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• W4386156729 abstract "To the Editors: An 8-month-old girl presented with painful swelling of the left foot. Three days before consultation, the child had a 2-day fever with an ephemeral exanthema, for which she had received acetaminophen. Since then, she had stopped crawling. No other symptoms or abnormalities were reported. There had been no sick contacts, travel history, animal contacts or injuries. The child was fully vaccinated. Child birth had been via C-section followed by antibiotic treatment due to neonatal infection. In addition, the patient underwent a withdrawal from amphetamine and fluphenazine due to the mother’s schizophrenia. We found an infant extremely sensitive to touch with a fever up to 39 °C and a pale, ephemeral exanthema. The left ankle and both wrists were swollen; the child held itself in a distinct relieving posture. After admission, the lab results showed the following: hemoglobin 10.2 g/dL, leucocytes 10,600/μL with 19% monocytes, thrombocytes 310,000/μL, C-reactive protein 40.7 mg/L, erythrocyte sedimentation rate 100 mm/h, Fibrinogen 565 mg/dL, Ferritin 186 ng/mL and antinuclear antibodies <1:40. Blood cultures were taken. An magnetic resonance imaging of the left lower limb yielded a panniculitis around the Mm. peroneus longus et brevis, no signs of osteomyelitis (Fig. 1). Echocardiography was normal. After 7.5 days, pleomorph Gram-negative rods grew in the anerobic blood culture, which were identified as Streptobacillus moniliformis via matrix-assisted laser desorption/ionization-time of flight mass spectrometry. The patient was treated with intravenous cefuroxime for 7 days and fosfomycin iv for 3 days, followed by oral cefuroxime. Upon further inquiry, mother and grandparents reported 2 additional significant facts: 2 weeks before consultation, the child screamed suddenly at night and was found to have been bleeding on a toe. The family resided close to a farm where rats had been sighted. Upon inspection of the foot, a very small lesion could be detected. Rat bite fever is an uncommon zoonosis caused by S. moniliformis and, to a lesser extent and mainly in Asia, by Spirillum minus.1 It is often associated with low hygiene standards.2 Typical symptoms are fever, exanthema and arthralgia.3 Since there are many differential diagnoses with this symptom triad, the diagnosis often relies on clues given at the initial presentation.4 In our case, the mother initially reported neither animal contacts nor the bite 2 weeks earlier nor the proximity to a farm. In addition, it is known that S. moniliformis is hard to detect in common blood cultures,5 as demonstrated in sparse growth on the last day of incubation in our case. These factors rendered it even more difficult to reach the final diagnosis. In daily routine, a thorough patient history is often the first thing to be cut short; still, it is important to remember that proper history with correct questions is just as important as a physical examination and advanced diagnostics. The first clue that leads to the correct diagnosis can often be found and should not be underestimated.FIGURE 1.: The sagittal Turbo inversion recovery magnitude sequence shows an extended hyperintense signal along the tendon of the M. tibialis post and M. flexor digitorum longus without any signs of edema of the tibia or tarsal bones.ACKNOWLEDGMENTS We acknowledge support by the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation) and Saarland University within the “Open Access Publication Funding” program." @default.
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• W4386156729 date "2023-09-04" @default.
• W4386156729 modified "2023-10-14" @default.
• W4386156729 title "A Rare Case of Rat Bite Fever in an 8-Month-old Girl" @default.
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• W4386156729 doi "https://doi.org/10.1097/inf.0000000000004073" @default.
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