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Aeromonas Hydrophila Septicemia in Acute Hand Injury: a Case Report

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Aeromonas Hydrophila Septicemia in Acute Hand Injury: a Case Report Aeromonas hydrophila septicemia AEROMONAS HYDROPHILA SEPTICEMIA IN ACUTE HAND INJURY: A CASE REPORT Chin-Chiang Yang, I-Feng Sun, Chia-Ming Liu, and Chung-Sheng Lai Division of Plastic and Reconstructive Surgery, Department of Surgery, Chung-Ho Memorial Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan. Aeromonas hydrophila is an uncommon and frequently overlooked cause of skin and soft-tissue infection. Rapid onset of cellulitis and bullae formation in the setting of soft-tissue trauma in connection with exposure to fresh water should alert the clinician to the possibility of infection by this organism. We report a case of severe necrotizing fasciitis due to A. hydrophila infection involving the hand and arm, complicated by septicemia within 30 hours of injury. In addition to appropriate antibiotic therapy and general supportive care, treatment involves early surgical exploration for compartment decompression and aggressive debridement of all necrotic tissue followed by skin grafting for delayed wound closure. There was good functional outcome after more than 1 year of follow-up. Early awareness of A. hydrophila infection, as well as of infection by Vibrio, is necessary in preventing crippling deformities of the hand in post-traumatic wound infection with a history of exposure to fresh water. Key Words: Aeromonas hydrophila, hand infection, sepsis (Kaohsiung J Med Sci 2004;20:351–6) Members of the Vibrionaceae family are primarily found siderophores, and adherence factors, all of which may play in water and are well known for their ability to produce a role in the pathogenesis of human disease [2–4]. Human gastrointestinal disease. The family includes three genera infections caused by Aeromonas include acute gastrointesti- associated with human disease: Vibrio, Aeromonas, and nal illness, soft-tissue infections, and sepsis, frequently in Plesiomonas. Clinical disease with bacteremia, wound association with malignancies and cirrhosis [5–10]. We re- infection, and cellulitis caused by Vibrio vulnificus is port a case of severe necrotizing fasciitis from Aeromo- relatively common in Taiwan, and septicemia commonly nas hydrophila infection involving the hand and arm, com- follows ingestion of raw or improperly handled seafood plicated by septicemia, that was treated successfully. [1]. In contrast, human infection caused by Aeromonas usu- ally follows exposure to untreated water, but disease has not been associated with consumption of shellfish or fresh- CASE PRESENTATION water fish. Factors that affect the virulence of Aeromonas include A 64-year-old female fell accidentally and received a small cytotoxins, endotoxins, hemolysins, enterotoxins, proteases, crush wound over the dorsal surface of her right middle finger (Figure 1) on the afternoon of April 29, 2002, while taking a walk in the park. She went to a local clinic imme- diately for first aid, and no bony fracture was found on Received: February 13, 2004 Accepted: April 30, 2004 roentgenography of the hand. She continued with her Address correspondence and reprint requests to: Dr. Chin-Chiang normal routine of regular home chores, including using Yang, Department of Surgery, Chung-Ho Memorial Hospital, st household tap water to clean the floor on the morning of the Kaohsiung Medical University, 100 Shih-Chuan 1 Road, Kaohsiung 807, Taiwan. next day. Unfortunately, progressive swelling and painful E-mail: [email protected] discomfort of her right hand developed in the late afternoon. Kaohsiung J Med Sci July 2004 • Vol 20 • No 7 351 © 2004 Elsevier. All rights reserved. C.C. Yang, I.F. Sun, C.M. Liu, and C.S. Lai Figure 1. Small crush wound over the dorsal surface of the right middle Figure 3. Swelling extends to the volar side of the hand. finger. Her condition did not improve after antibiotic injection in partate aminotransferase, 79 IU/L; alanine aminotrans- another clinic. Fever, nausea, vomiting, severe diarrhea, ferase, 89 IU/L; C-reactive protein (CRP), < 5.0 µg/mL. and relative hypotension were noted. She was brought Electrocardiography and chest roentgenography revealed to the emergency room at 7:30 am on May 1. Her blood no remarkable findings. pressure was 79/52 mmHg, pulse rate was 102/minute, Emergency fasciotomy was performed for compart- and body temperature was 39.4°C. She had a history of mental decompression at 9:00 pm on May 1. Severe sero- hypertension, renal cyst, and chronic hepatobiliary di- sanguineous bullae beneath the distended discolored sease (liver cyst, gallbladder stones). She was admitted for skin on the dorsal hand were found intraoperatively further evaluation and management of cellulitis in the (Figure 4). The patient underwent palmar fascia incision right hand. Physical findings in the right upper limb re- without carpal tunnel release. Unfortunately, postopera- vealed that the skin lesion on the right hand had extended tive sepsis developed and she was transferred to the rapidly towards the arm and become more livid, with no surgical intensive care