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UPPER EXTREMITY INFECTIONS FOLLOWING COMMON CARP FISH (CYPRINUS CARPIO) HANDLING
UPPER EXTREMITY INFECTIONS FOLLOWING COMMON CARP FISH (CYPRINUS CARPIO) HANDLING E. CALIF, N. PICK, U. DREYFUSS and S. STAHL From the Hand Surgery Unit of the Rambam Medical Centre and the Units of Clinical Infectious Diseases and Hand Surgery of the BNEI-ZION Medical Center, Haifa, Israel
Upper extremity infection caused by aquatic pathogens on fish is a well recognized clinical entity. We report five consecutive cases of upper extremity infections, ranging from a simple localized reaction to a life-threatening systemic illness, which developed after handling common carp fish (Cyprinus carpio). In four cases, infection occurred following a penetrating injury by either the bones or the fin spines of the fish. V|brio vulni¢cus was isolated from wound aspirates in four cases. Early broad-spectrum antibiotic therapy is mandatory. Deterioration in the clinical condition or a poor response to conservative treatment requires a meticulous surgical drainage and excision of both infected and necrotic tissues. Journal of Hand Surgery (British and European Volume, 2002) 27B: 1: 78–82 INTRODUCTION
Case 1
Upper extremity infections following penetrating injuries by the bones and fin spines of fish are well recognized. The primary injury is usually trivial, and is often overlooked. However, it may result in a devastating local infection, may cause systemic illness in susceptible individuals, and may occasionally cause a potentially fatal multisystem disease. Many aquatic pathogens have been identified as the cause of these conditions. Some of them are natural inhabitants of either brackish or salt water, for example the Vibrio species, especially Vibrio vulnificus (Bisharat et al., 1999). Others are found everywhere, even in home aquariums, such as Mycobacterium marinum (Huminer et al., 1986). Hence the pathogen may be inoculated during an occupational exposure, though anglers and fish fanciers are also at risk. Other pathogens have been isolated, including Streptococcus iniae (Weinstein et al., 1997), Aeromonas hydrophila, Enterobacteriaceae and Pseudomonas species (Murphey et al., 1992). Various species of fish can transmit infections. These include catfish (Baack et al., 1991; Mann and Werntz, 1991; Murphey et al., 1992), lionfish (Pterois volitans) (Patel and Wells, 1993) and St. Peter’s fish (Tilapia Zillii) (Bisharat et al., 1999; Said et al., 1998). We report five adults who developed upper extremity infections after handling common carp (Cyprinus carpio) (Fig 1), which is widely eaten but has not been recognized as a potential source of infections. Four of the five patients have incurred ‘‘finning’’ injuries to the hand from either bones or spine of the fish.
A 67-year-old women with a history of a chronic coronary heart and cerebrovascular disease, who required long-term anticoagulant therapy, punctured her right index finger with a fresh carp fish spine. Fourteen hours later she developed painful swelling of her index finger and hand tenderness. Clinical examination revealed localized tenderness, swelling, discoloration, blisters and skin epidermiolysis in the index finger and on the dorsum of the hand, which extended onto the palm. She was initially treated with intravenous amoxycillin-clavulanate (1 g 8-hourly) but developed septicaemia. An urgent incisional drainage of the index finger and the palm was therefore carried out. On the next day, irreversible necrotic changes were observed in the index finger and in the skin on the dorsum of the hand (Fig 2). An amputation of the index finger with meticulous debridement of the necrotic tissues was performed. This resulted in a rapid clinical improvement and pain alleviation. The patient refused to undergo further surgical procedures, and thus daily wound dressings were undertaken. The wounds healed by secondary intention within 5 weeks. Despite prompt physical therapy, including passive and active exercises, the patient was left with restricted finger movement and reduced grip strength. Case 2 A 67-year-old woman with non-insulin dependent diabetes mellitus and chronic coronary heart disease was admitted to hospital 24 hours after sustaining a puncture injury from a spine of a fresh carp fish to the tip of her right middle finger. There was rapidly increasing swelling, tenderness and restricted motion of her middle finger, which had not responded to oral antibiotic therapy (Fig 3). This lady was treated by intravenous amoxycillin-clavulanate (1 g 8-hourly) and responded well. Her fever, swelling and pain resolved,
CLINICAL CASES Five adult patients were treated between 1999 and 2000 at our Hand Surgery units. 78
HAND INFECTION FROM FISH
Fig 1 A common carp fish (Cyprinus carpio). Note the serrated dorsal and ventral fins.
