Hand salvage using a chimeric alt flap following extensive Vibrio vulnificus necrotizing fasciitis: a case report

Abstract

Background

Vibrio vulnificus infection is a rare, rapidly progressing condition often acquired through wounds exposed to aquatic environments or marine animals. It can cause septic shock, organ failure, and high mortality. Reports on limb salvage in necrotizing fasciitis caused by V. vulnificus are limited.

Case presentation

A 62-year-old Vietnamese male with alcohol use and hepatitis B developed swelling, bullae, and necrosis in his left hand after a tilapia fin injury. He experienced septic shock requiring resuscitation, antibiotics, and ventilation. Cultures confirmed V. vulnificus. Surgery showed necrotizing fasciitis, leading to extensive debridement. Reconstruction used a chimeric anterolateral thigh (ALT) flap and fascia lata flap. At 18 months, his hand improved significantly in function and appearance.

Conclusions

This case emphasizes the importance of local wound management in severe V. vulnificus infection. Early radical debridement after stabilizing hemodynamics is crucial. A chimeric ALT flap is a key option for one-stage reconstruction of multiple damaged components, ensuring functional and aesthetic hand salvage.

Highlights

• Infection with Vibrio vulnificus from tilapia fish fins can lead to severe necrotizing fasciitis and septic shock, posing a serious risk to life and limb.

• A structured management strategy that combines intensive resuscitation, radical debridement, and NPWT application can lead to better outcomes.

• ALT flap can be a successful "hand-saving" approach to simultaneously reconstruct extensive dorsal hand skin defects and extensor tendon losses.

Introduction

Infections caused by Vibrio vulnificus following exposure to aquatic animals and natural water sources have been reported [1–3]. The infection is rare but associated with a high mortality rate, especially in individuals with underlying conditions. There have been reports of cellulitis, necrotizing fasciitis, septic shock, and even fatalities occurring from minor injuries sustained while handling fish or coming into contact with contaminated pond or lake water [4–6]. For severe cases, in addition to resuscitative measures to stabilize vital functions, thorough debridement and wound care are essential steps in management. One-stage reconstruction of composite defects, including skin defects and tendon loss, remains a significant challenge for reconstructive surgeons aiming to preserve the function of the necrotic limb. In this article, we present a case of a patient who sustained a hand injury caused by a tilapia fin, which was successfully managed. Following initial resuscitation for septic shock, aggressive debridement of necrotizing fasciitis, application of negative pressure wound therapy (NPWT), and subsequent reconstruction using a chimeric anterolateral thigh (ALT) flap, the patient achieved favorable outcomes, reflecting the importance of a well-structured management strategy. This case report has been reported in line with the SCARE checklist [7].

Case report

A 62-year-old Vietnamese male with ethanol abuse and untreated hepatitis B was punctured by a tilapia dorsal fin on his left hand. He was admitted on day 3 with blistering, redness, and swelling extending to the forearm. Physical examination revealed severe hypothermia, tachycardia, tachypnea, and unmeasurable blood pressure, reflecting severe septic shock. Laboratory workup revealed WBC: 21.3 G/L, CRP: 245 mg/L, an extremely elevated procalcitonin level exceeding 57 ng/mL, and a lactate of 5.2 mmol/L. Patient requiring immediate aggressive fluid resuscitation and vasoactive support. Resuscitation and antibiotics were started. Comprehensive metabolic and hematologic panels confirmed multiple organ dysfunction syndrome, including renal impairment (serum creatinine: 189 mmol/L), hepatic dysfunction (AST: 142 U/L, ALT: 115 U/L), thrombocytopenia (PT: 62 G/L), and coagulopathy (prothrombin time activity: 48%, INR: 1.8). Due to severe hemodynamic instability, metabolic derangement, and multi-organ dysfunction—manifesting on day 6 with a Glasgow Coma Scale (GCS) score of 8 necessitating endotracheal intubation and mechanical ventilation—immediate surgical intervention carried a prohibitive risk of intraoperative mortality. Radical surgical debridement was intentionally deferred until the patient's vital functions stabilized. His left hand had bullae and necrosis from the dorsum of the hand to the forearm. Cultures grew Vibrio vulnificus, prompting a change in antibiotics. The patient was transitioned to a combination of a third-generation cephalosporin and Doxycycline. On day 10 post-injury, following intensive medical management, the patient achieved hemodynamic stability and was successfully extubated, allowing for safe surgical intervention. Surgical debridement revealed necrotizing fasciitis over the dorsal hand with exposed tendons; necrosis extended to digits II–V and the first web space, involving thenar muscles and interosseous compartments. Necrosis also involved the subcutaneous fat of the distal forearm and wrist. Cellulitis affected the entire upper and lower forearm (Fig. 1).

