Purpura fulminans secondary to Capnocytophaga canimorsus bacteraemia following a dog bite: A case report and review of literature
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Introduction. Infection due to Capnocytophaga canimorsus may result in a wide variety of clinical presentations. We present a case of life-threatening Capnocytophaga canimorsus infection with evolution of ecchymosis to purpura fulminans.
Case description. We present a case of a 43-year-old male with a history of excessive alcohol consumption who presented with features of sepsis following a dog bite. This was associated with a striking, widespread purpuric rash. A causative pathogen, C. canimorsus was identified through blood culture and 16S RNA sequencing. His initially purpuric rash underwent bullous transformation and was diagnosed clinically as purpura fulminans, confirmed on skin biopsy. He made a full recovery with prompt antimicrobial therapy, initially with co-amoxiclav but escalated to clindamycin and meropenem due to clinical deterioration and concerns of beta-lactamase resistance.
Discussion. β-Lactamase producing Capnocytophaga strains are of increasing concern. This particular concern is reflected in our case as 5 days into treatment with β-lactamase inhibitor combination therapy the patients clinical condition deteriorated but demonstrably improved on switching to a carbapenem.
The development of biopsy proven purpura fulminans in this immunocompetent case is a rare severe manifestation of the previously reported manifestation of disseminated intravascular coagulation (DIC) in Capnocytophaga bacteraemia. The case reported describes characteristics common with other DIC presentations such as the presence of clinical risk factors (history of excessive alcohol consumption) and symmetrical involvement. However, an unusual feature in that initial purpuric lesions were followed by the development of a bullous appearance and peripheral necrotic features concerning for purpura fulminans and confirmed with skin biopsy.
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Comments to Author
1. Description of the case(s) Case was detailed, well described with a clear timeline. 2. Presentation of results Lab results as well as tables that included information from literature review were well organized, some suggestions were made. 3. How the style and organization of the paper communicates and represents key findings Clear, easy to read, well written. 4. Literature analysis or discussion Good discussion about type of rash, creates awareness of antimicrobial resistance in this pathogen as well as possibility of significant incubation time before growth may be detected. 5. Any other relevant comments minor suggestions: Line 17 bullous "transformation" Line 19 amoxicillin/clavulanic acid or appropriate generic name, there are further changes need to be made in the document Line 29 …
Comments to Author
1. Description of the case(s) Case was detailed, well described with a clear timeline. 2. Presentation of results Lab results as well as tables that included information from literature review were well organized, some suggestions were made. 3. How the style and organization of the paper communicates and represents key findings Clear, easy to read, well written. 4. Literature analysis or discussion Good discussion about type of rash, creates awareness of antimicrobial resistance in this pathogen as well as possibility of significant incubation time before growth may be detected. 5. Any other relevant comments minor suggestions: Line 17 bullous "transformation" Line 19 amoxicillin/clavulanic acid or appropriate generic name, there are further changes need to be made in the document Line 29 history of excessive alcohol consumption Line 72 prior instead of past 48-hours Line 77 he was tachycardic and had cold peripheries Line 87 - define XR if needed Line 88 -define CTPA if needed Line 100 clotting function. Line 109 define MDT Line 125 a stat dose of amikacin was given. The patient had further fever Line 172 if the 5 is a reference it should be in brackets Other comments and questions. Would describe skin biopsy findings instead of reporting it as it were reported by pathology, if this is appropriate. Tazosin - use generic term Survived, survival in tables. What is ITU? Under treatment in tables. No identification of orgnanism for harana et al. ? On which day was the patient discharged? On which day was 16 S completed? Why did the culture not survive?
Please rate the quality of the presentation and structure of the manuscript
Very good
To what extent are the conclusions supported by the data?
Partially support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
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Comments to Author
Dear Authors, Thank you for submitting your manuscript to Access Microbiology Journal. This manuscript presents a case of Purpura fulminans due to Capnocytophaga canimorsus in a young patient affected by chronic substance use. This case report highlights important topics in Capnocytophaga clinical infection: beta-lactamase resistance and diagnostic workup. However, I would suggest a minor revision to improve its readability. 1. Many abbreviations, despite their widespread use in clinical practise, should be expanded at least during their first use. (line 27 DIC, line 82 DVT, line 87 XR, line 88 CTPA, line 89 PE, line 93 LFTs, line 99 MCS, line 106 US, line 109 MDT, line 111 WCC, line 109 CRP, line 117 TTP, line 134 ID.) 2. Line 19, page 1 "amoxiclav/clavulanic acid" should be corrected to …
Comments to Author
Dear Authors, Thank you for submitting your manuscript to Access Microbiology Journal. This manuscript presents a case of Purpura fulminans due to Capnocytophaga canimorsus in a young patient affected by chronic substance use. This case report highlights important topics in Capnocytophaga clinical infection: beta-lactamase resistance and diagnostic workup. However, I would suggest a minor revision to improve its readability. 1. Many abbreviations, despite their widespread use in clinical practise, should be expanded at least during their first use. (line 27 DIC, line 82 DVT, line 87 XR, line 88 CTPA, line 89 PE, line 93 LFTs, line 99 MCS, line 106 US, line 109 MDT, line 111 WCC, line 109 CRP, line 117 TTP, line 134 ID.) 2. Line 19, page 1 "amoxiclav/clavulanic acid" should be corrected to co-amoxiclav or, even better for non-English readers, amoxycillin/clavulanic acid. 3. Line 28, I would suggest changing the term "septicaemia" as it is not more used as a diagnostic term in modern clinical practise. 4. Some sentences might be improved (some sentences are widely accepted in our clinical jargon but should be rephrased for a peer-reviewed paper). "Gastrointestinal bacterial and viral PCR, plus ova, cysts and parasites were sent for diarrhoea.[..]Furthermore, mycoplasma serology and urinarypneumococcal and legionella antigens were collected due to hyponatraemia and abnormal LFTs." 5. Please use the same term to describe the patients' outcome in your summary Table ("survived" or "survival").
Please rate the quality of the presentation and structure of the manuscript
Satisfactory
To what extent are the conclusions supported by the data?
Strongly support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
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