A few sentences into a Washington Post article entitled “A dog bite sent him to the ER. A cascade of missteps nearly killed him”, I was thinking, “This sounds like a pretty typical Capnocytophaga canimorsus infection. I wonder if this guy lost his spleen earlier in life.”
It turns out that was true. Unfortunately, neither the person with the infection nor the initial healthcare providers had the same thought. It almost cost him his life, and we need improvement on both sides.
The scenario is pretty typical for infections caused by this bacterium, which is found in the mouths of most (or all) dogs. Rarely does it cause disease. People without spleens are actually the highest risk group, but they often don’t consider themselves immunocompromised.
The affected person in this case had been bitten by a neighbour’s dog 3 days before he got sick. The wound was washed out, and he went to an urgent care clinic the next day. He got a tetanus shot, and while the doctor offered antibiotics, he decided to forgo them.
The next day, his condition started to go downhill, and it progressed to the point where it wasn’t clear whether he would survive. Fortunately, he did pull through, ending up with profound hearing loss and amputation of a few toes. However, even though those are significant issues, he’s lucky. Most people die. Those who survive often lose multiple limbs or have other severe consequences.
This scenario shows a cascade of inadequate education and missed opportunities that ultimately could have cost him his life. At various points in the process, there were opportunities for intervention by both the patient’s family and the healthcare team.
1. Time of splenectomy
People who have their spleens removed need clear counseling that their immune system is compromised. As part of that, they need to know that if they are ever bitten by a dog, they must get antibiotics.
2. Time of dog bite
Good wound care, as was done here, is critical, but it’s also important for the person to see a doctor, to tell the doctor they don’t have a spleen, and to make sure they get antibiotics.
3. Doctor visit
Any evaluation of a person bitten by a dog should include a question about immunocompromise, and specifically if the person has lost their spleen. If the answer is yes, they must get antibiotics.
4. Hospital admission
The bite needs to mentioned initially (and repeatedly). It’s an abnormal event that preceded an abnormal medical situation. That doesn’t mean it’s always the cause, but it needs to be noted. Here, the bite wasn’t mentioned at the start.
Healthcare personnel also need to be notified that the person has no spleen. Since universal electronic medical records aren’t available, hospital personnel don’t have access to everyone’s full medical history on admission. This is a critical piece of the puzzle for a case like this.
We’ll never know, but if the patient in this case had been started on antibiotics at that first visit (or on the day of the bite, ideally), it’s likely that none of this cascade would have happened.
More information about Capnocytophaga can be found on the Worms & Germs Resources – Pets page.