title: Capnocytophaga canimorsus infection presenting with complete splenic infarction and thrombotic thrombocytopenic purpura: a case report.
abstract: BACKGROUND
  Animal bites are typically harmless, but in rare cases infections introduced by such bites can be fatal. Capnocytophaga canimorsus, found in the normal oral flora of dogs, has the potential to cause conditions ranging from minor cellulitis to fatal sepsis. The tendency of C. canimorsus infections to present with varied symptoms, the organism's fastidious nature, and difficulty of culturing make this a challenging diagnosis. Rarely, bacterial cytotoxins such as those produced by C. canimorsus may act as causative agents of TTP, further complicating the diagnosis. Early recognition is crucial for survival, and the variability of presentation must be appreciated. We present the first known case of C. canimorsus infection resulting in TTP that initially presented as splenic infarction.
  
  
  METHODS
  72-year-old Caucasian male presented with a four-day history of abdominal pain, nausea, vomiting, diarrhea, and intermittent confusion. On presentation, vital signs were stable and the patient was afebrile. Physical examination was unremarkable apart from petechiae on the inner left thigh, and extreme diffuse abdominal pain to palpation and percussion along with positive rebound tenderness. Initial investigations revealed leukocytosis with left shift and thrombocytopenia, but normal liver enzymes, cardiac enzymes, lipase, INR and PTT. Abdominal CT demonstrated a non-enhancing spleen and hemoperitoneum, suggesting complete splenic infarction. Although the patient remained afebrile, he continued deteriorating over the next two days with worsening thrombocytopenia. After becoming febrile, he developed microangiopathic hemolytic anemia and hemodynamic instability, and soon after was intubated due to hypoxic respiratory failure and decreased consciousness. Plasma exchange was initiated but subsequently stopped when positive blood cultures grew a gram-negative organism. The patient progressively improved following therapy with piperacillin-tazobactam, which was switched to imipenem, then meropenem when Capnocytophaga was identified.
  
  
  CONCLUSIONS
  There is a common misconception amongst practitioners that the presence of systemic infection excludes the possibility of TTP and vice versa. This case emphasizes that TTP may occur secondary to a systemic infection, thereby allowing the two processes to coexist. It is important to maintain a wide differential when considering the diagnosis of either TTP or C. canimorsus infection since delays in treatment may have fatal consequences.
authors.affiliation: Critical Care Trauma Centre, London Health Sciences Center, 800 Commissioners Road East, London, Ontario N6A 5W9, Canada. rkao3@uwo.ca.
authors.forename: Michal
authors.initials: M
authors.lastname: Brichacek
authors.forename: Peter
authors.initials: P
authors.lastname: Blake
authors.forename: Raymond
authors.initials: R
authors.lastname: Kao
mesh_terms: D000368:Aged; D000818:Animals; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D001733:Bites and Stings / Q000150:complications* / Q000382:microbiology; D002206:Capnocytophaga / Q000302:isolation & purification*; D004285:Dogs; D016905:Gram-Negative Bacterial Infections / Q000150:complications* / Q000188:drug therapy / Q000382:microbiology; D006801:Humans; D015378:Imipenem / Q000627:therapeutic use; D008297:Male; D000077731:Meropenem; D010397:Penicillanic Acid / Q000031:analogs & derivatives / Q000627:therapeutic use; D010878:Piperacillin / Q000627:therapeutic use; D000077725:Piperacillin, Tazobactam Drug Combination; D011697:Purpura, Thrombotic Thrombocytopenic / Q000188:drug therapy / Q000209:etiology* / Q000382:microbiology; D013159:Splenic Infarction / Q000188:drug therapy / Q000209:etiology* / Q000382:microbiology; D013845:Thienamycins / Q000627:therapeutic use
chemical_list: D000900:Anti-Bacterial Agents; D013845:Thienamycins; D000077725:Piperacillin, Tazobactam Drug Combination; D015378:Imipenem; D010397:Penicillanic Acid; D000077731:Meropenem; D010878:Piperacillin