Acute necrotizing cutaneous streptococcal infection following bites or scratch by dog or cat

INTRODUCTION: Domestic animal bites or scratches are quite frequent. Among banal bacteria isolated from infected bites or scratches, group A streptococcus seems to be frequently associated with severe infections. CASE REPORTS: Three cases of acute necrotizing cutaneous streptococcal infections, following cat or dog bite or scratch are reported. Twice, group A streptococcus was isolated from cutaneous swabs. In the third case, previous antibiotic therapy had sterilised bacteriological samples. Diagnosis was ascertained on the basis of clinical presentation and significant antistreptococcal antibodies elevation. Skin necrosis around the inoculation area was observed in the 3 cases. Cicatrisation required an average of two months under appropriate treatment. DISCUSSION: An evolution towards cutaneous necrosis localized to the initially injured area is common to these three cases. This peculiar evolution is worth to be known in order to choose an effective anti streptococcal antibiotherapy whenever domestic animals bites and scratches are to be treated.     

Seroepidemiology of Bartonella henselae infection in a risk group

BACKGROUND: Bartonella henselae infections are closely related to a number of clinical conditions of growing interest in our environment. As cats are the reservoir, and their bites and scratches are the main transmission mechanism, we attempted to study the seroepidemiology of the infection caused by this microorganism in a risk group of patients (cat owners) and a control group (blood donors). PATIENTS AND METHODS: October 1977. Measurement of antibody titres to B. henselae at different dilutions (breakpoint > or = 1:64) by indirect immunofluorescence (IFI) in 83 cat owners and 85 blood donors. Also, an epidemiologic investigation was carried out (age, sex, alcohol, intake, common cat exposure, cat bite or cat scratch, number and age of cats, bite or presence of fleas, use of repellents, clinical picture consistent with cat scratch disease [CSD]). RESULTS: Twenty-four cat owners (28.9%) and five blood donors (5.9%) had titres > or = 1:64 (OR: 6.51; 95% CI: 2.32 to 22.9). Also, the logistic regression analysis showed an association with daily alcohol intake and the previous antecedent of lymph node enlargement of unknown origin among cat owners. CONCLUSIONS: A high prevalence of antibodies to B. henselae was demonstrate among cat owners.     

Transitional cell carcinoma of the ureteral stump 13 years after nephrectomy for benign disease

OBJECTIVE: To estimate the magnitude of the dog bite problem in the US. METHODS: Data on dog bites were gathered as part of a 1994 national telephone survey of 5,238 randomly dialed households. Data were weighted to provide national estimates. RESULTS: The weighted total number of dog bites was 4,494,083 (estimated incidence = 18/1,000 population); of these, 756,701 persons sustained bites necessitating medical attention (incidence rate = 3/1,000). Children had 3.2 times higher medically attended bite rates than adults (6.4/1,000 children v 2/1,000 adults). CONCLUSIONS: More attention and research needs to be devoted to the prevention of dog bites. Potential prevention strategies include: educational programs on canine behavior, especially directed at children; laws for regulating dangerous or vicious dogs; enhanced animal control programs; and educational programs regarding responsible dog ownership and training. Unfortunately, the relative or absolute effectiveness of any of these strategies has not been assessed. Continuing surveillance for dog bites will be needed if we are to better understand how to reduce the incidence of dog bites and evaluate prevention efforts.     

Animal bites at the casualty department of the Oslo City Council]

During a 2-year period all Casualty Department data charts with the diagnosis "animal bite" were reviewed as part of internal quality control. Of 1,051 recorded episodes, 503 (48%) were women and 147 (14%) children under 16 years of age. 951 (90%) wounds were treated without closure. Half of the patients were not given antibiotics on the first visit, whereas one third were given penicillin. Tetanus status had been evaluated on 1,015 (97%) charts. Most bites were caused by dogs (76%), cats (17%), and horses (2%). Children were the victims of 118 (15%) dog bites, eight (4%) cat bites, and ten (53%) horse bites. More victims of dog bites than cat bites arrived within 12 hours of injury. German shepherd was the dog breed most often reported. Men were at greater risk of being bitten by dogs, adult women by cats and young girls by horses. Dogs bit children most frequently in the face and head areas and adults on the hands. In contrast, two thirds of children and adults were bitten by cats on the hands. Nearly all bite wounds were superficial and healed uneventfully; either without antibiotics, or with penicillin after wound treatment without closure. Computerized injury charts may ensure improved documentation of relevant information and simplify future quality control and research.     

