J Infect Chemother 21 (2015) 215e217

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Case report

Capnocytophaga canimorsus bacteremia presenting with acute cholecystitis after a dog bite Hiroaki Nishioka*, Tomohiro Kozuki, Hiroki Kamei Department of General Internal Medicine, Kobe City Medical Center General Hospital, 2-1-1 Minami-machi, Minatojima, Chuo-ku, Kobe, Hyogo 650-0047, Japan

a r t i c l e i n f o

a b s t r a c t

Article history: Received 24 May 2014 Received in revised form 21 August 2014 Accepted 4 September 2014 Available online 23 October 2014

Capnocytophaga canimorsus is part of normal gingival flora of dogs and cats. The organism can cause septicemia, meningitis, and endocarditis in humans after contact with dogs or cats. In spite of the frequency of gastrointestinal symptoms in C. canimorsus infection patients, specific gastrointestinal disease or clinical images have not been reported. We report a case of C. canimorsus bacteremia presenting with acute cholecystitis in elderly woman. She suffered from general fatigue and right upper abdominal pain. She had leukocytosis and abnormal liver function tests. She showed abnormal findings of the gallbladder by abdominal computed tomography and ultrasonography. She was diagnosed with acute cholecystitis without gallstones and was administered with antibiotics. C. canimorsus was isolated from blood cultures. A history of an insignificant wound secondary to a dog bite was elicited. She recovered completely with antibiotic treatment. This case revealed that C. canimorsus bacteremia can be presented with acute cholecystitis, suggesting that C. canimorsus could cause cholecystitis. And this cholecystitis can be treated with antibiotics without operation. Physicians seeing patients with acute cholecysitis should ask questions regarding animal contact. © 2014, Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

Keywords: Capnocytophaga canimorsus Dog bite Acute cholecystitis Blood culture

1. Introduction Capnocytophaga canimorsus is a gram-negative commensal bacillus in dog and cat saliva [1]. The organism can cause septicemia, meningitis, and endocarditis in humans who have come into contact with dogs or cats [1e5]. Although one-fourth of patients with C. canimorsus septicemia complain abdominal pain [6], specific gastrointestinal disease or clinical images have not been reported. We here report a case of C. canimorsus bacteremia presenting with acute cholecystitis in an elderly woman following a dog bite.

2. Case report An 80-year-old woman presented to the emergency room because of persistent abdominal pain in the right upper quadrant since that morning. General fatigue and appetite loss had begun the previous day. She had a history of hypertension and diabetes mellitus, for which she was being treated with amlodipine,

* Corresponding author. Tel.: þ81 78 302 4321; fax: þ81 78 302 7537. E-mail address: [email protected] (H. Nishioka).

vildagliptin, and rosuvastatin. She had no recent history of fever or abdominal pain. She did not smoke or consume any alcohol. She had no remarkable family history. On physical examination, she was conscious and alert. Her blood pressure was 94/50 mmHg, pulse rate was 101 beats/minute, respiratory rate was 20 breaths/minute, and temperature was 37.6  C. Her breath and heart sounds were clear. She felt mild pain and tenderness in the right upper quadrant of the abdomen. Her laboratory findings are shown in Table 1. She had leukocytosis, thrombocytopenia, coagulopathy, abnormal liver function tests, and the elevated level of C-reactive protein. Abdominal computed tomography (CT) and ultrasonography showed edematous thickening of the gallbladder wall. They did not show gallstones (Fig. 1). We suspected her to have acute cholecystitis, sepsis, and disseminated intravascular coagulopathy. We started to administer sulbactam/ampicillin 3 g every 6 h after obtaining two sets of blood cultures and transfused her with ten units of platelets. Her symptoms and laboratory data tended to improve from the next day. On day 6, ultrasonography showed a normal gallbladder. On day 5, gram-negative bacillus was isolated in blood culture (Fig. 2). On day 10, blood culture results confirmed C. canimorsus by catalaseeoxidase test, ID Test HN20 Rapid (Nissui Pharmaceutical Co., Ltd., Tokyo, Japan), and PCR. On day 12, she had completely

http://dx.doi.org/10.1016/j.jiac.2014.09.001 1341-321X/© 2014, Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

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H. Nishioka et al. / J Infect Chemother 21 (2015) 215e217

Table 1 Laboratory findings on admission. Peripheral blood cell count WBC RBC Hb Ht Plt Coagulation PT PT-INR APTT Serology CRP Biochemistry TP Alb T-Bill AST ALT LDH ALP gGTP BUN Cre Na K Ca Glu

10,600 397  104 11.8 36.2 1.7  104

/mL /mL g/dL % /mL

46.5 1.45 49.3

%

19.8

mg/dL

6.1 2.8 2.1 162 64 671 382 65 36.1 0.98 133 4.0 8.1 160

g/dL g/dL mg/dL IU/L IU/L IU/L IU/L mg/dL mg/dL mg/dL mEq/L mEq/L mg/dL mg/dL

s

recovered and was discharged with oral antibiotics amoxicillin/ clavulanate. A detailed history, obtained after the findings of bacillus in blood culture, revealed that 2 days prior to hospitalization, she had the dorsum of her right hand bitten by her pet dog and had a small wound which we did not notice on admission. On day 10, we found a small scar with a scab on her right hand (Fig. 3). She was diagnosed with C. canimorsus bacteremia presenting with acute cholecystitis following a dog bite. 3. Discussion The course of this patient suggested two important clinical issues. C. canimorsus bacteremia can be presented with acute cholecystitis, suggesting that C. canimorsus could cause cholecystitis. This acute cholecystitis can be treated with antibiotics without operation. First, C. canimorsus bacteremia can be presented with acute cholecystitis, suggesting that C. canimorsus could cause cholecystitis. The patient showed right upper abdominal pain, abnormal liver function tests, and abnormal CT findings, which

Fig. 1. Abdominal computed tomography showing edematous wall thickening of the gallbladder (white arrow).

