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J West Afr Coll Surg. 2016 Apr-Jun; 6(2): 1–19.
PMCID: PMC5342835

HUMAN BITE INJURIES ON THE JOS PLATEAU

Abstract

Background

Human bite injuries with the associated morbidity are not uncommon in this environment.

Objective

To determine the pattern, management modalities and treatment outcome of human bites in Jos, Plateau State, Nigeria.

Design

A prospective study of all human bite injuries managed at the Jos University Teaching Hospital, Jos, Nigeria between January 2012 and December 2014.

Setting

Jos University Teaching Hospital, Jos, Nigeria.

Main outcome measures

The pattern and management outcome.

Results

A total of 63 patients with human bite injuries were studied during the three-year period. There were 43 males and 20 females with a male:female ratio of 2:1. The age ranged from 8 - 65 years with a mean age of 30.2+/-17 years; in all about 75% of the patients fell into the 20 - 40 years bracket. Though all the social strata were affected, the bites were more common (50%) among the lower social classes and 70% of the patients presented late after 24 hours of sustaining bite injuries. Pain, bleeding, infected wounds, bite and scratch marks were the main presenting features. About 70% of the patients sustained major bites involving the underlying muscles and deeper structures while 89% of the patients sustained their bites during a fight, 8% while raping their victims, and in 3% of patients as they were being mugged. The bites were between spouses in 39% of cases, and between women in polygamous settings in 16%. The sites commonly affected were the upper limbs in 46%, chest in 21%, ears in 13%, abdomen in 10% and the penis in 6%. The associated injuries were scratch marks in 89%, blunt abdominal injuries in 29%, skin lacerations in 16% and urinary bladder/urethral injuries in 3%. There was no mortality but morbidity was 57% which included infections in 29%, disfigurement in 29%, penile injuries in 6% and minor urethral injuries in 3% of cases.

Conclusion

Human bite injuries in this tropical environment commonly affected the young male, the lower social class and the upper limbs; they were commonly sustained in assaults and domestic conflicts.

Keywords: Human bites, Young male adults, Upper limbs, Assaults, Domestic conflicts, Low social class, Late presentation.

Introduction

Human bite injuries are associated with high morbidity and most of the literature on the subject come from the industrialized countries with few from developing countries1,2. As soon as a baby sprouts the incisors, he/she uses the teeth rarely, and when the baby does, the teeth are applied gently to attract the mother’s attention. However, in older children and adults, human bite is inflicted mainly as an act of aggression – often along with scratch marks. Human bite injuries constituted about 1% of all emergency cases in some centres in the United States of America1. The bite wounds range from minor bruises to severely infected wounds in patients who present late. The incidence is under-reported because some of the victims are too embarrassed about the nature, circumstances and site of the bite injuries or may become afraid of legal repercussions and so do not present themselves for treatment; they resort to self medication2. The main challenges in management include the local wound, cosmesis, associated injuries and sepsis2,3. The organisms in the septic bite wounds comprise a mixed flora of aerobic and anaerobic microbes as well as HIV and hepatitis viruses2,3,4,5. Studies in human bites are well established in industrialized countries especially in the areas of forensic pathology where the unique nature of an individual’s set of teeth, the bite marks they produce, as well as the skin prised from under the finger nails from scratches during the struggle, are used to identify the culprits in rape, assault and homicide6,7,8,9,10. In developing countries like Nigeria however, such studies are sparse. In order to study the pattern, management and outcome in this environment, we prospectively studied all the cases of human bite injuries managed at Jos University Teaching Hospital, Jos, Nigeria within a three-year period.

Patients and Methods

A prospective study was conducted on 63 consecutive patients with human bite injuries managed at Jos University Teaching Hospital, Jos, Nigeria between January 2012 and December 2014. The demographics, clinical features, duration of injury before presentation, management modalities and outcome were entered in a proforma at the Accident & Emergency Unit and the surgical wards. The data obtained were analysed for means and frequencies using Microsoft Office Excel 2007. Relevant photographs of bite injuries and scratch marks were taken of patients who gave informed and written consent.

