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Clinical Vignette “Joint Pain”. Kathryn Skelly, MD, MSc Internal Medicine Resident , Maine Medical Center American College of Physicians Maine Chapter 2013 Annual Chapter Educational Meeting September 28, 2013. D.P. : 44 year old male. HPI : - PowerPoint PPT Presentation
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Kathryn Skelly, MD, MScInternal Medicine Resident , Maine Medical
Center
American College of Physicians Maine Chapter2013 Annual Chapter Educational Meeting
September 28, 2013
D.P. : 44 year old male HPI:
Polyarthralgias for 1 day (shoulders, hands, knees)Fever to 100.9 and “flu-like symptoms”Acute on chronic bilateral knee effusionsNo known tick exposure or rashNot sexually active. No penile discharge or dysuriaNo known family history of rheumatologic diseaseUses medical marijuana but denied other drug use
ROS: Mild headache earlier in the week that had resolved Denied cough, sore throat, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea.
History Past Medical History:
Osteoarthritis (spine and knees) GERD
Medications: Morphine 30 mg QID (chronic back and knee pain) Pantoprazole 40 mg BID Medical marijuana
Allergies: Celebrex, nexium Social History:
Works as a landscaper. Single 4 drinks of alcohol daily. No tobacco Marijuana as above No recent travel outside Maine.
Family History: Patient unsure of family history
Physical ExamVS: 37.3; 137/89; 91; 18; 94% on room air
General: Well-appearingHEENT: No lymphadenopathyRegular heart rhythm. No murmurs, rubs, or gallopsLungs clear to auscultation bilaterallyBenign abdominal examMusculoskeletal and Neurologic exams:
Visible trapezius and rhomboid muscle spasms. No bony point tenderness to palpation along the spine. Pain with bilateral upper extremity abduction, but full
range of motion Strength 5/5 in upper and lower extremities No warmth or erythema of knees, but effusions present
Laboratory Assessment
ESR: 48Total CK: 78
Alk phos: 97AST: 35ALT: 47
139
4.0
103
29
9
0.70101
12.74.8
36.5
157
Plan:
Patient diagnosed with likely viral reactive arthritis
Treated with prednisone 40 mg daily for 6 days, and oxycodone for pain.
Second Presentation HPI:
Presents to ED with worsening bilateral shoulder pain, low back pain, and knee pain
He took prednisone as prescribedHas been taking extra morphine, and
reports that pain is still “16/10”Denied feversDenied IV drug use or tick exposure.
Physical ExamVS: T 36.8, P 89, BP 156/89, RR 18, 98%
on RANotable for hyperesthesia of skin over shoulders and trapezius muscles
Swelling and erythema over AC joints bilaterally, with “exquisite” tenderness to palpation.
Bilateral knee effusions noted. No rash.
Patient referred to rheumatology
Third Presentation HPI
Patient presents with worsening joint pain
Back pain and knee pain now so severe, patient can’t get out of bed or ambulate
Family called 911 because patient was having rigors at home.
Physical ExamVS: 38.3, BP: 141/76, P: 88, RR: 22,
96% on RAWarmth and effusions of both knees and
right elbowtenderness and warmth over both AC
joints with decreased range of motion of shoulders
Tenderness along L5-S1 interspaceLimited neurologic exam secondary to
patient’s extreme painNo rash noted
Laboratory Results
ESR: 73
CRP: 22.71
CMP within normal limitsBlood cultures sentRight knee aspirated
11.38.2
32.6
231
Differential Diagnosis?Differential Diagnosis?
