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Capnocytophaga Bacteremia Precipitating Severe Infectious Disease Reports 2019; volume 11:8272 Capnocytophaga bacteremia carditis and meningitis and is associated precipitating severe thrombo- with bacteremia and sepsis.3 People who are Correspondence: Austin Hopkins, 5511 at increased risk of developing infections Butterfly Lane, Apt 302, Durham NC 27707, cytopenia and preterm labor in with C. canimorsus are asplenic patients USA. an asplenic host and those who chronically use alcohol and Tel: +1.919.271.3811. considered functionally immunocompro- E-mail: [email protected] 4,5 Austin M. Hopkins,1 mised. Infection in pregnancy is rare how- Key words: Capnocytophaga, thrombocytope- 2 ever, the few case reports published have Nerlyne Desravines, nia, preterm labor. described premature labor, chorioamnioni- Elizabeth M. Stringer,3 Katelin Zahn,2 3 1 tis, and neonatal septicemia associated with Acknowledgments: The authors would like to Carolyn M. Webster, Kayla Krajick, thank the staff of the Maternal Fetal Medicine 3 C. ochracea and other species commonly Neeta L. Vora found in human oral flora.6-9 However, little service for their assistance in the care of the 1University of North Carolina School of is known about the influence of zoonotic- patient presented. Medicine, Chapel Hill, NC; 2Department acquired Capnocytophaga infection during Contributions: AH, manuscript writing, case of Obstetrics & Gynecology, University pregnancy. analysis, and literature review; ND, manu- of North Carolina School of Medicine, script review and case analysis; EMS, manu- Chapel Hill, NC; 3Division of Maternal script review and case analysis; KZ, manu- Fetal Medicine, Department of script review and case analysis; CMW, case Case Report analysis; KK, case analysis; NVL, manuscript Obstetrics & Gynecology, University of review, case analysis. North Carolina School of Medicine, A 35-year-old female (gravida 5, para Chapel Hill, NC, USA 2022) presented to a tertiary care hospital at Conflict of interest: The authors declare no 36 weeks and 2 days gestation with new- potential conflict of interest. onset vaginal bleeding and a five-day histo- ry of fevers, headache, neck stiffness, and Funding: None. Abstract altered mental status three days after being onlyReceived for publication: 7 August 2019. bitten by a neighbor’s dog. Her prenatal his- Capnocytophaga species are gram-neg- Revision received: 23 October 2019. tory was significant for fetal intrauterine ative bacilli that inhabit mammalian oral Accepted for publication: 28 October 2019. surfaces and can cause opportunistic infec- growth restriction (IUGR) diagnosed at th tion, especially in asplenic patients. The 32w5d with a fetus weighing 1477guse (5 per- This work is licensed under a Creative species Capnocytophaga canimorsus is par- centile). Her past medical history was sig- Commons Attribution-NonCommercial 4.0 ticularly associated with dog bites and is nificant for a motor vehicular accident in a International License (CC BY-NC 4.0). known to cause endocarditis, meningitis, prior pregnancy with multiple traumatic © and sepsis in the general population. In injuries and resultant splenectomy. She also Copyright: the Author(s), 2019 pregnant patients, infections tied to suffered a diffuse axonal brain injury with Licensee PAGEPress, Italy loss of short-term memory with a secondary Infectious Disease Reports 2019; 11:8272 Capnocytophaga species from human flora doi:10.4081/idr.2019.8272 have been associated with preterm labor, seizure disorder. In subsequent pregnancies, chorioamnionitis, and neonatal septicemia. she required a cesarean delivery due to an 9 There is little known about the effects of unstable pelvis. Prior to admission, she sion was 8×10 /L, which was confirmed zoonotically-acquired Capnocytophaga reported tremulous chills and fevers to with repeat testing. She was transfused prior infection in pregnant patients. In this case 102.7°F (39.3°C). Her husband noted the to surgery with 2 units of platelet and report, we present a patient with patient was off-balance and was slurring her responded appropriately with a count of 9 Capnocytophaga bacteremia acquired after words. She also endorsed new-onset signif- 55×10 /L. In the immediate post-operative a dog bite associated with profound throm- icant fatigue, persistent headache, and tran- period, the patient’s platelet count bocytopenia and preterm labor. Dog bites sient spotting across bilateral visual fields. decreased to 16×109/L, suggesting a throm- are common in the United States, and we The patient then began to experience new bophilia. Routine laboratory screening dur- present basic recommendations Non-commercialfor manage- bright red vaginal bleeding. These symp- ing her pregnancy established a baseline ment of dog bites in pregnant