Bacteriology
Territorial waters of the Baltic Sea as a source of infections caused by Vibrio cholerae non-O1, non-O139: report of 3 hospitalized cases

https://doi.org/10.1016/j.diagmicrobio.2005.06.020Get rights and content

Abstract

A fatal infection with temporal relation to 2 other febrile infections caused by Vibrio cholerae non-O1, non-O139 (NCV) occurred in Finland in 2003. All infections were associated with contact with seawater. The patient who died had also eaten home-salted whitefish, tested positive for NCV, preceding his symptoms. All patients had compromising factors, and all strains were distinguishable by pulsed-field gel electrophoresis and negative for the ctx gene. These 3 cases illustrate that, despite being uncommon in Finland, NCVs can cause clinically significant and even fatal infections.

Introduction

Vibrio cholerae can be divided into 2 major groups: cholera-causing strains of the serogroups O1 and O139 and non-cholera vibrios (NCVs) (Sack et al., 2004). Whereas the former strains are responsible for cholera epidemics, the latter NCV strains are associated with other infections such as gastroenteritis, acute septicemia, and skin infections. NCV strains have been isolated from various patient samples, for example, from wounds, ear, sputum, urine, and cerebrospinal fluid (Morris, 1994, Hlady and Klontz, 1996). NCVs have usually been associated with sporadic diarrhea, but some outbreaks have also been reported (Albert et al., 1993, Ramamurthy et al., 1993, Kaper et al., 1995). Individuals with liver disease or an immunosuppressive condition are vulnerable to the NCV infections (Siegel and Rogers, 1982, Hlady and Klontz, 1996, Ko et al., 1998). The gastrointestinal infections caused by NCV usually have a favorable outcome, but invasive infections may be fatal (Hlady and Klontz, 1996, Ko et al., 1998).

The NCV strains typically do not carry the ctx genes coding for cholera toxin (CT) or toxin-coregulated pilus, which are the major virulence characteristics of the cholera-causing strains (Kaper et al., 1995, Faruque et al., 1998). However, recently, the presence of new variants of these genes in some clinical and environmental NCV strains has been published (Ghosh et al., 1997, Novais et al., 1999, Chakraborty et al., 2000, Nandi et al., 2000b).

In Finland, during the 10-year period the annual number of infections caused by NCVs has varied between 1 and 13 (Statistics of the Enteric Bacteria Laboratory, unpublished data). Most of these strains have been isolated from cultures of pus, fecal, and ear swabs. Only about 5% have been blood isolates.

NCVs can be found in the environment as normal free-living bacterial flora in coastal and estuarine areas throughout the world (Morris, 1994). Of the food items, oysters, in particular, but also crabs and shrimps, are the main animal reservoir for NCVs (Twedt et al., 1981, Davis and Sizemore, 1982, Reilly and Twiddy, 1992).

In this study, the clinical presentation of 3 NCV cases, 1 with a fatal outcome, are described. In addition, the DNA profiles of the isolates from blood, wound, and urinary specimens of the patients and from the samples of a whitefish, eaten by one of the patients, were compared.

Section snippets

Case 1

The patient was a 77 -year-old man who lived in the coastal area east of Helsinki (in Porvoo). He had coronary heart disease and underwent coronary artery bypass grafting in 1993, chronic atrial fibrillation, and type 2 diabetes mellitus. His daily medication contained acetosalicylic acid 100 mg, bisoprolol 7.5 mg, lovastatin 20 mg, glimepirid 2 mg daily, and insulin. He was brought to the emergency unit in August 2003 because of vomiting and diarrhea, and spells of confusion had also occurred.

Results

All the strains isolated from humans and fish were proven to be V. cholerae NCV strains with the following results: they were sucrose- and oxidase-positive, motile, β-hemolytic, produced no gas from glucose, grew in nutrient broth with 0% and 1% NaCl, sensitive to 150 μg of O/129, and according to API 20E they were V. cholerae (99.9%) (Table 1). The strains were sensitive to the antimicrobials tested excluding the strains IH 141744 (resistant to ampicillin) and IH 141750 and 141752 (both

Discussion

Cases of NCV are rare in Finland. Three such cases, which occurred in summer 2003, one of which was fatal, are reported here.

The NCV strains are common in coastal and estuarine areas throughout the world (Morris, 1994); therefore, the infections reported are often connected to seawater. There are several reports of seawater-associated NCV infections in patients with wounds or broken skin and with some underlying diseases (Siegel and Rogers, 1982, Bonner et al., 1983, Ko et al., 1998, Liou et

Acknowledgments

We are grateful to Pekka Alenius from the Finnish Institute of Marine Research for providing information on the mean temperatures of the seawater. The personnel of the Enteric Bacteria Laboratory, National Public Health Institute (KTL), are gratefully acknowledged for their skillful technical assistance.

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    Present address: Department of Bacteriology, Mycology and Parasitology, Statens Serum Institut, Copenhagen, Denmark.

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