Fulminant Septic Shock with Pasteurella multocida in a Young Infant: No Bite,Scratch,or Lick!

Abstract

This is a case of Pasteurella multocida septic shock encountered in a 7-week-old infant without any bites, scratch marks, or history of licks by pet animals (dog and cats in household). The infant required 3 days of vasopressor support and 4 days of mechanical ventilation to achieve normal hemodynamics. This is an unidentified route of transmission and our literature search for this topic discovered reported cases of life-threatening presentation with Pasteurella infections in the absence of a bite or any form of invasive contact with animals. We believe that this is an important public safety message to restrict animal contact of young infants to prevent severe infection.

Introduction

P asteurella species are nonmotile facultative anaerobic gram-negative coccobacilli found in the oral flora of many animals, especially cats and dogs with carriage rate up to 70–90% and 25–50%, respectively (Pickering et al. 2012). Pasteurella multocida is the most common human pathogen (Pickering et al. 2012). The incubation period is usually <24 h (Pickering et al. 2012). The most common mode of transmission is an animal bite or scratch. Cellulitis is the most common clinical manifestation observed after infection (Pickering et al. 2012). Septicemia is an unusual manifestation in any age group. We report a case of rapidly progressive fulminant P. multocida septic shock in an infant with no apparent history of any direct invasive animal exposure. We also present an extensive literature review of pediatric cases with Pasteurella septicemia and meningitis.

Case Report

Seven weeks old previously healthy full-term female with no perinatal complications presented to our emergency room with high fever, decreased oral intake, lethargy, and irritability for 6 h. No history of exposure to any sick contacts or day care was reported. The family had two cats and a dog at home. There was no history of any scratch or bites or licks by an animal. Parents deny any contact with pets and stated the pets spend a majority of their time outside the home.

On examination, she was lethargic with dusky appearance and decreased responsiveness with Glasgow coma scale 7, temperature 104.1°F, heart rate 232/min, poorly palpable peripheral pulses, capillary refill time delayed to 6 s, and with oxygen saturation 98–100% on room air. There was no bite or scratch marks found on examination. The remainder of her examination was nonfocal. With the initial working diagnosis of septic shock, initial laboratories were drawn that were significant for the following: hypoglycemia to 54 mg/dL, severe metabolic acidosis with pH 7.04 and base deficit of 15, neutropenia to 4000/mm³, anemia with hemoglobin level 8 g/dL, thrombocytopenia to 56,000/mm³, acute kidney injury with blood urea nitrogen 32 mg/dL and serum creatinine 1.1 mg/dL, acute liver injury with moderately elevated liver enzymes, and elevated inflammatory markers with initial C-reactive protein 12 mg/dL and highly elevated procalcitonin 88 ng/mL.

After securing intravenous access, she was resuscitated with intravenous dextrose, intravenous isotonic fluid boluses, and intubated for airway protection. She required total of 100 mL/kg intravenous fluid boluses and multiple inotropic and vasopressor support with dopamine, dobutamine, epinephrine, and stress dose hydrocortisone to stabilize her hemodynamics. Central venous access and an arterial access were secured. Once she was stabilized, a lumbar puncture was performed that showed two white blood cells, protein 58 mg/dL and glucose 64 mg/dL and negative gram stain. She was started on empiric coverage with ampicillin, cefotaxime, and acyclovir. She underwent an extensive workup for inborn error of metabolism, congenital heart disease, and neurological disorders. Echocardiogram revealed a normal heart structure and function, and electroencephalogram was negative for any epileptiform activity.

At 12 h into her admission, blood cultures grew gram-negative bacilli. Zosyn and gentamicin were added to microbial coverage, cefotaxime was discontinued. At 24 h, the gram-negative rod was identified as P. multocida, susceptible to ampicillin. Antibiotic coverage narrowed down to ampicillin monotherapy. Repeat blood cultures remained sterile. Her fever defervesced 48 h into treatment. Her renal function and liver function tests normalized over the next 7 days. She was extubated on day 4 of her hospital stay. She was back to her normal baseline by day 10 and completed total 14 days of intravenous antibiotics before discharge.

