Case 1: Fever & Rash

Medical Mystery Case 1: Fever, Pain and Rash

A 47-year-old man presents to the ED with one week of severe left shoulder pain and intermittent fevers. He states that all his joints hurt, but his left shoulder is by far the worst, followed by his toes. The Vicodin they gave him yesterday isn’t helping. He also states he has a lot of flea bites which he�s been getting at home. He is not sure if the fleas are from his dog or his pet rat that he bought two weeks ago. He mentions that the rat also bit him about two weeks ago. He denies any history of injection drug use.
On exam he has a fever of 101.3. He has his left wrist resting inbetween buttons on his shirt as a makeshift sling and demonstrates significant guarding of the shoulder, which is quite tender, but not red or swollen. He also has a maculo-papular rash on his legs and a healed, benign appearing, rodent bite on his left index finger. (See Images) Otherwise the exam is negative.

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Labs show a WBC of 15.7 but are otherwise normal. A CT of the shoulder is done to rule out an effusion and possible septic joint. No effusion is present, but calcium deposits in the bicipetal groove are noted. Is calcific tendonitis consistant with this patient’s presentation? What additional diagnoses should you consider?

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Quick Essentials: Emergency Medicine

ANSWER: You should consider a septic joint, but this is a classic case of Ratbite Fever

QUICK ESSENTIALS EXCERPT on RATBITE FEVER:
Cause: Streptobacillus moliniformis. Carriage 10-100% of rats
Exposure: Can get from scratch or fecal /oral also. 2-10day incubation.
Sx: HA, relapsing fever, maculopapular extremity rash, joint pain, V
Rx: Admit all as can be fatal. PCN. Alternate: Claforan, doxycycline.
Rabies?: No rabies cases in US ever documented from a rat

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