Our Differential DiagnosisInfection:
EndocarditisBacteremia and septic arthritis
Osteomyelitis of the spineDisseminated gonococcal
infectionTick-borne illness
Viral Infection (parvovirus, hepatitis)
Inflammatory Arthritis:
Rheumatoid arthritisSLE
Polymyalgia rheumatica
SpondyloarthropathyCrystal arthropathyReactive arthritis
DataMRI cervical spine:
Epidural and pre-vertebral abscess at C6-7MRI lumbar spine:
Septic facet arthropathy at L4-5 with 9X17 mm abscess extending into the right subarticular recess and posterior paraspinal muscle
Patient started on vancomycin, ceftriaxone, metronidazole
Neurosurgery and infectious disease consults
MRI Lumbar Spine
MRI Cervical Spine
More Data:Right knee aspirate:
13,200 leukocytes 88% PMN 12% lymphocytes
No crystals seenGram stain negative, culture no growth
Hepatitis panel negativeCCP Ab <6 (negative)RF 19 (0-13)ANA <1:80Parvovirus: IgG Ab positive, IgM Ab negativeLyme disease Ab: IgG, IgM negativeHIV negativeANCA negativeChlamydia, gonorrhea negativeTEE: Structurally normal valves, with no evidence of vegetationsBlood cultures negative at 48 hours, 2 sets
Hospital CourseCRP up to 29.35 (from 22.7 )
Hospital day #3:Blood cultures from admission now positive
for gram negative rods (2/2)Patient changed to cefepime (still on
vancomycin and metronidazole)
Patient reveals more history:Pets: iguanas and snakes at home
What are you thinking now?
Hospital CourseBlood cultures:
Gram negative rodsSuspected anaerobic activityPossible organisms:
SalmonellaBacteroidesPrevotellaFusobacterium
Hospital Day #5Patient reports that several days before
symptoms started, he was bitten by a live rat while feeding it to his pet snake (hospital admission was about 11 days after the bite)
Working Diagnosis“Rat bite fever”
Organism on gram stain resembles Streptobacillus moniliformisStill awaiting final speciation Still on cefepime and metronidazole
Likely septic polyarthritis (knees and AC joints) despite negative culture of aspirateFastidious organismWBC in aspirate likely low due to initial course of
prednisoneEpidural abscesses
Followed by neurosurgery No surgical intervention
Final Diagnosis:“Rat bite fever”, with cervical and lumbar
epidural abscesses, osteomyelitis, and septic polyarthritis
Hospital Day #16, final speciation on blood cultures:Streptobacillus moniliformis Identified in collaboration
between MMC and Mayo Clinic
Patient changed to IV penicillin G Q4 hours
HD #21: Patient discharged to rehab on IV penicillin therapy with weekly ID follow up
Rat Bite Fever
Rat Bite FeverThree Clinical Syndromes:
Streptobacillus moniliformis infection Accounts for most cases in the United States
Spirillum minus (sodoku) Mostly in Asia, but found worldwide
Haverhill Fever
First reported in the U.S. in 1914Causal organism named Streptobacillus
moniliformis in 1925
Streptobacillus MoniliformisPleomorphic filamentous
bacilliCharacteristic bulbous
swelling in chains and tangled clumps
FastidiousSlow growing
Must hold cultures at least 5 days
Aerobic and facultatively anaerobic
Torres et al. 2001
Haverhill FeverStreptobacillus moniliformis infection via
ingestion of contaminated foodContamination with infected excreta or
salivaTypical features:
Absence of known rat exposureLarge number of patients
Common geographical and temporal exposure
First described in 1926…
Outbreak in Haverhill, MA: 192686 patients developed symptoms over a 4 week periodSymptoms:
Abrupt, severe fever and chillsNausea, vomiting, headacheArthritis (>6 joints in 50% of patients)Relapsing and remitting rash
Macular or papular, petechial; wrists, arms, feet, ankles
Identified source of infection: raw milk92% of patients had received raw milk from local
bottling plantSuspected possible contamination from rat urine
Rat Bite Fever: Epidemiology2 million animal bites per year in the U.S.
