A 28yearold man presented with a 4day history of progressively worsening left calf pain and swelling that began after he was bitten by a dog. He also complained of fevers and rigors. Initial temperature was 38.4°C, blood pressure 100/52 mmHg, and heart rate 123 bpm. Examination revealed diffuse edema,blanching erythema extending from the ankle to the knee,and a small 1cm wound on the posterior calf. Admission labs were significant for WBC of 5.4 K/mcL, CPK 690 U/L, and unremarkable chemistry. An XRAY was normal and ultrasound showed only a tiny superficial fluid collection in the posterior calf. He was admitted for cellulitis and started on vancomycin and ampicillin/sulbactam. Next day, he became febrile to 40.0°C and progressively hypotensive to 81/45 mmHg despite antibiotics and aggressive fluid resuscitation. Given worsening calf swelling and concern for deep abscess, bedside needle aspiration was performed and yielded bloody, purulent fluid. He was promptly taken to the operating room by general surgery, and 65 mL of foulsmelling pus was drained from a tense subcutaneous abscess cavity. Intraoperative culture grew Pasteurella spp, though blood cultures remained negative. He remained tenuous throughout the day and became hypotensive to 78/57 mmHg before gradually recovering with aggressive treatment. Given his unexpectedly normal WBC, an HIV test was performed; it returned positive. He was discharged on hospital day 8 with amoxicillinclavulanate to finish a 14day course of therapy.
The common pathogens in wound infections following animal bites include their oral flora such as Pasteurella, Capnocytophaga, and anaerobes, as well as human skin commensals such as streptococci and staphylococci. Of these, Pasteurella spp. are the most commonly identified pathogens in dog bites. Pasteurella infections, particularly those involving PP. multocida, commonly trigger a profound inflammatory response that typically starts within 24 hours of exposure. Pasteurella soft tissue infection is characterized by pain and swelling and may present as wound infection, cellulitis, abscess, or, rarely, necrotizing fasciitis. Alternately, bone and joint infections can occur and manifest as osteomyelitis or septic arthritis. Respiratory infection can also be seen, while bacteremia, meningitis, and peritonitis are more rare but serious entities. As highlighted in this case, patients with Pasteurella infections may become severely ill and develop fulminant sepsis. This presentation has been reported more frequently in immunocompromised patients such as ours. Successful treatment of Pasteurella wound infections requires not only appropriate antibiotics, but also adequate debridement and abscess drainage. In our patient, a delay in identifying and draining a deepseated abscess likely contributed to his severe illness.
Infections following animal bites can infrequently produce a syndrome of severe septicemia, particularly in patients infected with HIV.
To cite this abstract:Patel A, Kalra G. Put a Leash on It Severe Sepsis and Shock Following Canine Attack. Abstract published at Hospital Medicine 2012, April 1-4, San Diego, Calif. Abstract 97766. Journal of Hospital Medicine. 2012; 7 (suppl 2). https://www.shmabstracts.com/abstract/put-a-leash-on-it-severe-sepsis-and-shock-following-canine-attack/. Accessed May 23, 2019.