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Letters to the Editor Perineal arterial compression has been demonstrated in long distance cyclists;5 our patient was a frequent bike rider. However, the relationship between bike riding and FG has not been established as a risk factor, so far. We speculate that repeated trauma to the perineum with an HIV-positive immunocompromised status could have been factors provoking a local trauma that led to a fatal infection. Conflict of interest: No conflict of interest to declare.
References
b
Family Medicine Department, Northern Branch of Ben-Gurion University, Ha’Emek Medical Center, Afula, Israel D. Kopelman Surgery B Ward, Ha’Emek Medical Center, Afula, Israel Z. Katz Urology Ward, Ha’Emek Medical Center, Afula, Israel D. Kniznik Intensive Care Unit, Ha’Emek Medical Center, Afula, Israel
1. Roca B, Cunat E, Simon E. HIV infection presenting with Fournier’s gangrene. Neth J Med 1998;53:168—71. 2. Ayumba BR, Magoha GA. Epidemiological aspects of Fournier’s gangrene at Kenyatta National Hospital. Nairobi East Afr Med J 1998;75:586—9. 3. Yeniyol CO, Suelozgen T, Arslan M, Ayder AR. Fournier’s gangrene: experience with 25 patients and use of Fournier’s gangrene severity index score. Urology 2004;64:218—22. 4. Elem B, Ranjan P. Impact of immunodeficiency virus (HIV) on Fournier’s gangrene: observations in Zambia. Ann R Coll Surg Engl 1995;77:283—6. 5. Sommer F, Konig D, Graft C, Schwarzer U, Bertram C, Klotz T, et al. Impotence and genital numbness in cyclists. Int J Sports Med 2001;22:410—3.
B. Chazan*,a,b Y. Chena R. Raza a Infectious Disease Unit, Ha’Emek Medical Center, Afula, Israel
The first outbreak of acute diarrhea due to a pandemic strain of Vibrio parahaemolyticus O3:K6 in Kolkata, India Since 1996, infections caused by Vibrio parahaemolyticus have increased globally. Outbreak and/or sporadic cases of diarrhea caused by V. parahaemolyticus have been reported from India, Indonesia, Japan, Taiwan, the USA, Laos, Korea, Chile, Bangladesh, Russia, Thailand, Spain, France, and Vietnam. This increase in incidence appears to be related to the emergence of a new clone belonging to the O3:K6 serovar, which has pandemic potential. Due to its spread in many countries with identical phenotypic and genotypic features, the recently emerged V. parahaemolyticus has now been termed a ‘pandemic strain’, which can be identified by group-specific GSPCR based on the sequence variation in the toxRS gene.1 In addition, the pandemic strains have a novel open reading frame orf8, which corresponds to a filamentous phage f237.2 On September 14, 2003, an outbreak of diarrhea occurred near Dumdum in Kolkata, India. About 200 people had diarrhea after consumption of rice with meat served at the blood donation camp. Twenty-one patients were admitted to the Infectious Diseases Hospital (IDH), Kolkata from this outbreak-affected area. Stool specimens were collected from all the patients and screened for common enteric pathogens
R. Colodner Microbiologic Laboratory, Ha’Emek Medical Center, Afula, Israel R. Raz Rappapot School of Medicine, Technion, Haifa, Israel *Corresponding author. Tel.: +972 4 6494259; fax: +972 4 6494470 E-mail address:
[email protected] (B. Chazan) Corresponding Editor: Salim S. Abdool Karim, Durban, South Africa 27 October 2005 doi:10.1016/j.ijid.2006.02.007
within two hours of collection, using standard methods.3 In addition, 3—5 Escherichia coli colonies grown in MacConkey agar from each stool specimen were screened for diarrheagenic E. coli (DEC) by PCR.4 In this assay, all the tested E. coli isolates were negative for common DEC such as enterotoxigenic E. coli, enteropathogenic E. coli, and enteroaggregative E. coli. V. parahaemolyticus was isolated from five patients (24%) and no other pathogens were detected in the other 16 patients. All the patients had acute diarrhea with watery stool and showed moderate-to-severe dehydration. The five V. parahaemolyticus strains were serotyped as O3:K6 using commercial antisera (Denka Seiken Corp., Tokyo, Japan). A PCR assay was performed to determine the speciesspecific toxR of V. parahaemolyticus5 and tdh and trh virulence genes.6 The GS and orf8 PCRs were also performed using published methods1,2 in an automated thermocycler (Model 9700, Applied Biosystems, CA, USA). All five V. parahaemolyticus strains were positive in toxR, tdh, orf8, and GSPCR assays. To confirm the clonal relationship, V. parahaemolyticus O3:K6 strains isolated before 1996 (AQ4037), during 1996 (KXV224), and in 2003 before the Kolkata outbreak (SC84 and SC179) were included in the pulsed-field gel electrophoresis (PFGE) along with the outbreak strains following the methods described previously.7 NotI (Takara Shuzo, Tokyo, Japan)
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Letters to the Editor donation camp were not available for further investigations to confirm the source of transmission of V. parahaemolyticus. Considering the large number of cases, and the reporting of patients occurring almost at the same time and from the same area, we suspect that the food served in the blood donation camp carried the outbreak pathogen. Food-handlers may also have been involved in this outbreak, since it has been shown in a study that the carrier status of V. parahaemolyticus in Kolkata is 21.4%.10 We have limited information on the incidence of V. parahaemolyticus in India and this pathogen should be included in surveillance. Considering its swift spread, awareness of the pandemic V. parahaemolyticus should be improved among health officials and proper preparedness should be made in order to deal with any such outbreaks in the future.
