Dog Bite SepticemiaDisseminated Intravascular Coagulation (DIC) from Capnocytophaga

Septicemia in an Asplenic Patient

Presented by Ariel L. Sarmiento, MPHRegion 1 Epidemiologist

( Ballard • Carlisle • Calloway • Fulton • Graves • Hickman Marshall • McCracken )

Epi Rapid Response Team Annual Conference August 30th, 2005

Frankfort, KY

Introduction

• Septicemia in pts. with Hx of splenectomy well documented in published literature

• much rarer, septicemia cases leading to deaths secondary to dog or cat bites also well documented

• Most common organism involved is Capnocytophaga canimorsus or others that are of the same species (Sarma, P., Mohanty S., 2001)

Introduction

• C. canimorsus (formerly known an Dysgonic fermenter 2 [Df2]) part of canine and feline normal flora (Centers for Disease Control and Prevention,1992)

• With asplenic humans, pathogen can be deadly (Centers for Disease Control and Prevention,1992)

Epidemiology of Bites

(CDC, 2003; PatientPlus, 2005)

• Most bite wounds caused by:– Dogs (60 - 90%)– Cats (5 - 18%)– Humans (4 – 23%)

• In 2001, 368,245 persons in US were tx for dog bite injuries ( incidence rate of 129.3/100,000)

Epidemiology of Bites

• Only 20% of people bitten by a dog seek medical help

• 1% of these people require hospitalization

• Around 42% of dog bites occur among children aged < 14 years, most often from a household pet

Epidemiology of Bites

• More than 70% of animal bites are caused by family pets or animals known to the person

• Incidence of dog bites increases during April to September (warmer months– dog bite prevention is in May)

• Most common injuries are to the arm and/or hand

Epidemiology of Bites

• Most common circumstances surrounding dog bites involving adults:– Trying to help an injured dog– Breaking up a fight between dogs

Literature Review

• Texas, early 90’s (August, J., 1990)

– 28 y.o. – Dog groomer in Vet clinic– Bitten in forearm by 2 y.o. male cocker spaniel– Bite wound area cleansed with povidone-iodine– Started Sx 3 days later: c/o chills, malaise,

weakness, ↑pain at bite site– Hx of splenectomy discovered when surgical scar

was observed in upper L quadrant of abdomen, spouse provided info upon questioning

Literature Review

• Texas, early 90’s(cont’d)…– IV penicillin treatment started after blood and

CSF specimens were collected– Capnocytophaga canimorsus (then known as

Dysgonic-fermenter 2) isolated after 5 days from pt specimen

– Pt recovered after antimicrobial therapy and treatment for renal failure without further complication

Literature Review

• New Mexico, June 1992 (CDC, 1992)

– 50 y. o. – Initially diagnosed as plague resulting to

septicemia– Undetermined source of infection with

possibilities arising from dog bite:• Pt owned several dogs• Add’l Hx provided by family indicated a swollen thumb• Hx of chronic alcohol consumption 4 – 6 drinks/day

– c/o of epigastric pain, nausea, fever, chills, rash

Literature Review

• New Mexico, June 1992 (cont’d…)– Tx with IV antibiotics but died of acute renal

failure and acute respiratory distress syndrome 3 days after ER presentation

– No Hx of splenectomy or immunosuppression– Autopsy reports confirmed internal hemmorhage

consistent with gram negative sepsis (DIC)– Capnocytophaga canimorsus (then known as

DF2) isolated from blood and CSF culture

Literature Review

• June 2004 (Deshmukh, P., et al, 2004)

– 45 y.o. – Employed by animal shelter where she was bitten

by a dog– No Hx of splenectomy,immunosuppresion,

alcohol abuse, or costicosteroid therapy– Pt presented to ER late in the course of infection – This may have greatly contributed to her death

Capnocytophaga Canimorsus:Microbiology and Pathology

• Previously classified by CDC as part of Group Dysgonic Fermenter-2 (DF-2)

• Slow growing gram negative rod-shaped bacterium

• Fastidious -- requires CO2 for growth

Capnocytophaga Canimorsus:Microbiology and Pathology

Capnocytophaga Canimorsus:Microbiology and Pathology

• Isolated from saliva of healthy dogs and cats as part of normal flora

• Human normal oral flora may also contain Capnocytophaga spp. – documented to cause periodontal disease

• Susceptible to various antibiotics:– penicillin, amoxicillin, erythromycin, tetracycline,

cefoxitine and clindamycin

Capnocytophaga Canimorsus:Microbiology and Pathology

• Opportunistic pathogen with low virulence except in susceptible hosts:

– Asplenia: splenectomy due to either abdominal trauma or underlying medical disorders (the latter being more susceptible to opportunistic infections)

• Splenectomized individuals are 30 to 200 times more prone to die from bacterial infections;

• highest is during 1st 2 years after splenectomy

Capnocytophaga Canimorsus:Microbiology and Pathology

• These individuals do not produce enough IgM and IgG2 (the spleen produces B cells which develop into antibody-producing plasma cells, memory cells)

• Also delayed macrophage mobilization (key defense against bacterial infection) occurs (spleen along with the liver contain macrophages that engulf and destroy foreign particulates such as bacteria in the bloodstream)

Capnocytophaga Canimorsus:Microbiology and Pathology

• Other high risk variables:

– Immunocompromised status (AIDS, chronic diabetes, etc)

– Chronic alcohol abuse

– Chronic pulmonary disease

– Hematologic malignancies

Capnocytophaga Canimorsus:Microbiology and Pathology

• First known case of infection was in 1976 when organism was isolated from a pt’s CSF and blood (August, J., year unknown).