Discussion

An extensive literature search was performed using PubMed and Medline for serious infections, specifically meningitis or septicemia by Pasteurella strains in the children <18 years of age. We found 66 cases to date since 1953. Of all the cases, only three were from strains other than P. multocida, namely Pasteurella gallinarum (Ahmed et al. 2002), Pasteurella canis (Yefet et al. 2011), and Pasteurella hemolytica (Punpanich and Srijuntongsiri 2012) contributing to one case each. Pediatric cases with both P. gallinarum and P. hemolytica were fatal.

The incidence of Pasteurella bacteremia is reported between 8% and 11% in patients with Pasteurella cutaneous infections. There were total 11 deaths out of 66 serious Pasteurella infections (16.6%) in pediatrics. Apart from invasive contact in form of bites or scratches, significant routes of transmission found were vertical transmission, licking, or other forms of noninvasive animal contact (Spencker et al. 1979, Zaramella et al. 1999). Information regarding mode of inoculation or exposure to animal was not available in 15 cases. Only five cases (7.5%), had traumatic inoculation in the form of animal bites, scratch, or lick over scalp injuries. Ten cases (15%) were after licking over child's body part or over the baby's pacifier. Twenty cases (32%) were with no clear evidence of any direct animal contact. Six of the deaths were in the neonatal age group, three out of these six fatal neonatal cases were from vertical transmission and for the remaining three cases the mode of transmission could not be established (Zaramella et al. 1999). Of 30 total neonatal cases, 6 deaths have been documented, making an estimated fatality rate of 20% for that age group (Table 1).

Table 1.

Demographic and Clinical Characteristics of the Neonatal Cases with Pasteurella Infections

No.	Year	Location	Age (days)	Gender	Animal exposure	Mode of transmission	Positive culture	Outcome	References
1	1953	Canada	20	F	UK	UK	Blood	Survived	Zaramella et al. (1999)
2	1965	United States	3	M	UK	UK	CSF, blood, pharynx	Death	Zaramella et al. (1999)
3	1971	United States	0	M	Cat	Vertical	Blood	Death	Zaramella et al. (1999)
4	1978	United States	25	M	Dog	UK	CSF, blood, umbilicus	Survived	Zaramella et al. (1999)
5	1981	France	2	M	Multiple farm animals	Vertical	CSF, blood	Survived	Zaramella et al. (1999)
6	1982	France	1	F	UK	UK	CSF	Death	Zaramella et al. (1999)
7	1984	United States	21	M	Cat	UK	CSF, blood	Survived	Zaramella et al. (1999)
8	1986	Canada	14	F	Dog	Bite	CSF	Survived	Steinbok et al. (1985)
9	1987	United States	2	M	Cat	Vertical	CSF, scalp abscess, mother's blood	Survived	Zaramella et al. (1999)
10	1993	Australia	2	M	Cat	Vertical	CSF, blood, mother's vaginal swab	Survived	Zaramella et al. (1999)
11	1994	France	27	F	Dog, cat	UK	CSF, blood	Survived	Zaramella et al. (1999)
12	1994	Finland	1	M	Cat	Vertical	Blood	Death	Zaramella et al. (1999)
13	1995	United States	17	M	Cat	UK	CSF	Survived	Zaramella et al. (1999)
14	1997	France	1	M	Dog	Vertical	Blood	Survived	Zaramella et al. (1999)
15	1997	United States	2	F	Cat	Vertical	Blood	Survived	Zaramella et al. (1999)
16	1999	Greece	28	F	Cat	Scratch	CSF, blood	Survived	Kouppari et al. (1999)
17	1999	Italy	1	M	Cat, dog	Vertical	CSF	Survived	Zaramella et al. (1999)
18	2001	France	10	F	Dog	UK	CSF, blood	Survived	Mestre et al. (2001)
19	2001	South Africa	4	F	UK	UK	CSF, blood, urine	Death	Ahmed et al. (2002)
20	2004	Canada	20	M	Cat, dog	UK	CSF	Survived	Hirsh et al. (2004)
21	2005	Australia	19	F	Cat	UK	CSF	Survived	Spencker et al. (1979)
22	2006	United States	26	M	Cat	UK	CSF, blood	Survived	Goytia et al. (2006)
23	2006	Germany	21	M	Cat	UK	CSF	Survived	Haase et al. (2006)
24	2006	Israel	28	F	Dog, cat	UK	CSF, blood	Survived	Punpanich and Srijuntongsiri (2012)
25	2006	Thailand	2	M	UK	Vertical	Blood	Death	Puwanant et al. (2006)
26	2008	Malta	1	F	Dog	Vertical	Blood	Survived	Pace and Attard-Montalto (2008)
27	2009	United States	25	M	Cat	UK	Blood	Survived	Kobayaa et al. (2009)
28	2012	Greece	17	F	Dog	UK	CSF, blood	Survived	Siahanidou et al. (2012)
29	2015	United States	17	M	Cat	Licking	CSF, blood	Survived	Boyanton et al. (2016)
30	2019	United States	12	M	Dog	Licking	CSF, blood	Survived	Ryan and Feder (2019)

