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Annals ofthe Rheumatic Diseases 1992; 51: 411-412 41 Ann Rheum Dis: first published as 10.1136/ard.51.3.411 on 1 March 1992. Downloaded from Rat bite without the bite

J N Fordham, E McKay-Ferguson, A Davies, T Blyth

Abstract transaminase 48 IU/l; y-glutamyltransferase 134 The case isreported ofa patient who developed IU/1; and bilirubin 34 [imol/l, rising to 49 an acute arthropathy, which was initially [tmol/1; alkaline phosphatase 210 IU/1. Chest diagnosed as acute septic . The true radiography showed basal pneumonic changes. diagnosis ofrat bite feverdue toStreptobacillus A diagnosis of was made and moniliformis was delayed because of difficulty the right knee was aspirated. Purulent synovial in growing the organism, which has fastidious fluid (10 ml) was withdrawn, and on direct film growth requirements. The patient had no a cluster of cocci, loosely arranged 'like a bunch history of rat bite, which is the usual form of of grapes', was seen. The organisms were of this disease. identified as 'probably Staphylococcus aureus'. He was treated with flucloxacillin 1 g four times a day and sodium fusidate 500 mg three times a Rat bite fever presents as an acute or chronic day, both given intravenously. Over the course illness characterised by polyarthralgia or poly- of the next six days he developed a widespread arthritis affecting the knees, shoulders, elbows, morbilliform , thought to be induced by the wrists, and hands. Other features are cough, . Flucloxacillin was stopped and , rash, chills, and fever.' The condition treatment was started with intravenous vanco- is due to by moniliformis mycin 1 g twice a day. or, less commonly, by Spirillum minus.2 The Twelve days after admission the synovial mode of transfer is by a bite from an infected fluid bacteriological report showed 'Grain rat, mouse, or similar rodent3 or ingestion of negative bacillus present throughout the food or milk4 or water contaminated by rat enrichment'. Two weeks after admission the excreta.5 Characteristically, the area of the bite organism was identified as Streptobacillus seems to be healing at the time of development moniliformis and was found to be 'very sensitive of severe and and at that to '. At this stage the patient had a stage the bite becomes inflamed and there is normal temperature, his joints had completely http://ard.bmj.com/ local .2 In the chronic form returned to normal, and the chest radiograph recurrent bouts of fever occur lasting for several had cleared. He was discharged a few weeks days at a time and often associated with rigor, after admission, and on review 10 weeks later nausea, and . The rash is character- the patient had no residual joint signs other than istically erythematous, sometimes pustular, and bilateral quadriceps wasting. petechial haemorrhages may also occur.6 (In spirillum infection lymphadenopathy and on September 24, 2021 by guest. Protected copyright. splenomegaly may occur.) Rarely, myositis, Discussion , splenic and renal Both Streptobacillus moniliformis and Spirillum infarctions may complicate the course of the minus have worldwide distribution. Strepto- illness.2 3 bacillus moniliformis is responsible for most of the rat bite fever recorded in America. Its natural habitus is the rat respiratory tract, being Case history present in up to 50% of healthy rats,7 and is A 63 year old pig farmer was admitted with a rarely transmitted to humans.8 five day history of malaise and anorexia. Three Streptobacillus moniliformis is extremely diffi- days before admission he had developed painful cult to identify because of its fastidious growth swelling of the ankles and a petechial rash over requirements and variable staining and mor- the feet and had been febrile with rigors. On phology.9 It is classified as a Gram negative Department of admission he had joint effusions affecting both rod but may retain the Gram stain and adopt Rheumatology, knees and right wrist. Cervical spinal movements coccal forms (McKay-Ferguson E, personal South Cleveland Hospital, were restricted and very painful. He had a communication). Marton Road, temperature of 38-9°C and there was a petechial Because of the difficulty in culturing the Middlesbrough, rash affecting the dorsum of both feet. There organism the diagnosis was delayed for two Cleveland TS4 3BW, were weeks. United Kingdom expiratory crackles throughout both lung The organism was cultured eventually J N Fordham fields. There was a small pustule over the right from an enrichment culture (Robertson's cooked E McKay-Ferguson olecranon. meat medium). Sodium polyanethol sulphonate, A Davies Investigations showed a plasma viscosity of which is present in many systems T Blyth 1 87 mPa.s; haemoglobin 120 g/l, later falling as an anticoagulant, might have contributed to Correspondence to: Dr Fordham. to 106 g/l; white cell count 13 2x 109/1, rising to the delay, and this has been shown to inhibit Accepted for publication 18 5x109/1; platelets 339x109/1, rising to growth of some strains of Streptobacillus monili- 29 May 1991 631 x109/l. Liver function tests showed alanine formis. 0 I I 412 Fordham, McKay-Ferguson, Davies, Blyth