Development of early-summer meningoencephalitis (FSME) in the Thurgau region 1990-1995--a new endemic area?

Tick-borne encephalitis (TBE) is a viral infection transmitted by bites of infected ticks. The clinical course is mostly mild, but death occurs in 1-2% of TBE infections and nearly half of patients with meningitis/meningoencephalitis show residual disease, above all chronic headache. TBE-infected ticks occur only in endemic areas. A knowledge of the endemic areas is very important for immunoprophylaxis of TBE. In recent years between 26 and 97 cases of TBE have occurred in Switzerland. The largest endemic areas are in Canton Schaffhausen, the northern part of Canton Zurich and the north-west of Canton Thurgau. Another endemic area is known in the region of Thun in Canton Berne. Another possible endemic area is known in the Zurich Oberland around Elgg, only 7 km from Aadorf in Thurgau. Up to now, Diessenhofen in the north-west of Thurgau was the only known possible endemic area. In 1994 and 1995 we observed an accumulation of TBE infections in western Thurgau. The question was whether there are other endemic areas in Thurgau. In this retrospective analysis we studied the TBE cases in Thurgau between 1990 and 1995 with data derived from the cantonal health authorities reports. Clinical data were taken from case histories of the two cantonal hospitals in Frauenfeld and Münsterlingen, completed by data from family doctors and patients. Between 1990 and 1995 30 TBE infections (1990; 1, 1991: 4, 1992: 3, 1993: 1, 1994: 4 certain, 3 uncertain, 1995: 14) were observed. TBE infections appeared between May and October (maximum in May). 14 patients remembered a bite by a tick several weeks before onset of the illness. 7 bites occurred in the area of Frauenfeld/Aadorf. Only one bite occurred in Diessenhofen. 2 patients were infected in well-known endemic areas in Canton Zurich, a vicinal region in the west of Thurgau. In 1995 the incidence of TBE in Thurgau was 5.4/100000 population. In 9 of the 14 patients recalling a bite by a tick (64.4%), the bites occurred near their domicile. No bite was seen east of a line between Steckborn and Weinfelden. The incidence of TBE in Thurgau in 1995 was clearly higher than the average in Switzerland in recent years (0.46/100000), and higher than in the well-known endemic areas in the vicinity (Schaffhausen 3.95, Zurich 1.31). Based on our data, the region Frauenfeld/Aadorf must be declared a new endemic area for TBE. Probably the well-known endemic area in the Zurich Oberland in the vicinity of Elgg has spread eastward. Persons who are often in the forests of this region should be advised to be vaccinated.     

Bacteriologic analysis of infected dog and cat bites. Emergency Medicine Animal Bite Infection Study Group