Fig. 2. Blood culture smears with gram staining showing gram-negative bacillus (fusiform-shaped rods).

strongly suggested acute cholecystitis. The CT findings (Fig. 1) were compatible with edematous cholecystitis which is classified to an early stage of acute cholecystitis. She did not show any other local site of infection. C. canimorsus was isolated from blood cultures and her episode of a dog bite was clarified. She was presumed to develop C. canimorsus bacteremia presenting with acute cholecystitis following a dog bite. Although gastrointestinal disturbances such as abdominal pain, vomiting, and diarrhea are often observed in C. canimorsus infection patients [6,7], specific gastrointestinal disease or clinical images have not been reported. To the best of our knowledge, this is the first case of C. canimorsus bacteremia presenting with acute cholecystitis. It is not conclusive in the present case that C. canimorsus primarily caused acute cholecystitis because of lack of specimens from gallbladder. This cholecystitis might be caused secondary to C. canimorsus bacteremia or by other pathogen, such as Pasteurella multocida which is also part of dog oral flora and may cause acute cholecystitis [8]. Second, this acute cholecystitis could be treated with antibiotics without operation or tube drainage. In most cases, acute cholecystitis is caused by gallstones. Early cholecystectomy is generally recommended to treat acute cholecystitis even for patients with acalculous cholecystitis [7]. We here experienced that acute cholecystitis accompanied by C. canimorsus bacteremia was successfully treated without operation or tube drainage. This might be

Fig. 3. Small scar with a scab on the dorsum of the right hand (black arrow).

H. Nishioka et al. / J Infect Chemother 21 (2015) 215e217

due to early detection and initiation of antibiotic therapy and the character of C. canimorsus infection. C. canimorsus, first isolated in 1976, is part of normal gingival flora of dogs and cats [1]. The organism is potentially lethal to humans [5,6]. While C. canimorsus is frequently present in dog bite wounds, it rarely results in documented clinical infections. This is likely because of its slow growth, susceptibility to antibiotics frequently used for post-dog bite prophylaxis, and lack of awareness by physicians. In our case, bacterial confirmation required 10 days. Careful history taking enables physicians to recognize the possibility of C. canimorsus infection before the development of serious sequelae. Treatment should be started before culture results become available. In conclusion, C. canimorsus bacteremia can be presented with acute cholecystitis, suggesting that C. canimorsus could cause cholecystitis. This acute cholecystitis can be treated with antibiotics without operation. When physicians see patients with acute cholecystitis without gallstones, they should take care to elicit an accurate history, including animal contact, and consider C. canimorsus as a causative agent. Further reports should be accumulated to determine whether C. canimorsus primarily causes acute cholecystitis.

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Conflict of interest The authors state that they have no conflict of interest. References [1] Bobo RA, Newton EJ. A previously undescribed gram-negative bacillus causing septicemia and meningitis. Am J Clin Pathol 1976;65:564e9. [2] Valtonen M, Lauhio A, Carlson P, Multanen J, Sivonen A, Vaara M, et al. Capnocytophaga canimorsus septicemia: fifth report of a cat-associated infection and five other cases. Eur J Clin Microbiol Infect Dis 1995;14:520e3. [3] Le Moal G, Landron C, Grollier G, Robert R, Burucoa C. Meningitis due to Capnocytophaga canimorsus after receipt of a dog bite: case report and review of the literature. Clin Infect Dis 2003;36:e42e6. [4] Sandoe JA. Capnocytophaga canimorsus endocarditis. J Med Microbiol 2004;53: 245e8. [5] Lion C, Escande F, Burdin JC. Capnocytophaga canimorsus infections in human: review of the literature and cases report. Eur J Epidemiol 1996;12:521e33. [6] Pers C, Gahrn-Hansen B, Frederiksen W. Capnocytophaga canimorsus septicemia in Denmark, 1982e1995: review of 39 cases. Clin Infect Dis 1996;23: 71e5. [7] Takada T, Strasberg SM, Solomkin JS, Pitt HA, Gomi H, Yoshida M, et al. TG13: updated Tokyo guidelines for the management of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci 2013;20:1e7. [8] Nagata H, Yamada S, Uramaru K, Kiyasu Y, Kano N. Acute cholecystitis with bacteremia caused by Pasteurella multocida. Surg Infect (Larchmt) 2014;15: 72e4.

Capnocytophaga canimorsus bacteremia presenting with acute cholecystitis after a dog bite.

Capnocytophaga canimorsus is part of normal gingival flora of dogs and cats. The organism can cause septicemia, meningitis, and endocarditis in humans...
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