1% are rat bites
Incidence likely very underestimatedRat bite fever is not a reportable diseaseGenerally low clinical suspicionDifficult to culture
Typical patient profile:Historically, children living in povertyDemographics changing
Children (pet rat), pet store workers, animal lab personnel
Disease Transmission Found predominantly in nasal and oropharyngeal flora of rats
10-100% of domesticated and lab rats 50-100% wild rats
Infection and colonization documented in other species: Guinea pigs, gerbils, ferrets, cats, dogs, mice
Infection resulting from: Rat bite Rat scratch Handling infected rat (can be transmitted via infected saliva) Ingesting food/water contaminated with infected rat feces Exposure in cases of infection can be unknown
Possible infection from dog bite after dog had contact with rat: (Wouters et al 2008): 3/18 dogs who had proven contact with
rats were found to have Streptobacillus moniliformis in their mouth
Graves and Janda (2001) Microbial Diseases
Laboratory, State of California:Documented cases of
human infection with Streptobacillus moniliformis from 1970-1998
N=45Rat exposure:
Bite, scratch, kiss, other rat association
Animal Exposure Percentage of Patients
Pet rat 54
School rat 14
Other rat exposure
11
Wild rat 9
Mouse 3
Squirrel 3
Exposure not known
6
Clinical Manifestations Symptoms start 3-7 days following exposure (can be up to 21 days)
Fever (intermittent)Myalgias, arthralgiasVomitingHeadachePolyarthritis (can last years)Sore throat
Serious complicationsMeningitisEndocarditisMyocarditisPneumoniaSeptic arthritisBacteremiaMultiple organ failure
Presenting Symptoms
Percentage of Patients
Fever 88
Arthritis/Arthralgia 73
Rash 65
Fatigue/Malaise 20
Headache 18
Chills 15(Graves and Janda, 2001)
Epidural Abscess and Streptobacillus moniliformis: One Case Report in the Literature (Addidle et al., 2012)58 year old male presented with 2 weeks back
pain, fevers, lower extremity weaknessMRI: Large epidural abscess (L4-S1)Urgently went to ORCulture from abscess negative, but blood cultures
grew gram negative rods:Patient treated empirically for Capnocytophaga
spp. due to history of his dog licking a woundAfter 21 days, organism identified as
Streptobacillus moniliformis.Patient treated with 5 weeks IV ceftriaxone
DiagnosisConsider in any patient with unexplained
febrile illness, with rash and/or polyarthritisParticularly if rat or other rodent
exposureBlood or synovial fluid
Alert lab, so they can optimize media and culture
Incubate cultures for 21 daysSerologic testing not available
TreatmentMortality rate 13% without treatmentTreatment of choice:
IV penicillin 400,000-600,000 IU (240-360 mg) per dayAdd streptomycin or gentamicin for
endocarditisAlternatives: Tetracycline, doxycycline,
streptomycinCephalosporins have been used
successfullyDuration of therapy is individualized
D.P. Clinical CourseAfter 6 weeks:
Still on IV PenicillinContinues to have severe back and
knee painCRP: 4.95Follow up MRI after 3 months:
Epidural abscesses had resolvedMultilevel osteomyelitis, discitis
and inflammatory changes improving
D.P. Clinical CourseAfter 5 months:
On oral Penicillin (500 mg QID)MRI shows stable disease in cervical spine, but progression of osteomyelitis in the lumbar spine
CRP 0.21IR guided biopsy of L5 facet pending…
5 Month MRI Lumbar Spine
Considerations for the Future:Zoonoses on the Rise?Changing planet:
Human wildlife conflict Habitat loss, dissolving boundaries Commercial bushmeat hunting worldwide
Urbanization of previously rural areasGlobal poverty
Lack of clean water supply, sanitary foodBlack market wildlife trade
Exotic pets Animal parts Consumption
ReferencesAddidle et al. 2012. Epidural Abscess Caused by
Streptobacillus moniliformis. Journal of Clinical Microbiology; 50(9): 3122-3124.
Elliot, S. 2007. Rat Bite Fever and Streptobacillus moniliformis. Clinical Microbiology Reviews. P. 13-22.
Graves and Janda, 2001. Rat-Bite Fever (Streptobacillus moniliformis): A Potential Emerging Disease. Int J Infect Dis; 5:151-154.
Wouters et al, 2008. Dogs as Vectors of Streptobacillus moniliformis infection? Vet Microbiol; 128(3-4): 419-22.
Torres et al, 2001. Remitting Seronegative Symmetrical Synovitis with Pitting Edema Associated with Subcutaneous Streptobacillus moniliformis Abscess. Journal of Rheumatology 2001; 28: 1696-8.