amplified from DNA extracted from the patient's blood and the bacterial isolate were consistent with S. moniliformis.

The patient had been employed at a pet store. She was bitten on her right index finger by a rat in the store 2 days before symptom onset and 4 days before arriving at the ED. She self-treated the wound by using antiseptic ointment immediately after being bitten. In addition, she had regular contact with several pet rats, cats, a dog, and an iguana at her home; however, no bites from these animals were reported. None of the animals were tested for S. moniliformis.

Washington. In late November 2003, a previously healthy woman aged 19 years was pronounced dead on arrival at a hospital ED. No laboratory studies were performed in the ED. An acquaintance reported that the patient had experienced a 3-day history of fever, headache, myalgias, nausea, and profound weakness without cough, vomiting, diarrhea, or rash. Before her transport to the ED, she exhibited anxiety, confusion, and labored breathing. ED staff noted that she appeared jaundiced. The body was transported to the coroner's office, where an autopsy was performed.

Cultures of blood and tissue from autopsy were negative for pathogenic organisms. A toxicology screen was negative. Serologic assays for leptospirosis, Epstein-Barr virus, cytomegalovirus, and viral hepatitis were negative for recent infection. Histopathology revealed findings suggestive of a systemic infectious process that included disseminated intravascular coagulopathy and inflammatory cell infiltrates in the liver, heart, and lungs. UNEX was contacted for assistance, and project staff facilitated the submission of diagnostic specimens to CDC for further laboratory evaluation. Immunohistochemical assays performed at CDC for Leptospira spp., Bartonella quintana, spotted fever and typhus group rickettsiae, flaviviruses, hantaviruses, and influenza viruses were negative. Clusters of filamentous bacteria were identified in sections of the liver and kidney by using a silver stain. The 16S rRNA gene sequence amplified from DNA extracted from paraffin-embedded, formalin-fixed samples of liver and kidney was consistent with S. moniliformis.

The patient worked as a dog groomer and lived in an apartment with nine pet rats. One pet rat with respiratory symptoms had recently been prescribed oral doxycycline after having been evaluated at a veterinary clinic. Doxycycline was subsequently used to treat a second ill rat. None of the rats were tested for S. moniliformis. The patient had no known animal bites during the 2 weeks preceding her death.

Reported by: WJ Pollock, MD, R Cunningham, Baptist Hospital; J Lanza, MD, S Buck, MD, PA Williams, Escambia County Health Dept, Pensacola; JJ Hamilton, MPH, R Sanderson, MA, Bur of Epidemiology, Florida Dept of Health. D Selove, MD, T Harper, Thurston County Coroner's Office; DT Yu, MD, Thurston County Dept of Health, Olympia; M Leslie, DVM, J Hofmann, MD, Washington Dept of Health. S Reagan, MPH, M Fischer, MD, A Whitney, MS, C Sacchi, PhD, P Levett, PhD, M Daneshvar, PhD, L Helsel, R Morey, Div of Bacterial and Mycotic Diseases; S Zaki, MD, C Paddock, MD, W Shieh, MD, J Sumner, J Guarner, MD, Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases; D Gross, DVM, EIS Officer, CDC.

## Editorial Note:

Although rapidly fatal pediatric cases of RBF have been described previously (2,3), similar mortality among adults has not been reported. Mortality attributed to severe systemic complications (e.g., endocarditis, myocarditis, meningitis, pneumonia, or multiple organ failure) has been documented in certain adult patients (1,4). Both patients described in this report died within 12 hours of presentation, allowing little opportunity for assessment and treatment. These case reports demonstrate that infection with S. moniliformis can cause fulminant sepsis and death in previously healthy adults. As a result, prevention of severe disease might depend on