Medical Mystery: A dog bite that nearly proved fatal

Becky Krall hurried through the sliding-glass doors of the hospital emergency room around 8 a.m. on Sept. 25, 2015, expecting to see her feverish husband, David, sitting among the patients waiting to see a doctor.

Instead Krall, who had left him for about 15 minutes while parking their car, was met by a nurse with an urgent message: Her 50-year-old husband had suddenly become unresponsive. "Your husband is very, very sick. You need to be prepared for him not to make it through the day," the nurse told her.

How, Krall remembers wondering, did her fit and healthy husband of 10 years get so sick so fast? The night before, Krall had driven him to the same ER, sent by an urgent-care center for a closer assessment of his fever and malaise. The couple had spent about five hours there but left before seeing a doctor because the ER was so swamped and David's condition seemed unchanged. They figured they'd have better luck in the morning.

That decision, Becky Krall says, was among a cascade of serious missteps that left David, an industrial engineer, battling a catastrophic illness that kills 60 percent to 80 percent of its victims. Doctors at the University of Kentucky Albert B. Chandler Hospital in Lexington managed to save David's life, but he was left with profound, permanent hearing loss.

Several of his toes had to be partially amputated. "I felt extremely guilty for a long time," said Becky, an associate professor of STEM education at the university who continues to struggle with the emotional aftermath of the ordeal. "I have lots of information now. But I didn't know any of it then."

Three days before he was hospitalized, David, a marathoner, had gone for a run after work, taking one of the couple's dogs. As he returned to his suburban home, a neighbor's dog wriggled out of its collar and made a beeline for the Kralls' dog. While Krall was trying to separate the animals, the neighbor's schnauzer sank his teeth into Krall's thigh, leaving a bloody gash. David washed the wound with soap and water and applied antibacterial cream.

The following day he visited an urgent-care center for follow-up treatment. A clinic doctor administered a tetanus shot; the dog had been vaccinated against rabies. The doctor offered to prescribe antibiotics as a precaution, but erroneously said that only 5 percent of bites become infected. (In fact, the figure for dog bites is closer to 20 percent, and many doctors prescribe antibiotics routinely if a bite breaks the skin.) Concerned about the overuse of antibiotics, David decided to forgo them.

Around 5 p.m. the next day, he called Becky and told her he felt too ill to drive home. She picked him up and took him back to the clinic. A nurse practitioner took his temperature, which was 102.9, and noted that the area around the bite seemed warm and slightly swollen. She advised the Kralls to head for the university hospital ER.

After a half-hour of waiting to see a doctor, Becky went home to walk the dogs and returned around 9:15 p.m. While she was gone, a triage nurse saw David, who told her he was seeking treatment for a high fever and that he'd had a flu shot (when he'd really had a tetanus shot) two days earlier. He did not mention the dog bite or other crucial details.

Records show that his blood pressure was low, and his temperature hovered around 101 degrees. His responses to questions seemed slow, and he complained of dizziness. But his initial blood tests looked fairly normal, said Derek Forster, the infectious-disease specialist who ultimately identified the underlying cause of David's illness.

Shortly after midnight, Becky told the paramedic monitoring David that they planned to go home and come back in the morning.  "I wouldn't leave if my girlfriend had blood pressure like this," she said the paramedic told her. "But you guys aren't doing anything," she remembers telling him. They went home.

At 4 a.m. after a fitful sleep, Becky took David's temperature. It registered 102.9. A few hours later, the couple drove back to the hospital.

When Becky rushed in with the nurse who had been dispatched to find her, David was lying on a gurney, his eyes closed, "clearly out of it." His fingernails were blue, a sign of shock.

Becky also told the staff something they hadn't learned the night before: David had no spleen — making him, as she would learn, especially vulnerable to infection.

His kidneys were failing, his breathing was labored, and he had developed disseminated intravascular coagulation, a condition that could cause him to bleed out spontaneously. A CT scan of his head showed that he probably had meningitis; doctors suspected it had invaded the bloodstream, causing septic shock.

After David was moved to the intensive-care unit, Becky said, she repeatedly mentioned the dog bite as a possible cause of his infection. But she said doctors were fairly certain that David's meningitis infection was caused by a bacteria known as Neisseria meningitidis. How he had acquired it was a mystery.

Becky grew increasingly insistent after a physiologist friend found articles in medical journals about a rare bacterium transmitted in dog saliva, Capnocytophaga canimorsus, which causes potentially fatal infections, particularly in people without spleens. Forster, who was called in on the sixth day of David's 51-day hospitalization, thought she might be right.

"I had seen a previous case as a fellow six years earlier," recalled Forster. Capnocytophaga "was the first thing I thought of."

A few days later, the lab confirmed his suspicion. "I had the advantage of seeing that earlier case," said Forster, adding that capnocytophaga is "fairly rare."

Fortunately, the treatments for both infections are similar, Forster said, although David's drug regimen was adjusted to specifically target capnocytophaga. David, who was in a medically induced coma for 11 days, faced many difficult months of recovery. Parts of three toes ultimately had to be amputated because of a persistent infection. A cochlear implant has helped mitigate the deafness caused by his illness.

Forster said he believes there is a "reasonable chance" that the antibiotics David declined after the bite might have prevented sepsis. "I don't think the provider . . . made him aware of the risk" of not taking them, Forster said.

Becky Krall says she and her husband hope their story underscores the importance of improving communication in emergency departments and the potential dangers facing people without spleens. She remains upset that the severity of David's illness wasn't addressed more quickly during his first ER visit and that she didn't know how sick her husband was.

She didn't learn until much later that in the throes of sepsis — when patients are often confused or delirious — David had given incorrect information to the triage nurse. Hospital officials say that had they known David had no spleen and had been bitten by a dog, his case would have triggered a sepsis alert and been given priority.

"If I could do it over again, I wouldn't have left the hospital to feed the dogs," Becky said. "Imagine my horror when I learned I was the only one that had the whole story."

Last year at their request, the Kralls met with hospital officials to discuss ways to improve communication. As a result of this and other cases, a physician is now part of the triage team during the busy afternoon and evening shifts, said Roger Humphries, UK HealthCare's director of emergency medicine.

"I think we're in a much better place than we were in the fall of 2015," he said. "We think we closed a lot of holes in the Swiss cheese."