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WrinkleFreeZone
11/07/2008, 08:52 AM
I have been inspired to begin posting information about marine infections after reading a post over in the "New to the Hobby" forum. Capn_hylinur experienced a severe infection after sustaining what at first appeared to be a trivial injury. Unfortunately, this is not an uncommon problem. It is one that can largely be prevented by some simple things though. One principle would be the use of gloves when you're working in your tank.

My intent here is to educate anyone who's interested in reading about these things. I'm a plastic surgeon with experience treating hand infections and I can draw on the medical literature and maybe explain some things about them. I'm not sure if there is other information on this site about this problem. If there is, I would appreciate it if posters to this would provide the links so that we can all learn.

Gathering accurate information and writing about these infections will take me a little time so stay tuned if you're interested.
-B

acrodave
11/07/2008, 10:38 AM
Do you think you can bulid tolerance or have a high immunity.To most of the stuff.I work in the hobby and i get cuts and scrapes all the time.I have to mess with uncured rock new corals and fish.and even get vermented snails broke off in my fingers and hand.Im not saying im superman but i do get a bit of red and sore but goes away after a few days..Gloves are important ..but i think after care is most important part of it

WrinkleFreeZone
11/07/2008, 10:47 AM
The Vibrionaceae family of bacteria are natural inhabitants of water. Members of this family are largely found in salt water, but there are species that have been identified in fresh water. This family of bacteria includes the genera Vibrio, Plesiomonas, and Aeromonas.

The intent of this post is to talk about Vibrio species wound infections and I won’t go into detail about the food borne Vibrio infections. Vibrio is an oxidase positive gram negative bacilli. Vibrio infections are broadly classified into Vibrio cholera infections and non cholera Vibrio infections. The vast majority of Vibrio infections in the United States each year are caused by eating foods infected with these bacteria. It is largely a food borne disease and confirmed Vibrio infections in the United States account for approximately 8000 illnesses yearly.

Non cholera Vibrio infections are on the rise. This is probably due to increased warming of our seas. In 2003, the CDC received reports of over 450 cases. Alabama, Florida, Louisiana, Texas, and Mississippi accounted for about 40% of these cases. This is not surprising given that Vibrio vulnificus typically lives in areas where the temperature is relatively warm – Gulf of Mexico. It also thrives in low to moderate salinity – Gulf of Mexico given the Mississippi River outflow. The remaining 60% of Vibrio infections reported in the United States occurred in other temperate coastal waters, so if you're from the East or the Pacific Coasts, don't think that you can't get it. Natural disasters such as hurricanes appear to have a direct impact on Vibrio infections. In fact, after Hurricane Katrina, the CDC reported 22 additional cases of these infections in Mississippi and Louisiana most likely due to injuries occurring during exposure to contaminated flood waters. Vibrio vulnificus accounted for over 80% of these infections.

Oyster lovers watch out, Vibrio infections are acquired from ingesting raw or undercooked shellfish contaminated with the bacteria. This is not surprising given that many shellfish are filter feeds and bacteria concentrations can become quite high in them, especially during the summer months. Infection can also occur with exposure of any wound to contaminated seawater. Typical histories from patients include development of infection following preparation of shellfish, stepping on a seashell or glass, injuries from fish hooks, or bites. Fans of “From Here to Eternity,” beware. In researching this, I even found a case report of infection occurring during sexual intercourse in the Gulf of Mexico! Individuals with complicating medical problems such as cancer, cirrhosis, hepatitis, alcoholism, and end stage kidney disease are at increased risk of infection. Immunosuppression due to an organ transplant, diabetes, or HIV/AIDS dramatically increases the risk of serious infection from these bacteria.