Fig. 1.

Surgical debridement. A Pre-operation. B Post-operation

One day after debridement, NPWT was started in dynamic mode at 70–110 mmHg for 12 days. On day 23, the second-stage surgery was performed; the wound showed healthy granulation tissue. The dorsal and posterior skin defects measured 13 × 12 cm over the hand and 10 × 5 cm on the distal forearm. The hand defect exposed tendons and bones, including the thumb's first phalanx and digits II–V's proximal and middle phalanges. Extensor tendons of digits II and III, about 14 cm long, were lost. A 15 × 6 cm skin defect on the distal forearm had muscle tissue without tendon or bone exposure. The ulnar artery was occluded, but the radial artery was patent. An ALT flap was planned using Doppler mapping, with three perforators from the descending branch of the lateral circumflex femoral artery. An adipocutaneous flap (15 × 23 cm) was harvested, thinned, and split into five paddles. A fascia lata flap (6 × 16 cm) was used to reconstruct tendons. The flap was transferred to the hand; the vascular pedicle was anastomosed to the radial artery. Fascial strips from the FL flap were sutured to tendons, and the hand defect was covered with the adipocutaneous flap (Fig. 2). Remaining defects were covered with a skin graft from the lower abdomen; the donor site was partially closed with a skin graft from the thigh. The forearm and hand were immobilized with a plaster splint.

Fig. 2.

Reconstructive surgery with ALT flap for skin defects and restoring extensor tendons loss. A Chimeric-thinned ALT flap consisting of an adipocutaneous flap and an FL flap. B Intraoperative flap placement. C Immediate postoperative result

Seven days after reconstructive surgery, the flap had survived almost completely. A 1 × 1 cm area of distal flap necrosis was noted on the dorsum of the middle phalanx of the third finger. The skin grafts adhered well and showed good healing at both the forearm recipient and flap donor sites. At the 18-month follow-up, the surgical wounds had completely healed. The flap had a favorable aesthetic outcome, with a good color match to the surrounding skin (Fig. 3). Functional assessment of the reconstructed extensor tendons showed a range of motion (ROM) of 0–60° at the metacarpophalangeal (MP) joints for both the second and third digits. The patient was satisfied with the surgical result and continued postoperative rehabilitation. Written informed consent was obtained from the patient for publication of this case report and any accompanying images.

Fig. 3.

Follow-up at 18 months postoperatively. A Dorsal view. B Radial side view. C There is limited flexion and extension of the fingers

Discussion

Vibrio vulnificus is a flagellated halophilic motile gram-negative curved rod [8]. This bacterium commonly infects through wounds exposed to contaminated water or via ingestion of raw or undercooked seafood [5, 9]. Liver diseases and chronic alcohol abuse have been reported as risk factors for Vibrio vulnificus infection [3, 6]. Tilapia, a relatively common freshwater fish in Vietnam, has also been associated with reported cases of Vibrio vulnificus infection following exposure [3, 6, 8]. Although such infections are rare, they are considered critical surgical emergencies due to the rapid progression to multiple organ dysfunction syndrome (MODS), septic shock, and extensive local necrotizing fasciitis. Initial medical management in the intensive care unit plays a vital role in stabilizing the patient’s hemodynamics and correcting coagulopathy, metabolic acidosis, and thrombocytopenia, which are prerequisites for surgical intervention [1, 8, 9].

