Logo

Log In Sign Up |  An official publication of: American College of Emergency Physicians
Navigation
  • Home
  • Multimedia
    • Podcasts
    • Videos
  • Clinical
    • Airway Managment
    • Case Reports
    • Critical Care
    • Guidelines
    • Imaging & Ultrasound
    • Pain & Palliative Care
    • Pediatrics
    • Resuscitation
    • Trauma & Injury
  • Resource Centers
    • mTBI Resource Center
  • Career
    • Practice Management
      • Benchmarking
      • Reimbursement & Coding
      • Care Team
      • Legal
      • Operations
      • Quality & Safety
    • Awards
    • Certification
    • Compensation
    • Early Career
    • Education
    • Leadership
    • Profiles
    • Retirement
    • Work-Life Balance
  • Columns
    • ACEP4U
    • Airway
    • Benchmarking
    • Brief19
    • By the Numbers
    • Coding Wizard
    • EM Cases
    • End of the Rainbow
    • Equity Equation
    • FACEPs in the Crowd
    • Forensic Facts
    • From the College
    • Images in EM
    • Kids Korner
    • Medicolegal Mind
    • Opinion
      • Break Room
      • New Spin
      • Pro-Con
    • Pearls From EM Literature
    • Policy Rx
    • Practice Changers
    • Problem Solvers
    • Residency Spotlight
    • Resident Voice
    • Skeptics’ Guide to Emergency Medicine
    • Sound Advice
    • Special OPs
    • Toxicology Q&A
    • WorldTravelERs
  • Resources
    • ACEP.org
    • ACEP Knowledge Quiz
    • Issue Archives
    • CME Now
    • Annual Scientific Assembly
      • ACEP14
      • ACEP15
      • ACEP16
      • ACEP17
      • ACEP18
      • ACEP19
    • Annals of Emergency Medicine
    • JACEP Open
    • Emergency Medicine Foundation
  • About
    • Our Mission
    • Medical Editor in Chief
    • Editorial Advisory Board
    • Awards
    • Authors
    • Article Submission
    • Contact Us
    • Advertise
    • Subscribe
    • Privacy Policy
    • Copyright Information

Rat-Bite Fever’s Non-Specific Symptoms Make Patient History Important for Diagnosis

By Nicole Vetter, MD | on March 16, 2015 | 2 Comments
CME CME Now Features
  • Tweet
  • Click to email a link to a friend (Opens in new window) Email
Print-Friendly Version
Rat-Bite Fever's Non-Specific Symptoms Make Patient History Important for Diagnosis
Introducing CME Now

You Might Also Like
  • Botulism Poisoning Diagnosed in Patient with Stroke-like Symptoms
  • Neonatal Meningitis Diagnosis Difficult Given Subtle Symptoms of Vomiting, Irritability
  • Recognize Pediatric Toxic Epidermal Necrolysis Symptoms, Manage Disease
Explore This Issue
ACEP Now: Vol 34 – No 03 – March 2015

ACEP Now features one article each issue related to an ACEP eCME CME activity.

Log on to the ACEP eCME CME site to complete the activity for this article and earn free AMA PRA Category 1 Credit.

The Case

Chief complaint: fever and rash. I stare at the triage notes of the eight-year-old female I had just picked up. Overwhelmed by the vast differential that comes to mind, I decide to approach the case by first ruling out the most life-threatening diagnoses, such as meningococcemia and Stevens-Johnson syndrome, even though they are highly unlikely in my patient.

As an EM intern, I’m still developing a sense for distinguishing “sick” versus “not sick,” but upon entering my patient’s room, I know immediately this girl is “sick.” A thin, pale child lies before me, splayed out on the stretcher and holding her right arm across her chest. She doesn’t even look up when I introduce myself. A morbilliform rash peeks through her gown, and I notice the rash on her face, extremities, palms, and soles (see Figure 1). “Palms and soles…” I recall the more-focused differential for a palms/soles rash: meningococcemia; Rocky Mountain spotted fever; hand, foot, and mouth disease; secondary syphilis…

The parents describe their child as becoming progressively more “lethargic” and febrile over the past week (Tmax 104°F). They had already visited the pediatrician three times but decided it was time to come to the ED when the patient woke up refusing to walk due to pain in her knees and ankles. Delving into my bank of fever questions, I ask about headache, neck stiffness, skipped vaccinations, sick contacts, recent travel, or any new medications. However, all of these questions return negative. Fever, rash, joint pain—what else could I ask? At a loss, I decide to ask about any known tick bites, though this is unlikely because we are at the peak of winter in New England. Still negative. Any new pets? Well, now that I mention it, they admit to buying a new pet rat a few weeks ago.

Figure 1. Morbilliform rash

(click for larger image) Figure 1. Morbilliform rash

On exam, the patient appears very fatigued. Her vital signs are significant for a fever of 38°C and heart rate of 126 bpm. Her respiratory rate, blood pressure, and SpO2 are within normal limits. The most striking exam findings are the patient’s pallor contrasted against a blanching morbilliform rash over her face, extremities, palms, and soles but sparing her torso. I also notice a petechial rash developing on the patient’s legs that I hadn’t seen previously. Despite mild postauricular lymphadenopathy, the rest of her head, eyes, ears, nose, and throat exam is normal. Her heart, lung, and abdomen exams are also normal. However, when I attempt to move the patient’s right shoulder and ankles, she moans in pain.

Rat-Bite Fever

As I return to my desk, the history of a new pet rat continues to resonate in my mind. I search the Internet for rat-borne diseases, and a recent news article appears as one of the top search results.1 The article describes the case of a young boy misdiagnosed with a viral illness, but worsening of his symptoms resulted in his death a few days later. On autopsy, the boy was found to be infected with the bacterium causing rat-bite fever (RBF), Streptobacillus moniliformis.

Pages: 1 2 3 | Single Page

Topics: Bites and EnvenomationCase PresentationContinuing Medical EducationCritical CareEmergency DepartmentEmergency MedicineEmergency PhysicianInfectious DiseasePediatrics

Related

  • Push-Dose Pressors in the Emergency Department

    June 29, 2025 - 1 Comment
  • Case Report: When Syncope Gets Hairy

    June 17, 2025 - 0 Comment
  • Influenza, Muscle Pain, and an Elevated Serum Creatine Kinase

    May 10, 2025 - 0 Comment

Current Issue

ACEP Now: July 2025

Download PDF

Read More

2 Responses to “Rat-Bite Fever’s Non-Specific Symptoms Make Patient History Important for Diagnosis”

  1. March 29, 2015

    Stephen Colucciello Reply

    The dose for IV PCN is WAY too low. “◾IV penicillin G: 200,000 units every 4 hours for 5–7 days (can be switched to PO once patient shows clinical improvement)”
    This should be 2,000,000 (two million NOT two hundred thousand) q 4 h.
    Off by a factor of 10!

  2. March 29, 2015

    Randall dloan Reply

    Never heard of this .

Leave a Reply Cancel Reply

Your email address will not be published. Required fields are marked *


*
*

Wiley
  • Home
  • About Us
  • Contact Us
  • Privacy
  • Terms of Use
  • Advertise
  • Cookie Preferences
Copyright © 2025 by John Wiley & Sons, Inc. All rights reserved, including rights for text and data mining and training of artificial technologies or similar technologies. ISSN 2333-2603