The problem with the various Vibrio species is that they produce cytotoxins and enzymes that cause extensive tissue damage and sepsis. For wound infections, an individual will typically report that they sustained what at first appeared to be a trivial injury to the hand or the sole of the foot. After an initial incubation period that may be as short as 3 or 4 hours, the person begins to develop rapidly progressive pain, redness, and swelling. This is often associated with high fever, whole body chills, and severe muscle aches. In severe cases the infection can rapidly progress to compartment syndrome, gangrene, or necrotizing fasciitis. An infected individual may develop large blisters full of bloody fluid or extensive bruising. As the infection progresses, the individual may develop septic shock, organ failure, and death. In cases where the individual develops septic shock, the mortality rate is 50%

Treatment of non cholera Vibrio wound infections involves immediate medical care. It is not an infection where you can say, “I’ll wait until tomorrow and if it’s not better, I’ll go see my doctor.” If you want to keep your hand or your foot you are going to need prompt antibiotics, aggressive medical therapies, and possibly multiple debridement or fasciotomy surgeries. In severe cases, amputation may be required. Unfortunately, if an involved limb requires surgery to treat the infection, there is significant morbidity with this and additional reconstructive surgeries and long, intensive therapy may be required.

So now that I have your attention, how do you avoid contracting non cholera Vibrio infections you may ask? Avoid eating raw seafood, especially if you have other underlying medical factors. Stay out of brackish or ocean water during the summer months if you have any wounds. My grandmother used to tell me to get into the ocean to let the salt water help dry out and heal my poison ivy. She didn’t know it but she was giving just about the worst advice she could give me. Obviously use caution when handling or preparing items that have been in contact with a marine environment. I encourage you to use gloves when working in your tank! Promptly clean any injury you sustain with soap and water. We're talking a good scrubbing here and vigilence on your part. Immediately seek medical attention if you sustain an injury that begins to develop any swelling, redness, pain, or drainage from the wound. Do not wait; a delay could lead to an amputation or worse.

And to give credit where credit is due, Emedicine, Journal if Infectious Disease, Annals of Internal Medicine, amongst others.
-B

WrinkleFreeZone
11/07/2008, 02:11 PM
Immunity is your body's ability to resist a significant infection after you have had exposure to a causative agent. "Resist" is the important word here.

Let me give you an example, as a child, most of us received vaccinations against the more common illnesses that can be associated with severe problems. Take the DTP or DTaP vaccine. The "P" in this refers to Bordetella pertussis, the causative agent for whooping cough. You may not know this but the reason that your mother made you get those shots is that Pertussis or whooping cough is one of the leading causes of vaccine preventable deaths. In the very young, this illness can be fatal. In fact, there are about 300,000 deaths each year world wide from it.

When you receive the DPaT vaccine, you are receiving an injection of components of the bacteria and some of the products it is capbable of producing. These components and products are called antigens and these are the molecules that your body's immune system is capable of recognizing. It is important to understand that not every cell in your immune system is capable of "seeing" these molecules. In vaccine type immunity, recognition of the antigen requires the involvement of different clones of cells, each one with different receptors that are looking to try and "fit" the antigen. This takes time. If you had received an injection of the live bacteria, this bacteria would be able to reproduce relatively unimpeded before the identification of the best "fit" occurs. This is why you are only injected with parts of it and actual infection does not occur. Once the "fit" is recognized, a new cascade of events occurs that leads to an increase in the numbers of cells with the best "fit." These cells are then able to spread to different areas of the body and identify the antigen much faster and as a result, your body's ability to respond and resist is much faster.

The problem is that if you are not exposed to an antigen for a period of time, the cells that are in the clone capable of recognizing it begin to die out. As the numbers of them decrease your body's ability to respond and resist the infection is reduced. This can lead to a waning resistance despite a history of a prior vaccination or exposure to the real deal. This is why people receive booster injections from time to time and why when you step on a nail 10 years after your last tetanus shot, you get another one.

