Monkey Bites Related Injury

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  • 1. Monkey Bites Related Injury Muhamad Na'im B. Ab Razak 4th year Medical student Group 7, orthopedic rotation 09/10 University Science Malaysia Bite wound exposing the subcutaneous fat The interaction between monkey and human has long existed. Back in India, a Hindus religion has associates monkey as one of the God’s avatar namely Hanuman that is symbolizes wisdom, devotion, righteousness and strength. Until now, monkey is considered as sacred especially in India. Nowadays, it has become a trend to raise monkey as an exotic pet therefore increasing the contact between monkey and human following the chain of breeders or hunters, exporters or importers, pet shop owner and finally the customers. In Malaysia, particularly in east coast, monkeys are breed to pluck coconut and stinking beans. It is also raised as animals particularly for playing with them. Apart from that, the interaction also exists among the people who involves with animal research facility.
  • 2. This interaction has lead to various type of injury to the human either zoonotic disease due to mucosal or fluid contact and also because of bite. The exact amount of animal bites, especially monkey is unknown since most of the cases are under reported. However, Goldstein EJ states that approximately 1% of total visit to emergency department is caused by animal bites and predominates mainly by dogs. Monkey bite is relatively uncommon. According to study by Ichhpujani RL et al, animal bites from monkey constitutes of 3.2% out of 1357 victims. Usually, the monkey becomes aggressive as their age past 2 years. Most of the time, it is either due to hunger, accidently treads on its tail or during breeding season. Monkey bite injury may give simple laceration injury to the extent of vast systemic complication. The famous examples of the monkey bite’s victim is King Alexander of Greece who died few days after being bitten by monkey while defending his pet dog as a result of sepsis in the year of 1920. The most common site for monkey bite is hand and face. All types of bite must be regards as contaminated because of the present of huge number of bacteria in oral cavity. Bacteroides species, Fusobacterium species, Eikenella corrodens, Streptococcus species, Enterococcus species, Staphylococcus species, Enterobacteriaceae and Simian herpes virus is common organism associated with monkey bites. Depending on the site of bite, injury may be limited only to the skin or involving the muscle, tendon, ligaments, nerves, blood vessel, bone, visceral organ and even loss of portion of body structures. This injury may give rise to bleeding, Hypovolumic shock, weakness, and deformity. However, the most frightening complication resulting from monkey bite especially from genus macaca is infection of Herpes B Virus (Herpesvirus simiae). Although rare, it could result in fulminant encephalomyelitis with 70%- 80% of mortality rates. The incubation period is from 2 days to 5 weeks after exposure. Patient usually presented with local skin rash, headache, signs of brain stem encephalitis or even respiratory arrest. Delay in diagnosis and treatment may result in death. Monkey bite injury may also associate with Rabies even though it is mostly link to dogs in 95% of the cases. It should be suspected especially in case with failure in seeking appropriates treatment.
  • 3. Principally, in all type of animal bite, the management is as follow; Proper wound assessment, injection of tetanus toxoid vaccines, stop the bleeding, thorough wound irrigation and debridement with delay primary healing and pain management. Open bone fractured may needs external fixations. Due to all types of complication, therefore, simple wound management is inadequate in treating patients who are bitten by exotic animals. Therefore, a further investigation is compulsory to exclude Herpesvirus simiae, rabies, and other bacteria. Hence, a blood culture and culture from site of bite is mandatory. Viral culturing, ELISA and western blot antibody testing, and magnetic resonance imaging all proved useful in the diagnosis of these patients' conditions [Davenport DS et al). PCR using synthetic oligonucleotide primers and probe could also be done Ideally, the responsible monkey should be caught and handle to veterinary department for testing against Herpesvirus simiae and rabies. X ray is useful to exclude bone fracture and also look for any evidence of bone penetration and retain foreign body. Empirical broad spectrum antibiotic to cover gram positive and anaerobes bacteria should be given. Patient who is suspected to be infected with Herpesvirus simiae can be treated with intravenous acyclovir or ganciclovir. Meanwhile, Rabies immunization should be commerce in place where rabies incidence is significant. Reference 1) Brian Hogan, "Herpes B", http://emedicine.medscape.com/article/235360-overview, accessed on 1 April 2010, 7.30 P.M 2) Davenport DS, Johnson DR, Holmes GP, "Diagnosis and management of human B virus (Herpesvirus simiae) infections in Michigan", Clin Infect Dis. 1994 Jul; 19(1):33-41. 3) Goldstein EJ, "Bite wounds and infection”, Clin Infect Dis. 1992 Mar; 14(3):633-8. 4) Ichhpujani RL, Mala C, Veena M, et al, "Epidemiology of animal bites and rabies cases in India. A multicentric study.", J Commun Dis. 2008 Mar;40(1):27-36. 5) Scinicariello F, Eberle R & Hilliard JK,"Rapid detection of B virus (herpesvirus simiae) DNA by polymerase chain reaction", J Infect Dis. 1993 Sep; 168(3):747-50. 6) Simon Robinson, "Monkey See, Monkey Do", TIME Magazines, Tuesday, Oct. 17, 2006 7) The New York Times, "King Alexander of Greece Dead" The New York Times, October 26, 1920 8) Tregle RW Jr, Loe CL, Earhart RH 3rd & d'Autremont SB, "Cercopithecine Herpesvirus 1 Risk in a Child Bitten by a Bonnet Macaque Monkey.", J Emerg Med. 2010 Mar 26