www.elsevierhealth.com/journals/jinf

Journal of Infection (2007) 54, e107ee109

CASE REPORT

Capnocytophaga ochracea causing severe sepsisand purpura fulminans in an immunocompetentpatient

Sima S. Desai a,*, Rebecca A. Harrison a, Melissa D. Murphy b

a Department of Medicine, CR-119, Oregon Health and Science University, 3181 S.W. Sam Jackson Park Road,Portland, OR 97201, USAb Department of Medicine, Infectious Disease Section, Veterans Administration Medical Center, 3710 S.W.Veteran’s Hospital Road, Portland, OR 97239, USA

Accepted 27 June 2006Available online 1 August 2006

KEYWORDSCapnocytophagaochracea;Immunocompetent;Purpura fulminans

Summary Capnocytophaga ochracea (C. ochracea), a known human microflora, has beenreported to cause sepsis in immunocompromised patients and less severe infections such asintrauterine infections, endocarditis, peritonitis and septic arthritis in the immunocompetentpatient. We present the first described case of C. ochracea causing severe sepsis and purpurafulminans in an immunocompetent host.ª 2006 The British Infection Society. Published by Elsevier Ltd. All rights reserved.

Case

C. ochracea, formerly known as CDC biogroup DF-1, is a gram-negative fusiform bacterium commonly isolated from thesubgingival sulcus and a known cause of periodontitis.1

C. ochracea is a recognized pathogen causing severe diseasein immunocompromised patients.2 We present an immuno-competent patient who developed sepsis with purpurafulminans secondary to Capnocytophaga ochracea infection.

* Corresponding author. Tel.: þ1 503 494 0772; fax: þ1 503 4940979.

E-mail addresses: desais@ohsu.edu (S.S. Desai), harrisor@ohsu.edu (R.A. Harrison), melissa.murphy@med.va.gov (M.D. Murphy).

0163-4453/$30 ª 2006 The British Infection Society. Published by Elsevdoi:10.1016/j.jinf.2006.06.014

A 49 year old, previously healthy, male developed chills,fevers, myalgias, and headache two weeks after an uncom-plicated dental extraction with an unknown antibioticprophylaxis regimen. Within 24 h, he experienced severeabdominal pain and presented to an emergency depart-ment with a temperature of 102 �F and hypotension at85/51 mmHg. Several hours later, he developed diffusepurpura on his ears, feet, hands and trunk, consistentwith purpura fulminans (Figs. 1 and 2). The remainder ofhis physical examination was normal. The results of hislaboratory tests were as follows: white blood cell count2.10 K/cu mm with 30% bands, hematocrit 35%, plateletcount 62,000/cu mm, blood urea nitrogen 26 mg/dl, creat-inine 3.0 mg/dl, INR 1.5, prothromboplastin time >212 s,fibrinogen 259 mg/dl, D-dimer 8.0 mcg/ml.

ier Ltd. All rights reserved.

e108 S.S. Desai et al.

He was initially started on dopamine, ciprofloxacin, andcefotetan. He developed respiratory failure and oliguricrenal failure requiring mechanical ventilation and hemodi-alysis with plasma exchange respectively. On the secondhospital day, blood cultures grew gram-negative rods lateridentified as a Capnocytophaga ochracea by using a rapidanaerobic enzyme identification method. There was nohistory of a dog bite.

The patient was transferred to our facility and antibi-otics were changed to imipenem-cilastin and clindamycinfor a two week course. Abdominal and chest CT scan wasunremarkable. An echocardiogram showed depressed leftventricular function without valvular vegetations. Furtherlaboratory tests revealed no cryoglobulins or evidence ofa hypercoagulable state. The patient had a recent negativeHIV test.

The purpura fulminans of his extremities progressed todry gangrene. During a two-month recovery period, heunderwent bilateral below the knee and phalanges

Figure 1 Purpura fulminans of the hand.

amputations, tracheostomy, continued nutritional supportand rehabilitation. After being hospitalized for 87 days, hewas discharged, hemodialysis dependent, to an aggressiverehabilitation and occupational therapy center.

Conclusion

We present the first described case of C. ochracea causingsevere sepsis, multisystem organ failure and purpurafulminans in an immunocompetent host. C. ochracea isa gram negative organism in the oral flora distinguishedby its fastidious growth, requirement of CO2, gliding motil-ity, production of a yellow-orange pigment on blood agar, andan inability to grow on MacConkey agar.3 Capnocytophagaspecies are usually sensitive to clindamycin, quinolones,and carbapenems. Susceptibilities to penicillin, extendedgeneration cephalosporins, metronidazole, vancomycin, andgentamicin are more variable and b-lactamase producingisolates are common.4 Capnocytophaga species produce po-tent toxins, one known to inhibit neutrophilic chemotaxis.5

Typically, immunocompetent patients with C. ochraceapresent with less severe infections such as periodontitisthough serious infections such as submandibular abscess,pericardial abscess, and endocarditis can also be seen.1,6,7

The largest series of immunocompetent patients withC. ochracea had infections ranging from empyema to bacter-emia, but none of those patients who were bacteremic hadleukopenia, oral pathology or sepsis.2

C. ochracea causes severe illness in immunocompro-mised patients with mortality rates reported between14e43%.8 Disruption of the oral mucosal barrier from muco-sitis or periodontal disease may cause Capnocytophagaspecies to gain entry into the bloodstream.9 Kristensenet al. reported seven profoundly granulocytopenic patientssuffering from hematologic diseases (leukemias, myelodys-plastic syndromes and aplastic anemia) who had positiveblood cultures for Capnocytophaga. All but one of theirpatients had oral lesions including ulceration, periodontitisand peridontal abscess.10 The severity of Capnocytophagainfection in patients who are granuloctyopenic and/orwho receive either chemotherapy or hematopoietic stemcell transplantation for hematologic malignancies is well-documented in several case series.9,10

Figure 2 Purpura fulminans of the feet.