Case Report

• Pt. Demographics/Medical Hx– 32 y. o., with Hx of splenectomy (done 5 years

prior due to abdominal trauma)

• Hx of illness – Pt woke up at 3 am, c/o fever, body aches,

nausea, vomiting, diarrhea x 10, hot and cold, chills and shaking, dizziness after each diarrhea episode

Case Report

• Hx of illness (cont’d…)– Presented at ER afternoon of same day

– Admitted to surgical floor with a Dx of gastroenteritis probably of viral etiology

– No Hx of ingestion of possibly contaminated food

Case Report

• Course of action, treatment, death– No Hx of close associates or family members

having enteric illness or Sx thereof

– Upon admission, immediately Tx for dehydration

– Given Hx of splenectomy, blood cultures were ordered to check for bacterial infection

Case Report

• Course of action, treatment, death (cont’d…)– CBC differential ordered

– @ 8 PM, Pt eventually revealed Hx of dog bite 2 days ago

– Extremities had already turned blue and mottled

suggesting compromised peripheral circulation

Case Report

• Course of action, treatment, death (cont’d…)– Thereafter, aggressive IV Tx with antimicrobials

was initiated

– Now evident that pt. had septic picture from a dog bite

– Now treated as a “life-threatening” event because of asplenic state

– Pt condition deteriorated rapidly

Case Report

• Course of action, treatment, death (cont’d…)– Pt transferred to CCU, ambu-bagged, intubated

– CPR performed, add’l epinephrine, bicarbonate, atropine administered then electric shock

– Code called at 11:09 pm

– Blood culture grew Capnocytophaga canimorsus

Case Report

• Autopsy

– Confirmed Disseminated Intravascular Coagulation (DIC) as cause of death

– Scabbed wounds on medial aspect of L hand consistent with dog bite

Discussions

• DIC as cause of death:

Mechanism of syndrome

Uncontrolled proliferation ofUncontrolled proliferation of

pathogen in the bloodstreampathogen in the bloodstream

aided by asplenic stateaided by asplenic state

Gram negative bacteriaGram negative bacteria

(as in this case) produces (as in this case) produces

a certain endotoxina certain endotoxin

Endotoxin activates severalEndotoxin activates several

steps in coagulation processsteps in coagulation process

Uncontrolled coagulation cascade occursUncontrolled coagulation cascade occurs

1.1. Can result to multiple Can result to multiple

organ failure due to organ failure due to

compromised circulationcompromised circulation

2.2. Peripheral circulation Peripheral circulation

also compromisedalso compromised

End-stage of DIC occurs: coagulation factors areEnd-stage of DIC occurs: coagulation factors are

depleted resulting to massive internal hemorrhagedepleted resulting to massive internal hemorrhage

Discussion

• Late discovery of dog bite Hx• Narrative on dog bite Hx

– Pt’s dog got into a fight with 2 other neighborhood dogs, pt intervened and got bitten by own dog in the process

– Dog initially quarantined but turned up clinically healthy (“rabies-free”) with up-to-date Hx of vaccination

• Description of wound– not severe (physical appearance)– Initially not thought of as serious by patient

Discussion

• Consultation with Frankfort– Dr. Auslander’s knowledge bank:

• LHD was informed by Hospital ICN the morning after pt’s death

• Hospital staff members were puzzled by the events• LHD consulted with Dr. Auslander who readily

recognized the s/sx of sepsis due to C. canimorsus• LHD received literature from Dr. Auslander and it was

immediately shared with hospital staff

Conclusions and Recommendations

• Protocols on prophylaxis for asplenic pts?

• How to protect against risks associated with asplenic state?

ReferencesAugust, J. (1990). Dysgonic fermenter-2 infections, Zoonosis Updates from the

Journal of the American Veterinary Medical Association. American Veterinary Medical Association Monograph, Library of Congress catalog number 90-082996.

Centers for Disease Control and Prevention (1992). Capnocytphaga canimorsus sepsis misdiagnosed as plaue– New Mexico, 1992. Retrieved May 16, 2005 from CDC website: http://www.cdc.gov/mmwr/preview/mmwrhtml/00019514.htm

Centers for Disease Control of Prevention (2003). Nonfatal dog bite—related injuries treated in hospital emergency departments—United States, 2001. MMWR, 52, 605-610.

Deshmukh, P., et al (2004). Capnocytophaga canimorsus sepsis with purpura fulminans and symmetrical gangrene following a dog bite in a shelter employee. The American Journal of the Medical Sciences, 327, 369-372.

Isselbacher, K. et al. (1996). Harrison’s Principle of Internal Medicine (13th ed). New York: McGraw-Hill.

References

Levi, M., ten Cate, H. (1999). Disseminated Intravascular Coagulation. The New England Journal of Medicine, 341, 586-592.

PatientPlus (2005). Bites- Human and Animal. Retrieved July 19,2005 from PatientPlus website: http://www.patient.co.uk/showdoc/40024910

Sarma, P., Mohanty S. (2001). Capnocytophaga cynodegmi cellulitis, bacteremia and pneumonitis in a diabetic man. Journal of Clinical Microbiology, 39, 2028-2029.

Schmaier, A. (2004). Disseminated Intravascular Coagulation. Retrieved August 11,2005 from E-Medicine Website: http://www.emedicine.com/med/topics577.htm

Thank You!!!!