BACKGROUND AND METHODS: To define better the bacteria responsible for infections of dog and cat bites, we conducted a prospective study at 18 emergency departments. To be eligible for enrollment, patients had to meet one of three major criteria for infection of a bite wound (fever, abscess, and lymphangitis) or four of five minor criteria (wound-associated erythema, tenderness at the wound site, swelling at the site, purulent drainage, and leukocytosis). Wound specimens were cultured for aerobic and anaerobic bacteria at a research microbiology laboratory and, in some cases, at local hospital laboratories. RESULTS: The infected wounds of 50 patients with dog bites and 57 patients with cat bites yielded a median of 5 bacterial isolates per culture (range, 0 to 16) at the reference laboratory. Significantly more isolates grew at the reference laboratory than at the local laboratories (median, 1; range, 0 to 5; P<0.001). Aerobes and anaerobes were isolated from 56 percent of the wounds, aerobes alone from 36 percent, and anaerobes alone from 1 percent; 7 percent of cultures had no growth. Pasteurella species were the most frequent isolates from both dog bites (50 percent) and cat bites (75 percent). Pasteurella canis was the most common isolate of dog bites, and Past. multocida subspecies multocida and septica were the most common isolates of cat bites. Other common aerobes included streptococci, staphylococci, moraxella, and neisseria. Common anaerobes included fusobacterium, bacteroides, porphyromonas, and prevotella. Isolates not previously identified as human pathogens included Reimerella anatipestifer from two cat bites and Bacteroides tectum, Prevotella heparinolytica, and several porphyromonas species from dog and cat bites. Erysipelothrix rhusiopathiae was isolated from two cat bites. Patients were most often treated with a combination of a beta-lactam antibiotic and a beta-lactamase inhibitor, which, on the basis of the microbiologic findings, was appropriate therapy. CONCLUSIONS: 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 by clinical microbiology laboratories and not previously recognized as bite-wound pathogens.     

Dog bites in children admitted to Pennsylvania trauma centers

Dog bites are a major public health problem in the pediatric population, requiring emergency treatment for wound repair and possible hospitalization in a trauma center. Data from the Pennsylvania Trauma Outcome Study were analyzed, and the records of 183 pediatric dog bite patients from 1990 to 1995 were evaluated. Dog bites were found to constitute a very small proportion of the total pediatric admissions to Pennsylvania trauma centers; however, the findings were similar to other reported studies.     

Evaluation of commercial slides for detection of immunoglobulin G against Bartonella henselae by indirect immunofluorescence

Four commercial slides were compared with in-house slides for the detection of immunoglobulin G (IgG) against Bartonella henselae in 58 healthy persons from a rural region by an indirect immunofluorescence assay. MRL-BA slides (MRL Diagnostics, USA) and Virion slides (Virion, Switzerland) with agar-derived Bartonella henselae showed IgG titers of > or = 1:256 in 44.8% and 51.7%, respectively, whereas Bion slides (Bios, Germany), MRL-Vero slides (MRL Diagnostics), and in-house slides with cell-associated Bartonella henselae showed such titers in 3.4%, 5.1% and 3.4%, respectively. The MRL-Vero slides (Bartonella IgG substrate slides, MRL Diagnostics) were further evaluated with 26 patients with cat scratch disease, 20 patients with lymphadenopathy not due to cat scratch disease, 100 blood donors from an urban area, and 120 blood donors from a mixed urban/rural area. In our mixed urban/rural population the IgG titer of 1:256 had a sensitivity of 84.6% and a specificity of 93.4% for the serodiagnosis of cat scratch disease. Seroprevalence was higher in blood donors from the mixed area (50.8%) than from the urban area (37%). MRL-Vero slides were considered useful for the serodiagnosis of cat scratch disease by indirect immunofluorescence and have replaced our in-house system. However, patients with low IgG titers should be retested three to four weeks after initial sampling to demonstrate a possible rise of IgG titers in paired sera.     

Nuclear structure of 178Lu

A retrospective study of infections due to Pasteurella (P.) and related groups was performed between the Pasteurella National Center and Nancy's hospital from 1985 to 1991. Among the 958 cases recorded, wound infections (bites, scratches and punctures) were the common forms of pasteurellosis (66%) caused by P. multocida (48%), P. canis (11%), P. dagmatis (5%), P. stomatis (4%), and in few cases by groups EF-4 and M-5 (14 and 13%, respectively). In human infections unrelated to animal wounds, respiratory tract diseases and bacteremia-septicemia were the predominant infections with respectively 19 and 11%, and caused by P. multocida. Next in importance were urogenital (2.5%), abdominal (1%) and central nervous system (< 1%) infections. The majority of animal bite wound infections was treated with penicillins or tetracyclines; with other forms, penicillins and cephalosporins were more likely.     