Don't be fooled into thinking that just because you have had small localized infections in the past after working with marine organisms that you are immune. I promise you that there will be a day that you could be at risk of developing a significant one. You will encounter a bacteria that you have not been exposed to before, or be dealing with an organism that has evolved an ability to evade detection, or that produces different products that give them an edge in establishing an infection. Furthermore, if the innoculum or dose of bacteria is large enough or if the wound has certain characteristics, say a puncture into a deep space, the bacteria will be quite capable of overrunning your immune system. My counsel to you is that you should be wearing gloves.
-B

Playa-1
11/07/2008, 07:46 PM
This is an interesting thread and makes me think about all the Sting Ray encounters that I have seen at the beach. I would suspect that a wound inflicted by a Sting Ray would be especially susceptible to this type of infection. The normal treatment is soaking in Hot Water for roughly an hour to provide immediate pain relief and neutralize the poison. After the soak I've noticed that it's common to see swelling and oozing from the wound. I'm sure I will get nailed by a Sting Ray sooner or later out here so I'm curious should a person that is on the wrong end of the Sting Ray barb seek further medical attention after the hot water soaking or should they wait and see if there are any other signs of infections beyond the normal swelling and oozing?

otrlynn
11/07/2008, 08:26 PM
Thanks doc for taking the time to post this valuable information. I have bookmarked it so that I can find it again easily. It sounds like there is every good reason to wear gloves, but I admit I don't do it. Shoulder length gloves are really needed to keep out the water; shorter gloves could be used just to prevent nicks and scratches to the hands (though skin will still be in contact with the saltwater). It just seems like such a pain to don gloves to do something as simple as grab the nori clip to re-load it. Then there is the problem of hanging the gloves somewhere to dry...

WrinkleFreeZone
11/08/2008, 08:09 AM
Playa-1, great question. Keep them coming folks. I also have some experience with envenomations, but here in Texas the type that I see are usually from copperheads or rattlesnakes. Since you brought up stingray envenomation, let me give you the overview:

If you've never been stung by one, let me tell you that a stingray's sting packs a powerful punch. The pain can last for up to 48 hours! The venom contains many proteins in it that we don't fully understand. In the vast majority of people, the sting will cause severe or excruciating pain and be limited to this. How the venom causes pain is up for debate but likely has to do with some affect on nerve conduction. What we do know is that the venom is very heat sensitive so you are absolutely right to begin treatment of a stingray envenomation by immersing the affected part with hot water. The water should be as hot as you can tolerate. Do not submerse in water hotter than this or you can cause burns. A water temperature of about 110 degrees is usually sufficient. You would want to exchange the water as it cools and treat for about a hour, sometimes more. If you don't have hot water, try a hot pack or some other way to deliver heat. My grandfather used to tell me that the old Navy cure was to have someone urinate on the wound. This probably makes sense, but I'll personally go for hot water. The application of heat causes quick reduction of the pain. In some victims, the envenomation causes additional effects to include fainting, abdominal pain, vomiting, cramping, and in some cases shock. If you experience any symptoms beyond pain at the site of the sting you must seek medical care. There have been some rare cases of death after envenomation.

To answer your question specifically; if you've been unfortunate enough to be stung I would still recommend that you seek medical care. The reason for this is that in some envenomation injuries, the barb or pieces of it will actually break off from the stingray's tail. This can often be seen on Xrays. If you don't remove these things you are going to be a setup for infection. Furthermore, since the wound is typically a deep puncture, this also increases the risk for infection. If you have not had a recent tetanus shot, it is likely that one would be administered. Many physicians, myself included, will treat the wound prophylactically with antibiotics and recommend that you return in a few days to have your wound examined again.

If a sting occurs to you at a dive destination with no chance of medical attention, my counsel to you is the following: Apply heat to reduce the pain. Wash the wound aggressively. If you see a piece of barb sticking out of your skin remove it. Don't go digging for one as you can cause additional injury to yourself. Keep the wound clean and out of seawater. Be vigilant for signs of a deeper problem or infection including fever, bleeding from the wound that continues, increasing redness or red streaking, increasing pain, swelling, or drainage of pus from the wound. If these things occur, you must get yourself to medical attention promptly.
-B

wrott
11/08/2008, 09:29 AM
Will Cipro kill most marine infections?
After building my 120g stand and moving, I had so many cuts and sore fingers that I started a round of Cipro prophylactically before moving the 3 aquariums inhabitants--took 0.5g BID for 10 days.
I usually take a bottle of Cipro on dive trips or if I go out of country in case somthing happens.

