Correspondence

Infected Dog and Cat Bites

N Engl J Med 1999; 340:1841-1842June 10, 1999

Article

To the Editor:

In their analysis of infected dog and cat bites, Talan et al. (Jan. 14 issue)1 found that pasteurella species could be isolated from 50 percent of infected dog-bite wounds. In the accompanying editorial, Fleisher2 mentioned the importance of careful exploration of apparently trivial animal-bite wounds in order to rule out damage to underlying structures or penetration of body cavities.

We describe a 21-month-old boy who had been bitten by a dog on the left side of his head one month previously. He had been examined in a clinic and was discharged with no medication after the wound was cleaned. Three weeks later the child became unwell, with poor appetite, regression, and inability to move the right side of his body. On admission, he was drowsy, with a temperature of 39.5°C and no neck stiffness. He had a puncture mark on the left side of the scalp, with surrounding swelling of soft tissue. Examination confirmed right hemiplegia. A computed tomographic scan of the head (Figure 1Figure 1Contrast-Enhanced Computed Tomographic Scan of the Head of a Child, Showing a Large, Ring-Enhancing Lesion in the Left Frontoparietal Area with Edema and Mass Effect.) showed irregularity of the left coronal suture near the vertex, with an underlying large, ring-enhancing lesion in the left frontoparietal area. Surrounding edema and mass effect had caused obliteration of the left lateral ventricle and dilatation of the right lateral ventricle.

The cerebral abscess was treated surgically with burr-hole drainage of 100 ml of pus. Pasteurella multocida, which is susceptible to penicillin, was isolated from the pus. Penicillin and chloramphenicol were administered orally for six weeks postoperatively. One month later, the child had minor residual weakness; he was able to walk and beginning to talk. Follow-up at six weeks showed continued improvement.

We know of only one previous report3 of a brain abscess due to P. multocida after severe, penetrating dog-bite injuries to the head of a child. In the case of our patient, the dog bite appeared initially to be minor, with only a single puncture wound, but ultimately resulted in cerebral abscess.

This case report highlights the fact that seemingly trivial animal bites can result in severe complications and that P. multocida is an important cause of infection in dog bites. The use of prophylactic antibiotics has been recommended for all bites to the head and neck, and such an approach might have averted the devastating consequences in our patient. Dog bites can be regarded as trivial only in retrospect.4

Nicola Jones, M.B., B.S., M.R.C.P.
Manikhant Khoosal, B.Sc.
Baragwanath Hospital, Johannesburg 2000, South Africa

4 References

1
Talan DA, Citron DM, Abrahamian FM, Moran GJ, Goldstein EJC. Bacteriologic analysis of infected dog and cat bites. N Engl J Med 1999;340:85-92
Full Text | Web of Science | Medline

2
Fleisher GR. The management of bite wounds. N Engl J Med 1999;340:138-140
Full Text | Web of Science | Medline

3
Klein DM, Cohen ME. Pasteurella multocida brain abscess following perforating cranial dog bite. J Pediatr 1978;92:588-589
CrossRef | Web of Science | Medline

4
Moore F. “I've just been bitten by a dog.“ BMJ 1997;314:88-90
CrossRef | Web of Science | Medline

To the Editor:

Talan and colleagues conducted a prospective, multicenter study of dog and cat bites that met specific criteria for infection; their study included culturing of specimens for aerobic and anaerobic bacteria. They conclude that “infected dog and cat bites have a complex microbiologic mix that usually includes pasteurella species but may also include many other organisms not routinely identified . . . and not previously recognized as bite-wound pathogens.”

Several studies have suggested that cats are the reservoir for Bartonella henselae. 1 Zangwill and colleagues2 found that patients with cat scratch disease were most likely to have been scratched or bitten by a kitten. An estimated 24,000 cases of cat scratch disease occur annually in the United States, with 2000 hospital admissions. Even here in Japan, we have detected serum IgG antibody to B. henselae (titer, >1:64) on standard immunofluorescence assay in 3 of 200 healthy, pregnant women. The prevalence of bartonella infection among symptomatic patients is now thought to be higher than previously recognized.

On the basis of an analysis of three U.S. national data bases, the incidence of cat scratch disease is between 0.77 and 0.86 per 10,000 per year among hospitalized patients, whereas the incidence of the disease among ambulatory patients is 9.3 per 10,000 per year.1 Is bartonella being neglected as a pathogen in dog and cat bites in emergency departments?

Kei Numazaki, M.D., Ph.D.
Shunzo Chiba, M.D., Ph.D.
Sapporo Medical University, Sapporo, Hokkaido 060-8543, Japan

Hiroshi Ueno, D.V.M., Ph.D.
Rakunogakuen University, Ebetsu, Hokkaido 069-8501, Japan

2 References

1
Anderson BE, Neuman MA. Bartonella spp. as emerging human pathogens. Clin Microbiol Rev 1997;10:203-219
Web of Science | Medline

2
Zangwill KM, Hamilton DH, Perkins BA, et al. Cat scratch disease in Connecticut -- epidemiology, risk factors, and evaluation of a new diagnostic test. N Engl J Med 1993;329:8-13
Full Text | Web of Science | Medline

Author/Editor Response

Dr. Fleisher replies:

To the Editor: I appreciate the case report by Jones and Khoosal of a brain abscess due to P. multocida after a dog bite to the head in a 21-month-old boy. The authors cite a similar report,1 and I am aware of a case in a two-year-old child, described by Sutton and Alpert,2 in whom a brain abscess due to peptococcus species developed under almost identical circumstances. That child had multiple, deep facial lacerations, which required a complex repair in the emergency department and presumably drew attention away from a small puncture wound to the scalp, which went undetected. Although the child received prophylactic antibiotic therapy, he returned four days later with a brain abscess and fever. At surgery, a tear of the dura in the right parietal area was noted.

Jones and Khoosal comment, “The use of prophylactic antibiotics has been recommended for all bites to the head and neck, and such an approach might have averted the devastating consequences in our patient.” However, not all authorities agree about the need for prophylaxis in this situation.3 In addition, I am skeptical whether prophylactic antibiotics would have prevented the brain abscess in their patient. The best hope of avoiding this complication in such cases probably lies in meticulous wound care and in further evaluation to ascertain whether the dog's fangs have penetrated the child's skull.

Gary R. Fleisher, M.D.
Children's Hospital, Boston, MA 02115

3 References

1
Klein DM, Cohen ME. Pasteurella multocida brain abscess following perforating cranial dog bite. J Pediatr 1978;92:588-589
CrossRef | Web of Science | Medline

2
Sutton LN, Alpert G. Brain abscess following cranial dog bite. Clin Pediatr (Bologna) 1984;23:580-580

3
Fleisher GR. The management of bite wounds. N Engl J Med 1999;340:138-140
Full Text | Web of Science | Medline

Citing Articles (3)

Citing Articles

1
Claire Dendle, David Looke. (2008) Review article: Animal bites: An update for management with a focus on infections. Emergency Medicine Australasia 20:6, 458-467
CrossRef
2
Barbara J. Bryant, Cathy Conry-Cantilena, Alice Ahlgren, Anthony Felice, David F. Stroncek, Joan Gibble, Susan F. Leitman. (2007) Pasteurella multocida bacteremia in asymptomatic plateletpheresis donors: a tale of two cats. Transfusion 47:11, 1984-1989
CrossRef
3
Fredrick M. Abrahamian. (2000) Dog bites: Bacteriology, management, and prevention. Current Infectious Disease Reports 2:5, 446-453
CrossRef