An outbreak of vampire bat bite in a Brazilian village

An outbreak of 26 cases of vampire bat bite in one month in the rural area of Honorópolis, a Brazilian village, is reported. All patients were bitten during the night, when they were asleep, and most bites were on their toes. No complication attributed to the bite was reported. The patients were given prophylactic antirabies serum and rabies vaccine. Control of the outbreak was achieved by visiting bat roosting sites, smearing captured vampire bats (Desmodus rotundus) with a paste of 2% warfarin in vaseline, and releasing them. No case of human or animal rabies was diagnosed in a 5-month follow-up. A possible explanation for the outbreak of bat bite is that, because of man-induced environmental modifications in their habitats, vampire bats in Honorópolis now live in the peridomiciliar area, where people are more exposed to their bites. An alternative explanation is related to the use in cattle of a pyrethroid insecticide to control the horn fly, Haematobia irritans, as both events were temporally related. The insecticide could have had a repellent effect on bats, that then started to seek alternative food sources.     

Chromosomal abnormalities and tumor development: from genes to therapeutic mechanisms

PURPOSE: To summarize the epidemiologic, diagnostic, and clinical features of the 32 laboratory-confirmed cases of human rabies diagnosed in the United States from 1980 to 1996. DATA SOURCES: Data were obtained from case reports of human rabies submitted to the Centers for Disease Control and Prevention by state or local health authorities. STUDY SELECTION: All cases of human rabies reported in the United States from 1980 to 1996 in which infection with rabies virus was confirmed by laboratory studies. DATA EXTRACTION: Patients were reviewed for demographic characteristics, exposure history, rabies prophylaxis, clinical presentation, treatment, clinical course, diagnostic laboratory tests, identification of rabies virus variants, and the number of medical personnel or family members who required postexposure prophylaxis after coming in contact with an exposed person. DATA SYNTHESIS: 32 cases of human rabies were reported from 20 states. Patients ranged in age from 4 to 82 years and were predominantly male (63%). Most patients (25 of 32) had no definite history of an animal bite or other event associated with rabies virus transmission. Of the 32 cases, 17 (53%) were associated with rabies virus variants found in insectivorous bats, 12 (38%) with variants found in domestic dogs outside the United States, 2 (6%) with variants found in indigenous domestic dogs, and 1 (3%) with a variant found in indigenous skunks. Among the 7 patients with a definite exposure history, 6 cases were attributable to dog bites received in foreign countries and 1 was attributable to a bat bite received in the United States. In 12 of the 32 patients (38%), rabies was not clinically suspected and was diagnosed after death. In the remaining 20 cases (63%), the diagnosis of rabies was considered before death and samples were obtained specifically for laboratory confirmation a median of 7 days (range, 3 to 17 days) after the onset of clinical signs. Of the clinical differences between patients in whom rabies was diagnosed before death and those in whom it was diagnosed after death, the presence of hydrophobia or aerophobia was significantly associated with antemortem diagnosis (odds ratio, 11.0 [95% CI, 1.05 to 273.34]). The median number of medical personnel or familial contacts of the patients who received postexposure prophylaxis was 54 per patient (range, 4 to 179). None of the 32 patients with rabies received postexposure prophylaxis before the onset of clinical disease. CONCLUSIONS: In the United States, human rabies is rare but probably underdiagnosed. Rabies should be included in the differential diagnosis of any case of acute, rapidly progressing encephalitis, even if the patient does not recall being bitten by an animal. In addition to situations involving an animal bite, a scratch from an animal, or contact of mucous membranes with infectious saliva, postexposure prophylaxis should be considered if the history indicates that a bat was physically present, even if the person is unable to reliably report contact that could have resulted in a bite. Such a situation may arise when a bat bite causes an insignificant wound or the circumstances do not allow recognition of contact, such as when a bat is found in the room of a sleeping person or near a previously unattended child.     