Results

The age range of the 63 patients in this study was 8 to 65 years with a mean of 30.2±17 years; 75% of the patients fell into the 20-40 years bracket. The age distribution of these patients is shown in Fig. 1. The male:female ratio was 2:1 as there were 43 males to 20 females. Pain, bleeding, bite marks, scratch marks, infected wounds, disfigurement and associated injuries were the main complaints as shown in Table 1. Minor bites not involving the underlying muscle made up 22% of the cases as against 78% major bites; 14% of patients had both minor and major bites. All the 8(13%) children in this study sustained minor bites which involved the skin and subcutaneous tissues. The bites were inflicted between spouses in 39% of the cases, between two women in polygamous setting in 16% of cases, in assaults in 34%, rape in 8% and mugging in 3% as shown in Table 2. The events leading to the bites are shown in Table 3. The upper limbs were affected in 46%, chest in 21%, ear in 13%, abdomen in 10% and the penis in 6% as shown in Table 4. Fig. 2 shows an infected bite wound of the penis. The associated injuries sustained during the scuffle included scratch marks in 89%, blunt abdominal injuries in 29%, lacerations in 16%, urinary bladder and urethral injuries in 3.2% each as shown in Table 5. Fig. 3 shows a rapist with bite and scratch marks as well as scalp lacerations sustained during the scuffle. The social classes of the patients are shown in Table 6. Staphylococcus and streptococcus species were isolated in 100% of the cases while E. coli, Proteus and Pseudomonas species were isolated in 68% of the cases. The treatment modalities in this study included tetanus prophylaxis and appropriate antibiotics in all cases, primary closure of all facial wounds, debridement of infected wounds in 16(25.4%) patients, surgical repair in 18(29%) and urethral bouginage in the 2(3%) patients with partial urethral stricture.

There was no mortality. Morbidity occurred in 57% of patients in the form of infections in 18(29%) patients, disfigurement in 18(29%), penile injuries in 4(6.3%) and urethral injuries in 2(3%) as shown in Table 7.

Discussion

The main findings of this study were that human bite injuries were not uncommon in this tropical environment and mainly affected young adults, the upper limbs and between spouses; late presentation was common.

Since Humble6 reported the first case of human bite in literature in which bite mark evidence was admitted in formal legal proceeding, the place of bite marks in forensic pathology and surgery had become well established in industrialized nations6,7,8,9,10. The uniqueness of each individual’s dentition and the marks produced could be reproduced by photography7, plaster casts and digital overlays9. When this is combined with DNA analysis of body fluids and the skin prised from underneath the nails of the victim following scratch marks in the ensuing struggle, both the biter and the bitten could be objectively identified11.

In this study, the incidence in males was double that of females and majority (75%) of the patients with human bite injuries were in the 20-40 year bracket as shown in Fig. 1. This is the active age group and the male preponderance had been identified by other workers12.

The main complaints were pain, bite marks, scratch marks, infected wounds and disfigurement as shown in Table 1. Scratch marks were noted in 89% of the patients. In all cases, the bites breached the skin. There were minor superficial bites involving only the skin and subcutaneous tissues in 22% of cases while in 78% of cases the bites were major as they affected deep tissues, face/ears, clenched-fist and the genitals. In 14% of cases, the patients presented with both minor and major bites.

With diligent history taking, physical examination and the characteristic imprints of the upper and lower sets of teeth of bite marks, the diagnosis of human bite injuries had been reported not to be difficult to make12,13.

Husbands were bitten by their wives in domestic quarrels in 33% of cases while in 16%, the bites were inflicted by a woman on another woman as a result of matrimonial conflict in polygamous settings – an observation that had been noted by a worker in Southern Nigeria14. The act of biting in humans could either be for attack or defence13. In 6% of cases, the bites were inflicted by husbands on their wives. This state of affair was noted in the four cases of penile bites where the scorned wife bit the penis of her husband in retaliation for alleged infidelity; Fig. 2 shows one of the infected penile bites. The husband, in order to extricate himself from the grip and bite on his genitals, inflicted a bite on his wife. These bites were located on the hand in one case and on the arm in three cases. Human bite, in this situation, was used as a defensive weapon of the desperate. The relationship between the biter and the victim in this study was as shown in Table 2 and about half of the cases occurred between spouses. In 90% of cases, the event leading to the bites was physical assault as shown in Table 3. In five cases, the patients sustained their bites while raping their victims; Fig. 3 shows one of the rapists with bite mark on the side of the chest, scratch mark on the left deltoid as well as lacerations over the left temporal region which the victim inflicted on him with a sharp object. The two patients who were mugged were all bitten on the dorsum of the hand with which they held tenaciously to their valuables. The aim of the muggers in biting their victims was in a desperate effort to inflict enough pain to make it easy to prise the valuables off their victims.