Necrotizing fasciitis is a rapidly progressive condition that evolves from cellulitis and extends along the subcutaneous tissues and fascial planes. Early diagnosis can be challenging, as initial symptoms often mimic cellulitis—swelling, erythema, and acute localized pain [10]. Necrotizing fasciitis caused by Vibrio vulnificus is uncommon and is classified as type III in Morgan’s classification. Local lesions often progress rapidly, presenting with swelling, bullae formation, and skin discoloration [4]. Current recommendations for management include the use of broad-spectrum antibiotics in combination with early surgical debridement [9]. However, in patients with septic shock and hemodynamic instability, delaying surgery is often unavoidable. Some authors propose a staged surgical plan that includes an initial incision and drainage, followed by repeated debridement and autogenic skin grafting [4]. In our case, the patient progressed rapidly to necrotizing fasciitis with septic shock. We opted for a single radical debridement, preserving only well-vascularized tissue. However, the infection had caused extensive tissue necrosis, resulting in exposed bone and significant soft-tissue loss. Exploration also revealed thrombosis of the ulnar artery at the distal forearm, with only the radial artery supplying the hand, posing additional challenges to both reconstruction and limb salvage. In previous reports, deep and proximal necrosis often led to limb loss, even after the patient recovered from septic shock [2, 11]. In our approach, we decided on a single-stage radical debridement for three primary reasons: accurate assessment of tissue damage to inform reconstructive planning; limiting the spread of infection and necrosis through complete removal of devitalized tissue; and this facilitated the application of NPWT after debridement, thereby eliminating the need for daily dressing changes and reducing the risk of secondary infection. For extensive defects with exposed tendons and bones, free-flap reconstruction was the optimal choice, providing sufficient coverage and enabling functional recovery of the hand. The ALT flap is particularly advantageous for necrotizing fasciitis reconstruction due to its large harvestable area, minimal donor-site morbidity, multiple components, and skin color compatibility [12, 13]. In this patient, the hand defect posed several reconstructive challenges, including the need for a thin flap, simultaneous tendon reconstruction, and a robust blood supply to support flap tailoring at the metacarpophalangeal joint level. We selected a chimeric ALT flap, combining a thinned adipocutaneous paddle for coverage and a fascial vascularized flap for tendon reconstruction. The use of a vascularized FL for tendon reconstruction offers numerous advantages, including enhanced healing and a significant improvement in tendon gliding and mobility. Several authors recommend secondary flap division to reconstruct the web spaces; however, this approach may delay the initiation of finger rehabilitation and potentially lead to postoperative joint stiffness. Given the thrombosed ulnar artery, we performed an end-to-side arterial anastomosis between the flap pedicle and the radial artery at the wrist to ensure continued perfusion of the hand. In addition, the free-flap's wound healing progressed rapidly, allowing early initiation of hand rehabilitation in the third postoperative week.

Conclusions

Infection with Vibrio vulnificus from tilapia fish fins can lead to severe necrotizing fasciitis and septic shock, posing a serious risk to life and limb. Early recognition and a multidisciplinary approach, including aggressive medical treatment, surgical debridement, and NPWT, are essential for improving outcomes. For complex hand defects with exposed bone or tendon loss, the chimeric ALT flap provides an effective reconstructive solution, restoring function and minimizing donor-site morbidity. This approach can reduce the risk of amputation and enhance long-term functional recovery in cases of extensive necrosis.

Author contributions

Trần Thiết Sơn: performed the operation and conceptualization, writing, editing, and supervision; Phan Tuấn Nghĩa: performed the operation, writing—review and editing, and corresponding author; Đặng Phương Nam: data curation and formal analysis; Phạm Thị Việt Dung: performed the operation; Tạ Thị Hồng Thúy: performed the operation.

Funding

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional review board (Ref 938/GCN-HĐĐĐĐNCSYHN-ĐHYHN) and with the 1964 Helsinki Declaration and its later amendments, or with comparable ethical standards. All participants provided written informed consent before enrolment in the study. The privacy and confidentiality of patient records were adhered to in managing the clinical information in conducting this research.

Consent for publication

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Competing interest

The authors have no relevant financial or non-financial interest to disclose.