and she was discharged after 4 days. She made an uneventful recovery and regained full finger motion. Case 3 A 68-year-old healthy man pricked his right thumb on a carp fish spine. Thirty-six hours later he presented with
79
marked swelling and tenderness of his thumb, which had been treated with oral antibiotics by his family physician. As he was experiencing increasing pain, swelling, blister formation (Fig 4) and had a temperature of 39.48C, an incisional drainage was performed on the palmar aspect of the thumb. Serous fluid with necrosis of the subcutaneous fat was found. Intravenous amoxycillin-clavulanate was administered perioperatively and the wound subsequently healed by secondary intention. At 6 months’ follow-up, he still had minor residual swelling and an extension lag of 108 at the thumb interphalangeal joint. However, there was no evidence of persistent infection. Case 4 A 64-year-old woman with liver cirrhosis due to chronic viral hepatitis (type C) and hypersensitivity to penicillin developed progressive pain and swelling of her right hand and forearm shortly after she had handled fresh carp fish. She denied any identifiable injury to her hands. Oral cloxacillin was administered without any
Fig 2 Case 1, irreversible necrotic changes that developed in the index (a) and the dorsum (b) of the hand (poor-quality pictures).
80
Fig 3 Case 2, swelling of the middle finger and a necrotic wound at its tip.
improvement. She was therefore hospitalized and received oral doxycycline (100 mg 12-hourly) and intravenous ceftazidime (1 g 8-hourly). However, her clinical condition deteriorated, her arm became very oedematous and she experienced severe pain with a temperature of 39.38C and rigors. She then developed an acute confusional state and became shocked with a systolic blood pressure of 85 mmHg. After resuscitation, an immediate incisional drainage of the palm, which included all interdigital web spaces, was undertaken, as well as a carpal tunnel release. Postoperatively, the patient was monitored in intensive care and was artificially ventilated because of persistent septic and coagulation problems. She was treated by wide-spectrum antibiotics (intravenous ceftazidime 1 g 8-hourly and oral doxycycline 100 mg 12hourly, subsequently substituted with intravenous minocycline 100 mg 12-hourly) and by fresh frozen plasma. She was taken off the ventilator after 2 days and her coagulopathy gradually resolved within 10 days. Her wounds healed by secondary intention. She required prolonged rehabilitation but regained good hand func-
THE JOURNAL OF HAND SURGERY VOL. 27B No. 1 FEBRUARY 2002
Fig 4 Case 3, swelling and a hemorrhagic blister on the dorsal aspect of the thumb.
tion, though had residual extension lags of the metacarpophalangeal and proximal interphalangeal joints of the index, middle and ring fingers.
Case 5 An 81-year-old woman, with no chronic diseases, sustained a prick to her right thumb from a carp fish bone. A few hours later, she developed a necrotic wound and painful swelling of the thumb tip, together with a fever of 38.28C. There was also tender oedema in the forearm. Intravenous amoxycillin-clavulanate (1 g 8hourly) and oral doxycycline (100 mg 12-hourly) were prescribed, and subsequently replaced by intravenous ceftazidime (1 g 8-hourly). However, the infection persisted, and three debridements of the wound were required (Fig 5). Unfortunately, the infection persisted and an amputation of the thumb was subsequently required. The wound was left open, daily dressings were performed and a delayed primary closure was later undertaken.
HAND INFECTION FROM FISH
Fig 5 Case 5, progressive necrotic changes developed in the thumb despite sequential debridements.