The initial choice of treatment with fluclo- infection. Treatment with , which

xacillin was satisfactory, as was subsequent will eradicate the organism causing septic Ann Rheum Dis: first published as 10.1136/ard.51.3.411 on 1 March 1992. Downloaded from treatment with Vancomycin, and disc diffusion arthritis, will usually be effective in rat bite tests confirmed both antibiotics to have been fever, , and gonococcal arthritis. appropriate. Both penicillin and vancomycin act Our patient presented with a short history of by interfering with bacterial cell wall synthesis arthralgia and subsequently arthritis associated and are much more active against Gram positive with rigors and rash. The absence of readily than Gram negative (with the exception available serological tests for this organism and ofcertain Gram negative cocci such as neisserias). lack of any clear history of origin for the The satisfactory clinical outcome in this case infection retarded the correct diagnosis being supports the conclusion that Streptobacillus made. We would like to draw attention to the moniliformis should properly be regarded as a possibility of rat bite fever as a cause of Gram positive organism. pyogenic arthritis, particularly where initial There was no history of rat bite, but, pos- microbiological analysis has been unrevealing. sibly, inhalation or gastrointestinal absorption of excreta might have been the portal of entry. The piggery had been infested with rats and the 1 Murray H W. Streptobacillus moniliformis (rat bite fever). patient remembered numerous episodes of In: Mandell G L, Douglas R G, Bennett J E, eds. Principles grazing the skin of both elbows on the sides of and practices ofinfectious disease. 2nd ed. New York: Wiley, 1985: 1305-6. the pig pens. It is possible, therefore, that 2 Huskisson E C, Dudley Hart F. Joint disease: all the ofthis organism might have occurred arthropathies. Bristol, London: Wright, 1987: 122. 3 McGill R C, Martin A M, Edmunds P N. Rat bite fever due through this route. Two recent reports from to Streptobacillus moniliformis. BMJ 1%6; i: 1213-4. America also note streptobacillus 4 Parker F, Hudson N P. The aetiology of ( arthriticum epidemicum). Am J Pathol 1926; 2: which occurred without a history of rat bites: a 357-79. 48 year old warehouse fork-lift operator who 5 McEvoy M B, Noah N D, Pilsworth R. Outbreak of fever caused by Streptobacillus moniliformis. Lancet 1987; ii: had a three month history ofgradually increasing 1361-3. symptoms before diagnosis, and a 59 year old 6 Shanson D C, Gazzard B G, Midgley J, et al. Streptobacillus moniliformis isolated from blood in four cases of Haverhill alcoholic man who had a one month history of fever. First outbreak in Britain. Lancet 1983; ii: 92-4. arthritic symptoms before diagnosis. In neither 7 Strangeways W I. Rats as carriers of Streptobacillus moni- liformis. J Pathol Bacteriol 1983; 37: 45-51. of these cases had any recollection of contact 8 Anderson L C, Leary S L, Manning P J. Rat bite fever in with rats or of a rat bite been noted.'2 13 animal research laboratory personnel. Lab Anim Sci 1983; 33: 292-4. The in this case would 9 Rogosa M. Streptobacillus moniliformis and Spirillum include other causes of septic arthritis, such as minus. In: Lennette E H, Balows A, Hausler W J, Shawdomy H J, eds, Manual ofclinical microbiology. 4th ed. Lyme disease and gonococcal arthritis and Washington DC: American Society for Microbiology, 1984: brucella, as well as other non-infectious inflam- 400-6. 10 Lamb D W, McPhedran A M, Mertz J, Stewart P. matory polyarthropathies, including rheumatoid Streptobacillus moniliformis isolated from a case of arthritis. 13 Haverhill fever: biochemical characterisation and inhibitory effect of sodium polyanethol sulfate. Am J Clin Pathol http://ard.bmj.com/ Presentation with fever and rash may mimic 1973; 60: 854-60. systemic erythematosus, drug reactions, 11 Shanson D C, Pratt J, Greene P. Comparison of media with and without Panmede for the isolation of Streptobacilius viral infections, rickettsial infections, and moniliformis from blood cultures and observations on the secondary . inhibition of sodium polyanethol sulphonate. J Med Microbiol 1985; 19: 181-6. Of cases of septic arthritis in adults, up to 12 Rumley R L, Patrone N A, White L. Rat bite fever as a cause 60% are due to staphylococci, with streptococci of septic arthritis. Ann Rheum Dis 1987; 46: 793-5. 13 Holroyd K J, Reiner A P, Dick J D. Streptobacillus also being prominent. 14 Gram negative infections moniliformis polyarthritis mimicking : on September 24, 2021 by guest. Protected copyright. aremainlyrestricted to theimmunocompromised an urban case of rat bite fever. Am J Med 1988; 85: 711-4. 14 Goldenburg D C. Bacterial arthritis. In: Keiley W N, Harris and the elderly. Infection with anaerobes E D Jr, Ruddy S, Sledge C B, eds. Textbook ofrheumatology. mainly occurs in those with postoperative 3rd ed. Philadelphia: Saunders, 1989.