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Vibrio Fluvialis applyparastyle “fig//caption/p[1]” parastyle “FigCapt” Open Forum Infectious Diseases NOVEL ID CASES Vibrio fluvialis Liver Abscess and Bacteremia in a Sashimi Lover: A Case Report and Review of the Literature Satoshi Kitaura,1, Koh Okamoto,1 Yoshitaka Wakabayashi,1 Yuta Okada,1 Aiko Okazaki,1 Mahoko Ikeda,1 Ryunosuke Hakuta,2 Yousuke Nakai,2 Shu Okugawa,1 Kazuhiko Koike,2 and Kyoji Moriya1 1Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan, and 2Department of Gastroenterology, The University of Tokyo Hospital, Tokyo, Japan Vibrio fluvialis is a foodborne pathogen known to cause a cholera-like gastroenteritis syndrome. Here we report the first case of V. fluvialis liver abscess and bacteremia presumed to be from sashimi, a Japanese raw seafood delicacy. We also provide a literature Downloaded from https://academic.oup.com/ofid/article/7/6/ofaa212/5854108 by guest on 29 September 2021 review of reported cases of V. fluvialis extra-intestinal diseases including bacteremia. Keywords. bacteremia; liver abscess; Vibrio fluvialis; Vibrio species. Vibrio fluvialis is commonly encountered [1], being the fifth presentation. He gradually lost appetite and mainly consumed commonest species (6%) among 1252 cases of Vibrio infection sashimi, a Japanese seafood delicacy, purchased at a nearby fish reported to the Centers for Disease Control and Prevention [2]. market on a daily basis. V. fluvialis is increasingly recognized as a foodborne pathogen Upon admission, he was alert and oriented with mild lethargy. associated with poor sanitation and increased seafood con- Physical examination revealed moderate conjunctival pallor, but sumption [1]. Acute gastroenteritis is the most common presen- no focal findings, including abdominal tenderness or perito- tation, although extra-intestinal infections have been reported neal signs. Complete blood count results were as follows: white infrequently [1]. Here, we report a case of V. fluvialis liver ab- blood cell count, 21.5×103/μL; hemoglobin, 7.7 mg/dL; and scess with concomitant bacteremia and review the literature platelet count, 34.4×104/μL. Liver enzyme levels were as follows: regarding extra-intestinal, including bacteremic, V. fluvialis aspartate transaminase, 34 U/L; alanine transaminase, 20 U/L; infections. gamma-glutamyl transpeptidase, 132 U/L; alkaline phosphatase, 652 U/L; and total bilirubin, 0.5 mg/dL. Urinalysis and chest ra- CASE PRESENTATION diogram were unremarkable. Abdominal ultrasound revealed a low echoic lesion ~20 mm in size in segment 6 of the liver. This A 65-year-old man with a history of pancreatic head cancer and finding was confirmed with computed tomography with intrave- surgically resected bladder cancer presented to the outpatient nous contrast, which showed a newly identified space-occupying clinic following 1 week of lethargy. He denied any abdominal lesion compatible with liver abscess in the corresponding loca- pain, diarrhea, or other gastrointestinal symptoms. He was ex- tion (Figure 1A). He subsequently underwent fluid resuscitation pected to receive chemotherapy for pancreatic cancer; how- and percutaneous transhepatic abscess aspiration with empiric ever, he was admitted to the internal medicine ward because of piperacillin-tazobactam. The following day, blood cultures and profound hypotension and tachycardia. Twelve months before, aspirate from the liver abscess were positive for gram-negative pancreatic duct dilation was incidentally noted on follow-up bacilli (Figures 1B and C). Matrix-assisted laser desorption/ computed tomography for bladder cancer. He was subsequently ionization time-of-flight mass spectrometry (MALDI-TOF MS; diagnosed with pancreatic head cancer following bile duct bi- Bruker, Billerica, MA, USA) identified V. fluvialis (score of 2.129). opsy via endoscopic retrograde cholangiopancreatography. Antimicrobial susceptibility testing revealed that the isolate He underwent 2 biliary stent placements and 2 chemotherapy was sensitive to ampicillin, ampicillin/sulbactam, piperacillin/ courses with gemcitabine and nab-paclitaxel 7 months before tazobactam (minimal inhibitory concentration of 8 μg/mL), cefmetazole, ceftriaxone, ceftazidime, cefepime, aztreonam, Received 11 March 2020; editorial decision 28 May 2020; accepted 1 June 2020. meropenem, amikacin, minocycline, and levofloxacin. Because Correspondence: Koh Okamoto, MD, MS, Department of Infectious Diseases, The University of Tokyo Hospital 7-3-1 Hongo, Bunkyo-ku, Tokyo 113–8655 Japan ([email protected]). the abscess failed to decrease in size with the initial antibiotic Open Forum Infectious Diseases® treatment alone, minocycline and piperacillin/tazobactam were © The Author(s) 2020. Published by Oxford University Press on behalf of Infectious Diseases administered, along with additional biliary stent placement and Society of America. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs licence (http://creativecommons.org/licenses/ percutaneous transhepatic abscess drainage. by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any After 3 weeks of parenteral antibiotic treatment, the reg- medium, provided the original work is not altered or transformed in any way, and that the work is properly cited. For commercial re-use, please contact [email protected] imen was switched to enteral clindamycin and minocycline. He DOI: 10.1093/ofid/ofaa212 was discharged and completed 6 weeks of treatment, achieving NOVEL ID CASES • OFID • 1 A Downloaded from https://academic.oup.com/ofid/article/7/6/ofaa212/5854108 by guest on 29 September 2021 B C 20 μm Figure 1. A) A computed tomography scan depicting a low-density area compatible with liver abscess (white arrow). B) Vibrio fluvialis colony growing on thiosulfate- citrate-bile-sucrose agar plate. C) Gram stain of blood culture depicting curved gram-negative bacilli (black arrow). radiographic liver abscess resolution. The patient died from The scarcity of extra-intestinal and bacteremia cases may partly be progression of pancreatic head cancer 6 months after this epi- because of difficulty in identifying V. fluvialis [1]. Although classical sode without any recurrence of V. fluvialis infection. thiosulfate-citrate-bile salts-sucrose agar medium and biochemical assays, including API20E and Vitek GNI+ systems, are often used for identification, different Vibrio species may show similar results [1]. DISCUSSION V. fluvialis is closely related to V. furnissii, and differentiation may be V. fluvialis is prevalent in aquatic environments and seafood, difficult [12, 14]. Both species were originally classified as V. fluvialis; which are the main risk factors for acquiring the disease [1]. however, V. furnissii was later distinguished as separate owing to its Gastroenteritis is the most common clinical manifestation [1], gas-producing capability [14]. Besides biochemical identification and only few extra-intestinal infections have been reported [1]. methods, more reliable identification methods include polymerase Here, we review clinically relevant reports of 7 extra-intestinal chain reaction (PCR) DNA testing or MALDI-TOF MS [12, 14]. PCR infection cases including 7 bacteremia cases (Table 1) [3–13]. results, using rpoB and the more conventional toxR gene segment, Cases were mainly from island and peninsular regions [3–13]. and MALDI-TOF MS results completely agreed in 1 study [14]. Patients were typically middle-aged, with a 52-year median age, In line with reported cases, our patient was a middle-aged man except for 1 infant [3–13]. There was no sex difference overall; with biliary tract disease owing to pancreatic cancer who was re- however, 5 of 6 bacteremia cases occurred in male patients with ceiving chemotherapy. MALDI-TOF MS (Bruker, USA) reliably ≥1 comorbidity, primarily diabetes mellitus [3–13]. Water or identified V. fluvialis. We presume that he acquired V. fluvialis from seafood exposure was noted in approximately half of cases [3– sashimi. Both the liver abscess and bacteremia were successfully 13]. Most bacteremia cases resulted from severe gastroenteritis, treated with combination therapy and aggressive drainage. and 50% of patients died [3–13]. Extra-intestinal cases included In summary, while gastroenteritis is the most common pres- 2 peritonitis cases, 1 hemorrhagic cellulitis, cerebritis, otitis entation, extra-intestinal V. fluvialis infection is uncommon externa, urinary tract infection, and cholangitis case; however, and exhibits high mortality. Heavy seafood consumption is a liver abscess has never been reported. Treatment was variable major risk factor [1]. As raw seafood consumption is getting across cases, although combination therapy involving beta- more common than before worldwide, physicians should con- lactams and agents, including aminoglycosides, quinolones, sider V. fluvialis infection alongside other Vibrio species in pa- and tetracyclines, was used [3–12]. tients with heavy exposure to seafood, including sashimi. 2 • OFID • NOVEL ID CASES Table 1. Literature Review of Extra-intestinal Infection Including Bacteremia by V. fluvialis Route of Case Age, y Sex Country Site of Disease Bacteremia Underlying Disease Acquisition Treatment Outcome Reference 1 40 Female Taiwan Otitis externa No None Seawater AMPC/CVA Survived 3 exposure 2 88 Female Taiwan Cholangitis No DM, ESRD, cirrhosis, None PIPC/TAZ + Survived 4 intrahepatic ductal trans-hepatic biliary stones drainage
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