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Adjacent penile ulcers 5 days after human bite.
Almost complete healing at 1-month follow-up.
Potentially Transmissible Diseases After Human Bite

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Genital Ulcer Caused by Human Bite to the Penis

Sexually Transmitted Diseases26(9):527-530, October 1999.

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From Baylor College of Medicine, Department of Dermatology, Houston, Texas
Address correspondence to Ted Rosen, MD, Baylor College of Medicine, Department of Dermatology, One Baylor Plaza, Houston, TX 77030.
Received for publication November 16, 1998, revised June 1, 1999, and accepted June 14, 1999.
Human bite injuries, while less frequent than cat or dog bites, usually stem from aggressive behavior, sports, or sexual activity. It has been thought that human bites have a higher rate of infection than animal bites, but this view is likely skewed because of the frequency of closed fist injuries presenting to emergency rooms. Human bites to the genitalia also occur, but are not often reported because of embarrassment.
We report a genital ulceration after a human bite to the penis and review appropriate diagnostic and therapeutic maneuvers.
This article reports the development of a severe genital ulcer associated with a human bite to the penis secondarily infected, as verified by culture, with an oral flora organism Eikenella corrodens.
The genital ulceration healed after appropriate antibiotic therapy.
Treatment of human bites focuses on obtaining an accurate history and performing a salient physical examination, as well as early irrigation and debridement. Transmission of communicable disease should be considered as a possible consequence. Prophylactic antibiotic treatment and primary closure of wounds continue to be areas of controversy.
BITE WOUNDS, WHETHER from a human, a dog, a cat, or other animal are uncommonly 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% of all emergency room visits are for treatment of bite wounds, and that approximately $30 million/year is spent for the medical management of bite wounds. 1 The wounds tend to vary in severity depending on the location of the bite, the species inflicting the wound, host factors, and the time delay between the onset of injury and institution of treatment. The most common complication is localized infection caused by microorganisms carried in the saliva, leading to ulceration, cellulitis, abscess formation, lymphadenitis, or lymphangitis, or less commonly, to seeding of joints (arthritic or prosthetic). Rarely, bacteremia and sepsis can ensue if the bite is severe or the host is immunocompromised. 2 Even less frequently, bites may allow inoculation and, therefore, transmission of systemic communicable diseases.
Bites involving the genitalia are especially problematic because of the ease of physical damage to delicate tissue at this site. Human bites to the genitalia are also particularly dangerous because a potentially serious secondary infection with oral flora may develop because of the ease of spread through the loose subcutaneous tissue There is a paucity of literature on this subject, likely because of a low reported incidence because of embarrassment and attempts at self-treatment.
A 66-year-old man with insulin-dependent diabetes presented 5 days after a human bite to the penis. The man had been involved with a prostitute who deliberately bit him while performing fellatio when he threatened not to pay her for services rendered. Two days later, he developed several adjacent erosions located in the coronal sulcus, which rapidly developed into deep, painful ulcerations ( Fig. 1 ). Aside from the ulcerations, covered with necrotic and purulent debris, 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 one ulcer grew sparse Staphylococcus aureus and abundant Eikenella corrodens. The ulcerations were irrigated with povidone iodine and obviously necrotic tissue gently debrided. The patient was given ceftriaxone 250 mg by intramuscular injection and amoxicillin-clavulanate 500 mg twice daily for 14 days. At 1-month follow-up, the lesions had reepithelialized, although there were residual depressed, slightly hypopigmented scars ( Fig. 2 ). A baseline and 5-month follow-up serologic test for human immuno-deficiency virus were negative, as were serologic tests for hepatitis A and B.
Two types of human bites are typically recognized, 1) occlusional, in which a person's teeth bite into another's body part, and 2) closed fist injury (CFI), in which one's hand contacts another person's teeth usually with high velocity. In the past, human bites were thought to be associated with a high risk of infection. However, it has been recognized that the reported incidence was unbalanced because of the high number of CFIs, “fight bites,” which have a propensity toward infection because of their location, frequent delay in treatment, and the ease of spread through the readily penetrated layers of the hand. 2,3
Occlusional bites to the penis in particular can inflict serious physical damage to the glans, urethra, and internal structures of the shaft, leading to disfigurement and sexual dysfunction. Such bites may result in localized bacterial infection caused by contamination of otherwise sterile genital soft tissues by organisms carried in the oral flora or on anogenital skin. Moreover, human bites to the genitalia carry the theoretical potential for the inoculation and transmission of systemic 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 before 1985. 4 Potential infectious diseases associated with a human bite to the genitalia, excluding those strictly related to oral or anogenital flora, are summarized in Table 1 . While infection through a bite has not yet been conclusively proven for many diseases, there has been documented transmission of syphilis through a human bite to the genitalia. 5 Transmission of HIV, found in the saliva of 44% of patients who are HIV positive, has been considered “biologically” possible through a bite wound 1 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. 6
