Fernando et al. Journal of Medical Case Reports 2011, 5:171 http://www.jmedicalcasereports.com/content/5/1/171 developed multiple clear fluid filled blisters on his left lower extremity extending to his medial thigh (Figure 1); the largest blister measured 6 cm by 7 cm in size. His temperature was 100.2 ˚F; heart rate, 115/min; blood pressure, 92/63 mmHg; and respiratory rate, 34/min. His left lower extremity was warm, tender, erythematous and oedematous with fluid filled blisters and a 2 cm by 2 cm ulcer on the plantar aspect of the left foot. His hemoglobin was 6.6 g/dl with indirect hyperbilirubine- mia; LDH, 196 IU/L; white blood cells 6.1 k/ mcl (neu- trophils 48%, bands 36%, and lymphocytes 4%), platelets 160 k/ mcl, creatinine 3.1 mg/dl, CK 538 U/L and lactic acid 6.4 mg/ dl. X-rays of the left lower extremity showed diffuse soft tissue swelling without bony involve- ment. Compression ultrasonography ruled out deep venous thrombosis. A noncontrast computed tomogra- phy (CT) of the left lower extremity did not demon- strate muscle necrosis and a CT abdomen showed diffuse colonic thickening. His respiratory status declined and he was intubated. His blood pressure dropped and he was put on two pressors and transfused two units of packed red blood cells and two units of fresh frozen plasma. He was admitted to the critical care unit with a working diagnosis of sepsis and cellulitis. Bedside exploration and subsequent surgical debride- ment ruled out necrotizing fasciitis. A sample from the blister and blood samples were taken for culture. Stool culture was not performed. Aggressive management with intravenous fluids and empiric treatment with cef- triaxone (2 g intravenously every 24 hours) and cipro- floxacin (400 mg intravenously every 12 hours) was initiated. Blister aspirate and blood cultures were posi- tive for a gram-negative, non-lactose fermenting bacilli. The isolate did not ferment sucrose and yielded round blue-green colonies in thiosulphate citrate bile salt Page 2 of 3 sucrose agar. Microbiologic testing demonstrated Vibrio parahemolyticus. Subsequently the patient developed thrombophlebitis and necrotic skin in a circumferential pattern from the ankle to the knee on the left lower extremity that ultimately required debridement and split thickness skin graft. The patient was treated with cef- triaxone and ciprofloxacin and was discharged home in a stable condition. Discussion Vibrio species are a rare cause of soft tissue infections. Exceedingly rare is soft tissue infection with V. parahe- molyticus, which can occur in patients with underlying co-morbidities such as cancer, liver disease, kidney dis- ease, heart disease, recent gastric surgery, or antacid use [4,6]. Wound infection may occur after contamination of skin laceration with warm seawater, after direct trauma with pieces of shellfish, fishhooks or utensils contaminated with seawater or translocation from the gastrointestinal tract [6]. Bacteraemia and septicaemia occur in three to five percent of Vibrio infections and is a concern in immunocompromised patients especially those with liver disease [3]. Superficial infection can extend to deeper soft tissue causing cellulitis or necro- tizing fasciitis and may require radical surgical debride- ment [6]. The diagnosis of V. parahemolyticus soft tissue infection is difficult. Clinical suspicion must be high in people returning from coastal areas such as the Gulf of Mexico especially with a history of raw seafood consumption or extremity wounds. Soft tissue infections are hard to recognize and difficult to differentiate from necrotizing fasciitis. Our patient underwent a bedside exploration and then debridement to definitively exclude necrotizing fasciitis. V. parahemolyticus causes skin and soft tissue necrosis which can further confound the A B Figure 1 Vibrio parahemolyticus cellulitis. A. Large hemorrhagic bulla of left lower extremity. B. Blistering cellulitis of the left foot. Bedside debridement excluded necrotizing fasciitis.