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A young boy presents with a dog bite to the face
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A 9 ½-year-old boy was bitten in the face by a neighbor’s Rottweiler while playing with the dog. The dog’s rabies vaccinations are verified as up-to-date, and the event was considered a “provoked” attack. The patient was taken to an ED for care at a small community hospital and was found to have two puncture wounds on the face; one just under the right lower eyelid and one at the left lower maxillary area.
James H. Brien
His medical history was that of a healthy male. Immunizations were stated to be up-to-date, according to his father, who said his last tetanus booster was 4 or 5 years ago. The wounds were cleaned, and the left cheek wound was sutured. He was given a prescription for amoxicillin/clavulanate (Augmentin) but it was not filled. The next day, the patient returned with fever (103°F) and painful swelling and surrounding erythema. The suture was removed, and the patient was given a dose of IV clindamycin and sent home to take the Augmentin previously prescribed. He took one dose of Augmentin, but because of rapidly worsening pain and swelling, he was taken back to the ED, where he was given a dose of ceftriaxone IM, and sent for admission.
His vital signs were normal on admission. His exam revealed two areas of injury, as noted above, with yellowish discharge from each and surrounding erythema and swelling (Figure 1). The rest of his exam was normal.
Question #1: Does he need a tetanus booster?
- Yes
- No
Question #2: What’s Your Diagnosis?
A. Staphylococcus aureus
B. Eikenella corrodens
C. Group A streptococcus
D. Pasteurella multocida
The patient’s exam revealed two areas of injury, as noted above, with yellowish discharge from each and surrounding erythema and swelling (Figure 1).
Source: Brien JH
Answer #1: In my opinion, this patient should receive a tetanus booster in the form of Tdap (because he is older than 7 years), as there was uncertainty about whether the last tetanus dose was 4 or 5 years ago. With no documentation of immunizations, it’s always better to err on the side of safety, and this injury would qualify for boosting if it had been more than 5 years since the last dose. Please refer to the February 2014 column for a more detailed discussion of this question.
Answer #2: The culture grew group A streptococcus (C). This can often be predicted, based on the speed with which the infection developed after the injury and the rapid progression. Of course, there can be exceptions, and only a culture will tell the tale, but your selection of empiric therapy can be influenced by this historic information, along with the exam. With the chances of group A strep (Streptococcus pyogenes) being likely, one might want to select a combination of antimicrobials, such as a beta-lactam plus clindamycin (for its activity at the 50S ribosome to inhibit toxin production). This patient was empirically treated with ampicillin-sulbactam (Unasyn, Roerig) plus clindamycin — changing to ampicillin alone with clinical improvement, as well as surgical drainage of the left cheek abscess (Figure 2) — and sent home on hospital day 4, taking amoxicillin at about 80 mg/kg/day. He made an uneventful recovery.
This patient was empirically treated with ampicillin-sulbactam plus clindamycin — changing to ampicillin alone with
clinical improvement, as well as surgical drainage of the left cheek abscess (Figure 2).
S. aureus by far leads the list of causes of skin and soft tissue infections, but usually is a bit slower to develop after an injury; commonly 3 to 5 days later, rather than overnight. Otherwise, the infection appears essentially the same.
E. corrodens is a common “mouth” organism and frequent cause of human bite infections. However, it can also be found in dog and cat bite infections (Figure 3 and 4; E. corrodens from a dog bite), especially about the head and neck. It is a gram-negative bacillus and considered a fastidious facultative anaerobe that usually takes days to weeks after the injury to demonstrate clinical signs of infection. It is likely to be on the patient’s skin, rather than in the mouth of the biting animal. It is commonly seen as a cause of “clinched fist” injuries from fights, causing cellulitis of the hand (Figure 5). It is usually easy to distinguish it from staph and strep, with a history, and is treated with penicillin (Figure 6, same patient seen in Figure 5, see page 20).
Figure 3 and 4 shows E. corrodens from a dog bite.
Lastly, Pasteurella multocida, a gram-negative coccobacillus and common cause of infected cat bites and some dog bites, has similar features as group A strep, in that it has a rapid onset and progression after the bite — usually within 24 hours. It is usually easily treated with drainage and penicillin or ampicillin.
E. corrodens is commonly seen as a cause of "clinched fist" injuries from fights, causing cellulitis of the hand (Figure 5). It is usually easy to distinguish it from staph and strep, with a history, and is treated with penicillin (Figure 6).
Columnist Comments
As summer approaches, get ready for an increase in these bites and injuries, and the tetanus questions that accompany them.
I was recently excited to receive my 2014 copy of Nelson’s Pediatric Antimicrobial Therapy. In addition to new drugs and updates, this 20th edition of Nelson’s famous pocketbook, which is 43 pages larger, contains a section of references organized by chapter, at the back of the book. Additionally, the preface indicates that due to rapid changes in antimicrobials, future editions will be published annually, rather than biennially.
You can obtain a copy from the AAP bookstore online for less than $40 — a great bargain, and a must for a busy practice. At the risk of losing business, I must say that with Nelson’s pocketbook, and the AAP Red Book at your fingertips (such as your iPhone), you can find the answers to the vast majority of questions that I get in the form of phone calls and consults to the pediatric infectious diseases clinic, which can save you time and possibly save your patients money. Lastly, if anyone can name the drug represented by the molecular formula on the cover of this new edition, write me at jhbrien@aol.com, and I will recognize you in the next issue of this column. Good luck.
History moment as promised
The first recognized “pediatrician,” by virtue of his publication of the first pediatric textbook, The Diseases of Children, in the 10th century, was the great Persian physician Muhammad ibn Zakariya Razi (aka Rhazes; 854 CE-925 CE). While he wrote extensively on various topics of medicine, chemistry, philosophy and ethics, it was this first dedicated text on pediatrics that brought attention to our specialty at a time when that was unheard of, earning him widespread recognition as the Father of Pediatrics. Rhazes studied music and chemistry in his early years, but by the age of 30, he turned his interest to medicine, becoming a prolific writer.
Of his numerous papers and texts (some biographers reference more than 200), his Treatise on the Smallpox and Measles is often quoted as a landmark paper. Biographical accounts also refer to his charity toward his poor patients and his selfless dedication to teaching his students. It appeared that he was somewhat of an iconoclast; seeing the need to criticize the man he admired, Galen, while advocating for medical evidence by experimentation, and emphasizing knowledge of anatomy, to be a good physician. His knowledge of, and emphasis on, human anatomy is told in the tale of his refusal of treatment of his chronic eye disease by a physician who could not name the different layers of the eye. He was, ultimately, blinded by his eye disease, possibly cataracts. This may have had something to do with his expertise in ophthalmology, but does not explain his knowledge of nephrology, obstetrics, surgery, anesthesia, infectious diseases and other areas such as pediatrics, as noted.
Much of his work was translated into different languages for subsequent instruction in various European schools of medicine. Publication space limitations prohibit more detail, but perhaps this has whetted your appetite for medical history.
Please let me know your feedback, especially corrections and constructive criticism, and feel free to send along a brief paragraph on a person of historic interest for consideration in an upcoming column.
James H. Brien, DO, is vice chair for education in the department of pediatrics at McLane Children’s Hospital at Scott & White/Texas A & M College of Medicine in Temple, Texas. He is also a member of the Infectious Diseases in Children Editorial Board. Brien can be reached at: jhbrien@aol.com.
Disclosure: Brien reports no relevant financial disclosures.