F, female; M, male; UK, unknown.

In our analysis of 66 cases, only 1 case was >1 year old (21 months old), 9 cases (13.6%) were between 3 months and 1 year of age, 26 cases (39%) were between 29 days and 3 months of age, and 30 (45.5%) were neonates. Children less than 3 months of age contributed to 85% of all cases. Of the 30 neonates and of all 66 cases, vertical transmission was the cause in 10 (15%) cases. For 3 out of these 10 cases (30%) with vertical transmission, the final outcome was death. In proven vertical transmission cases, the organism was isolated from maternal vaginal secretions (Zaramella et al. 1999).

Our literature review clearly denotes that transmission through hands of family members and caregivers is one of the potential routes of transmission, and hand hygiene between taking care of pets and children is of utmost importance in preventing infection. Due to significant number of cases reported following animal lick only, close contact of an infant with animals should be discouraged (Wade et al. 1999). Another possibility for such cases is passive transport of saliva and organism through cushions, beddings, or other form of fomites. It has been shown that the organism can survive from few minutes to days in animal saliva and in aerosols depending upon environmental humidity and temperature (Thomson et al. 1992).

Apart from dogs and cats, other animals were also implicated in transmission such as pigs, roosters, rabbits, and sheep (Guillet et al. 2007). Children who have survived their illness have shown good neurological and overall outcome (Spencker et al. 1979, Zaramella et al. 1999, Wade et al. 1999). Only three cases showed neurological morbidity after recovery, namely moderate neurological sequelae, residual hemiparesis, and hypotonia with questionable hearing loss (Spencker et al. 1979, Zaramella et al. 1999, Wade et al. 1999). Almost all the cases received penicillin, ampicillin, or cephalosporins as empiric antimicrobial therapy. The drug of choice remains penicillin. Other effective oral agents include ampicillin, amoxicillin, cefuroxime, cefixime, cefpodoxime, doxycycline, and fluoroquinolones. For patients who are allergic to beta-lactam agents, azithromycin or trimethoprim–sulfamethoxazole are alternative choices (Pickering et al. 2012).

Conclusions

We present a life-threatening presentation of Pasteurella infection with no apparent direct animal contact. Our review highlights an important public safety message in terms of safety of infants especially <3 months of age in a house with pets. Close contact of young infants with pets or pet supplies should be avoided. Strict hand hygiene needs to be maintained between taking care of infants and pets as the implications can be serious.

Footnotes

Author Disclosure Statement

No conflicting financial interests exist.

Funding Information

No funding was received for this article.

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