patients in toms prompted the patient’s husband to platelet count of 400×109/L. Initially, there bring her to the tertiary care hospital system order to avoid morbidity associated with was a concern for immune thrombocytope- 1.5 hours away from their home. The delay in time to antibiotic treatment of nia (ITP) or thrombotic thrombocytopenia wound on her index finger from the dog bite infection as described in this case. (TTP), a hematologic emergency requiring appeared to be well-healing with no erythe- plasmapheresis. However, the clinical histo- ma, swelling, or tenderness to palpation. Immediately on presentation, she was ry in this patient suggested an infectious eti- noted to have a persistently category 2 fetal ology and splenic platelet sequestration Introduction heart tracing which was initially attributed impossible given the patient’s lack of a Capnocytophaga spp. are gram-nega- to a placental abruption given her vaginal spleen. tive bacilli that are colonized in mammalian bleeding. She underwent an emergent Hematology evaluation was negative oral flora but may also cause infection fol- repeat low transverse cesarean section. The for schistocytes on peripheral smear and lowing dog or cat bites.1 Capnocytophaga neonate was admitted to the neonatal inten- revealed a normal ADAMST13 level, the canimorsus, (C. canimorsus), is a compo- sive care unit (NICU) and was diagnosed latter of which essentially excluded TTP. nent of canine and feline oral flora and with respiratory failure necessitating intu- However atypical, sepsis with or without infection with C. canimorsus is primarily bation. and core temperature lability with disseminated intravascular coagulation associated with dog bites.2 C. canimorsus is stable hemodynamic vitals. (DIC) became the most likely underlying known to cause infections such as endo- This patient’s platelet count on admis- etiology. She had no evidence of DIC given [Infectious Disease Reports 2019; 11:8272] [page 37] Case Report normal coagulation studies including a nor- and a fluctuating mental status suggesting platelet count of 8×109/L, suggesting a mal fibrinogen, prothrombin time (PT) and an intracranial component to her symptoms. hematologic pathology. Concurrently, she partial prothrombin time (PTT). In sepsis With her platelet count of less than presented with fevers and altered mental syndromes, platelet counts generally are 70×109/L, a lumbar puncture placed her at status following multiple zoonotic expo- lower than 100×109/L with clinical severity high risk for bleeding.14 In discussion with sures. The impact of both processes was associated with the magnitude of the the Maternal Fetal Medicine, Hematology, concerning particularly in the setting of decrease in platelet count, so this patient’s and Infectious Disease teams, the benefits intrauterine growth restriction. profound thrombocytopenia due to infec- and risks of this invasive procedure were tion was not a classic presentation.10 On fur- discussed. The patient’s symptomology was Fetal considerations ther review, she had a remote history of a determined to be more suggestive Perinatal infection with 9 platelet count of 14×10 /L around the time encephalopathy, due to the altered mental Capnocytophaga species is rare with only of the patient’s traumatic MVA five years status being the predominant neurological scattered cases across medical literature with prior. ITP was an additional leading diagno- finding. Lumbar puncture was deferred. An a predominance of focus on species found in sis for her thrombocytopenia that was unre- MRI, in the evaluation of infectious central human flora. Infection with these species are sponsive to transfusion, although the plausi- nervous system disease, is a sensitive form a demonstrated potential risk factor for of neuroimaging.15 She underwent an MRI bility of profound platelet destruction by preterm birth and an infrequent cause of of the brain with contrast which showed no 17 ITP in an asplenic patient was considered chorioamnionitis and neonatal infection. evidence of encephalitis, no acute intracra- unlikely. Following cesarean delivery for Several reported cases involved afebrile nial processes but did note some chronic category 2 fetal heart tracing on arrival, she women who presented in preterm labor with change consistent with her prior brain was started on clindamycin, gentamicin, intact membranes and mild leukocytosis.18-21 injury. and metronidazole due to concern for an Three cases described neonatal morbidity as Blood cultures obtained at infectious process. The asplenic patient is a result of maternal infection.8,22,23 These admission were positive for gram negative an effectively immunocompromised patient reports are based on relatively healthy moth- bacilli and preliminarily grew
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