Rat-bite fever

Abstract: RATBITE fever is an acute illness caused by Streptobacillus moniliformis or Spirillum minus , and characterized by chills, rash, and intermittent or relapsing fever. Arthritis or a local lesion at the bite-site, usually associated with regional lymphadenopathy, may also occur with the onset of other symptoms, depending upon the causative organism involved. Although penicillin is accepted as the treatment of choice for the disease, no agreement can be found in the literature concerning the most desirable dosage and duration of therapy. This paper reports a case of streptobacillary-ratbite fever successfully treated with penicillin. Previous American, Canadian, and British experience with cases in which the causative microorganisms were clearly demonstrated are reviewed, and the therapeutic programs used have been compared with the results achieved in an attempt to determine optimal management with antimicrobials now available. Report of a Case A 38-year-old white male radioisotope laboratory technician was admitted to the medical service

Abstract: A laboratory animal technician experienced undulating fever, chills, and myalgia 3 days after he was bitten by a laboratory rat. The clinical symptoms subsided with antibiotic therapy, but recurrent fever, malaise, and joint pain occurred when therapy was discontinued. Streptobacillus moniliformis was cultured from the patient's blood.

Abstract: The similarity in the cases of rat-bite fever recorded in the literature establishes it as a definite clinical entity The same symptomatology occurs in cases from Asia, Europe, and America The greater frequency of the disease in Japan than elsewhere is probably due to the housing conditions and habits of the people resulting in the more frequent occurrence of rat-bites It does not seem necessary to consider that cases occurring in Europe and America are due to the bites of rats that have been imported from Japan The clinical picture and course of the disease indicate that it is infectious in origin Until Schottmuller's case appeared in 1914, the etiology had been undiscovered He isolated from his case in eight consecutive blood cultures a streptothrix which he has designated Streptothrix muris ratti His work has been confirmed by the isolation of an identical streptothrix from the blood during life and at autopsy in the case here reported Further confirmation of the etiological relationship of this organism to the infection in our patient is found in the production of powerful agglutinins for the organism in the blood serum of this case and in the demonstration of the organism in the vegetation on the mitral valve It is not unreasonable to suppose that Proescher (13) observed the same organism in the sections of the excised wound in his case Although it is fully realized that Koch's postulates have not been fulfilled in the absence of successful animal experimentation, nevertheless the accumulated evidence here presented leaves little reason to doubt that the specific cause of rat-bite fever is Streptothrix muris ratti The pathology of rat-bite fever has hitherto been largely a matter of surmise One autopsy only has been recorded in the literature (Miura (22)), and nothing abnormal was noted other than injection of the pial vessels The autopsy in the case here reported has proved of considerable interest in the extent and character of the lesions found A streptothrix septicemia with the localization of the organism in the mitral valve producing an acute ulcerative endocarditis is the most striking feature of the case The infarcts of the spleen and kidney are a natural sequence of the endocarditis The subacute lesions of the myocardium, liver, adrenal, and kidneys, glomerular and interstitial, are all of a similar nature, consisting of areas infiltrated with leukocytes, lymphocytes, plasma, and endothelial cells with varying degrees of degeneration of the normal cells of the affected area In no instance has the presence of the streptothrix in these lesions been demonstrated, and it is not unreasonable to assume that they are toxic in origin The data here presented may be correlated with the clinical features of rat-bite fever to give us a clear understanding of the course and nature of the disease The patient is inoculated by the bite of a rat with Streptothrix muris ratti After a variable incubation period a non-suppurative inflammatory reaction occurs at the site of the wound with extension to the neighboring lymphatics and lymph nodes Invasion of the blood stream follows, accompanied by the onset of severe toxic symptoms Clinically the nervous system and frequently the kidneys seem to be especially involved That the myocardium, liver, and adrenals may also suffer is shown by the autopsy findings in the case reported above Ulcerative endocarditis is probably a rare occurrence In the majority of cases after a more or less prolonged course, the disease terminates spontaneously and so may be considered a self-limited infection This is presumably brought about by the development in the body of a protective mechanism against the streptothrix That such a process does occur is evidenced by the demonstration of agglutinins in our case Whether a permanent immunity is acquired after one attack of rat-bite fever is not known No instances of a second infection are recorded in the literature Although rat-bite fever varies somewhat in its symptomatology in individual cases, the picture is sufficiently characteristic to make the diagnosis not a difficult matter The history of a rat-bite, latent incubation period with subsequent non-suppurative inflammatory reaction of the wound, lymphangitis, and enlarged lymph nodes, severe chill at onset, high fever of the relapsing type, intense muscular pain and nervous symptoms, and the characteristic bluish red exanthem, present a symptom-complex not easily overlooked The disease is frequently complicated by a severe nephritis, and prolonged cases develop a high grade of anemia and cachexia In the case here reported ulcerative endocarditis occurred In the large majority of cases the prognosis is favorable for a successful termination The patients, however, are often incapacitated for a considerable period of time The mortality is about 10 per cent, death usually occurring in the first febrile period apparently from a profound toxemia, or at a later stage due to the development of a severe nephritis Until recently treatment has been entirely symptomatic and has been of little avail in altering the course of the disease Miyake has found immediate treatment of the wound by cauterization or with carbolic acid highly efficient as a prophylactic measure Hata (30) in 1912 introduced salvarsan therapy and reported eight cases so treated, seven of which showed marked and rapid improvement One case was apparently unaffected Two of the cases receiving only small doses had a subsequent relapse Surveyor (31) and Dalal (18) also have reported success with salvarsan injections It is to be hoped that further experience with this method of treatment will yield equally favorable results