52 year old woman presented with finger and hand pain in the setting of bites suffered from a Capuchin monkey. Five days prior to admission, the patient was bitten by her pet on her left first digit. She noted near immediate edema and erythema. After consultation with her primary care provider, she obtained a prescription for two unknown antibiotics. She continued these through the day of admission, when given persistence of her pain and worsening erythema, she presented to the emergency department. X-ray of the left hand was within normal limits. The patient underwent bedside debridement of her wound via Hand Surgery service, was given tetanus vaccine and started on ampicillin-sulbactam.
She had no other significant past medical history. She took no medications. Social history was notable for her pet Capuchin monkey which she’d raised since near birth, but had been noted to have increasingly aggressive tendencies as he’d aged. A year prior to this event, the patient suffered a similar finger bite and received unknown oral medications from her primary care provider. Her erythema and edema at that time improved within days.
On arrival to the floor, her vital signs were within normal limits. She noted nausea but denies vomitting or fevers. Examination of the left first digit showed an erythematous circular lesion surrounding a deeper wound lateral to the distal interphalangeal joint, of which flexion and extension was limited by edema and pain. Her general neurological and musculoskeletal exam were otherwise within normal limits. Laboratories including complete blood count and metabolic panel were within normal limits. After infectious disease consultation, the patient was started on IV valacyclovir, and continued on IV ampicillin-sulbactam for post-exposure prophylaxsis. Her symptoms improved over the course of five days and the patient was discharged on oral amoxicillin-clavulanate and valacyclovir to outpatient follow-up.
Discussion:
While animal bites contain a variety of bacterial pathogens, concern for viral infection in monkey bites. B Virus (Cercopithecine herpesvirus 1) causes a herpes simplex virus-like infection in these primates but can cause vesicular or ulcerative lesions, influenza-like illness, and severe CNS symptoms including nausea, vomiting and headaches ultimately leading to fatal encephlomyelitis.
Conclusions:
Post-exposure prophylaxis with antiviral therapy is critical to prevent morbidity and mortality in monkey bite–Valacyclovir being the drug of choice.