A 70 year-old woman with diabetes and end stage renal disease presented with acute severe left hand pain and swelling. Six hours prior, she incurred a puncture wound from a catfish spine while cleaning the fish. She was afebrile and in pain. Left hand was cool, edematous, and pale with a small puncture wound on the palm with no crepitus. She had hyperesthesia of the hand and forearm and increased pain with movement. Radial pulse was 1+. Radiograph of the hand revealed severe diffuse soft tissue swelling with no gas or foreign body. She was admitted for cellulitis and treated with vancomycin, piperacillin-tazobactam, doxycycline, and clindamycin to provide coverage for MRSA, anaerobic organisms, Vibrio species, and toxin producing gram-positive organisms.
Twelve hours after admission, she became unresponsive and hypotensive requiring vasopressors and intubation. She developed multiple ruptured bullae with erythema extending to the arm. CT revealed emphysematous changes of the soft tissues in the hand concerning for necrotizing fasciitis. The arm was irrigated and debrided but continued to worsen. The hand and forearm became cold with green-grey color and black nail beds. Amputation at the level of the elbow was performed. Blood cultures were persistently negative. Days later, intraoperative wound cultures grew Plesiomonas shigelloides, Pseudomonas aeruginosa, alpha-hemolytic Streptococcus, and coagulase negative Staphylococcus. She was diagnosed with polymicrobial toxic shock syndrome. Despite timely antibiotic coverage, she did not clinically improve and she passed away on day seventeen of admission.
Hospitalists routinely treat patients with cellulitis in the inpatient setting. These patients can clinically decompensate due to sepsis and shock. Necrotizing fasciitis should be investigated in toxic appearing patients because urgent surgical debridement is essential.
Given the history of symptoms after a puncture wound by a catfish sting, envenomation should also be considered. All species of catfish living in southeastern Louisiana have bony spines on their dorsal and pectoral fins. Many species also have glands in the spine sheath that produce venom capable of inducing severe local inflammatory reaction at the puncture site characterized by intense pain, edema, erythema or pallor, and rarely cutaneous necrosis. Management includes immersion in hot water to inactivate heat-labile toxins and counteract vasoconstricting toxins. While these symptoms often subside within a day, immunocompromised patients are at risk for life-threatening secondary infections inoculated into the wound at the time of the sting.
Her wound culture grew organisms commonly identified in secondary infections of aquatic puncture wounds. For example, Plesiomonas is a facultative anaerobic gram-negative bacillus found in fresh and brackish water that causes cutaneous infections. This bacteria is often resistant to penicillins and cephalosporins; treatment with ciprofloxacin is recommended. The likely diagnosis was polymicrobial toxic shock syndrome and necrotizing fasciitis complicating an initial puncture wound versus envenomation secondary to catfish spine.
With commonly seen cellulitis, hospitalists tailor the antimicrobial therapy depending on environmental exposures. In aquatic exposure, treatment with broad-spectrum antibiotics including ciprofloxacin may be needed to aggressively treat severe infections.
To cite this abstract:Davis D, Bhatnagar D. Death by Catfish. Abstract published at Hospital Medicine 2015, March 29-April 1, National Harbor, Md. Abstract 500. Journal of Hospital Medicine. 2015; 10 (suppl 2). https://www.shmabstracts.com/abstract/death-by-catfish/. Accessed July 17, 2019.