V. fluvialis infection’s typical clinical presentation is gastroenteritis. Nevertheless, an increasing incidence of extraintestinal infections has been reported, most commonly observed in insular or peninsular regions of Asia. These include otitis [11], wound infections [9, 10], necrotizing fasciitis [12], hemorrhagic cellulitis and cerebritis [13], cholangitis [14,15,16,17], peritonitis [18, 19], liver abscess [20], walled-off pancreatic necrosis [21], and urinary tract infections [22], in some cases with associated bacteremia [13,14,15, 20, 23,24,25,26,27]. A review of published literature on patients with V. fluvialis bacteremia highlighting key clinical and epidemiological features, antimicrobial treatment and outcome is summarized in Table 2.

Water or seafood exposure was noted in most of cases [5, 6]. Most of the patients affected by V. fluvialis bacteremia were middle-aged males [13, 15, 20, 24, 26, 27], many of them were affected by more than one comorbidity [14, 15, 24,25,26], primarily diabetes mellitus [14, 24,25,26], and approximately 35% of them died [13, 23, 26].

In our knowledge, V. fluvialis bacteremia has never been reported in Europe, while only one case of biliary infection with liver abscess has been reported worldwide, in Japan [20]. Our patient was a frail immunocompromised man with diabetes mellitus; the family denied salt water and seafood exposure, especially raw. The clinical presentation was atypical for cholangitis: he complained of severe epigastric and right upper quadrant pain but the first blood test was totally normal and he did not develop fever in any moment. In line with the high mortality of the documented extra intestinal infections, the prognosis of our patient was poor, quickly developing refractory septic shock and death despite optimal treatment. In our case, the patient was treated with ceftriaxone, to which the bacterium demonstrated susceptibility according to EUCAST breakpoint criteria. In previously documented cases of extraintestinal V. fluvialis infections, antimicrobial treatment strategies have been diverse, with both monotherapy and combination therapy commonly incorporating beta-lactams alongside aminoglycosides, quinolones, or tetracyclines, among the most frequently employe approaches [9, 11,12,13,14,15,16, 18,19,20,21,22,23,24,25,26].

The incidence of human Vibrio spp. infections is increasing worldwide [28]. Contributing factors to this trend include the global increase in seafood consumption, the internationalization of seafood trade, the expanding use of coastal waters for recreational purposes, and the effects of climate change, particularly rising sea surface temperatures, which promote the proliferation of Vibrio spp [28, 29]. As raw seafood consumption is getting more common than before, physicians should consider V. fluvialis infection alongside other Vibrio species in patients with exposure to seafood, especially if they are immunocompromised and/or affected by diabetes mellitus.