SHM Converge Scientific Abstract ePoster Gallery-Palms and Soles Rash on the Pediatric Wards: Horse, Zebra, Or...rat?

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This case describes a 14-year-old boy with autism who presented with five days of high fever, vomiting, shortness of breath, painful rash on the palms and soles, and polyarthralgia. He was initially diagnosed with hand-foot-mouth disease, but persistent symptoms led to hospital admission. Exam showed painful macules, papules, petechiae, and pustules on the palms and volar feet, with thrombocytopenia and elevated liver enzymes.<br /><br />The differential diagnosis included Rocky Mountain spotted fever, meningococcemia, Kawasaki disease, MIS-C, syphilis, and toxin-mediated bacterial syndromes. He was initially treated empirically with doxycycline, then ceftriaxone, as clinicians considered RMSF, MIS-C, and meningococcemia. When his fever and rash worsened, further history revealed that he had a pet rat and often fed it by hand. Blood cultures later grew gram-negative rods identified as Streptobacillus moniliformis, confirming rat bite fever.<br /><br />Rat bite fever is a rare but potentially fatal zoonotic infection, usually caused by exposure to saliva, urine, or feces from infected rodents. In North America, it is most commonly due to S. moniliformis. Typical features include fever, rash involving the palms and soles, pustules, and polyarthralgia. Untreated disease can lead to serious complications such as hepatitis, meningitis, endocarditis, and death. Diagnosis depends on blood cultures, but the organism is fastidious, so the lab must be alerted if the diagnosis is suspected. First-line treatment is penicillin G.<br /><br />The patient improved after switching to IV penicillin G and was discharged on oral penicillin V for seven days. At one-month follow-up, his symptoms, thrombocytopenia, and transaminase elevations had fully resolved. This case highlights the importance of a detailed exposure history when evaluating pediatric patients with fever and palm/sole rash.

Asset Subtitle

Paul Maler

Meta Tag

Author List Kareem Shehab, Nancy Chen, Paul Maler

Category Clinical Vignettes

Concept Rat Bite Fever

Concept Fever

Concept Streptobacillus moniliformis

Concept Antibiotic Therapy

Concept Palmar Rash

Distinguished Non-Finalist

Presenter Organization University of Arizona Family and Community Medicine Residency

Presenting Author Paul Maler

Track Pediatric

Keywords

rat bite fever

Streptobacillus moniliformis

pediatric fever

palm and sole rash

polyarthralgia

rodent exposure

blood culture

thrombocytopenia

penicillin G

zoonotic infection

Rat Bite Fever

Fever

Streptobacillus moniliformis

Antibiotic Therapy

Palmar Rash