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Surface electrode recording on the right fifth finger abductor and left trapezius muscles, respectively. Under basal conditions (i.e., with the muscle previously relaxed), a significant drop (>10%) in the amplitude of the 4th compound motor action potential (green arrows) is observed with respect to the 1 st (blue arrows) with low frequency stimulation trains (3 Hz), as well as an absence of the facilitation phenomenon with high frequency stimulation trains (30 Hz) in both nerves (star). This is a characteristic pattern of a postsynaptic neuromuscular transmission disorder, compatible with myasthenia gravis. The pattern of repetitive stimulation after exertion (voluntary muscle activation) is not assessable in this case as the patient is under sedation.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Diego Durán Barata, Olga Fedirchyk, Celia Corral Tuesta" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Diego" "apellidos" => "Durán Barata" ] 1 => array:2 [ "nombre" => "Olga" "apellidos" => "Fedirchyk" ] 2 => array:2 [ "nombre" => "Celia" "apellidos" => "Corral Tuesta" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775323000234" "doi" => "10.1016/j.medcli.2023.01.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775323000234?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020623001651?idApp=UINPBA00004N" "url" => "/23870206/0000016000000010/v2_202311101432/S2387020623001651/v2_202311101432/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S238702062300181X" "issn" => "23870206" "doi" => "10.1016/j.medcle.2022.12.012" "estado" => "S300" "fechaPublicacion" => "2023-05-26" "aid" => "6161" "copyright" => "Elsevier España, S.L.U." 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(A) Dorsocervical spine MRI showing a posterior epidural abscess (arrow). (B) Transesophageal echocardiography, long-axis longitudinal plane, showing a periannular aortic abscess (arrow).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Capnocytophaga canimorsus (C. canimorsus)</span> is a gram-negative bacillus that is part of the normal oral flora of dogs and cats and is the main human pathogen associated with dog bites.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It is known to cause fulminant sepsis in patients with risk factors such as asplenia, alcohol consumption or immunocompromised patients, but its ability to cause infective endocarditis (IE) in immunocompetent patients is less well described.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of an 80-year-old woman with a history of arterial hypertension and non-symptomatic aortic stenosis, who presented with a week’s history of dyspnoea, asthenia, fever and arthralgias.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The week before the onset of symptoms she was bitten by a dog on the proximal phalanx of the left hand.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The physical examination revealed functional impotence to raise the shoulders, the presence of a murmur in the aortic area and purpuric lesions in the lower limbs.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Laboratory analysis showed an erythrocyte sedimentation rate > 120 mm/h. Repeat blood cultures were negative. An electromyogram was performed which identified motor axonal involvement in the lower limbs, so a dorsocervical MRI was performed which showed a posterior epidural collection from D4 to D9 (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A, arrow), as well as fluid in the left glenohumeral joint. A transthoracic echocardiogram showed no signs of endocarditis.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Arthrocentesis of the left shoulder showed 56,000 cells, 90% of which were polymorphonuclear. Cultures were taken and empirical treatment with intravenous amoxicillin-clavulanic acid was initiated.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Subsequently, the patient presented with extreme bradycardia with electrocardiogram showing third degree atrioventricular block, which required the implantation of an electrocatheter.</p><p id="par0040" class="elsevierStylePara elsevierViewall">A transesophageal echocardiogram was performed and showed signs of IE over native aortic and mitral valve with aortic peri annular abscess (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B, arrow). Serologies for endocarditis-causing microorganisms with negative blood cultures were negative.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Synovial fluid culture was positive for <span class="elsevierStyleItalic">C. canimorsus.</span> Upon a presumptive diagnosis of IE due to <span class="elsevierStyleItalic">C. canimorsus,</span> treatment was replaced by ceftriaxone.</p><p id="par0050" class="elsevierStylePara elsevierViewall">As complications she developed dysarthria due to cerebral infarction in the territory of the left posterior cerebral artery of cardioembolic aetiology and acute respiratory insufficiency with a torpid course; she finally died.