All five patients were febrile at some stage of their illness, and all had an elevated erythrocyte sedimentation rate and a leukocytosis. No foreign bodies were visible on the radiographs of the affected hands. Vibrio vulnificus was isolated from wound aspirates from four of the five patients. DISCUSSION Many fish-borne pathogens can cause infection following penetrating injuries by fish bones and fin spines. Several virulent biogroups of Vibrio species can cause infections (Bisharat and Raz, 1996; Bisharat et al., 1999; Nudelman et al., 1997; Said et al., 1998; Tacket et al., 1984; Zielinski and Bora, 1984) either by direct contamination of a skin abrasion, a penetrating injury or rarely by ingestion of the pathogen. Such infections may cause bacteraemia, and are sometimes life-threa-
81
tening, especially in immunocompromised individuals such as those with pre-existing liver diseases (Bisharat et al., 1999; Hlady and Klontz, 1996). Vibrio vulnificus, a gram-negative bacterium, is usually found in warm salt water, especially coastal water, but is also found in brackish inland water (Bisharat and Raz, 1996). In Israel, most of the fish industry uses fishponds, the salinity of which is about 0.5% NaCl (Bisharat and Raz, 1996). In the summer months this salinity may reach 1.25% NaCl due to evaporation (Nudelman et al., 1997) and the water temperature is approximately 278C, both of which provide a suitable environment for Vibrios. Vibrio vulnificus is known for its susceptibility to low temperature and it is thought that changes in fishmarketing practices, such as not packaging the fish in ice and the handling of fresh fish by untrained individuals, result in increased survival of the bacterium, which increases the risk of infection (Bisharat et al., 1999). We report a group of five patients with hand infections which developed after handling fresh carp fish. These ranged from simple local infections to lifethreatening systemic illnesses, with severe coagulopathies, respiratory failure and haemodynamic compromise. In one case no penetrating injury was involved, although a fulminant local and systemic disease developed. The common carp (Cyprinus carpio) is cultivated in Israel for local marketing and export. It is estimated that up to 70% of the pond-cultivated fish in Israel are common carp (Rottbird, 1988). The specific strain of carp available in Israel is a hybrid of various Cyprinidae ancestors which were imported from countries such as Yugoslavia, the Netherlands and China (Rottbird, 1988). It has undergone genetic enhancement and advanced breeding technologies have been applied to increase productivity. It reaches a marketable body weight of about 1 kg within 1 year and is characterized by long dorsal fins. These carp need to be handled carefully and hand infections following exposure to carp fish, even in the absence of an identifiable penetrating injury, should be seriously addressed. In vitro and in vivo studies (Bisharat et al., 1999) have shown that a wide range of antibiotics are effective against the Vibrio vulnificans bacteria, including amoxycillin-clavulanate, third-generation cephalosporins and tetracyclines (Fang, 1992). Nevertheless, this vulnerable pathogen can cause local extensive damage with upredictable systemic complications. Its aggressive behaviour mimics that of the invasive Streptococcus group A bacteria and further investigations are needed to elucidate whether its virulence is due to particular toxins. A high index of suspicion and early aggressive treatment with intravenous antibiotics are required. In addition to obtaining blood cultures, wound aspirates should be gram-stained and cultured. Isolates should preferably be sent to a Vibrio reference laboratory for final identification and strain differentiation. Poor responses to conservative
82
treatment or deterioration in the clinical condition are indications for urgent surgical treatment. Meticulous surgical excision and thorough debridement of all necrotic tissues is then required. References Baack BR, Kucan JO, Zook EG, Russell RC (1991). Hand infections secondary to catfish spines: case reports and literature review. Journal of Trauma, 31: 1432–1436. Bisharat N, Raz R (1996). Vibrio infection in Israel due to changes in fish marketing. The Lancet, 348: 1585–1586. Bisharat N, Agmon V, Finkelstein R et al. (1999). Clinical, epidemiological, and microbiological features of Vibrio vulnificus biogroup 3 causing outbreaks of wound infection and bacteremia in Israel. The Lancet, 354: 1421–1424. Fang FC (1992). Use of tetracycline for treatment of Vibrio vulnificus infection. Clinical infectious Diseases, 15: 1071–1072. Hlady WG, Klontz K (1996). The epidemiology of Vibrio infections in Florida, 1981–1993. Journal of Infectious Diseases, 173: 1176–1183. Huminer D, Pitlik SD, Block C, Kaufman L, Amit S, Rosenfeld JB (1986). Aquarium-borne Mycobacterium marinum skin infection. Report of a case and review of the literature. Archives of Dermatology, 122: 698– 703. Mann JW, Werntz JR (1991). Catfish stings to the hand. Journal of Hand Surgery, 16A: 318–321. Murphey DK, Septimus EJ, Waagner DC (1992). Catfish-related injury and infection: report of two cases and review of the literature. Clinical infectious Diseases, 14: 689–693.
