved him from severe complications, and, probably spared his life.

Doctors at CMC were forced this week [last week of July 2004] to amputate

both legs of a Houston man, who also has suffered organ failure since

infection early in July 2004, and, who remained in critical condition on

Wed 28 Jul 2004. He waited just a couple of days after the initial

infection, friends say, before seeing a doctor. Another man, who contracted

the infection around the same time, and in the same area, has lost most of

the tissue between the ankle and knee of one leg. On Wed 28 Jul 2004, he

was listed as stable but remained in intensive care at CMC.

A 4th man, another fishing guide, was hospitalized this week [last week of

July 2004] with _V. vulnificus_ infection in his right leg. He already has

undergone 2 surgeries to remove damaged tissue. " On Friday, [9 Jul 2004], I

cut my leg on the trailer, but didn't think anything of it, " the patient

said from his hospital room in Bay City. " I fished the next 5 days. It got

worse and worse. By the next Friday, I was bedridden. My fever got to 104

(degrees). "

_V. vulnificus_ also found its way into the arm of a Rockport guide this

month [July 2004]. His said that his temperature was 104.7 degrees

[Fahrenheit; 40.4 degrees Celsius], when paramedics checked him at the

dock, " and he was drinking a cold drink when they took it. " This patient

has undergone surgery, and skin grafting, to repair his arm. He's

improving, his wife said, but he won't able to work again for weeks.

Dr James Oliver, a PhD at the University of North Carolina in Charlotte,

has studied the _Vibrio_ family for nearly 3 decades. He was surprised by

the number of wound-related cases in Texas over such a short time and over

such a small area. Matt Richardson, an epidemiologist at TDH in Austin,

confirmed that _V. vulnificus_ is the " absolute worst of the marine

bacteria " on a list that includes many other family members, as well as a

slow-growing, but tough-to-kill, germ called atypical mycobacteria. He

advised all coastal anglers to be cautious but said that it won't attack

unbroken, healthy skin. People in generally good health who are exposed to

this bacterium through wounds usually experience only mild symptoms that do

not persist. Ingestion by healthy people, reports CDC, may cause vomiting,

diarrhea, and abdominal pain.

Common-sense precautions should be adequate to avoid life-threatening

infection. Keep an antibacterial soap and generous supply of fresh water

nearby. If the skin is broken, clean and flush the area at the 1st

opportunity. Should the site worsen, or other indications such as redness,

fever, lethargy, or flu-like symptoms appear, go straight to the emergency

room. " Vibrio infections can be successfully treated with antibiotics if

treated early, " according to the TDH. The CDC's recommendation is for

" doxycycline or a 3rd-generation cephalosporin (such as ceftazidime). "

[byline: Doug Pike]

******

[3]

Sat 14 Jul 2004

Stephen M Apatow

The following information provides an excellent overview of the challenges

associated with warm weather, along the Gulf of Mexico, providing a

suitable niche for microbial growth and existence, including bacterial

genera of clinical importance (_V. vulnificus_, _V. cholerae_, _V.

parahaemolyticus_, _V. mimicus_, _Aeromonas_, _Plesiomonas_), as well as

discussion of economic issues:

Microbes and Marine Biotechnology: Pathogen Detection in Shellfish, Asim K

Bej, Department of Biology, University of Alabama at Birmingham

<http://dhp.disl.org/PDFs/SAME-2003.pdf>

Economic value of marine resources:

1. Contributes about 1/3 of the USA gross national products (GNP).

2. Seafood industry is one of the primary contributors to this GNP.

3. Gulf of Mexico coastal water is rich in seafood, due to the warm

weather, and is a major resource for the seafood industry.

4. The economy of many coastal cities and states depends upon the revenue

generated from the seafood industry.

Impact of _Vibrio vulnificus_:

1. In the past several years, the fishery industry, in the state of Texas,

lost potential revenue of USD 3.4 million from oysters and crabs, because

of closure due to bacteria and other contaminants.

2. The Interstate Shellfish Sanitation Conference (ISSC) suggests that

post-harvest-treated consumable oysters must not consist of >3 _V.

vulnificus_ per gram of meat.

3. This year (2003), the state of California released emergency

restrictions on sales of all oysters harvested from the Gulf of Mexico

between May and October, unless they are treated with a scientifically

validated method to reduce _V. vulnificus_ to non-detectable levels (3

organisms per gram of oyster meat).

4. ISSC Goal: An at least 60 per cent reduction of _V.vulnificus_-related

illnesses by 2007.

--

Stephen M Apatow

Humanitarian Resource Institute

<s.m.apatow

[For noncholera _Vibrio_ infections other than gastroenteritis, the

combination of ceftazidime and doxycycline, or an antipseudomonal

penicillin (such as, ticarcillin and clavulanate, piperacillin and

tazobactam) is the therapy of choice. Alternative antibiotics are

cefotaxime, ceftriaxone, or a fluoroquinolone.

