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Vibrio Vulnificus (VV) septicemia is a rare but potentially fatal disease associated with raw oyster consumption. The virulence of VV has been associated with the production of toxins including cytolisin/hemoysin VvHA and Multifunctional Autoprocessing Repeats-in-Toxins (MARTX), both contributing to dissemination. MARTX is related to lethal sepsis, prothrombotic activity and cytokine release. Patients with underlying liver disease, hemochromatosis, immunosuppressive states and chronic kidney disease are at increased risk of VV infection and septicemia.
We present a case of Vibrio Vulnificus septicemia and the effect of Continuous Renal Replacement Therapy (CRRT) with oXiris® hemofilter on hemodynamic instability and interleukin-6 levels.
38-year-old mexican woman presented with abdominal pain, fever, watery nondysenteric diarrhea, leg discomfort and rash that started 24 hours after eating raw oysters. Patient had history of cyanocobalimin/steroid intramuscular injection. On admission, vitals were significant for hypotension and tachycardia, requiring intravenous vasopressors during first hours of hospital stay. Physical examination revealed scattered purpuric lesions on lower extremities. Broad-spectrum antibiotics were initiated. CRRT was started due to hemodynamic instability and anuria, using oXiris® membrane (exchange qid during the first 48 hours), with a marked reduction in vasopressor dose. Growth of bullae aspirate and blood culture identified Vibrio Vulnificus. During clinical course, the patient developed disseminated intravascular coagulation (DIC) complicated with gastrointestinal bleeding and a high transfusion requirement. Despite aggressive supportive care, clinical condition worsened, and per family request, therapeutic efforts were halted.
Extracorporeal blood purification has been suggested as adjuvant therapy to antimicrobial use in sepsis, intending to modulate and control inflammatory response by means of endotoxin and cytokine removal. The rationale for this is to limit the systemic effects derived from a dysregulated immune activation that culminate in cellular injury, immunoparalysis and organ dysfunction. Different techniques (High-volume hemofiltration, Coupled plasma filtration and adsorption) and filters (Cytosorb®, Toraymixin®, AN69) have been evaluated with this goal in mind with inconclusive results, limitations related to adsorptive characteristics and potential adverse effects. oXiris® hemofilter combines renal replacement therapy, local anticoagulation and cytokine/endotoxin adsorption comparable with other filters. Case series of Gram-negative-associated sepsis have demonstrated a benefit on survival and improved hemodynamic stability. Significant reduction in mortality, severity scores and length of ICU stay has been found with oXiris® compared to other filters. Our patient’s hemodynamic status improved during the first 48 hours of treatment, accompanied by a significant reduction in measured IL-6. Outcome was negatively affected by the development of DIC conditioned by VV exotoxins3. Despite available data, definitive recommendations on the initiation of CRRT in sepsis are lacking, requiring more RCTs to assess the patient profile that would benefit most from this modality of treatment.