Trigeek
11/08/2008, 09:43 AM
Thanks, Doc, for starting this very important thread.

What antibiotic therapy is recommended for oxidase positive gram negative bacilli?

Is there a difference in the treatment of the cholera v. non-cholera Vibrio?

What are the first response or first aide strategies (scrub/irrigate with beta-dine, peroxide etc) you should use before leaving your house for the hospital?

Playa-1
11/08/2008, 12:32 PM
Thanks for the information, I feel better prepared for the inevitable. Keep up the gr8 thread

:thumbsup:

WrinkleFreeZone
11/08/2008, 05:27 PM
Wrott, Ciprofloxacin or "Cipro" is a broad spectrum antibiotic with good activity against many types of bacteria. This includes both Gram positive and Gram negative organisms (this refers to a staining technique that is used in identifying them). It is ineffective against many types of anaerobic bacteria. Ideally, you would take an antibiotic under the direction of a physician who is making a best guess at the type of bacteria responsible for the infection and then prescribing an appropriate antibiotic. If a culture is obtained, the antibiotic is then adjusted based on the culture results and the sensitivities of the organism to the antibiotic. Because Cipro is so broad spectrum and covers so many different bacteria, it is a good choice to take with you when you travel abroad. This makes great sense if you are not going to be in an area where you can obtain medical care. This way you can at least begin treatment if you have a problem and the likelihood is that you will be covered. If your infection happens to be due to a bacteria that Cipro doesn't have activity against, the infection is likely to progress. In this case, find a way to get to a doctor.
-B

WrinkleFreeZone
11/08/2008, 08:57 PM
Trigeek, "oxidase positive" and "gram negative" are terms used to describe the bacteria after performing a test on them as part of the identification of the organism. "Non cholera Vibrio infection" is just a way to describe an infection caused by any member of the genus Vibrio (there are several species) except for Vibrio cholerae.

Vibrio cholerae is the bacteria that cause cholera in humans. If you're unsure of what cholera is, think: food borne/water borne illness that causes nausea, vomiting, severe diarrhea (sometimes bloody), abdominal pain and cramping, fevers. Cholera is usually self limited if you can be supported through the episode with IV fluids to avoid dehydration. It is not always treated with antibiotics.

Non cholera Vibrio wound infections are commonly caused by Vibrio vulnificus. The treatment for them is different and depends on what flavor of infection you have. It usually requires more than one type of antibiotic and surgery to treat adequately. See my prior post.

In terms of cleaning up a wound, I would recommend an aggressive wash in soap and water. Peroxide can be used for a wound that contains a fair amount of debris. Betadine won't be available to everyone and if you're going to seek medical attention anyway, not necessary.
-B

WrinkleFreeZone
11/09/2008, 07:32 AM
Otrlynn, sorry, I missed your post. I agree with you. Wearing gloves every time you're in the tank is a pain and I don't want to come across as the glove enforcer. I'm a surgeon whose livelihood depends on his hands and truth be told I don't wear gloves every time I'm in the tank. I think the decision to wear them or not should come down to the idea that certain activities are going to be associated with greater risk for injuries than others. Grabbing a Nori clip that falls down and is laying in the open on the bottom of your tank is a low risk activity if you don't have cuts on your hands. Your risk of irritating the wife with the dripping gloves is going to be far greater and you're going to get away with it the vast majority of the time. Depending on the inhabitants of your tank it may not be so risk free though. If you keep rays or urchins or other species that carry a venomous spine that could jab you while you're in there, I'd take a long look at those gloves before putting my hands in the tank. Other activities such as preparing your live rock after it arrives from the reef, or adjusting your rockwork, or dealing with shells, etc. are going to be higher risk. In these types of activities I would certainly recommend that you wear gloves. The other time to wear gloves is when you have any cuts or scrapes on your hands or arms. These wounds could be the point of entry for an infection.
-B

whosjohnny
12/07/2008, 02:53 PM
Wow, thanks doc for the heads up. I was refer to here by this thread:
http://www.reefcentral.com/forums/showthread.php?s=&threadid=1524622&perpage=25&pagenumber=2

