1. See supplemental attachment for references. A Fishmonger’s Tale Lysenia Mojica, MD 1 *, Lily Jones, DO 1, Abraham Yacoub, MD 1, Tyler Janz, BS 1, John N. Greene, MD 2 1 University of South Florida Morsani College of Medicine 2 Moffitt Cancer Center, Tampa, FL Fish are vectors of several zoonoses that can pose serious health problem in immunocompromised patients. The clinical manifestation is often cutaneous and occurs at the site of inoculation. However, bacteremia and deep-seated infection have been described. Vibrio spp, Mycobacterium marinum, Aeromonas, and Streptococcus iniae are among the most common bacteria linked to these cutaneous infections. Certain chronic medical conditions can predispose fishmongers to infections. We report a case of Pseudomonas aeruginosa causing ecthyma gangrenosum in an immunosuppressed patient after fish handling and review the literature of previously reported cases of fish handling related infections. INTRODUCTION Thirty-eight cases of infections acquired through fish handling were identified. The median age was 58 years. The most common underlying medical conditions were diabetes mellitus (DM), alcoholism, and rheumatic heart disease (RHD). The most common bacteria involved were Streptococcus iniae (11 cases), Vibrio vulnificus (7 cases), and Mycobacterium marinum (7 cases). Other pathogens reported were Erysipelothrix rhusiopathiae, Aeromonas hydrophila, Vibrio damsela, Proteus vulgaris, Morganella morganii, Lactococcus garvieae, Mycobacterium abscessus, Streptococcus halichoeri, and as in our case, Pseudomonas aeruginosa. Cellulitis was the most common manifestation but necrotizing fasciitis, tenosynovitis, osteomyelitis, endocarditis, and septic shock have been documented. Beta-lactam agents such as penicillin, or ampicillin-sulbactam were often prescribed for streptococcal infection while anti-mycobacterial agents such as rifampin, ethambutol, and clarithromycin were often used for M. marinum infection. Four cases of death were reported, representing a mortality of 11%. RESULTS PUBMED search from 1990 to 2014 utilizing keywords of “fishmonger” etc. The data was organized into table format which include basic demographics such as age, sex, underlying chronic medical condition, isolated bacteria in culture, type of infection, the treatment employed, and outcome. After collecting the data, a comparative analysis was performed. Figure 1 MRI of a patient with second right digit cellulitis consistent with ecthyma gangrenosum after handling fish. Blood cultures grew Pseudomonas aeruginosa. METHODS CONCLUSIONS REFERENCES Chronic medical conditions such as DM, alcoholism, and RHD can predispose patients to infection, particularly among fishmongers. Early recognition of infection especially in immunosuppressed patients was important Streptococcus iniae, Vibrio vulnificus, and Mycobacterium marinum were the most common bacteria causing cutaneous infections in fishmongers. The majority of the patients treated with a beta-lactam antibiotic. For example the use of ampicillin-sulbactan for S. iniae infections resulted in an overall good outcome. A thorough history, including occupational and recreational exposure, is essential to prompt the clinician to consider these atypical zoonotic pathogens in the differential diagnoses and provide the appropriate management in a timely manner. CT scans of the same patient revealing resolution of a large 6.5 cm right middle lobe pneumonia CASE REPORT 686 *lmojica@health.usf.edu A 48-year-old male with history of chronic lymphocytic leukemia presented with neutropenic fever and right second digit cellulitis. The patient reported that 4 days prior to admission, he accidently injured his right second digit from a fishing line. He continued to handle and process fish after the incident. The patient also was recently admitted to the hospital with a right upper lung nodular consolidation that was thought to be secondary to bacterial pneumonia versus a less likely fungal pneumonia. His review of systems was unremarkable other than a temperature of 100.4 °F and an erythematous right second digit. His physical examination was pertinent for right second digit with a 3 x 1 cm lesion with violaceous discoloration with surrounding erythema. An early black eschar was forming and was deemed consistent with ecthyma gangrenosum. The palm of the hand had a 0.5 cm circular area of erythema as well from a second puncture wound. Laboratory workup revealed WBC 0.61 / mm 3, absolute neutrophil count 310, absolute lymphocyte count 180, creatinine 1.0 mg/dL, and liver function tests within normal limits. Blood cultures grew Pseudomonas aeruginosa. The patient was treated empirically with vancomycin, cefepime, and levofloxacin. Subsequently the regimen was narrowed to cefepime for a total of 2 weeks. Figure 2 Figure 3