A 56 year old Caucasian male presented to the ED with left tongue swelling. His symptoms started 3 days prior with left neck and facial pain, and he had gone to an ENT who diagnosed him with a likely ear infection and started him on augmentin. On initial hospital presentation, he reported a gradual fullness in his mouth in addition to the pain. In the ED he was treated for a presumed allergic reaction, and after a period of observation his swelling had improved so he was discharged. Within 12 hours the swelling recurred, at which point he returned to the ED. Labs were only significant for a mild leukocytosis. ENT was called and performed bedside laryngoscopy with no upper airway findings. CT neck/soft tissues showed no collections or abscesses to explain his symptoms. He was given dexamethasone, started on broad spectrum antibiotics and admitted to MICU for airway monitoring. Blood cultures drawn in the ED were positive within 13 hours with gram negative rods in anaerobic bottles, later speciated as Pasteurella multocida. Upon later questioning, he mentioned that he had recently gotten a new kitten and had some mild superficial scratches days prior to his presentation.
P. multocida is an aerobic/facultative anaerobic, gram negative coccobacillus commensal to dogs, cats and many other animals. It typically causes local soft tissue infections and, less commonly, septic arthritis, osteomyelitis, sepsis, and meningitis, especially in infants and immunocompromised hosts. Soft tissue infections typically occur after a cat or dog scratch or bite, usually occurring within less than 24 hours of the inciting event. In immunocompromised hosts, P. multocida can also cause a variety of upper and lower respiratory tract infections, including glossitis, pharyngitis, sinusitis, otitis media, mastoiditis, epiglottitis, pneumonia, and lung abscess (3).
Bacteremia occurs in 25-50% of patients with Pasteurella infection. There are few reports of isolated pasteurella bacteremia in the literature, none however in otherwise immunocompetent patients. Typical patients have been those with cirrhosis, pulmonary disease, cerebrovascular disease, autoimmune disease, malignancies, and diabetes leading to varying degrees of immunocompromise. Review of the literature found one such similar case, in which the only presenting symptom was tongue swelling with subsequent bacteremia. However, that patient also had multiple comorbidities, including advanced age and severe seizure disorder (1,3).
This case shows a rare complication of Pasteurella infection causing bacteremia and tongue swelling in an immunocompetent patient, reminding clinicians that P. multocida should be considered as a possible etiologic agent in any infection occurring after an animal bite or scratch, including in those with no other underlying diseases. Though our patient had refused HIV testing, it would also be important to look for etiologies of immunocompromise in otherwise healthy patients with Pasteurella infection.