Red-back spider bites to Perth children, 1979-1988

The aim of this study was to describe the pattern of illness caused by red-back spider bites to children in Perth, Western Australia, over a 10 year period, and to compare it with that in adults. The case-notes of 241 (89%) of the 271 children admitted to Princess Margaret Hospital and Fremantle Hospital with suspected red-back spider bite from 1979 to 1988 were available for analysis. A definite bite was defined as a definite bite by a positively identified red-back spider, positive identification of a red-back spider with no definite bite but the later development of typical symptoms or no definite history of red-back spider bite but strong clinical evidence and complete recovery after administration of antivenom. Systemic envenomation was accepted if there were symptoms of vomiting, generalized pain or sweating, or abdominal pain. Sixty-five per cent of children were definitely bitten. As found in previous adult and mixed studies, there was a peak incidence in the warmer months with a male preponderance (68%); 81% of bites were to the extremities and 83% of bites occurred in the daytime. The syndrome produced in children was usually similar to that seen in adults. Twenty-one per cent of children received antivenom, a rate comparable to previous studies in older age groups; however, no child received more than one ampoule. Compared with data extracted from a previously published study at Fremantle Hospital, in which 37% of adults treated with antivenom received more than one ampoule, these findings suggest that contrary to current opinion children may not be at an increased risk of morbidity from latrodectism.     

The association of patellar ultrasound transmissions and forearm densitometry with vertebral fracture, number and severity: the Saunders County Bone Quality Study

A population survey was conducted to determine the incidence of injuries among preschoolers and their risk factors. A systematic sample (15%, n = 4540) of families with at least one child aged 0-5 years in 1991 living in the Canton of Vaud (Switzerland) received a mailed questionnaire in February 1992. There were 5827 eligible children in the sample. The response rate was 67.5% after two recall mailings. Injuries were defined as those from all causes with at least one physician contact in 1991. The overall incidence was 224 injuries per 1000 children (95% CI [= confidence intervall]: 211-237); 188 per 1000 children were injured over 1 year (95% CI: 176-200, n = 746), of whom 16.5% (n = 123) had 32 injuries. Falls represented 66% of all injuries, followed by burns (8%) and poisonings (5%). The proportion of hospitalized cases was 4.8% and the population incidence of hospitalization due to injury was 10.8/1000 children. Socioeconomic factors did not influence the occurrence of injuries. CONCLUSION: The measured incidence of injuries among preschoolers is among the highest in developed countries. Practitioners could contribute more effectively to injury prevention through routine information and counselling of parents from all social backgrounds.     

Premature separation of centromere and aneuploidy: an indicator of high risk in unaffected individuals from familial breast cancer families?

OBJECTIVES: Injury is the leading cause of death in the male working population of Brazil. An important fraction of these deaths are work related. Very few cohort studies of steel workers, and none from developing countries, have reported on mortality from injuries. This paper analyses mortality from work and non-work related injuries among Brazilian steel workers. METHODS: Deaths during employment from 1 January 1977 to 30 November 1992 were analysed in a cohort of 21,816 male steel workers. Mortality rates specific for age and calendar year among the workers were compared with those of the male population of the state where the plant is located. Work related injuries were analysed by comparing the mortality rates for different subgroups of the cohort. RESULTS: The number of deaths (391) was less than half that expected based on death rates of the general population. Over 60% (242) of deaths were due to injuries. Mortality from most causes was substantially below that in the general population, but that from unintentional injury, was 50% above that of the general population. Standardised mortality ratios (SMRs) were highest for the youngest and the oldest employees and for labourers and clerical workers. Mortality from motor vehicle injury was twice that expected from population rates (SMR = 209, 95% confidence interval (95% CI) 176-244). There was a 67% fall in the age adjusted mortality from occupational injuries in the study period. CONCLUSION: The healthy worker effect in this cohort was greater than that commonly found in studies of occupational groups in developed countries, probably because of a greater socioeconomic gap between employed and unemployed populations in Brazil, and unequal distribution of health care resources. Mortality was especially high for motor vehicle injuries. The fall in mortality from occupational injuries during the study period was probably due to improvement in safety standards, increased automation, and better medical care. There is a need to investigate risk factors for unintentional injuries among steel workers, especially those due to motor vehicle injuries. Prevention of occupational and nonoccupational injuries should be a main priority in Brazil.     

