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創 傷 弧 菌 感 染 症： 臨 床 表 徵 、 致 病 機 轉 及

創 傷 弧 菌 感 染 症： 臨 床 表 徵 、 致 病 機 轉 及 抗 生 素 治 療 之 新 進 展. 奇美醫學中心 醫學研究部 及 內科部. 莊 銀 清 教 授. Vibrio vulnificus infection. ¤ clinical manifestations ¤ epidemiology ¤ pathogenesis genes toxins ¤ in vitro & in vivo study

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創 傷 弧 菌 感 染 症： 臨 床 表 徵 、 致 病 機 轉 及

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  1. 創 傷 弧 菌 感 染 症： 臨 床 表 徵 、 致 病 機 轉 及 抗 生 素 治 療 之 新 進 展 奇美醫學中心 醫學研究部 及 內科部 莊 銀 清 教 授

  2. Vibrio vulnificus infection ¤ clinical manifestations ¤ epidemiology ¤ pathogenesis genes toxins ¤ in vitro & in vivo study ¤ clinical study

  3. 65-year-old M CC: local pain, swelling of the left hand PH: bilateral knee joint pain treated with herb drug for 10years PI: left index finger was pricked by a shrimp 12 h later he began to suffer from above symptoms transferred from local hospital

  4. PE Appearance: Cushingoid face BP: 70/50 mmHg, PR: 120/min Left hand: marked swelling, bullous formation, gangrenous change

  5. Lab: WBC: 31500/mm3, myelocyte: 1%, metamyelocyte: 2%, band: 41%, segment: 54% GOT: 41 IU/L, GPT: 24 IU/L Blood culture: Vibrio parahemolyticus sensitive to all antibiotics

  6. Blood culture: Vibrio vulnificus

  7. 海洋弧菌Vibrio vulnificus感染導致敗血症及下之皮膚壞死– 1 病例報告 阮仲垠 阮仲洲 魏東界 李阿買* 陳定堯** 海洋弧菌Vibrio vulnificus是嗜鹽性弧菌,棲息於沿海各地,它可以引起腸管外感染,具有強力的毒素,會引起敗血症及肢體壞死。本病例為一位63歲女性,有20年喝米酒的歷史,臨床症狀為低血壓、菌血症及下肢皮膚壞死,自血液中及肢體壞死膿汁培養為Vibrio vulnificus使用Moxalactam治療,補充體液及皮膚移植後,平安出院。本文除了討論Vibrio vulnificus的感染經過、臨床症狀、致病因素外,對於各家文獻亦作一番回顧與探討。 Key word: Vibrio vulnificus, septicemia, gangrene (台灣醫誌 1987; 86: 448-451)

  8. Scand J Infect Dis 21: 721-726, 1989 CASE REPORT Vibrio vulnificus Infection YIN-CHING CHUANG, CHENDEN YOUNG and CHAN-WEI CHEN From the Section Disease, Department of Internal Medicine, National Cheng kung University Hospital, Tainan, Taiwan, Republic of China

  9. Materials and Methods Study period: Hospitals: May 1985 through July 1990 Veterans General Hospital Cheng Kung University Hospital Father Fox Memorial Hospital Yuan’s General Hospital Chang Gung Memorial Hospital

  10. Results: 29 episodes 28 patients Age: 19-76 y/o (mean: 56 y/o) Sex: male : female = 5:2

  11. Prevalence (per 106 population) No. of patients Year Figure 1. Estimated prevalence (per 106 population) and annual number of cases of Vibrio vulnificus infection reported from 1985 to 2000 in Taiwan. More than 90%of the reported cases occurred in residents of southern Taiwan. EID: 2004; 10:1363-8

  12. Figure 2. The peak months forVibrio vulnificus infection were June-August (summer season) when the temperature of the surface seawater in Taiwan was about 26-29 C. CID: 1992; 15:271-6

  13. Table1.Clinical characteristics of 84 patients with V. vulnificus infections who were treated at three major hospitals in Taiwan from 1995 to 2000.

  14. Table1.Clinical characteristics of 84 patients with V. vulnificus infections who were treated at three major hospitals in Taiwan from 1995 to 2000.

  15. Table1.Clinical characteristics of 84 patients with V. vulnificus infections who were treated at three major hospitals in Taiwan from 1995 to 2000.

