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Penile ulcer from traumatic orogenital contact

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Penile ulcer from traumatic orogenital contact
Ted Rosen MD
Dermatology Online Journal 11 (2): 18

Baylor College of Medicine, Department of Dermatology, Houston. vampireted@aol.com

Abstract

Human bite injuries, although less frequent than animal bites, usually stem from aggressive behavior, sports participation, or sexual activity. Human genital bites and similar traumatic events also occur, but are infrequently reported because of embarrassment. A genital ulceration following mild trauma during oral-genital contact is reported and appropriate diagnostic and therapeutic interventions reviewed. The ulcer was infected, as verified by culture, with an aggressive oral flora organism, Eikenella corrodens. The genital ulceration healed following appropriate antibiotic therapy. Treatment of human bites focuses on obtaining an accurate history and salient physical examination, as well as performing early irrigation and debridement. Prophylactic antibiotic treatment and primary closure of bite wounds remain areas of controversy. Because there is an inherent high risk of infection, genital human bite wounds (and similar traumatic events related to orogenital contact) should be managed with prophylactic antibiotic administration.



Introduction

Mammalian bite wounds are not commonly reported because most victims do not seek medical treatment. However, it is estimated that half of all Americans will be bitten during their lifetime, that 1 percent of all emergency room visits are for treatment of bite wounds, and that approximately $30 million per year is spent for the medical management of bite wounds [1]. Bite wounds vary in severity depending on the method by which the bite occurred, the location affected, the species inflicting the wound, host factors, and the time delay between the onset of injury and institution of treatment. A serious complication is localized infection attributed to microorganisms carried in the saliva, leading to erosion and ulceration, cellulitis, abscess formation, lymphadenitis or lymphangitis, and infrequently to seeding of arthritic or prosthetic joints. Bacteremia and sepsis can ensue if the bite is very severe or if the host is immunocompromised [2]. Even less frequently, bites may facilitate inoculation and therefore transmission of communicable diseases. Mammalian bites involving the genitalia are particularly problematic because of the ease of debilitating physical damage to delicate tissue in this site and because of potentially destructive infection with oral flora [3, 4].


Clinical synopsis

A 72-year-old man with type-II diabetes and hypertension presented 4 days following an episode of fellatio performed by a prostitute. During the orogenital contact, the patient noted intermittent searing pain, which he subsequently discovered was the result of superficial trauma from dental devices (braces) that inadvertently scraped the glans. After 2 days, he developed multiple erosions; these rapidly coalesced into an extensive, extremely painful ulcer covered with necrotic debris. (Fig. 1) The remainder of a pertinent physical examination was unremarkable. A darkfield preparation, viral culture for herpes simplex, chancroid culture, and serologic test for syphilis were all negative or nonreactive. Tissue obtained from the ulcer grew abundant Eikenella corrodens. The ulcerations were irrigated with povidone iodine and obviously necrotic tissue was gently debrided. The patient was given ceftriaxone 250 mg by intramuscular injection and amoxicillin-clavulanate 500 mg twice daily for 14 days. At 2-months followup, the lesion had re-epithelialized, although there was a residual slightly hypopigmented scar. Both a baseline and followup serologic test for human immunodeficiency virus done 6 months later were negative.


Figure 1
Extensive penile ulceration 4 days after traumatic orogenital contact

Discussion

Oral contact with the genitalia may result in traumatic injury, either deliberate or accidental. Penile bites can result in serious physical damage to the glans, urethra, and internal structures of the shaft, leading to disfigurement and sexual dysfunction. Such injuries may result in localized bacterial infection from contamination of otherwise sterile genital soft tissues by organisms normally found in the oral flora [4, 5]. Moreover, human genital bites carry the theoretical potential for the transmission of communicable infectious disease, especially when the person inflicting the bite is a high-risk patient, such as a prostitute, promiscuous homosexual, intravenous drug abuser, hemophiliac, or patient who received multiple transfusions prior to 1985 [5]. Although infection via a genital bite has not yet been conclusively proven for many diseases, transmission of syphilis via a human bite to the genitalia has been documented [6]. Transmission of HIV, found in the saliva of 44 percent of retrovirus positive patients, has been considered biologically possible via a bite wound; such transmission was recently documented in Slovenia when a 47-year-old man with AIDS suffered a seizure and bit his neighbor, who had no HIV risk factors, while attempts were made to establish an airway. The neighbor seroconverted 54 days after the bite [7].

Characteristically, a genital bite wound can present as an exudative or inflamed laceration, an ulcer, cellulitis, or balanoposthitis. There has also been a unique report of Fournier gangrene following a human penile bite [8]. In general, a delay in presentation, and thus treatment, is associated with increased risk of complication following bite wounds. Wolf and associates [5] report two cases of delayed presentation of genital bite wounds with the subsequent development of inguinal abscesses, likely preventable by earlier therapeutic intervention.


