Fever and a Rat Bite

269 A70-year-old previously healthy man presented to the emergency department with a three-day history of fever. Two weeks before, while working in the kitchen of his restaurant, he captured a rat. The rat bit him on his right thumb, prompting the man to kill the rat and dispose of it in the garbage. He saw his family physician, who gave him a topical antibiotic ointment and a tetanus booster. The wound healed and the patient felt well until 10 days later when he developed fever, chills and sweats. At the same time, his thumb became painful, swollen and erythematous. The wound dehisced spontaneously. He returned to his family physician, who prescribed oral cloxacillin and referred him to the emergency department. Upon arrival at the emergency department, his temperature was 39.1°C and his oxygen saturation was 90% on room air. Blood and wound swab cultures were obtained. The patient was given a second tetanus booster and a consultation with the infectious diseases service was requested. The patient was from China and had lived in Canada since 1996. He had not travelled outside Canada since his arrival. His vaccination history was unknown. There was no history of arthralgias, myalgias or rash. On physical examination by the infectious disease service, his blood pressure was 110/80 mmHg, his heart rate was 70 beats/min and regular, and his temperature was 36.7°C. His oxygen saturation was 97% on room air. There was no cervical adenopathy and his conjunctiva were normal. His neck was supple. Cardiovascular and abdominal examinations were normal. Auscultation of his chest revealed bibasilar inspiratory crackles. There was no rash, petechiae, jaundice or clubbing. His right thumb was swollen and erythematous to the base. There was a superficial puncture wound on the ventromedial aspect of his thumb (Figure 1). There was no drainage. His thumb was tender and indurated. There was also evidence of lymphangitis on the dorsal aspect of his right forearm. Initial laboratory investigations revealed a white blood cell count of 9.5×109/L, and normal electrolyte, renal and liver profiles. Two sets of blood cultures were negative. A Gram stain of the sample from the wound showed Gramnegative bacilli on microscopy, but the culture was negative. Radiographs of his chest and hand were normal. What is your diagnosis and how would you treat this patient?

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