Rat Bite Fever Resembling Rheumatoid Arthritis

Table 1

Reported Cases of Rat bite fever with initial presumed diagnosis of rheumatological disorders.

Study/year/; reference

Age/sex

Rat bite/scratch

Occupation

Family history of rheumatological disorders

Clinical features

Affected joints

Joint aspirate analysis

Joint aspirate culture

Identification method of Streptobacillus moniliformis

Blood culture

Rheumatological workup

Joint erosion

Initial presumed diagnosis

Treatment

Outcome

Legout et al./2005; [3]

60/female

Rat bite

Pet shop employee

Father- seropositive rheumatoid arthritis

Fever and polyarthritis

Symmetrical affecting small joints of both hands and ankles and right knee

Right knee synovial fluid: leukocytosis (40 × 10^9/L) with 90% neutrophils

GNB

PCR amplification of part of 16S RNA gene

Negative

RF, ANA, ANCAs, specific anti-filaggrin antibody, and cryoglobulin were negative

No erosion

Rheumatoid arthritis

Initial: NSAIDs and IV  methylprednisolone 500 mg/day for 3 days, no improvement; Postculture: arthrotomy of right knee and 4 weeks of antibiotics which included IV penicillin followed by oral rifampin and clindamycin

Successfully treated

Dendle et al./2006; [4]

49/female

Rat bite

Not reported

Not reported

Polyarthritis, fever, rash, pneumonia, and hepatitis

MCP, wrists, knees, right elbow, and right ankle

Right elbow: numerous PMN; No formal analysis-sample clotted

Pleomorphic GNB

16S rRNA gene sequencing

Negative

ANA and RF compliment levels were normal

No erosion

Rheumatoid arthritis or Still’s disease

Initial: oral prednisone 25 mg daily with worsening synovitis; Postculture: doxycycline 100 mg twice daily for 6 weeks

Successfully treated

Stehle et al./2003; [5]

72/male

Rat bite

Not reported

Not reported

Polyarthritis

Both knees, elbows, and left 3rd MCP

Right Knee: leukocytosis; (around 50 × 10^9/L) with 83% neutrophils; Rearthrocentesis of both knees, right elbow, and left 3rd MCP: analysis not reported

Streptobacillus moniliformis grew on repeat synovial fluid culture

16S rRNA gene sequencing

Negative

Not reported

No erosion

Atypical rheumatoid arthritis

Outpatient: NSAID and deflazacort for almost 1 month, no improvement; Postadmission: bolus of IV steroids, minimal improvement; Postculture: broad spectrum antibiotics

Successfully treated

Holroyd et al./1988; [6]

59/male

No

Not reported

Not reported

Fever and polyarthritis

PIP, MCP, wrist and knees, ankles, elbows, and shoulders bilaterally

Left knee: leukocyte 3,700/mm^3 with 80% PMN; Left wrist: 57,000/mm^3 and 90% PMN

Left wrist: pleomorphic GNB with bullous swelling

Gas chromatography of the cellular fatty acid of organism

Streptobacillus moniliformis

Negative RF and weakly positive ANA 1 : 40

Not reported

Rheumatoid arthritis

Outpatient: patient took NSAIDs for 1 day prior to admission; Postculture:  ticarcillin and gentamicin; penicillin G for total 10 days

Successfully treated

Kanechorn and Niumpradit/; 2005 [7]

61/female

Rodent bite

Retired nurse

Not reported

Fever, petechial rash, myalgia, and symmetrical polyarthritis

Fingers, wrists, knees, and ankles

Site of joint aspiration not reported.; Analysis: leukocyte counts of over 64,000 cells/mm^3 and all neutrophils

Negative

Not reported

Negative

ANA and RF negative

Not reported

Septic arthritis and rheumatoid arthritis

Initial: erythromycin, Ibuprofen as well as rabies vaccination and tetanus toxoid prior to admission; Postadmission:  dexamethasone 4 mg every 6 hours,  amoxicillin/clavulanic acid plus doxycycline, no improvement; After joint analysis: ceftriaxone and penicillin G for 4 weeks, arthrotomy and debridement of joints, unreported sites of joints

Successfully treated

Abdulaziz et al./2006; [8]

68/male

Rat exposure, no bite

Dairy farmer

Not reported

Symmetrical polyarthritis, rash, fever, myalgias, and headache

PIP’s, MCP’s, wrists, ankles, and knees

Left knee: white blood cell count of 19,250/mm^3, 84% PMN leukocytes, and CPPD crystals

Negative

Not reported

Pleomorphic gram negative bacilli

Not reported

No erosion

Acute polyarticular pseudo gout

Initial:  ibuprofen and NSAIDs; Postculture:  penicillin G for 14 days successfully treated

Successfully treated

Tattersall and Bourne/2003; [9]

56/male

Rat bite

Not reported

Not reported

Fever, rash, asymmetric polyarthritis, hand ischemia, sore throat, and loose stools

Right elbow, wrist, shoulder, left thumb MCP joint, both midtarsal joints, and right ankle

Left thumb MCP: analysis not reported; Left ankle: urate crystals

Gram negative pleomorphic coccobacillus Streptobacillus moniliformis

DNA sequencing

Negative

Autoantibodies and ANCAs were negative

Not reported

Vasculitis; or reactive arthritis

Initial: IV methylprednisolone and cyclophosphamide for few days with minimal improvement; Postculture: oral doxycycline for 6 weeks

Successfully treated

Dworkin et al./2010; [10]

59/male

Rat exposure, no bite

Not reported

Not reported

Polyarthritis, diarrhea, malaise, and presumed endocarditis

knees, ankles, wrists, right elbow

Left knee: analysis not reported

Pleomorphic GNB

16S rRNA gene sequencing

Negative

ANA elevated 1 : 160 and normal compliment, RF and, ANCA levels

Not reported

Polyarthritis of infectious or collagen vascular disease etiology

Initial: NSAIDs and steroids; Postculture: penicillin, doxycycline, and gentamycin for 6 weeks

Successfully treated

Budair et al./2014; [11]

29/male

Rat exposure

Manual laborer in a warehouse

Not reported

Malaise, fever, sore throat, rash, and polyarthralgia

Right second MCP, right elbow, right knee and both ankles

Right ankle aspiration: yellow cloudy fluid; Analysis not reported

Culture negative

16S rRNA PCR identified organism

Negative

ANA, double stranded DNA antibody, glomerular basement membrane antibody, myeloperoxidase antibody and proteinase-3 antibodies, RF, and immunoglobulins were all normal

Not reported

Vasculitis

Postorganism identification: intravenous benzylpenicillin and 3 weeks of oral amoxicillin

Successfully treated

GNB: gram negative bacilli; PIP: Proximal Interphalangeal; MCP: metacarpophalangeal; RF: rheumatoid factor, ANA: anti-nuclear antibody, ANCA: anti-neutrophil cytoplasmic antibody; NSAID: nonsteroidal anti-inflammatory drug; IV: Intravenous; PCR: polymerase chain reaction; PMN: Polymorphonuclear; CPPD: calcium pyrophosphate dihydrate.