THE JOURNAL OF HAND SURGERY VOL. 27B No. 1 FEBRUARY 2002 Nudelman A, Edelson G, Linden A, Raz R (1997). Infection by Vibrio vulnificus after a prick from the spine of a Tilapia. Harefuah, 133: 502. Patel MR, Wells S (1993). Lionfish envenomation of the hand. Journal of Hand Surgery, 18A: 523–525. Rottbird S. Cyprinus carpio. In: Alon A (ed) Plants and Animals of the Land of Israel. An illustrated encyclopedia, Vol 12. Israeli Ministry of Denfence, The Publishing House and Society for Protection of Nature, 1988: 264–265. Said R, Volpin G, Grimberg B, Friedenstrom SR, Lefler E, Stahl S (1998). Hand infections due to non-cholera Vibrio after injuries from St. Peter’s fish (Tilapia Zillii). Journal of Hand Surgery, 23B: 808–810. Tacket C, Brenner F, Blake P (1984). Clinical features and an epidemiological study of Vibrio vulnificus infections. Journal of Infectious Diseases, 149: 558–561. Weinstein MR, Litt M, Kertesz DA et al. (1997). Invasive infections due to a fish pathogen, Streptococcus iniae (S. iniae study group). New England Journal of Medicine, 337: 589–594. Zielinski CJ, Bora FW Jr (1984). Vibrio hand infections: a case report and review of the literature. Journal of Hand Surgery, 9A: 754–757. Received: 22 February 2001 Accepted after revision: 15 June 2001 Dr S Stahl, Hand Surgery Unit, Rambam Medical Center, POB 9602 Haifa 31096, Israel. E-mail: [email protected] # 2002 The British Society for Surgery of the Hand doi: 10.1054/jhsb.2001.0660, available online at http://www.idealibrary.com on
Upper extremity infection caused by aquatic pathogens on fish is a well recognized clinical entity. We report five consecutive cases of upper extremity infections, ranging from a simple localized reaction to a life-threatening systemic illness, which developed after handling common carp fish (Cyprinus carpio). In four cases, infection occurred following a penetrating injury by either the bones or the fin spines of the fish. V|brio vulni¢cus was isolated from wound aspirates in four cases. Early broad-spectrum antibiotic therapy is mandatory. Deterioration in the clinical condition or a poor response to conservative treatment requires a meticulous surgical drainage and excision of both infected and necrotic tissues. Journal of Hand Surgery (British and European Volume, 2002) 27B: 1: 78–82 INTRODUCTION
Case 1
Upper extremity infections following penetrating injuries by the bones and fin spines of fish are well recognized. The primary injury is usually trivial, and is often overlooked. However, it may result in a devastating local infection, may cause systemic illness in susceptible individuals, and may occasionally cause a potentially fatal multisystem disease. Many aquatic pathogens have been identified as the cause of these conditions. Some of them are natural inhabitants of either brackish or salt water, for example the Vibrio species, especially Vibrio vulnificus (Bisharat et al., 1999). Others are found everywhere, even in home aquariums, such as Mycobacterium marinum (Huminer et al., 1986). Hence the pathogen may be inoculated during an occupational exposure, though anglers and fish fanciers are also at risk. Other pathogens have been isolated, including Streptococcus iniae (Weinstein et al., 1997), Aeromonas hydrophila, Enterobacteriaceae and Pseudomonas species (Murphey et al., 1992). Various species of fish can transmit infections. These include catfish (Baack et al., 1991; Mann and Werntz, 1991; Murphey et al., 1992), lionfish (Pterois volitans) (Patel and Wells, 1993) and St. Peter’s fish (Tilapia Zillii) (Bisharat et al., 1999; Said et al., 1998). We report five adults who developed upper extremity infections after handling common carp (Cyprinus carpio) (Fig 1), which is widely eaten but has not been recognized as a potential source of infections. Four of the five patients have incurred ‘‘finning’’ injuries to the hand from either bones or spine of the fish.