unit. Vital signs became normal on clear demarcation (Figures 2 and 3). May 3: blood pressure, 120/70 mmHg; pulse rate, 88/min- On admission, the following laboratory findings were ute; respiratory rate, 23/minute; body temperature, 36.3°C; conspicuous: leukocyte count, 11,400/mm3, with 93.6% although CRP was elevated (83.9 µg/mL). neutrophils; hematocrit, 32.1%; hemoglobin, 11.1 g/dL; Left subconjunctival hemorrhage developed, and ten- prothrombin time, 31 seconds; creatinine, 1.1 mg/dL; der erythematous nodulation was noted in the right axillary blood urea nitrogen, 26 mg/dL; glucose, 106 mg/dL; as- Figure 4. Severe serosanguineous bullae formation beneath the distended Figure 2. Marked swelling on the dorsum of the right hand. discolored skin. 352 Kaohsiung J Med Sci July 2004 • Vol 20 • No 7 Aeromonas hydrophila septicemia region 5 days later, on May 6 (Figure 5). Further debridement and full-thickness skin graft to resurface the dorsal hand on May 6 and May 15 removed the remaining necrotic fascia skin defect were performed successfully on May 22 (Figure and subcutaneous tissues over the dorsal hand (Figure 6). 7). The patient was discharged on May 28, satisfied with the The patient’s general condition was much improved through result. Good functional outcome was demonstrated after intensive wound care and supportive treatment. Delayed more than 1 year of follow-up (Figure 8). primary closure of the decompressed palmar incision wound Both blood and wound (bullae aspiration) cultures re- Figure 5. Tender erythematous nodulation over the right axillary Figure 7. Successful full-thickness skin graft over the dorsal hand skin region. defect. A A B B Figure 6. Debridement of the necrotic fascia and subcutaneous tissues Figure 8. Good functional outcome after more than 1 year of follow-up: of: (A) the dorsal hand; and (B) the volar hand. (A) hand flexion; (B) hand extension. Kaohsiung J Med Sci July 2004 • Vol 20 • No 7 353 C.C. Yang, I.F. Sun, C.M. Liu, and C.S. Lai vealed A. hydrophila. Sensitivity testing revealed resistance accompanied by other aerobic and anaerobic pathogens. to amoxicillin plus clavulanic acid, erythromycin, and Signs of infection usually appear 8 to 48 hours following clindamycin, but full sensitivity to azlocillin, cefuroxime, puncture or laceration injury. Infection is frequently rapid- co-trimoxazole, chloramphenicol, piperacillin, cefotaxime, ly progressive, with fascia, tendon, muscle, bone, or joint tetracycline, amikacin, mezlocillin, ofloxacin, and cipro- involvement. Von Graevenitz and Mensch also reported floxacin. that one-third of their 30 A. hydrophila isolates were in pure culture [11]. No co-isolated pathogen was found in our case, although more than one pathogen culture has DISCUSSION been reported elsewhere [3,12,20]. Hanson and associates have observed that the cha- Aeromonas are Gram-negative bacilli with worldwide dis- racteristic syndrome of wound infection with A. hydro- tribution, and are found in lakes, rivers, streams, springs, phila is indistinguishable from that of group A strep- rainwater, swimming pools, tap water, and seawater [2,3]. tococci [21]. Purulent inflammation develops rapidly As ubiquitous inhabitants of fresh and brackish water, they (within 24–30 hours) and is accompanied by moderate commonly cause infectious diseases in cold-blooded aqua- fever and an elevated leukocyte count. A. hydrophila sep- tic animals [4]. Diseases in man caused by, or linked to, ticemia has been described as enteric fever, rheumatic- Aeromonas are acute gastrointestinal illness, skin and soft- fever-like syndrome, and flu-like illness, similar to other tissue infections, and sepsis, frequently in association with types of Gram-negative septicemia. It is characterized malignancies and cirrhosis, with a fatality rate of between by rapid pain and, occasionally, nausea and vomiting. 30% and 70% [11–14]. A. hydrophila has also been implica- Usually, severe local bullous lesions are noted [14,22]. ted as a cause of liver abscess, meningitis, conjunctivitis, A. hydrophila was cultured from blister fluid and blood corneal ulcer, endocarditis, pneumonia, septic arthritis, in our case. In addition, the infection (cellulitis) was found osteomyelitis, and gas gangrene. Iatrogenic infection to be spreading from the right dorsal hand to the distal following the use of medicinal leeches as an adjunct to portion of the forearm and up to the axilla (lymphadenitis); microsurgery or in flap salvage secondary to venous localized pustule formation developed later (Figure 5) congestion [15,16], and infection of burn patients with and responded quite well to incision and drainage. Aeromonas organisms have been reported [17,18]. Besides antibiotic therapy, early surgical intervention In this case, pre-existing liver disease was considered a for compartmental pressure release, adequate necrotic tis- risk factor for Aeromonas infection. The impaired immune sue debridement, and wound reconstruction by skin graft system, with a deficiency in the number or function of or flap are the general principles of treatment in severe hand neutrophils, or lack of heat-stable opsonins, may also have trauma or infection, as in this case.
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