A Rash on Her Palms and the Bottoms of Her Feet Was the Clue That Turned the Case
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Version 0 of 1. “We’re going to the hospital,” the mother said to her 24-year-old daughter. The young woman had been crying in pain all night — and for the past three weeks. Her symptoms started with a couple of days of nonstop vomiting and a fever of 103. The vomiting stopped, but the fever continued. Then she broke out in a rash on her hands and feet. That’s when the pain started. First her right knee became stiff and swollen. Then her wrists and ankles. And soon after that, everything hurt. This was so unlike her daughter. The mother had never seen her in this kind of pain. An avid equestrienne for most of her life, the young woman had gritted her teeth through sprained wrists and ankles, horse-trodden feet and, last year, a fracture. She helped her daughter out of bed, then hurried to get dressed. They made their way in the predawn light to the emergency room at nearby Yale New Haven Hospital. She’d already taken her daughter to the E.R. once that week. That was after a few visits to urgent care and the woman’s primary-care doctor. ↓ Worse and Worse The doctor at urgent care thought she had some kind of virus. Her primary-care doctor gave it a name: hand, foot and mouth disease — a common viral illness seen mostly in young children. It usually lasted less than 10 days, so she would probably start feeling better soon, he told the patient. But she didn’t. Every day she felt worse. The pain in her joints was incapacitating. Walking was nearly impossible, and her wrists and hands were so sore she couldn’t type on her phone. When she didn’t get better, her doctor sent off blood tests to look for the coxsackievirus, the most common cause of hand, foot and mouth disease, as well as other possibilities. The tests indicated that she didn’t have any of the usual tick-borne infections. And it wasn’t rheumatoid arthritis or lupus. The coxsackievirus test would take a while, but the doctor assured her that it was the most likely diagnosis. ↓ A Diagnosis That Feels Wrong When the young woman read up on hand, foot and mouth, she just couldn’t believe that was what she had. It was supposed to last a little over a week; she was deep into the second week and still felt more miserable every day. Most kids with this virus had a low-grade fever, but hers was still high, even when taking ibuprofen and acetaminophen. Finally, most people with hand, foot and mouth had sores in their mouths and only mild joint pain. She didn’t have any sores in her mouth, and her joint pain was intense, despite the powerful painkillers her doctor prescribed. In the emergency room, the patient was given an anti-inflammatory medication called Toradol and prednisone for her joint pain. It helped a little, but she was still so uncomfortable that she couldn’t walk. The decision was made to admit her to the hospital to treat her pain. ↓ Clues on the Palms and Soles That evening, the patient was seen by Dr. Sonali Advani, an infectious-disease physician. She introduced herself to the patient and her mother, then sat down. “Tell me everything that happened,” she said. She listened as the woman described the pain and fever of the past few weeks. Her hands and feet were dotted with blisters — filled with pus or blood. At first, they itched, the young woman told her. But now they just hurt. What struck Advani about the rash was that it spread to the soles of her feet and the palms of her hands. Because the skin there is different than that found any other place on the body, only a very few kinds of rashes appear there. The rash that accompanied hand, foot and mouth disease was one, but not the only one. She told the women that she would be back in the morning and went to look at the patient’s chart. There were possibilities that hadn’t been investigated. She wrote her recommendations, including tests for other diseases. ↓ Animals in the Barn The next morning, Advani returned to see the patient. She had questions about the animals she was exposed to in the barn where the horses she rode were kept. The young woman thought for a moment. She saw the horses every day. There were chickens, but they weren’t in the barn. Oh, and there were two new kittens. That caught Advani’s attention. Had she been scratched or bitten by the kittens? No, they weren’t house cats, the young woman replied; they were barn cats, there to catch rats. Were there rats in the barn? Yes. Had she been bitten by one? No, she answered. And then she hesitated. A few days before she got sick, she had seen what she thought was a baby mouse in the middle of the road. She worried that it might get run over, so she picked it up and moved it. It gave her a little nibble, which barely broke the skin. She doused it with hydrogen peroxide, and the mark disappeared within a couple of days. ↓ The Role of the Rat Advani felt a burst of excitement. She looked at the mother, who had her computer open. Advani asked her to look up rat-bite fever. The Centers for Disease Control provided a list of the symptoms, which the mother read: fever, vomiting, headache, muscle pain, joint pain, rash — everything her daughter had been experiencing. Rat-bite fever is rare in the United States because we have limited exposure to rodents, who are the carriers of this infection. But the disease is seen in those who work with rats in a lab or pet shop or those who keep them as pets. In this country, the infection is usually caused by a bacterium called Streptobacillus moniliformis, which can be transmitted by rodents. Without treatment, nearly one in eight who get this infection will die. ↓ Unsure About the Diagnosis The medical team caring for the patient was skeptical. Rat-bite fever was so rare that most of them had never heard of it. Moreover, the test for the coxsackievirus had come back positive. It was much more likely that she had an unusually bad case of hand, foot and mouth disease. When the team went to see the patient later that day, they put on the required protective gear — gown, gloves and mask — to prevent transmission of the coxsackievirus from patient to doctor. The patient told them she was pretty sure she had rat-bite fever. She told them about her close encounter with the baby rat. She pulled up the C.D.C. web page with all her symptoms. She showed them the pictures of the matching rash. The medical team was persuaded — so much so that they took off their face masks. This was a disease that couldn’t be transmitted human to human. ↓ Explaining a Test One important question remained: If she had rat-bite fever, why would she test positive for coxsackievirus? There are more than 20 strains of coxsackievirus that can cause disease. It turned out she had antibodies to a strain that doesn’t cause hand, foot and mouth, the only coxsackie infection to cause the palm-and-sole rash. And because the test measures antibodies and not the bug itself, it can’t distinguish between current and past infections. She also tested positive for the rat-bite-fever bacterium. Before the result came back, she was started on the recommended six weeks of intravenous penicillin. She finished treatment this fall and is back to training and riding horses. How did this young doctor make a diagnosis that eluded so many others? Advani told me that she missed a question on a test she took to prepare for the infectious-diseases boards. That question involved a young woman with fever and a rash on her palms who was exposed to animals in a pet store. She had rat-bite fever. The number of infections that can cause this rash is small, Advani’s teacher told her. She should learn that list. So Advani did. And when she saw this young woman and heard about her exposure to rats, she immediately recalled that other young woman and rat-bite fever. |