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Subcutaneous Injection of Intranasal Canine Kennel Cough Vaccine

TO THE EDITOR:  Consultation psychiatrists are often called upon to evaluate a patient after a suicide attempt. Dramatic and original methods of self-harm are not uncommon presentations in a general-medical hospital. Often, available literature provides little guidance for our treatment of these, at times very ill, patients.

Here, we present a case of self-injurious behavior in which, because of the unique nature of the attempt, medical management and potential consequences were unclear.

Case Report
"Ms. A," a 38-year-old woman with a history of a previous suicide attempt, substance abuse, depression, chronic back pain, and pancreatitis presented to the emergency department with her boyfriend after a suicide attempt. She reported that she became frustrated about her physical condition while walking her dogs. Unable to reach her outpatient therapist, she became increasingly upset, and injected three vials of reconstituted canine intranasal kennel cough vaccine into her right forearm to "end the pain." She immediately told her boyfriend what she did and subsequently sought medical treatment.

Upon presentation, Ms. A was afebrile, with stable vital signs. Physical examination was significant for several injection sites on her right arm, complicated by erythema, warmth, tenderness, and swelling. Pertinent admission labs revealed no leukocytosis and a blood-alcohol level of 0.046. Blood cultures were obtained. Ms. A was admitted to the medical service for further monitoring and treatment. She was initially started on IV vancomycin to treat skin flora, including MRSA, and azithromycin to cover Bordetella, a component of the vaccine. The Infectious Disease department was consulted and switched her antibiotics from azithromycin to doxycycline for more effective Bordetella coverage. A psychiatric consultation was requested.

Ms. A did not exhibit evidence of alcohol-withdrawal. Her pain was addressed with oxycodone/acetaminophen, gabapentin, and celecoxib. Blood cultures were negative, and liver-function tests remained within normal limits throughout her hospitalization. Over the course of 4 days, her arm pain, erythema, and swelling improved. Ms. A admitted to severe depression and associated vegetative symptoms. Multiple current psychosocial stressors were identified, including domestic abuse, limited social support, chronic pain, and unemployment. The patient was subsequently started on duloxetine for depression. Once her acute medical issues had stabilized, she was transferred to an inpatient psychiatric unit. One month after initial presentation, recurrent right forearm swelling prompted a biopsy and revealed fibrosis, but no evidence of hypersensitivity reaction or fat necrosis.

Discussion
Consultation psychiatrists need to be aware of the diverse means that individuals may utilize in an attempt to harm themselves. Infectious tracheobronchitis, known as "kennel cough," is a disease affecting the respiratory tract of dogs. It is usually self-limiting and requires little-or-no medical intervention. The disease is caused by a number of infectious agents, but the most common are canine parainfluenza virus, Bordetella bronchiseptica, and canine adenovirus type 2. Several vaccines exist, some delivered by injection and some intranasally. There is one case report in the veterinary literature of an inadvertent subcutaneous administration of the intranasal vaccine in a dog. The dog developed a local inflammatory reaction and acute hepatocellular degeneration and necrosis. Amikacin and IV fluids were given, but evidence of hepatocellular disease persisted after 2 months.¹ The case presented here represents the first known use of a canine vaccine in a human, a unique method of self-injurious behavior.

REFERENCES

1. Toshach K, Jackson MW, Dubielzig RR: Hepatocellular necrosis associated with the subcutaneous injection of an intranasal bordetella bronchiseptica-canine parainfluenza vaccine. J Am Anim Assoc 1997; 33:126–128

Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Email this article to a Colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My Articles & Searches Download to citation manager Citing Articles via Google Scholar Articles by Kapfhamer, J. Articles by Heinrich, K. Search for Related Content PubMed Citation Articles by Kapfhamer, J. Articles by Heinrich, K. Impulse Control Disorders Miscellaneous Addictive Disorders

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