The following is extracted from the " FDA Bad Bug Book. "

<http://vm.cfsan.fda.gov/~mow/chap10.html>

_Vibrio vulnificus_, a lactose-fermenting, halophilic, Gram negative,

opportunistic pathogen, is found in estuarine environments and associated

with various marine species, such as plankton, shellfish (oysters, clams,

and crabs), and fin fish. It is found in all of the coastal waters of the

United States. [Cases of illness have also been associated with brackish

lakes in New Mexico and Oklahoma.] Environmental factors responsible for

controlling members of _V. vulnificus_ in seafood, and in the environment,

include temperature, pH, salinity, and increased dissolved organics.

This organism causes wound infections, gastroenteritis, or a syndrome known

as " primary septicemia " . Wound infections result either from contaminating

an open wound with sea water harboring the organism, or by lacerating part

of the body on coral, fish, etc., followed by contamination with the

organism. The ingestion of _V. vulnificus_ by healthy individuals can

result in gastroenteritis. The " primary septicemia " form of the disease

follows consumption of raw seafood containing the organism by individuals

with underlying chronic disease, particularly liver disease. In these

individuals, the microorganism enters the blood stream, resulting in septic

shock, rapidly followed by death in many cases (about 50 per cent). Over 70

per cent of infected individuals have distinctive bulbous skin lesions.

In Feb 2004, the Southern Medical Journal published a review, an editorial,

and a case report regarding _V. vulnificus_:

The review (1) summarized cases with atypical aspects, including sepsis in

a windsurfer who developed infection after being struck by lightning in the

water, and who was later resuscitated, an infected corneal ulcer in an

oyster shucker who sustained shell fragments in his eye, and a bacteremia

in an HIV infected host. In the review, the authors reviewed treatment,

which included appropriate wound care, with debridement as needed, and

antimicrobial agents. They pointed out that, though the incidence of this

infection is low (0.5-2.0 reported cases per million individuals), its

significant mortality (the leading cause of foodborne mortality in some

areas) makes _V. vulnificus_ an important public health issue.

The editorial (2) points out that individuals with preexisting live disease

are 80 times more likely to become ill, and 200 times more likely to die,

as a consequence of eating raw oysters contaminated with this organism,

than are those without liver disease. Other risk factors include

hemachromatosis (iron overload disease), long term corticosteroid use,

diabetes, renal failure, and all forms of cellular immunosuppression.

The case report (3) highlights a unique case of a woman with chronic leg

ulcers who developed infection of the ulcer with _V. vulnificus_ after

being treated by a traditional folk healer, who sprayed fresh fish blood on

the ulcer.

1. Ulusarac O, Carter E. Varied clinical presentations of _Vibrio

vulnificus_ infections: a report of 4 unusual cases and review of the

literature. South Med J 2004; 97:163-8.

2. Mitra AK. _Vibrio vulnificus_ infection: epidemiologicy, clinical

presentations, and prevention. South Med J 2004; 97: 118-9.

3. Tal S, Guller V, Zimhony O, et al. A 'fishy remedy " : an unusual

transmission of _Vibrio vulnificus_ infection. South Med J 2004; 97: 205-7.

- Mod.LL]

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http://vm.cfsan.fda.gov/~mow/chap10.html

All individuals who consume foods contaminated with this organism are

susceptible to gastroenteritis. Individuals with diabetes, cirrhosis, or

leukemia, or those who take immunosuppressive drugs or steroids are particularly

susceptible to primary septicemia. These individuals should be strongly advised

not to consume raw or inadequately cooked seafood, as should AIDS / ARC

patients.

http://pets.care2.com/

http://www.theanimalrescuesite.com

" It is impossible to defeat an ignorant man in argument. " -- William G. McAdoo

August 21, 2004

There was a fellow who almost lost his arm last week due to vibrio. He was

fishing in Rockport Bay ( Rockport, Texas), had a small cut on his arm, and

had apparently been exposed during fishing. Within two days he had lost most

of the arm. This I am certain of.

I had been told also of a fellow in Austin, Texas recently, who had severe

brain damage- vibrio related- from eating sushi.

I am wondering if this- like the brown and red tides- is related to the high

(+80 degree) water temps. I dont recall hearing of vibrio during winter

months.

If this is related to temps, then the old wisdom about " not eating shellfish

unless harvested in a month with an 'R' in it " - which are the winter months-

may be very sound advice.

Michael

DitziSis [mk2967]

Monday, August 16, 2004 7:16 PM

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Infections hit Texas coast

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