Characteristically, a genital bite wound can present as an ulcer, an exudative or inflamed laceration, cellulitis, or balanoposthitis. There has also been a report of the development of Fournier's gangrene after a human bite to the penis. 7 In general, a delay in presentation, and thus treatment, is associated with an increased risk of complication after bite wounds. 8 Wolf and associates 4 correlate two cases of delayed presentation of genital bite wounds with the subsequent development of inguinal abscesses, which may have been prevented with earlier medical intervention.
History surrounding the bite is essential, covering such information as how and when it happened, the health status of the biter (if known), the time elapsed since the injury, specific complaints, and the victim's medical condition, allergies, medications, and immune status. Physical examination should focus on the genitalia, lymph nodes, and abdomen. Evaluation should establish the depth of the wound, assessment of vascular supply, and observation for overt evidence of any infection. Laboratory investigation should include a routine wound culture for aerobic and anaerobic organisms. When a genital bite wound presents as an ulceration, one must consider the possibility that the lesion is the result of a sexually transmitted disease (STD) rather than the result of bacterial infection from the “biter's” oral flora or the recipient's skin flora. In North America, genital ulcerations caused by STDs are most often secondary to herpes simplex virus (HSV) and syphilis. 9 Thus, a 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 endemic areas. Culture for other pathogens (e.g., Mycobacteria, Actinomycosis) and baseline and periodic follow-up serologic tests for syphilis, HIV, and hepatitis may be obtained as appropriate to the situation. When the “biter” is in a high-risk category, then emergent HIV testing should be performed, if possible. Radiographs may be necessary in rare instances to rule out implantation of a foreign body (e.g., a tooth).
Prompt treatment of a human genital bite is desired to avoid complications. At presentation, immediate irrigation with a bactericidal and virucidal solution should be done using 150 ml of 1% povidone-iodine solution through an 18- to 19-gauge needle. 1 Such irrigation also debrides the wound bed. Tetanus prophylaxis can be administered if immunizations are out of date.
A variety of antibiotic choices are available for therapeutic treatment of bite wounds. Potential pathogens derived from the oral flora or from the genital skin include gram positive bacteria ( S. aureus and Streptococcus species), gram negative bacteria (because adjacent to the rectum), and oral anaerobes (which are usually susceptible to common antibiotics). 4 Dicloxacillin can be given to cover for gram positives, and penicillin V to cover for E. corrodens. Cefuroxime, a second generation cephalosporin, is an alternative treatment that has good S. aureus, E. corrodens, and other gram negative coverage, but is expensive. 4 Recently, amoxicillin plus clavulanate has been shown to be effective in the management of clearly infected bites. 10 Nonetheless, it should be remembered that 42 different types of bacteria have been found in human saliva ( Streptococcus > S. aureus > E. corrodens ) and 192 types found in the mouth of a person with gingivitis or periodontitis. 1 Therefore, culture of the infected human bite is advisable before administration of empirical antibiotic therapy.
In our case, the patient developed a painful ulcer after a human bite to the genitalia. Culture of the ulcer yielded E. 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 human bites are involved. 1,11 Aside from local infection of human bite wounds, E. 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. 8 There is also a possible association between E. corrodens bite infections and intravenous drug abusers who are bitten. 8 E. corrodens is an opportunistic pathogen that reduces nitrates and requires a low oxygen environment for growth. Thus, synergism with alpha hemolytic Streptococci, Staphylococcus, Bacteroides, and other gram negatives can facilitate its growth because these microbes consume excess tissue oxygen. 1,8 It 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
Antibiotic therapy of symptomatic and obviously infected bites is clearly indicated. However, prophylactic antibiotic use remains controversial because of the lack of adequate studies, the variation in wounds, and the 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% developed infection after mechanical treatment only, whereas none developed infection after mechanical and prophylactic antibiotic treatment. 12 Thus, these authors recommend mechanical wound care along with broad spectrum oral antibiotics, even for uncomplicated bites. Others stress the importance of prophylactic antibiotics in high-risk patients who suffer a bite wound. This group includes deep puncture wounds, asplenia, diabetes mellitus, immunodeficiency, a wound more than 8 hours old, and facial and genital bites. 1,2,13 Genital bites are considered high risk because the copious amount of loose subcutaneous tissue easily allows bacterial spread. 8
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, with irrigation and debridement as key measures to be implemented. Antibiotics should be given if obvious signs of infection are present, including coverage for the most common pathogens, and prophylactic antibiotics, although controversial, are generally recommended for human bites to the genitalia. Primary closure also remains a controversial issue, but the genitalia should be considered as an area with high risk of infection, and thus primary closure is not indicated.

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