慢性肝病患者发生创伤弧菌坏死性筋膜炎1例

A case of necrotizing fasciitis of V. vulnificus occurred in a patient with chronic liver disease

对2023年8月8日海南医学院第一附属医院收治的1例慢性肝病患者感染创伤弧菌(Vibrio vulnificus)的诊疗经过进行回顾性分析。患者男,34岁,渔民,患有慢性乙型病毒性肝炎。8月3日捕鱼时腿部擦伤,当天夜里出现发热、双下肢持续性胀痛,左下肢为甚,发病第4天至当地医院就诊检查后采用抗生素治疗,并于8月8日转诊至海南医学院第一附属医院。接诊时患者血压低,下肢皮温高,末梢血运较差,可见多处结痂,并出现感染性休克征象。入院12 h行左小腿脓肿切开引流术+创面负压吸引术并送检左下肢感染组织,病原体培养提示创伤弧菌感染,病理结果提示坏死性筋膜炎,予美罗培南联合万古霉素抗感染、维持血压、维持水电解质平衡等对症支持治疗,富马酸丙酚替诺福韦片抗病毒治疗及多烯磷脂酰胆碱胶囊保肝治疗,根据药敏结果予左氧氟沙星+头孢他啶抗感染,并依据创面情况行清创治疗。入院后17 d,患者感染基本控制,但肝功能酶仍高于正常水平,创面仍有渗血及渗液,患者及家属要求出院,出院后伤口愈合不佳,于2023年9月11日再次入院,予抗病毒及保肝治疗。第5天分泌物病原体培养结果为纹带棒状杆菌(Corynebacterium striatum)合并斯氏普鲁威登菌(Providencia stuartii)感染,并报告纹带棒状杆菌为多重耐药菌,换用敏感抗生素治疗及对症支持治疗。第2次入院后16 d,患者一般情况可,但肝功能酶指标仍高于正常,予办理出院。患者出院4个月后对其进行电话随访,自述第2次出院后遵医嘱积极抗病毒治疗及戒酒,创面恢复尚可。该患者有典型暴露史及临床表现,符合创伤弧菌导致的脓毒性休克及坏死性筋膜炎特征,临床中应根据其病理学特点、临床特征对创伤弧菌感染进行早期诊断、处理,改善患者预后。

This retrospective analysis examines the diagnosis and treatment of a case of chronic liver disease infected with Vibrio vulnificus,admitted to the First Affiliated Hospital of Hainan Medical University on August 8,2023.The patient,a 34-year-old male fisherman,had chronic viral hepatitis B.He sustained a leg abrasion while fishing on August 3,and developed fever and continuous swelling pain in both lower limbs,more severe in the left limb,on the night of the injury.On the fourth day of the disease,he went to the local hospital where he received antibiotic treatment and was transferred to the First Affiliated Hospital of Hainan Medical College on August 8.Upon admission,the patient exhibited low blood pressure,high lower limb skin temperature,poor peripheral blood transport,visible scab,and signs of infectious shock.Within 12 hours of admission,an abscess incision and drainage procedure was performed on his left calf,along with negative pressure wound therapy,and tissue samples from the infected left lower limb were sent for microbial culture.The pathogen culture indicated a Vibrio vulnificus infection,and the histopathology results confirmed necrotizing fasciitis.Treatment included meropenem combined with vancomycin for infection control,maintenance of blood pressure and electrolyte balance,tenofovir disoproxil fumarate for antiviral therapy,and polyene phosphatidylcholine capsules for liver protection based on the drug sensitivity results.Additionally,levofloxacin and cefotaxime were administered for infection control and debridement was performed based on wound conditions.After 17 days of hospitalization,the infection was substantially controlled,but the liver function enzyme was still higher than the normal level,and the wound still had blood and exudation.The patient and his family members requested discharge;however,due to poor wound healing,he was readmitted on September 11,2023,receiving antiviral and liver preservation treatment.On the fifth day,the secretion culture identified a co-infection with Corynebacterium striatum and Providencia stuartii infection.Corynebacterium striatum was subsequently reported as multidrug-resistant,prompting an immediate switch to sensitive antibiotics and supportive care.Sixteen days after readmission,the patient's general condition improved,but the liver function enzyme levels were still higher than normal,so he was discharged.Four months after discharge,a follow-up phone call revealed that the patient had actively pursued antiviral treatment and abstained from alcohol,showing reasonable wound recovery.The patient's case,with a typical exposure history and clinical manifestations,matches the characteristics of septic shock and necrotizing fasciitis caused by V.vulnificus.Clinically,it is crucial todiagnose and treat V.vulnificus infection early according to its pathological characteristics and clinical characteristics to improve the prognosis of patients.