The management of human bite injuries of the hand

Human bites of the hand cause small wounds that are often incorrectly treated as "minor' injuries. We reviewed the management and outcome of patients with human bite or "punch' injuries of the hand. Significant morbidity resulted from late presentation and inadequate initial management. We propose a treatment protocol, in which all patients are immediately referred and admitted to hospital for surgical debridement.     

Wounds of the hand contaminated by human or animal saliva

A prospective and retrospective evaluation of 75 patients with hand wounds contaminated by human saliva (35) or animal saliva (40) demonstrates that a program of outpatient management can be sufficient for optimal care in many patients. This series challenges the proposition that hospitalization, radiographs, and surgical debridement are necessary for most such wounds. Sixty-seven per cent did not have surgical intervention and no complications resulted. Ninety-two per cent received antibiotics. Radiographs were obtained only when bony injury or entry into a joint was suspected. Delay in seeking treatment until obvious signs of infection or pain are present is common. Literature review details the anatomic factors important in the natural history and control of these infections, and the changes with respect to modes of treatment for these potentially dangerous wounds. The injury is caused by bites with the hand extended or, in fight-bite wounds, with the metacarpal-phalangeal and interphalangeal joints flexed, allowing deeper penetration and then sealing of the wound when the first is opened. Staphylococcus and Streptococcus are the organisms most frequently found in human bites, and in animal bites; Pasteurella multocida should be considered in dog and cat bites.     

Bite injuries in the head and neck area

In Germany about 8500 dog-bite injuries in the face occur every year; more than 50% of the victims are infants and schoolchildren. Besides dogs, other animals such as cats or horses may be responsible for these accidents. Even human bites are reported. The predominant areas are the nose and the auricles. The tissue defects may be superficial, but they can even cause amputations, including severe vascular and nerve or bony destruction. Systemic antibiotic therapy is needed when the wound is infected. The surgical approach to bite injuries includes local wound cleansing, careful excision of necrotic tissue and primary closure of the wound whenever possible. Regarding the importance of surgery in the head and neck area plastic-reconstructive techniques including autologous transplantations and various local or regional flaps should be used at the time the wound is first repaired.     

Bartonella henselae infection in immunocompetent patients: cat scratch disease

BACKGROUND: Cat scratch disease, whose etiologic agent is Bartonella henselae, is a benign disease in immunocompetent subjects, characterized by lymphadenopathy of prolonged course and occasional involvement of other organs such as liver, spleen, central nervous system, eye and lung. In immunocompromised patients, the infection is bacteremic and disseminated. AIM: To report Chilean cases of cat scratch disease. PATIENTS AND METHODS: Ten children (seven male, aged between 6 and 13 years old) with histologically or serologically confirmed cat scratch disease are reported. RESULTS: Lymphadenopathy location was pre auricular in four cases, axillary in two, inguinal in two and epitrochlear in two. Three children had fever over 39 degrees C and two had a parinaud syndrome. Nine children had a history of cat scratch and one of a cat byte. Six had an erythrocyte sedimentation rate over 40. Lymph node ultrasound examination was a useful diagnostic tool. Two patients had splenic granulomas. Lymph node biopsies were obtained in four cases, showing a suppurative granulomatous lymphadenitis in all and a positive Warthin-Starry stain in two. Serology, done in patients without histological confirmation was positive with titles ranging from 1:64 to 1:8192. All patients had a satisfactory outcome with regression of lymphadenopathy. CONCLUSIONS: Infections by Bartonella hemselae occur in the Chilean population and must be considered in the differential diagnosis of regional lymph node enlargement.