| Vibrios CASE 1 • A 43 year old man from a coastal town is brought to the emergency department with profuse watery diarrhea and hypovolemic shock. He was found by the roadside in a lethargic, semi-conscious condition. His pulse is thready at a rate of 144/minute and his blood pressure is 70mmHg systolic. He is not febrile. He clothes are wet. After rapid rehydration and resuscitation with 2 liters of normal saline, the patient regains alertness and is able to give a history. • One day earlier, his illness began with a few large volume watery stools. This diarrhea rapidly progressed to purging of turbid water with no solid content, having the appearance of water drained from cooked rice ("rice water stools"). The patient tried to drink enough water to replace his losses but became increasingly nauseated and able to keep up. He suggests that he must have passed out while walking to the hospital to seek care. • The patient was previously in good health except for intermittent gastritis for which he uses copious amounts of antacids. Three days earlier, an exceptionally heavy rain caused flooding in his neighborhood. Water from a local estuary overflowed its banks and drained into his well. Even though none of the other members of his household would drink the contaminated water, he did. Questions: 1. Only one disease can cause rapid, potentially fatal, dehydrating diarrhea in an adult. What is it?
CASE 2 • A 23 year old man develops abdominal cramps and diarrhea with streaks of blood. A routine stool culture does not yield Salmonella, Shigella, or Campylobacter. The patient is given ciprofloxacin empirically, and the diarrhea resolves over 2-3 days. • The patient is a lover of seafood and has recently been eating large quantities of raw oysters and steamed clams. Questions: 1. What causes of gastroenteritis are suggested by the patient's eating habits? CASE 3 • A 49 year old man with a history of alcoholic liver disease is brought to the hospital with fever and delirium. He was in his usual state of health until 2 days ago when he developed a recurrent chills with fever. He was treated empirically for malaria but appeared to worsen rapidly thereafter. • The patient is an artisan and a sports fisherman. He frequently fishes in the ocean while wading waist-deep into the water. He also regularly consumes crabs and squid that he obtains from local vendors in his coastal hometown. • On physical examination, he is obtunded and has cool extremities consistent with worsening sepsis. His blood pressure is 90/55 mmHg. Examination of his lower extremities reveals large bullous lesions on both legs filled with dark brown blister fluid. A puncture of one of these blisters is performed, and the fluid is Gram-stained and cultured. The Gram stain is negative, but the culture grows Vibrio vulnificus. He is treated with an appropriate antibiotic and is given fluid resuscitation but succumbs to overwhelming sepsis within the next 24 hours. Questions: 1. Why is the presentation of this illness different from that of Case 2? Is it the organism or the host? Or is it both?
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