The upper limbs were the sites of predilection for the bites as shown in Table 4 as nearly half of the bites affected the upper limbs. Human bites affecting the hands were noted in 30% of cases and both left and right limbs were almost equally affected; 21% sustained clenched-fist injuries while 9% of the cases were bitten on the dorsum of the hand. Bite wounds of the hand had been known to lead to expanding cellulitis because of the presence of both aerobic and anaerobic organisms in the wound15. Six (10%) patients with clenched-fist injuries presented with septic arthritis and stiffness of the metacarpo-phalangeal joints. Clenched-fist injuries were sustained when one struck someone’s teeth with a clenched fist. The injury was usually deep seated and the resulting infection affected deep tissues of the hand and the complications were often severe and serious16,17.

The associated injuries inflicted during scuffle in this study include blunt abdominal injuries in 29%, skin lacerations in 16%, penile injures in 6%, urethral injuries in 3% and bladder injuries in 3% of cases as shown in Table 5. These associated injuries increased morbidity.

In two cases, the biters presented whilst still bleeding from lacerations on their lips and they were brought along with the bitten for treatment. These were the only cases in which HIV and Hepatitis serology of both victims and assailants were serially determined on presentation, three months and six months later – after informed consent - but none was positive for HIV or Hepatitis B. Though the incidence of HIV infection following human bites was uncommon, the infection had been reported elsewhere following human bites18,19,20,21. In 15% of cases, the bites affected the face and the ears. Infected human bites at these sites were usually associated with disfigurement and repeated surgical operations22.

Though every social class was affected in this study, half of the patients with human bites injuries were in the lower social class while 10% of the cases affected professionals and the business class – the upper social class – as shown in Table 6. The place of inequality in social class in medicine had been highlighted by other workers23.

The principles of management of bite injuries include resuscitation, debridement, reconstructive surgery as well as surgery for associated injuries, prevention and treatment of infection as well as counselling. Antibiotic therapy and tetanus prophylaxis were given to all the patients in this study. Sixteen(25%) patients had debridement while 18(29%) had surgical repair and another two(3%) patients had bouginage for their partial urethral strictures.

In 6% of cases, the bites affected the penis. Human bites of the genitalia were uncommon but had been classified as high risk bite injuries in the category of bite wound of the hands, feet and joints because of the great morbidity associated with genital bites24,25. In this study, the bite was longitudinal on the dorsal surface of the penile shaft in two cases while in the other two, it was circumferential with urethral injuries leading to infected penile ulcers and partial urethral strictures. There was no case of love bite in this report though love bite of the male genitalia had been reported by other workers25. We did not record any case of cannibalism26 or vampirism27 as in those studies where cultic blood- sucking bites were practised.

The main limitations in this study were the absence of facilities for forensic analysis to objectively confirm the culprits as well as facilities for anaerobic culture during the study.

Although we did not record any mortality, the morbidity rate of 57% was high. The commonest complication was wound infection which occurred in 29% of patients and the commonest organisms isolated were staphylococcus and streptococcus species – both organisms were seen in all the cases; the commonest gram-negative organisms isolated were E. coli, proteus and pseudomonas species. Other complications include disfigurement in 29%, penile injuries in 6% and partial urethral strictures in 3%. The worst disfigurements were noted in avulsive bites of the ear, bite marks on the face and penile injuries. Though human bite wounds of the ear were uncommon, they could lead to disfigurement if partially or totally avulsed28. The complications are as shown in Table 7. All the patients with complications presented late for treatment and this negatively impacted on the treatment outcome.

Conclusions

Human bite injuries in this tropical environment commonly affected the young male, the lower social class and the upper limbs; they were commonly sustained in assaults and domestic conflicts.

Fig. 1
Age distribution of the patients
Fig. 2
Infected bite wound of the penis
Fig. 3
A rapist with bite mark and scratch mark in the left deltoid region as well as scalp lacerations
Table 1
Clinical features of the patients
Table 2
Victim/assailant relationship
Table 3
Events leading to the human bites
Table 4
Site of bites
Table 5
Associated injuries
Table 6
Social classes of the patients
Table 7
Complications

Acknowledgment

Immense thanks to Professor C. Ogbonna of the Department of Community Health, University of Jos, Jos, Nigeria for reviewing the statistical analysis.

Footnotes

Competing Interests: The authors have declared that no competing interests exist.

Grant support: None

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