</p><p id="par0055" class="elsevierStylePara elsevierViewall">IE due to <span class="elsevierStyleItalic">C. canimorsus</span> is extremely rare, with 18 cases reported in the literature between 1977 and 2019.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The aortic valve is the main valve affected (61.1%), followed by the tricuspid valve (33.3%) and less often the mitral valve (22.2%). Less than 1/4 of the patients previously described had underlying heart disease. On the other hand, almost 1/3 of the reported cases had some degree of immunosuppression due to chemotherapy or alcohol consumption. Two thirds of the cases described had a history of dog bite or close contact with dogs.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Our patient is the oldest case published to date and the third case of native valve endocarditis due to <span class="elsevierStyleItalic">C. canimorsus</span> involving the aortic and mitral valve.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">C. canimorsus</span> infections can result in a wide range of clinical manifestations, ranging from skin and soft tissue infection to haematogenous spread with complications such as endocarditis, meningitis, septic arthritis, as well as fulminant infection in the absence of risk factors. This is why the diagnosis of IE requires a high index of suspicion, as the clinical signs may be non-specific and blood cultures are often negative<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>.</p><p id="par0070" class="elsevierStylePara elsevierViewall">In our case, the diagnosis of IE according to the current classification based on the modified Duke criteria, is based on the findings in the transesophageal echocardiogram (1 major criterion) and the presence of temperature > 38 °C, embolic phenomena and known valvular heart disease (3 minor criteria) as the definitive diagnosis, assuming given the context, due to <span class="elsevierStyleItalic">C. canimorsus</span>.</p><p id="par0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Capnocytophaga species</span> are susceptible to penicillins, third generation cephalosporins and carbapenems. Antibiotic prophylaxis after a dog bite consists of amoxicillin with clavulanic acid.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The interest of the clinical case lies in the importance of suspecting IE due to <span class="elsevierStyleItalic">C. canimorsus</span> in an immunocompetent patient with negative blood cultures, with a history of recent dog bite even in the absence of typical clinical features, especially if there is previous valvulopathy, as well as taking into account the use of prophylactic antibiotics after risk exposure.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1480 "Ancho" => 2758 "Tamanyo" => 319250 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Imaging tests performed on the case. (A) Dorsocervical spine MRI showing a posterior epidural abscess (arrow). (B) Transesophageal echocardiography, long-axis longitudinal plane, showing a periannular aortic abscess (arrow).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Capnocytophaga canimorsus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "L. Chanqueo" 1 => "P. 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Yamamoto" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/s12879-019-4492-3" "Revista" => array:5 [ "tituloSerie" => "BMC Infect Dis" "fecha" => "2019" "volumen" => "19" "paginaInicial" => "927" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/31684875" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Double valve infective endocarditis due to <span class="elsevierStyleItalic">Capnocytophaga canimorsus</span>" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. Harrigan" 1 => "K. Murnaghan" 2 => "M. Robbins" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.idcr.2022.e01448" "Revista" => array:3 [ "tituloSerie" => "IDCases" "fecha" => "2022" "volumen" => "27" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000016000000010/v2_202311101432/S2387020623001675/v2_202311101432/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000016000000010/v2_202311101432/S2387020623001675/v2_202311101432/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020623001675?idApp=UINPBA00004N" ]
Journal Information
Vol. 160. Issue 10.
Pages 463-464 (May 2023)
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Vol. 160. Issue 10.
Pages 463-464 (May 2023)
Letter to the Editor
Infective endocarditis due to Capnocytophaga canimorsus in an immunocompetent patient
Endocarditis infecciosa por Capnocytophaga canimorsus en una paciente inmunocompetente
Didac González Sans
, Pau Carratalà Marín, Alfredo Guillen-del-Castillo
Corresponding author
Servicio de Medicina Interna, Hospital Vall d’Hebron, Barcelona, Spain
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From Monday to Friday from 9 a.m. to 6 p.m. (GMT + 1) except for the months of July and August which will be from 9 a.m. to 3 p.m.
Calls from Spain
932 415 960
Calls from outside Spain
+34 932 415 960
E-mail