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Myocardial Infarction After Dog Bite
glance suggest transmural ischemia and an acute inferolateral
myocardial infarction, it is uncharacteristic to find ST elevation
in lead I and an upsloping ST segment in V2 and V3, rather than
reciprocal ST depression given this degree of ST elevation in
inferolateral leads; (2) echocardiography showed diffuse left
ventricular hypokinesia and not the typical regional akinesia
expected with an inferolateral infarction; and (3) in the absence
of embolic endocarditis or severe sustained hypotension, there is
no plausible pathogenic link (and the authors suggest none)
between bacteremia/disseminated intravascular coagulation and
the acute occlusion of an epicardial coronary artery leading to
myocardial infarction, and the latter is rarely, if ever, described
as a complication of the former. The far more likely diagnosis is
toxic-infectious myocarditis, which can notoriously mimic acute
myocardial infarction.2 Acute myocarditis would better account
for the atypical ECG features and the diffuse left ventricular
hypokinesia in the context of a severe systemic clinical
presentation.
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To the Editor:
We do not agree with the diagnosis of myocardial infarction in
the case of a 36-year-old man 2 days after a dog bite1. For several
reasons, we believe that the patient had myopericarditis rather
than myocardial infarction.
First, the patient had symptoms, signs, and laboratory findings
consistent with sepsis, and blood cultures yielded Capnocytophaga canimorsus. Myocardial infarction occurs occasionally in
patients with bacteremia, and it usually results from sepsisassociated hypotension or from endocarditis with septic embolism to the coronary arteries. However, viral and bacterial
infections are more commonly the cause of pericarditis and
myocarditis.2,3 ECG patterns of acute myopericarditis are known
to resemble those seen with acute myocardial infarction.4 The
presented ECG demonstrated ST elevations in both anterior and
inferior leads in a manner consistent with the pattern found in
acute myopericarditis.4,5
Second, the absence of regional wall motion abnormalities and
the documentation of diffuse hypokinesia with left ventricular
systolic dysfunction are typically seen in myopericarditis. Abnormal regional wall motion is nearly universally present in
acute myocardial infarction. Presentation with chest discomfort
and laboratory examinations with elevated levels of creatine
kinase and raised troponin-I concentrations are consistent with
myopericarditis as well as with myocardial infarction.
Third, coronary angiography demonstrating normal vessels
without signs of atherosclerosis is also consistent with the
diagnosis of myopericarditis. This finding makes acute myocardial infarction less likely but does not definitely rule out previous
coronary artery occlusion.
In summary, we think that the diagnosis of acute myopericarditis is more likely than acute myocardial infarction in the
reported case.1
Peter Bogaty, MD
Quebec Heart Institute/Laval Hospital
25 Chemin Ste-Foy
Ste-Foy, Quebec, Canada G1V 4G5
[email protected]
1. Scharf C, Widmer U. Myocardial infarction after dog bite. Circulation.
2000;102:713–714.
2. Narula J, Khaw BA, Dec GW Jr, et al. Brief report: recognition of acute
myocarditis masquerading as acute myocardial infarction. N Engl J Med.
1993;328:100 –104.
Myocardial Infarction After Dog Bite
To the Editor:
I read with interest the report by Scharf et al1 of a 36-year-old
man with an acute myocardial infarction presenting 2 days after
a dog bite that was associated with leucocytosis and elevated
C-reactive protein (CRP). Although I agree with the authors that
infection and bacteremia may precipitate an acute myocardial
infarction,2 I disagree with their statement that “it usually results
from hypotension or from endocarditis with septic emboli to the
coronary arteries.” None of my patients with pharyngitis and
consequent acute myocardial infarction had hypotension or
evidence of endocarditis, and those catheterized had normal or
minor coronary artery disease.2
Inflammation, both local and systemic, plays a role in plaque
vulnerability. Inflammation at the systemic level leads to elevated CRP and amyloid A levels and to activation of monocytes
and adhesion molecules,3,4 all of which have been associated
with acute coronary syndromes. Thus, the inflammatory response
to the dog bite and the elevated CRP and leucocytosis, among
other factors, led to endothelial dysfunction and changes in
circulating clotting factors such as fibrinogen, which led to an
increased clotting tendency and thrombotic coronary occlusion.5
Because no intravascular ultrasound was done, a minor atheroma
instability or small plaque rupture associated with the inflammatory response cannot be excluded.
Johann Auer, MD
Robert Berent, MD
Bernd Eber, MD
Department of Cardiology and Intensive Care
General Hospital Wels
Wels, Austria
1. Scharf C, Widmer U. Myocardial infarction after dog bite. Circulation.
2000;102:713–714.
2. Lorell BH, Braunwald E. Pericardial disease. In: Braunwald E, ed. Heart
Disease. 4th ed. Philadelphia: Saunders; 1992:1465–1472.
3. Zayas R, Anguita M, Torres F, et al. Incidence of specific etiology and
role of methods for specific etiologic diagnosis of primary acute pericarditis. Am J Cardiol. 1995;75:378 –382.
4. Goldberger AL, Goldberger E. Miscellaneous ECG patterns: pericarditis
and pericardial effusion; myocarditis. In: Goldberger AL, Goldberger E,
eds. Clinical Electrocardiography. 5th ed. St Louis: Mosby Year Book;
1994:131–133.