Do all beauty surgeon this knowledgeable as you or you're quite the exception? =) Thanks for the great education! Where do you buy one of those Ciprofloxacin or "Cipro" broad spectrum antibiotic? I want one in my first-aid kit at home, in the car, and for travel to Pacific vacations.

christew
12/08/2008, 08:05 AM
Great information you are gving us here, doc. I have not using any gloves and just yesterday i was restacking my tank. Guess what, after a few hours, my arm is full of rashes; red and angry looking and itches like hell. Question: you have menioned infection through digestion or broken skin. My arm did not have any broken skin. I hd to ***** the 'boils' to squeeze out some transparent fluild. How need the bacteria penitrate the surface in the first place.

DLANDINO
12/08/2008, 08:16 AM
This is a great thread! Thanks very much. It is contributors like this that make RC such a wealth of information. Also, because I am a glove delinquent my hands are literally itching after reading this thread. Power of suggestion is so strange. You have me convinced, Marine Depo Sells long gloves for 7.00 per 6 pair.

Dave

WrinkleFreeZone
12/08/2008, 09:40 AM
Christew, If you developed a red, angry, itchy rash and are squeezing things that contained a clear fluid it sounds like you have a skin sensitivity to something in your tank. It is likely that you have a contact allergy to something that you encountered while you were adjusting your rockwork. This type of reaction could be considered something similar to the rash that some people develop after coming in contact with poison ivy. We refer to this type of reaction on the medical side as a "delayed type hypersensitivity." I won't go into the specifics of it here, but you have its name if you want to google a mouthful. This is not an infectious problem. It is due to a severe response within your skin to an allergen. This type of allergy is usually due to a compound or chemical that can bond with our skin and can be difficult to wash off or one that can be spread around by touching other areas. The problem is that in our tanks there are loads of possible allergens so unless you can remember exactly what you touched it may take you awhile to figure out what is causing it. If this is the first time that this has happened to you I would recommend that you use gloves when working in your tank. Also, after working in your tank avoid touching other areas of your body before a good scrub with soap unless you want to experience it on your face or other more intimate areas. While this is not due to an infection, the wounds caused by it can become infected so if you've got them stay out of your tank until you've healed.

WrinkleFreeZone
12/08/2008, 10:00 AM
Whosjohnny, all antibiotics including Ciprofloxacin (Cipro) will require a prescription from your doctor. Assuming you are not allergic to this class of antibiotics, it is a great idea to get a prescription for this if you are going to be traveling anywhere outside of the United States or to a remote area for an emergency use. Just ask your doctor for one when you travel and he or she will likely prescribe it for you. I was recently in China and carried a bottle with me. When your trip is over you should throw the medication away. When you have no chance for medical care is the only time that it's "ok" to do this.

I would not recommend to anyone to keep a bottle of it laying around for "just in case" kinds of things. The drug needs to be used under the direction of a physician. Your doctor will prescribe an antibiotic to you based on decisions regarding the type of infection, causative bacteria, sensitivities of this bacteria to the medication, etc. You won't be able to make this decision. If you try to treat an infection caused by a bacteria not sensitive to the antibiotic you may as well be taking sugar pills. Misuse of the antibiotic can also lead to the development of drug resistant bacteria (think Methicillin or Oxacillin Resistant Staph. Aureus that has made it into the headlines recently). Furthermore, there are expiration dates on your pill bottles because over time the drug can lose its effectiveness as temperature and humidity can affect them. If you think you have an infection, please, talk to your doctor.
-B

christew
12/09/2008, 06:38 AM
Hi doc, thanks for the advise. This is the first time it happen after so many years to the putting my hands into the tank. :( Other than my palm which came in touch contact with some rocks during the stacking, I did not come in contact with any elements. I guest it must be something in the water column. Question: is there any oilment or medicine which I can apply to hasten the healing process; or do I have do go throughits entire incubation period; maybe 3-4 days? Cause it really itches some much!!
Thanks again for your time.