Management of human bite and similar wounds

History surrounding the bite is essential, including how and when it happened, the health status of the biter (if known or determinable), the time elapsed since the injury, specific current symptoms, and the victim's medical condition, allergies, medications, and immune status. Physical examination focuses primarily on the genitalia and lymph nodes; evaluation establishes the depth of the wound, viability of vascular supply, and evidence for overt superficial or deep infection. Laboratory investigation should include a routine wound culture for aerobic and anaerobic organisms. When a genital bite wound presents as ulceration, one must consider the possibility that the lesion is the result of a sexually transmitted disease (STD) rather than from bacterial superinfection related to either the biter's oral flora or the recipient's skin flora. In North America, genital ulcerative STDs are most often secondary to herpes simplex virus and syphilis [9]. Thus, a true genital ulcer resulting from a human bite should be subjected to a darkfield examination (when feasible), a viral culture for HSV, and a chancroid culture (in rare endemic areas). Culture for other pathogens (e.g., Mycobacteria, Actinomycosis) and baseline and periodic followup serologic tests for syphilis, HIV, and hepatitis, may be obtained as appropriate. When the biter is in a high risk category, then emergent HIV testing should be performed. Radiographs may be necessary in selected instances to rule out implantation of a foreign body (e.g., a tooth).

Prompt treatment of a human genital bite avoids complications. Upon presentation, immediate irrigation with a bactericidal and virucidal solution (1% povidone-iodine) should be performed using an 18-19 gauge needle.[1]. Such irrigation helps debride the wound bed. Tetanus prophylaxis can be given if immunizations are outdated.

A variety of antibiotic choices are available for initial, empiric therapy of genital bite wounds. Potential pathogens derived from either the oral flora or from the genital skin include gram positive bacteria (Staphylococcus aureus and Streptococcus species), various gram negative bacteria, and oral anaerobes. Dicloxacillin can be given to cover for gram positives, and penicillin V to cover for Eikenella corrodens. Although expensive, cefuroxime, a second generation cephalosporin, is an alternative treatment having good Staphylococcus aureus, Eikenella corrodens, and gram negative coverage [4, 5]. Recently, amoxicillin plus clavulanate has been shown to be very effective in the management of obviously infected bites [10]. Nonetheless, it should be remembered that forty two different bacteria have been found in normal human saliva, and 192 types found in the mouth of a person with gingivitis or periodontitis [1]. Therefore, culture of an infected human bite is advisable prior to administration of empiric treatment.

In our case, the patient developed an extensive, painful geographic ulcer following superficial traumatic injury to the genitalia by an oral dental appliance. Culture of the ulcer yielded Eikenella corrodens. This pathogen is a fastidious, slow growing, gram negative, oxidase positive, facultative anaerobic rod. It is typically found in the mucous membranes of the oral cavity, respiratory tract, gastrointestinal tract, and genitourinary tract, and should be considered as a potential pathogen when a human bite (or similar trauma) are involved [1, 4, 11]. Of note is the propensity of this particular organism to cause exceptionally painful and rapidly necrotic lesions, as evidenced by this case and others [4]. Aside from local infection of human bite wounds, Eikenella corrodens has been most commonly associated with abscesses of the abdominal cavity, head, and neck, as well as meningitis, endocarditis, osteomyelitis, and fatal gram negative sepsis. Eikenella corrodens is an opportunistic pathogen that reduces nitrates and requires a low oxygen environment for growth. Thus, synergism with other bacteria can facilitate its growth as the latter microbes consume excess tissue oxygen [1]. Eikenella corrodens is usually susceptible to penicillin, amoxicillin-clavulanic acid, cefoxitin, trimethoprim-sulfamethoxazole, ceftriaxone, tetracycline, and ciprofloxacin, but resistant to dicloxacillin, nafcillin, first generation cephalosporins, clindamycin, aminoglycosides, and erythromycin [1, 4].

Antibiotic therapy for symptomatic and obviously infected bites is clearly appropriate. However, prophylactic antibiotic administration remains controversial because of the lack of adequate clinical studies, variation among wounds, and an incomplete correlation between in vitro and in vivo antimicrobial sensitivities. In a study by Zubowicz and associates, it was found that among ostensibly uninfected hand bites, 46.7 percent developed infection following mechanical treatment only, whereas none developed infection following mechanical treatment along with prophylactic antibiotics treatment [12]. Others stress the importance of prophylactic antibiotics in high-risk patients who suffer a bite wound. This group includes persons who have deep puncture wounds, asplenia, underlying diabetes mellitus, immunodeficiency, a wound more than 8 hours old, and both facial or genital bite sites [1, 2, 4, 5]. Genital bites are considered to carry an inherent degree of high risk because there is a copious amount of loose subcutaneous tissue that may allow bacterial spread.

In summary, the management of human bite wounds to the genitalia parallels the care for other common mammalian bite wounds. The history and physical should direct the physician to any unique circumstances and any precautions that should be taken, including an evaluation of the risk of infectious disease transmission. Early wound treatment is essential; irrigation and debridement are key measures to be implemented. Antibiotics should be given if obvious signs of infection are present, and the selection of antibiotics should include coverage for the most common pathogens. Prophylactic antibiotics, although controversial, are generally recommended for human bites (or equivalent trauma) to the genitalia. Primary closure of linear or ovoid wounds also remains a controversial issue, but because the genitalia are considered to be an area of high risk for infection, primary closure is not indicated.

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