Necrotizing fasciitis due to Vibrio cholerae non-O1/non-O139 after exposure to Austrian bathing sites

Abstract

SummaryWe report on two cases of necrotizing fasciitis of the lower leg due to nontoxigenic Vibrio cholerae (V. cholerae). A 73-year-old woman (case 1) and an 80-year-old man (case 2) were hospitalized with symptoms of necrotizing fasciitis on July 18 and August 15, 2015, respectively. In both cases, symptoms started the day after swimming in local ponds. Swabs gained intraoperatively and a blood culture from the male patient, yielded V. cholerae non-O1/non-O139, negative for cholera toxin gene ctx and positive for hemolysin genes hlyA and hlyB. Water samples taken from pond A on August 17, 2015 (32 days after exposure of case 1) and from pond B on August 20, 2015 (7 days after exposure of case 2) yielded non-O1/non-O139 V. cholerae in most-probable numbers of > 11,000 per 100 ml each. The occurrence of two cases of necrotizing fasciitis within a 1 month period related to two Austrian non-saline bathing waters, previously not known to harbor V. cholerae, is probably linked to the prevailing extreme weather conditions (heat wave, drought) this summer in Austria. While case 1 was discharged in good clinical condition after 73 days, case 2 died after four months of hospitalization. Public health authorities are challenged to assess the effects of long-term climate change on pathogen growth and survival in continental bodies of fresh water.

Application of three different methods to determine the prevalence, the abundance and the environmental drivers of culturableVibrio choleraein fresh and brackish bathing waters

“…) and two slightly saline small ponds, where maximum concentrations of >11 000 MPN per 100 ml were found in 2015 (Hirk et al . ). For the Baltic Sea—as the most prominent example—where dramatically increasing numbers of V. cholerae infections have been reported in recent years (Baker‐Austin et al .…”

“…Up to now, it is not clear how V. cholerae nonO1/nonO139 abundance relates to disease risk. In Austria, notified V. cholerae infections (mild gastrointestinal infections, wound infections, ear infections, necrotizing fasciitis) have only been associated with bathing waters with rather high V. cholerae concentrations, the Lake Neusiedler See (Huhulescu et al 2007) and two slightly saline small ponds, where maximum concentrations of >11 000 MPN per 100 ml were found in 2015 (Hirk et al 2016). For the Baltic Sea-as the quantitative data on V. cholerae concentrations are available.…”

“…In Austria, two extremely severe cases of necrotizing fasciitis occurred for the first time in 2015. Both cases were associated with bathing activities in two ponds (Hirk et al 2016) and occurred in August during an extreme summer heatwave within the second warmest year recorded in our country (www.zamg. ac.at).…”

“…Both cases were associated with bathing activities in two ponds (Hirk et al . ) and occurred in August during an extreme summer heatwave within the second warmest year recorded in our country (http://www.zamg.ac.at). So far, endemic V. cholerae infections have been associated only with the brackish lake Neusiedler See (Huhulescu et al .…”

“…Especially in Northern Europe (Baltic Sea), infections of swimmers have been predominantly caused by V. cholerae nonO1/nonO139 (Baker-Austin et al 2016b). Some serious infections of swimmers due to V. cholerae nonO1/nonO139 have also been reported from other European countries (Stypulkowska-Misiurewicz et al 2006;Huhulescu et al 2007;Sterk et al 2015;Dobrovic et al 2016;Engel et al 2016;Hirk et al 2016;Maraki et al 2016). The observed increase in infection frequency has been linked to global warming and the significantly increased water temperatures observed in many aquatic environments (Baker-Austin et al 2016b;Vezzulli et al 2016).…”