Acknowledgements This work was supported in part by a research grant from the Japan International Cooperation Agency (JICA/NICED project 054-1061-E-0) and a grant-in-aid from the Ministry of Health, Labor and Welfare of Japan (Project H 17-Shinkou-3). Conflict of interest: No conflict of interest to declare.
Figure 1 NotI digested chromosomal DNA banding patterns of non-pandemic (AQ4037) and pandemic V. parahaemolyticus strains. Strain KXV224 was isolated during 1996, while SC84 and SC179 were isolated before the diarrheal outbreak in Kolkata in 2003. Strains SC188-190, 192, and 193 were isolated during the outbreak.
digested inserts of V. parahaemolyticus were applied to contour-clamped homogenous electric fields in a CHEF Mapper system (BioRad, Hercules, CA, USA). PFGE results of the five outbreak V. parahaemolyticus isolates showed identical profiles comparable to that of SC84, which was isolated in Kolkata on June 5, 2003 and closely related to SC179, which was isolated on September 1, 2003 (Figure 1). The O3:K6 pandemic strain KXV224, which was isolated in 1996 was closely related to the outbreak strains as it had three bands difference compared to the outbreak isolates (Figure 1). However, AQ4037, the non-pandemic V. parahaemolyticus isolate had a distinct banding pattern (Figure 1). PFGE results established that (i) the outbreak-associated O3:K6 pandemic strains belonged to an identical clone, (ii) the current Kolkata V. parahaemolyticus O3:K6 strains have undergone genetic changes compared to KXV224, and (iii) considering the PFGE profiles of outbreak strains and pre-outbreak strain (SC84), the new clone is already prevalent in Kolkata. When the pandemic strain of V. parahaemolyticus emerged during 1996, the O3:K6 serotype was the most prevalent among sporadic diarrheal cases in Kolkata.8 In India, the first diarrheal outbreak caused by V. parahaemolyticus belonging to serotypes O4:K12 and O1:K20 was reported in Vellore, Tamil Nadu, during 1982, and associated with consumption of fish preparation and contaminated meat used in sandwich paste.9 Ours is the first report of a diarrheal outbreak caused by the pandemic strain of V. parahaemolyticus O3:K6 in India. Leftover foods served in the blood
References 1. Matsumoto C, Okuda J, Ishibashi M, Iwanaga M, Garg P, Ramamurthy T, et al. Pandemic spread of an O3:K6 clone of Vibrio parahaemolyticus and emergence of related strains evidenced by arbitrarily primed PCR and toxRS sequence analysis. J Clin Microbiol 2000;38:578—85. 2. Nasu H, Iida T, Sugahara T, Yamaichi Y, Park KS, Yokoyama K, et al. A filamentous phage associated with recent pandemic Vibrio parahaemolyticus O3:K6 strains. J Clin Microbiol 2000;38:2156—61. 3. World Health Organization. Manual for laboratory investigation of acute enteric infections. CDD/83.3. Geneva, Switzerland: World Health Organization; 1987. 4. Chakraborty S, Deokule JS, Garg P, Bhattacharya SK, Nandy RK, Nair GB, et al. Concomitant infection of enterotoxigenic Escherichia coli in an outbreak of cholera caused by Vibrio cholerae O1 and O139 in Ahmedabad. India J Clin Microbiol 2001;39:3241—6. 5. Kim YB, Okuda J, Matsumoto C, Takahashi N, Hashimoto S, Nishibuchi M. Identification of Vibrio parahaemolyticus strains at the species level by PCR targeted to the toxR gene. J Clin Microbiol 1999;37:1173—7. 6. Tada J, Ohashi T, Nishimura N, Shirasaki Y, Ozaki H, Fukushima S, et al. Detection of the thermostable direct hemolysin gene (tdh) and the thermostable direct hemolysin-related hemolysin (trh) of Vibrio parahaemolyticus by polymerase chain reaction. Mol Cell Probes 1992;6:477—87. 7. Chowdhury NR, Chakraborty S, Ramamurthy T, Nishibuchi M, Yamasaki S, Takeda Y. Molecular evidence of clonal Vibrio parahaemolyticus pandemic strains. Emerg Infect Dis 2000;6:631—6. 8. Okuda J, Ishibashi M, Hayakawa E, Nishino T, Takeda Y, Mukhopadhyay AK, et al. Emergence of a unique O3:K6 clone of Vibrio parahaemolyticus in Calcutta, India, and isolation of strains from the same clonal group from Southeast Asian travelers arriving in Japan. J Clin Microbiol 1997;35:3150—5. 9. Lalitha MK, Walter NM, Jesudason M, Mathan VI. An outbreak of gastroenteritis due to Vibrio parahaemolyticus in Vellore. Indian J Med Res 1983;78:611—5. 10. Sircar BK, De SP, Sengupta PG, Mondal S, Sen D, Deb BC. Studies on transmission of Vibrio parahaemolyticus infections in
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Letters to the Editor Calcutta communities: a preliminary report. Indian J Med Res 1979;70:898—907.
B. Sen B. Dutta S. Chatterjee M.K. Bhattacharya R.K. Nandy A.K. Mukhopadhyay D.N. Gangopadhyay S.K. Bhattacharya T. Ramamurthy*
National Institute of Cholera and Enteric Diseases, P-33, CIT Road, Scheme XM, Beliaghata, Kolkata — 700 010, India *Corresponding author. Tel.: +91 33 2350 0448; fax: +91 33 2350 5066 E-mail address:
[email protected] (T. Ramamurthy) Corresponding Editor: Raymond A. Smego, Sohar, Oman 3 August 2005 doi:10.1016/j.ijid.2005.11.008