A 67-year-old women with a history of a chronic coronary heart and cerebrovascular disease, who required long-term anticoagulant therapy, punctured her right index finger with a fresh carp fish spine. Fourteen hours later she developed painful swelling of her index finger and hand tenderness. Clinical examination revealed localized tenderness, swelling, discoloration, blisters and skin epidermiolysis in the index finger and on the dorsum of the hand, which extended onto the palm. She was initially treated with intravenous amoxycillin-clavulanate (1 g 8-hourly) but developed septicaemia. An urgent incisional drainage of the index finger and the palm was therefore carried out. On the next day, irreversible necrotic changes were observed in the index finger and in the skin on the dorsum of the hand (Fig 2). An amputation of the index finger with meticulous debridement of the necrotic tissues was performed. This resulted in a rapid clinical improvement and pain alleviation. The patient refused to undergo further surgical procedures, and thus daily wound dressings were undertaken. The wounds healed by secondary intention within 5 weeks. Despite prompt physical therapy, including passive and active exercises, the patient was left with restricted finger movement and reduced grip strength. Case 2 A 67-year-old woman with non-insulin dependent diabetes mellitus and chronic coronary heart disease was admitted to hospital 24 hours after sustaining a puncture injury from a spine of a fresh carp fish to the tip of her right middle finger. There was rapidly increasing swelling, tenderness and restricted motion of her middle finger, which had not responded to oral antibiotic therapy (Fig 3). This lady was treated by intravenous amoxycillin-clavulanate (1 g 8-hourly) and responded well. Her fever, swelling and pain resolved,
CLINICAL CASES Five adult patients were treated between 1999 and 2000 at our Hand Surgery units. 78
HAND INFECTION FROM FISH
Fig 1 A common carp fish (Cyprinus carpio). Note the serrated dorsal and ventral fins.
and she was discharged after 4 days. She made an uneventful recovery and regained full finger motion. Case 3 A 68-year-old healthy man pricked his right thumb on a carp fish spine. Thirty-six hours later he presented with
79
marked swelling and tenderness of his thumb, which had been treated with oral antibiotics by his family physician. As he was experiencing increasing pain, swelling, blister formation (Fig 4) and had a temperature of 39.48C, an incisional drainage was performed on the palmar aspect of the thumb. Serous fluid with necrosis of the subcutaneous fat was found. Intravenous amoxycillin-clavulanate was administered perioperatively and the wound subsequently healed by secondary intention. At 6 months’ follow-up, he still had minor residual swelling and an extension lag of 108 at the thumb interphalangeal joint. However, there was no evidence of persistent infection. Case 4 A 64-year-old woman with liver cirrhosis due to chronic viral hepatitis (type C) and hypersensitivity to penicillin developed progressive pain and swelling of her right hand and forearm shortly after she had handled fresh carp fish. She denied any identifiable injury to her hands. Oral cloxacillin was administered without any
Fig 2 Case 1, irreversible necrotic changes that developed in the index (a) and the dorsum (b) of the hand (poor-quality pictures).
80
Fig 3 Case 2, swelling of the middle finger and a necrotic wound at its tip.
improvement. She was therefore hospitalized and received oral doxycycline (100 mg 12-hourly) and intravenous ceftazidime (1 g 8-hourly). However, her clinical condition deteriorated, her arm became very oedematous and she experienced severe pain with a temperature of 39.38C and rigors. She then developed an acute confusional state and became shocked with a systolic blood pressure of 85 mmHg. After resuscitation, an immediate incisional drainage of the palm, which included all interdigital web spaces, was undertaken, as well as a carpal tunnel release. Postoperatively, the patient was monitored in intensive care and was artificially ventilated because of persistent septic and coagulation problems. She was treated by wide-spectrum antibiotics (intravenous ceftazidime 1 g 8-hourly and oral doxycycline 100 mg 12hourly, subsequently substituted with intravenous minocycline 100 mg 12-hourly) and by fresh frozen plasma. She was taken off the ventilator after 2 days and her coagulopathy gradually resolved within 10 days. Her wounds healed by secondary intention. She required prolonged rehabilitation but regained good hand func-
THE JOURNAL OF HAND SURGERY VOL. 27B No. 1 FEBRUARY 2002
Fig 4 Case 3, swelling and a hemorrhagic blister on the dorsal aspect of the thumb.
