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  1. Opportunity for a "one health" approach overlooked?

    To Whom It May Concern

    "Lick of death: Capnocytophaga canimorsus is an important cause of sepsis in the elderly"1 describes an excellent outcome thanks to an elegant diagnostic work up and excellent treatment. However, I believe the headline "Lick of death" is unnecessarily fear-mongering and unwarranted (the patient, after all, did not die). Additionally, while the authors should be congratulated for educating practitioners about C. canimorsus, I feel there is scope for discussion with veterinarians to reduce further risk to this and other patients.

    The authors conclude that the source of the patient's infection was the owner's own dog, via a lick, on the grounds that Capnocytophaga canimorsus was isolated from that patient, that it is a zoonotic organism and that the patient admitted to being licked by the dog. My understanding is that this conclusion is based on findings that C canimorsus colonises the mouths of dogs and cats. This seems reasonable though for the sake of completeness and illuminating our understanding of this condition I feel it would have been helpful to examine and test the dog, and here there is scope for veterinary input2.

    As the authors note, the elderly rely on companion animals. Could C canimorsus be isolated from the oral cavity of the patient's Italian greyhound? Was the dental and periodontal health of the dog assessed? What measures could be taken to reduce the risk of exposure, apart from avoiding being licked by the dog? A recent UK study found that 9.3 per cent of dogs suffered from periodontal disease3. What we don't know is whether regular dental scaling may reduce carriage of C canimorsus.

    Another question, perhaps to be answered by veterinarians, is whether the patient's comorbidities contributed to the licking by the dog? Companion animals may alter behaviour in response to owners, and may engage in licking or biting as an attempt to rouse owners with a reduced state of consciousness4. In fact, licking behaviour was performed by 50 per cent of seizure response dogs when owners suffered seizures5. (It is important to note that while licking may be detrimental, seizure response dogs can save lives - in the previous study, one dog brought the cordless phone, another rolled the owner, who had a history of aspiration pneumonia, onto their side, and yet another turned off the electric wheelchair as several accidents had occurred during seizures).

    Human animal interactions are complex, involving mutual benefit as well as potential risks to both parties. This complexity demands a genuine 'one health' approach. Discussion of the role of the dog in this case with a veterinarian may help illuminate and reduce animal-based risk factors.

    Sincerely,

    Anne Fawcett

    References

    1. Wilson JP, Kafetz K, Fink D. Lick of death: Capnocytophaga canimorsus is an important cause of sepsis in the elderly. BMJ Case Reports 2016;2016. 2. Speare R, Mendez D, Judd J, et al. Willingness to Consult a Veterinarian on Physician's Advice for Zoonotic Diseases: A Formal Role for Veterinarians in Medicine? Plos One 2015;10(8):8. 3. O'Neill DG, Church DB, McGreevy PD, et al. Prevalence of Disorders Recorded in Dogs Attending Primary-Care Veterinary Practices in England. Plos One 2014;9(3):16. 4. Seligman WH, Manuel A. The cat and the nap. Medical Journal of Australia 2014;200(4):229-29. 5. Kirton A, Winter A, Wirrell E, et al. Seizure response dogs: Evaluation of a formal training program. Epilepsy Behav 2008;13(3):499-504.

    Conflict of Interest:

    I am a companion animal veterinarian and co-habit with companion animals.

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