Musculoskeletal systemCase Type
Elena Cebada Chaparro, Alejandro Urbina Balanz, María José Moreno Casado, Antonio Ruiz OlleroPatient
58 years, male
A 58-year-old Chinese male with a history of at least 6 years Child-Pugh Class A hepatitis C virus cirrhosis and diabetes mellitus presented with severe pain and swelling in his lower extremities, fever and other septic symptoms (hyperventilation, fast heart rate and confusion) . He indicated vomiting and diarrhoea during a flight from China a few days before his consult, as well as a significant intake of oysters recently.
Chest and abdominal X-ray were normal. Contrast-enhanced abdominal CT showed signs of cirrhosis and portal hypertension. However, no infective acute processes were seen (Fig 1). Doppler-US depicted deep vein thrombosis in the lower extremities.
An MRI of the lower extremities was performed. An increase in signal intensity in STIR and T2-weighted images was present in the subcutaneous bilateral fat in thighs and legs, consistent with oedema and cellulitis. Oedema is also seen in multiple muscles in both lower extremities, predominantly around the anterolateral compartment of both legs, suggesting myositis (Fig 2 and 3). Subfascial and intramuscular fluid collections is present, more extensive in the territory of peroneus longus and brevis bilaterally, suggesting abscesses. After the administration of intravenous contrast material, T1 fat-saturated images revealed an enhancement of the muscular fascias and peripheral enhancement of collections (Fig 4 and 5).
Clinical examination and prior imaging exams didn’t reveal any diabetes-associated lower limbs complications.
Vibrio vulnificus is a halophilic gramnegative bacillus found in warmer seawater (temperature>20º), contaminating shellfish and fishes , which can cause infections with a wide range of gravity .
Vibrio vulnificus is usually acquired through the contamination of a previous cutaneous wound or through ingestion. Wound infections can affect immunocompetent or immunocompromised individuals, who can develop from moderate to severe symptoms such as severe cellulitis or necrotizing fasciitis. When a pathogen is acquired through ingestion, most patients develop a limited infection with gastrointestinal symptoms. However, some patients, especially those who are immunocompromised or with diabetes mellitus, end-stage renal disease, rheumatoid arthritis and chronic liver disease, may develop primary septicemia [4,5], with or without gastrointestinal symptoms. Cirrhotic patients are especially vulnerable because V. vulnificus invades the bloodstream by entering the portal system in those with portal hypertension [6, 7]. Septicemia is associated with fever, chills, gastrointestinal symptoms and frequent skin and soft-tissue lesions, primarily in the lower extremities, with bullae, ecchymosis, rash and necrotic ulcer, necrotizing fasciitis and myonecrosis,  and finally death. Pneumonia, meningoencephalitis, peritonitis, tuboovarian abscess and pyogenic spondylitis are atypical clinical cases which have been described [9, 10, 11, 12].
MRI is the best imaging technique to identify the severity of soft tissue infection and provide accurate anatomic resolution. Imaging shows non-specific findings, such as subcutaneous and muscular oedema, fluid collections, fascial thickening and enhancement. Intramuscular T1-hyperintensity may represent haemorrhage .
These MRI findings in both lower extremities in a septic patient is suspicious of Vibrio vulnificus sepsis, especially with a history a recent fish or shellfish intake. Therefore, MRI helps establishing a proper and early treatment, allowing surgeons to plan abscess draining or debridement if required.
As bowel infection are quite common in those cases, abdominal CT imaging is also a useful tool to support the diagnosis. 
Positive blood or wound culture for V. vulnificus confirms the diagnosis .
V. vulnificus infection is a life-threatening condition. In this context, soft tissue infection, especially necrotizing fasciitis, associates high mortality rates. Properly timed and appropriate antibiotic treatment is extremely important. Nevertheless, early debridement and amputation is sometimes required . In our case, positive blood culture confirmed the diagnosis. Our patient was managed in a conservative manner with intravenous antibiotics, therefore debridement was unnecessary, and lower limbs lesions were recovered.
Take-Home Message / Teaching Points
MRI helps early recognition and treatment, and adequate assessment of soft tissue infection in case surgery is required.
 Zakaria HM. Vibrio Vulnificus Infection: A Rare Cause of Necrotizing Fascitiis. Biomedical Research 2010;21(1): 47-50.
 Yun NR, Kim DM. Vibrio vulnificus infection: a persistent threat to public health. Korean J Intern Med. 2018 Nov;33(6):1070-1078. [PMID:29898575]
 Leng F, Lin S, Wu W, Zhang J, Song J, Zhong M. Epidemiology, pathogenetic mechanism, clinical characteristics, and treatment of Vibrio vulnificus infection: a case report and literature review. Eur J Clin Microbiol Infect Dis 2019;38(11):199-2004. [PMID: 31325061]
 Johnston JM, Becker SF, McFarland LM. Vibrio vulnificus. Man and the sea. JAMA. 1985;253:2850–2853. [PMID: 3989959]
 Barton JC, Acton RT. Hemochromatosis and Vibrio vulnificus wound infections. J Clin Gastroenterol. 2009;43:890–893. [PMID: 19349902]
 Daniels NA. Vibrio vulnificus oysters: pearls and perils. Clin Infect Dis. 2011;52:788–792. [PMID: 23167733]
 Haq SM, Dayal HH. Chronic liver disease and consumption of raw oysters: a potentially lethal combination: a review of Vibrio vulnificus septicemia. Am J Gastroenterol. 2005;100:1195–1199. [PMID: 15842598]
 Kim DM, Hong SJ. Vibrio vulnificus sepsis. Korean J Med. 2012;82:671–679 .
 Park SD, Lee JY, Kim HD, Yoon NH. Clinical study of Vibrio vulnificus sepsis. Korean J Dermatol 2006;44:696-707.
 Ok HS, Kim BK, Kim KH, et al. Vertebral osteomyelitis resulting from hematogenous spread of Vibrio vulnificus gastroenteritis. Korean J Med 2014;86:519-522.
 Kim CS, Bae EH, Ma SK, Kim SW. Severe septicemia, necrotizing fasciitis, and peritonitis due to Vibrio vulnificus in a patient undergoing continuous ambulatory peritoneal dialysis: a case report. BMC Infect Dis 2015;15:422.
 Midturi J, Baker D, Winn R, Fader R. Tubo-ovarian abscess caused by Vibrio vulnificus. Diagn Microbiol Infect Dis 2005;51:131-3.
 Tso DK, Singh AK. Necrotizing fasciitis of the lower extremity: imaging pearls and pitfalls. (2018) The British journal of radiology. 91 (1088): 20180093. [PMID: 29537292]
 Wongpaitoon V, Sathapatayavongs B, Prachaktam R, Bunyaratvej S, Kurathong S. Spontaneous Vibrio vulnificus peritonitis and primary sepsis in two patients with alcoholic cirrhosis. Am J Gastroenterol. 1985 Sep;80(9):706-8. [PMID: 3898820}
 Bross MH, Soch K, Morales R, Mitchell RB. Vibrio vulnificus infection: diagnosis and treatment. Am Fam Physician. 2007 Aug;76(4):539-44. [PMID: 17853628]
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.