tion, though had residual extension lags of the metacarpophalangeal and proximal interphalangeal joints of the index, middle and ring fingers.
Case 5 An 81-year-old woman, with no chronic diseases, sustained a prick to her right thumb from a carp fish bone. A few hours later, she developed a necrotic wound and painful swelling of the thumb tip, together with a fever of 38.28C. There was also tender oedema in the forearm. Intravenous amoxycillin-clavulanate (1 g 8hourly) and oral doxycycline (100 mg 12-hourly) were prescribed, and subsequently replaced by intravenous ceftazidime (1 g 8-hourly). However, the infection persisted, and three debridements of the wound were required (Fig 5). Unfortunately, the infection persisted and an amputation of the thumb was subsequently required. The wound was left open, daily dressings were performed and a delayed primary closure was later undertaken.
HAND INFECTION FROM FISH
Fig 5 Case 5, progressive necrotic changes developed in the thumb despite sequential debridements.
All five patients were febrile at some stage of their illness, and all had an elevated erythrocyte sedimentation rate and a leukocytosis. No foreign bodies were visible on the radiographs of the affected hands. Vibrio vulnificus was isolated from wound aspirates from four of the five patients. DISCUSSION Many fish-borne pathogens can cause infection following penetrating injuries by fish bones and fin spines. Several virulent biogroups of Vibrio species can cause infections (Bisharat and Raz, 1996; Bisharat et al., 1999; Nudelman et al., 1997; Said et al., 1998; Tacket et al., 1984; Zielinski and Bora, 1984) either by direct contamination of a skin abrasion, a penetrating injury or rarely by ingestion of the pathogen. Such infections may cause bacteraemia, and are sometimes life-threa-
81
tening, especially in immunocompromised individuals such as those with pre-existing liver diseases (Bisharat et al., 1999; Hlady and Klontz, 1996). Vibrio vulnificus, a gram-negative bacterium, is usually found in warm salt water, especially coastal water, but is also found in brackish inland water (Bisharat and Raz, 1996). In Israel, most of the fish industry uses fishponds, the salinity of which is about 0.5% NaCl (Bisharat and Raz, 1996). In the summer months this salinity may reach 1.25% NaCl due to evaporation (Nudelman et al., 1997) and the water temperature is approximately 278C, both of which provide a suitable environment for Vibrios. Vibrio vulnificus is known for its susceptibility to low temperature and it is thought that changes in fishmarketing practices, such as not packaging the fish in ice and the handling of fresh fish by untrained individuals, result in increased survival of the bacterium, which increases the risk of infection (Bisharat et al., 1999). We report a group of five patients with hand infections which developed after handling fresh carp fish. These ranged from simple local infections to lifethreatening systemic illnesses, with severe coagulopathies, respiratory failure and haemodynamic compromise. In one case no penetrating injury was involved, although a fulminant local and systemic disease developed. The common carp (Cyprinus carpio) is cultivated in Israel for local marketing and export. It is estimated that up to 70% of the pond-cultivated fish in Israel are common carp (Rottbird, 1988). The specific strain of carp available in Israel is a hybrid of various Cyprinidae ancestors which were imported from countries such as Yugoslavia, the Netherlands and China (Rottbird, 1988). It has undergone genetic enhancement and advanced breeding technologies have been applied to increase productivity. It reaches a marketable body weight of about 1 kg within 1 year and is characterized by long dorsal fins. These carp need to be handled carefully and hand infections following exposure to carp fish, even in the absence of an identifiable penetrating