  16. 3 major syndromes caused by V. vulnificus： ☺Primary bacteremia ☺Wound infection ☺Gastroenteritis：under reported

  17. Common findings of V.vulnificus infection : • Cutaneous lesion • Incubation period: 12-16 hours • Summer season (May-October) • Male predominant, aged

  18. Cutaneous manifestations : • ecchymosis • bullous formation • mecrotizing fasciitis. • gangrenous change. • cellulitis • Pyomyositis • Developed at admission or within 24 h, became more severe by the hour

  19. Figure 1. Characteristic hemorrhagic bullous necrotic cutaneous lesions in lower limb of a Vibrio vulnificus septicemic patient (Arch Intern Med, 2006: in press)

  20. Figure 2. Characteristic skin lesions of Vibrio vulnificus infection and morphotype of the microorganism. (A) Gangrenous change with hemorrhagic bullae over the leg in a 75 year-old patient with liver cirrhosis who developed septic shockand V. vulnificus bacteremia. (B) V. vulnificus bacteremia developed one day after a fish bone injury over the 4th finger of the left hand (arrow) in a 45 year-old patient with uremia. (C) Gram-negative curved bacilli (arrowhead) isolated from a blood sample of the 45 year-old patient with uremia.

  21. Skin manifestations of V. vulnificus infection in Taiwan Overall involved rate: 23/29(79.3%) Clin Infect Dis: 1992; 15:271-6

  22. Treatment • Early recognition • Prompt antimicrobial therapy • Aggressive surgical intervention • Supportive therapy

  23. Treatment: CID: 1992; 15:271-6

  24. Mortality rate: CID: 1992; 15:271-6

  25. Table Summary of Vibrio vulnificus reported in the literature CID: 1992; 15:271-6

  26. Discussion

  27. Vulnus – wound Ficus – related Vibrio vulnificus 創傷弧菌 Marine vibrio 海洋弧菌

  28. Microbiology ---- Vibrio Vulnificus ---- ¤ Halophilic, Lactose (+) marine Vibrio species ¤ Missed as Aeromonas hydrophillia, Plesiomonas shigelloides or Vibrio parahaemolyticus ¤ Salt is required for isolation ¤ Disc diffusion test for sensitivity, and MIC test: sensitive to nearly all kinds of antibiotics ¤ Clinical response to antibiotics is not always correlated with the drug sensitivity test

  29. Risk factors for Taiwanese people • Small island with ＞22 Million people. • Seafood is extremely popular • High hepatitis－B.C rate, liver cirrhosis • aquaculture in fish pond.

  30. Q: Is protease an important virulence factor for Vibrio vulnificus? It’s role(s) in bacterial invasion, mediating skin damage, edema, and ulceration formation ?

  31. Extracellular products such as cytolysin, phospholipase, and protease are putative virulence factors for V. vulnificus infection.

  32. Cloning and expression of Vibrio vulnificus metalloprotease gene in Escherichia coli

  33. Mouse Skin Damage Caused by Protease from Vibrio vulnificus and by V. vulnificus Infection 創傷弧菌蛋白質分解酵素及創傷弧菌感染在白老鼠引起的皮膚病變 Yin-Ching Chuang1, Wen-Chien Ko1, Hamm-Ming Sheu2, Tsong-Ming Chang3, Ming-Chung Chang3, Kun-Yen Huang4 Departments of Medicine1, Dermatology2, Biochemistry3, and Microbiology4, National Cheng Kung University Medical College Tainan, Taiwan 莊銀清1, 柯文謙2, 許漢銘3, 張聰明3, 張敏政3, 黃崑巖4 國立成功大學醫學院 內科1, 皮膚科2, 生化科3, 微生物科4

  34. Materials & Methods Protocol for animal treatment • Swiss ICR albino mice (NCKU, Animal Center) 6-8wks • Depilated the dorsal surface of mice 24 h before experiment • Three groups, intradermal injection • a. 0.1ml of V. vulnificus (1 x107 CFU/ml) • b. 0.1ml protease (+) preparation • c. 0.1ml protease (-) preparation • 4. Sacrificed the mice by cervical dislocation Light and electron microscopic examinations

  35. Vector pBR322 ↓ BamHI ↓ BAP ↓ 5’-dephosphate linear pBR322 Extraction of genomic DNA ↓sucrose density gradient ↓Sau3AI partial digest ↓sucrose density gradient ligation Recombinant plasmid Transformation of E. coli MC1061 Replica onto casein plate Turid zone Cloning of protease gene from V. vulnificus

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