C. ochracea causing severe sepsis and purpura fulminans e109

Our patient’s presentation is more consistent with Cap-nocytophaga canimorsus, the most notable of the Capnocy-tophaga species to cause sepsis with purpura fulminans andgangrene.11 C. canimorsus, previously known as CDC groupDF-2, resides in the oral cavity of dogs and cats and can betransmitted to humans by bite, scratch or simple exposureto animals.12 C. canimorsus has very similar microbiologiccharacteristics as compared to C. ochracea except C. cani-morsus is oxidase and catalase positive whereas C. ochra-cea is oxidase and catalase negative.13 In a literaturereview of C. canimorsus infections, Kullberg et al. notedmore than 60% of patients having a predisposing medicalcondition including splenectomy, history of alcohol abuseor corticosteroid treatment. The case fatality rate forC. canimorsus is around 30% but may not be related tothe immune state of the patient.11,13 C. canimorsus andochracea share many microbiological and epidemiologicalsimilarities with C. canimorsus and ochracea causing severedisease in immuncompromised patients. However, therehave been no reports of C. ochracea causing a syndromeof sepsis and purpura fulminans in an immunocompetentpatient as there have been with C. canimorsus.

At a three year follow up our patient is off hemodialysisand has displayed no evidence of immunosuppression ormalignancy. We believe the portal of entry in this patientwas his recent dental extraction and his transient neutro-penia was secondary to his Capnocytophaga bacteremia.

This case is the first report of C. ochracea causing severesepsis, multisystem organ failure and purpura fulminans inan immunocompetent host. While an infection with C.ochracea necessitates a workup for an underlying immuno-deficiency, it should also be recognized as a cause of seriousand potentially life-threatening infection in the immuno-competent host.

Acknowledgements

SSD, RAH, MDM have no financial support or conflict ofinterest.

References

1. Hawkey PM, Malnick H, Glover SA, Cook N, Watts J. Capnocyto-phaga ochracea infection: two cases and a review of thepublished work. J Clin Path 1984;37(9):1066e70.

2. Parenti DM, Snydman DR. Capnocytophaga species: infectionsin non-immunocompromised and immunocompromised hosts.J Infect Dis 1985;151:140e7.

3. Newman MG, Sutter VL, Pickett MJ, Blachman U,Greenwood JR, Ginenko V, et al. Detection, identification,and comparison of Capnocytophaga, Bacteroides ochraceus,and DF-1. J Clin Microbiol 1979;10:557e62.

4. Roscoe DL, Zemcov JV, Thornber D, Wise R, Clarke AM. Antimi-crobial susceptibilities and b-lactamase characterization ofCapnocytophaga species. Antimicrob Agents Chemother 1992;36:2197e9.

5. Shurin SB, Socransky SS, Sweeney E, Stossel TP. A neutrophildisorder induced by Capnocytophaga, a dental micro-organism.NEJM 1979;16:849e54.

6. Matlow A, Vellend H. Capnocytophaga: a pathogen in immuno-competent hosts. J Infect Dis 1985;152:233e4.

7. Buu-Hoi AY, Joundy S, Acar JF. Endocarditis caused by Capno-cytophaga ochracea. J Clin Micro 1988;26:1061e2.

8. Forlenza SW, Newman MG, Lipsey AI, Siegel SE, Blachman U.Capnocytophaga species: a newly recognized clinical entity ingranuloctyopenic patients. Lancet 1980;I:567e8.

9. Martino R, Ramila E, Capdevila JA, Planes A, Rovira M,Ortega M, et al. Bacteremia caused by Capnocytophaga speciesin patients with neutropenia and cancer: results of a multicen-ter study. Clin Infect Dis 2001;33:e20e2.

10. Kristensen B, Schonheyder HC, Peterslund NA, Rosthoj S,Clausen N, Frederiksen W. Capnocytophaga (Capnocytophagaochracea group) bacteremia in hematological patients withprofound granulocytopenia. Scand J Infect Dis 1995;27:153e5.

11. Kullberg B, Westendorp R, Wout J, Meinders A. Purpurafulminans and symmetrical peripheral gangrene caused byCapnocytophaga canimorsus (Formerly DF-2) septicemia e acomplication of dog bite. Medicine 1991;70(5):287e92.

12. Deshmukh P, Camp C, Rose F, et al. Capnocytophaga canimor-sus sepsis with purpura fulminans and symmetrical gangrenefollowing a dog bite in a shelter employee. Am J Med Sci2004;327(6):369e72.

13. Pers C, Gahrn-Hansen B, Frederiksen W. Capnocytophagacanimorsus septicemia in Denmark, 1982e1995: review of 39Cases. CID 1996;23:71e5.