injury, should be seriously addressed. In vitro and in vivo studies (Bisharat et al., 1999) have shown that a wide range of antibiotics are effective against the Vibrio vulnificans bacteria, including amoxycillin-clavulanate, third-generation cephalosporins and tetracyclines (Fang, 1992). Nevertheless, this vulnerable pathogen can cause local extensive damage with upredictable systemic complications. Its aggressive behaviour mimics that of the invasive Streptococcus group A bacteria and further investigations are needed to elucidate whether its virulence is due to particular toxins. A high index of suspicion and early aggressive treatment with intravenous antibiotics are required. In addition to obtaining blood cultures, wound aspirates should be gram-stained and cultured. Isolates should preferably be sent to a Vibrio reference laboratory for final identification and strain differentiation. Poor responses to conservative
82
treatment or deterioration in the clinical condition are indications for urgent surgical treatment. Meticulous surgical excision and thorough debridement of all necrotic tissues is then required. References Baack BR, Kucan JO, Zook EG, Russell RC (1991). Hand infections secondary to catfish spines: case reports and literature review. Journal of Trauma, 31: 1432–1436. Bisharat N, Raz R (1996). Vibrio infection in Israel due to changes in fish marketing. The Lancet, 348: 1585–1586. Bisharat N, Agmon V, Finkelstein R et al. (1999). Clinical, epidemiological, and microbiological features of Vibrio vulnificus biogroup 3 causing outbreaks of wound infection and bacteremia in Israel. The Lancet, 354: 1421–1424. Fang FC (1992). Use of tetracycline for treatment of Vibrio vulnificus infection. Clinical infectious Diseases, 15: 1071–1072. Hlady WG, Klontz K (1996). The epidemiology of Vibrio infections in Florida, 1981–1993. Journal of Infectious Diseases, 173: 1176–1183. Huminer D, Pitlik SD, Block C, Kaufman L, Amit S, Rosenfeld JB (1986). Aquarium-borne Mycobacterium marinum skin infection. Report of a case and review of the literature. Archives of Dermatology, 122: 698– 703. Mann JW, Werntz JR (1991). Catfish stings to the hand. Journal of Hand Surgery, 16A: 318–321. Murphey DK, Septimus EJ, Waagner DC (1992). Catfish-related injury and infection: report of two cases and review of the literature. Clinical infectious Diseases, 14: 689–693.
THE JOURNAL OF HAND SURGERY VOL. 27B No. 1 FEBRUARY 2002 Nudelman A, Edelson G, Linden A, Raz R (1997). Infection by Vibrio vulnificus after a prick from the spine of a Tilapia. Harefuah, 133: 502. Patel MR, Wells S (1993). Lionfish envenomation of the hand. Journal of Hand Surgery, 18A: 523–525. Rottbird S. Cyprinus carpio. In: Alon A (ed) Plants and Animals of the Land of Israel. An illustrated encyclopedia, Vol 12. Israeli Ministry of Denfence, The Publishing House and Society for Protection of Nature, 1988: 264–265. Said R, Volpin G, Grimberg B, Friedenstrom SR, Lefler E, Stahl S (1998). Hand infections due to non-cholera Vibrio after injuries from St. Peter’s fish (Tilapia Zillii). Journal of Hand Surgery, 23B: 808–810. Tacket C, Brenner F, Blake P (1984). Clinical features and an epidemiological study of Vibrio vulnificus infections. Journal of Infectious Diseases, 149: 558–561. Weinstein MR, Litt M, Kertesz DA et al. (1997). Invasive infections due to a fish pathogen, Streptococcus iniae (S. iniae study group). New England Journal of Medicine, 337: 589–594. Zielinski CJ, Bora FW Jr (1984). Vibrio hand infections: a case report and review of the literature. Journal of Hand Surgery, 9A: 754–757. Received: 22 February 2001 Accepted after revision: 15 June 2001 Dr S Stahl, Hand Surgery Unit, Rambam Medical Center, POB 9602 Haifa 31096, Israel. E-mail: [email protected] # 2002 The British Society for Surgery of the Hand doi: 10.1054/jhsb.2001.0660, available online at http://www.idealibrary.com on