We initially considered the possibility of a bacterial infection with Vibrio. Multiple blood cultures and a skin culture were negative. In addition, this patient's presentation was not consistent with V. vulnificus infection, which has been associated with three very different clinical syndromes: primary septicemia, wound infections, and gastrointestinal illness without septicemia or wound infection [1]. Patients with primary septicemia have a preexisting liver disease, and some have reported a recent history of consuming raw oysters. Patients with wound infections often have fever, pain and swelling at the wound site, and cellulitis. In a study of the clinical and epidemiologic features of V. vulnificus infections in Florida from 1981 to 1987, V. vulnificus was cultured from the wound site alone in 8 of 17 patients with wound infections and from skin lesions or blood in the rest. Of the four patients who died, all had blood cultures positive for V. vulnificus, and all had underlying chronic diseases. None of the 11 patients without chronic diseases died. Rapid extension of the cellulitis and swelling in the same extremity as the wound was seen.

Our patient was a healthy young man with no underlying illness. Dexamethasone was started in his second visit to the hospital. At that time, 24 hours after the sting, he was already encephalopathic. Blood and wound cultures were all negative, and no evidence of cellulitis or inflammation was noted surrounding the lesion. Liver study findings did not suggest ischemic liver injury.

A lower IgG titer is more consistent with previous exposure. Although it would have been preferable to measure IgM, the technique for this is not available. Because the titers were high and were from the same species recognized as the offender, we feel that the serologic results indicate acute envenomation.