christew
12/09/2008, 06:38 AM
Hi doc, thanks for the advise. This is the first time it happen after so many years to the putting my hands into the tank. :( Other than my palm which came in touch contact with some rocks during the stacking, I did not come in contact with any elements. I guest it must be something in the water column. Question: is there any oilment or medicine which I can apply to hasten the healing process; or do I have do go throughits entire incubation period; maybe 3-4 days? Cause it really itches some much!!
Thanks again for your time.

WrinkleFreeZone
12/09/2008, 08:20 AM
Christew, I'm sorry to hear that your rash is so irritating. I cannot give you specific advice on your particular case because of some liability issues and if you are not located in Texas I could essentially be practicing medicine in another state. My license only applies to Texas.

With that being said, I can comment on some generalizations: Let's just say for the sake of argument that I experienced a rash soon after working in my tank. I know for a fact that I was not stung. The first thing that I would do is wash all of the affected areas with soap and water to reduce the chance that the rash could be spread if it was due to an allergen. I would also change and wash my clothes as the allergen is likely to be splashed onto them as well. From this point forward my goal would be to keep any of the affected areas clean and dry. Small wounds like this can become infected secondarily if I was to scratch them, or work in an unclean environment (like my tank). I would watch for the development of infection and at the first sign of this I would visit with my doctor. In terms of ointments to help me heal, there is not any good evidence to suggest that these help. If I was having a lot of trouble with itching I would take Benadryl as it has some very good anti-itch properties, just watch out for the sedating affects. The use of other medications such as steroids would need to be used under the guidance of my physician.
-B

ReefEnabler
12/09/2008, 10:21 AM
for me, tea tree oil dabbed on the skin helps most rashes from stings, anything from stinging nettle plants to bristle worm spikes.

I usually use gloves when working in the tank majorly, but last week I picked up a brain coral without gloves so I could scrape off some algae from the base.

Didn't realize there was a bristle worm on the bottom until I saw it, at which point I realized I had already touched it with my middle finger on my left hand.

A couple tiny spikes in the hand basically equated to a bee sting injury that lasted 2-3 days. tea tree oil made the stinging feeling subside.

christew
12/10/2008, 07:41 AM
Thanks doc for the advise again. Another quick question: As I got it(s) in the water column (not due to touching some corals), could the allergen(s) be artificially accumulated in our tank (the additives we added?)or is it as in the open sea? In other words, does it mean that I cannot dive anymore without having to scratch myself all over ? :(

WrinkleFreeZone
12/10/2008, 09:15 AM
If I had to guess, I doubt you would be allergic to the natural components of sea water. Our bodies are full of "salt water" at lower concentrations than what is found in the ocean. It is possible that an additive could do it. I would bet that diving will still be fair game for you. If I had to guess, you probably contacted something on the rock when you were moving it around and then this was spread to other areas of your arms when you used a towel to dry off.

Assuming the reaction was not severe and did not cause swelling, particularly in the face or neck, a relatively easy test to determine the source of the reaction would be to take a few drops of tank water and to put it onto an area of skin that was not affected. If this area breaks out with a rash in that test spot then it's something in the water column. If it doesn't it's from contact with something in the rockwork, a chemical (coral warfare?) in the water column at the time that you were in the tank, or from a sting.
-B

thecichlidpleco
12/10/2008, 10:16 AM
Reefenabler, thanks for the advice, I have had bristleworm bristles in my fingers for a few days, and I didnt wash it with vinegar soon enough, so I will try the tea tree oil.