5. Eber B, Auer J, Berent R. Perikarditis. In: Eber B, ed. EKG: Einfach,
Kurz, Genau. 2nd ed. Graz, Austria: Leykam; 1998:51.
Myocardial Infarction After Dog Bite
Edward G. Abinader, MD, FRCPI
Bnai-Zion Medical Center
Medical Faculty, Technion
Golomb Street 47
Haifa, Israel
To the Editor:
Scharf and Widmer describe a case of dog bite resulting in
sepsis, implicating the Gram-negative bacteria Capnocytophaga
canimorsus, with accompanying chest discomfort, ST-segment
elevation, and a cardiac enzyme rise.1 They conclude that
myocardial infarction occurred as a complication of bacteremia
“in the absence of both hypotension and endocarditis.” They did
not consider another possibility that should have entered into the
differential diagnosis given the following elements of the clinical
presentation: (1) although the presenting ECG might at first
1. Scharf C, Widmer U. Myocardial infarction after dog bite. Circulation.
2000;102:713–714.
2. Abinader EG, Sharif D, Omary M. Inferior wall myocardial infarction
preceded by acute exudative pharyngitis in young males. Isr J Med Sci.
1993;29:764 –769.
1
2
Correspondence
3. Liuzzo G, Biasucci LM, Gallimore JR, et al. The prognostic value of
C-reactive protein and serum amyloid A protein in severe unstable
angina. N Engl J Med. 1994;331:417– 424.
4. Mazzone A, De Servi S, Ricevuti G, et al. Increased expression of
neutrophil and monocyte adhesion molecules in unstable coronary artery
disease. Circulation. 1993;88:358 –363.
5. Meier CR, Jick SS, Derby LE, et al. Acute respiratory-tract infections and
risk of first-time acute myocardial infarction. Lancet. 1998;351:
1467–1471.
Response
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Differentiation between myocarditis and infarction cannot be
made easily, and the gold standard for a positive diagnosis of
myopericarditis would be a myocardial biopsy, which was not
available in our patient. We still favor the diagnosis of myocardial infarction for the following reasons.
The picture of the patient’s nose, together with laboratory
results of disseminated intravascular coagulation, are signs of
microvascular thrombosis with cutaneous and systemic manifestations. The hemorrhagic skin lesions developed at the same time
as the myocardial necrosis (ie, a few hours before admission).
Therefore we assume that infectious-triggered disseminated intravascular coagulation caused microvascular thrombosis and
myocardial infarction initially in the inferolateral region, with
subsequent spread over more than one area supplied by the main
3 coronary arteries. The occlusion of multiple small coronary
vessels explains the global hypokinesia and the normal coronary
angiogram. Most importantly, several other cases illustrate acute
myocardial infarction after dog bite. In one case, typical chest
pain and ST elevation appeared 1 day before fever and systemic
infection.1 In another patient, acute coronary thrombosis was
documented angiographically 3 weeks after dog bite. The patient
had no signs of infection and was discharged after 10 days but
had to be readmitted when blood cultures yielded Capnocytophaga canimorsus.2
In conclusion, Capnocytophaga canimorsus sepsis can rarely
present as a distinct clinical pattern with disseminated intravascular coagulation and widespread capillary thrombosis, similar to
Waterhouse-Friderichsen syndrome or thrombotic thrombocytopenic purpura,3 which can lead to extensive gangrene4 and a
mortality ⬎30%.5 Clinical diagnosis before time-consuming
microbiological isolation is mandatory to insure early antibiotic
treatment. The old Roman mosaic in the “House of the Tragic
Poet” in the ruins of Pompeii with the engraved Latin comment
cave canem (beware of dog) and our images should be kept in
mind when taking care of patients with signs of acute myocardial
infarction after animal bites.
Christoph Scharf, MD
Urs Widmer, MD
Department of Medicine
University Hospital
CH-8091 Zurich
Switzerland
1. Ehrbar HU, Gubler J, Harbarth S, et al. Capnocytophaga canimorsus
sepsis complicated by myocardial infarction in two patients with normal
coronary arteries. Clin Infect Dis. 1996;23:335–336.
2. Newton NL, Sharma B. Acute myocardial infarction associated with
DF-2 bacteremia after a dog bite. Am J Med Sci. 1986;291:352–354.
3. Scarlett JD, Williamson HG, Dadson PJ, et al. A syndrome resembling
thrombotic thrombocytopenic purpura associated with Capnocytophaga
canimorsus septicemia. Am J Med. 1991;90:127–128.
4. Kullberg BJ, Westendorp RG, van Meinders AE. Purpura fulminans and
symmetrical peripheral gangrene caused by Capnocytophaga canimorsus
(formerly DF-2) septicemia: a complication of dog bite. Medicine (Baltimore). 1991;70:287–292.
5. Pers C, Gahrn HB, Frederiksen W. Capnocytophaga canimorsus septicemia in Denmark, 1982–1995: review of 39 cases. Clin Infect Dis.
1996;23:71–75.
Myocardial Infarction After Dog Bite
Johann Auer, Robert Berent and Bernd Eber
Circulation. 2001;103:e95
doi: 10.1161/01.CIR.103.18.e95
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