Ferri – Cat-Scratch Disease

Mar 25, 2020 admin Uncategorized 0

Cat-Scratch Disease

  • Glenn G. Fort, M.D., M.P.H.

 Basic Information

Definition

Cat-scratch disease (CSD) is an infectious disease consisting of gradually enlarging regional lymphadenopathy occurring after contact with a feline. Atypical presentations are characterized by a variety of neurologic manifestations as well as granulomatous involvement of the eye, liver, spleen, and bone. The disease is usually self-limiting, and recovery is complete; however, patients with atypical presentations, especially if immunocompromised, may suffer significant morbidity and mortality.

Synonyms

  1. Cat-scratch fever

  2. Benign inoculation lymphoreticulosis

  3. Nonbacterial regional lymphadenitis

ICD-10CM CODES
A28.1 Cat-scratch disease

Epidemiology & Demographics

Prevalence

Unknown

Incidence (In U.S.)

  1. •

    9 to 10 cases per 100,000 persons per year (22,000 cases per year)

  2. •

    Majority of reported cases occur in persons <21 yr

Peak Incidence

August through January

Physical Findings & Clinical Presentation

  1. •

    Classic, most common finding: regional lymphadenopathy occurring within 2 wk of a scratch or contact with felines; usually a new kitten in the household

  2. •

    Tender, swollen lymph nodes most commonly found in the head and neck (Fig. E1), followed by the axilla and the epitrochlear, inguinal, and femoral areas

  3. •

    Erythematous overlying skin, showing signs of suppuration from involved lymph nodes

  4. •

    On careful examination, evidence of cutaneous inoculation in the form of a nonpruritic, slightly tender pustule or papule

  5. •

    Fever in most patients

  6. •

    Malaise and headache in fewer than a third of patients

  7. •

    Atypical presentations in fewer than 15% of cases

    1. 1.

      Usually in association with lymphadenopathy and a low-grade or frank fever (>101 °F, >38.3 °C)

    2. 2.

      Include granulomatous involvement of the conjunctiva (Parinaud’s oculoglandular syndrome) and focal masses in the liver, spleen, and mesenteric nodes

  8. •

    CNS involvement: neuroretinitis, encephalopathy, encephalitis, transverse myelitis, seizure activity, and coma

  9. •

    Osteomyelitis in adults and children

  10. •

    Can be a cause of culture-negative endocarditis

  11. •

    In HIV-infected and other immunocompromised patients, Bartonella henselae is the cause of bacillary angiomatous and peliosis hepatis

FIG.E1 

Cat-scratch disease.
A, Ulcerated papule on the cheek caused by a cat scratch 2 weeks previously and enlargement of submandibular lymph nodes. B, Line of papules on the forearm of another patient at the site of a cat scratch. C, Marked enlargement of the ipsilateral axillary lymph nodes.
Courtesy B.J. Zitelli and H.W. Davis. From Zitelli BJ: Atlas of pediatric physical diagnosis, St Louis, 2002, Mosby.

Etiology

  1. •

    Major cause: Bartonella henselae, possibly Afipia felis and Bartonella clarridgeiae

  2. •

    Mode of transmission: predominantly by direct inoculation through the scratch, bite, or lick of a cat, especially a kitten

  3. •

    Also can be transmitted by flea bite (with the flea obtaining the bacteria from a bacteremic cat); rarely after exposure to a dog, probably secondary to flea bites

  4. •

    Approximately 2 wk after introduction of the bacteria into the host, regional lymphatic tissues displaying granulomatous infiltration associated with gradual hypertrophy

  5. •

    Possible dissemination to distant sites (e.g., liver, spleen, and bone), usually characterized by focal masses or discrete parenchymal lesions

     

Diagnosis

Differential Diagnosis

Granulomas of this syndrome must be differentiated from those associated with:

  1. •

    Tularemia

  2. •

    Tuberculosis or other mycobacterial infections

  3. •

    Brucellosis

  4. •

    Sarcoidosis

  5. •

    Sporotrichosis or other fungal diseases

  6. •

    Toxoplasmosis

  7. •

    Lymphogranuloma venereum

  8. •

    Benign and malignant tumors such as lymphoma

Workup

Diagnosis should be considered in patients who present with a predominant complaint of gradually enlarging regional (focal) lymphadenopathy, often with fever and a recent history of having contact with a cat. A primary ulcer at the site of the cat scratch may or may not be present at the time lymphadenopathy becomes manifest.

Laboratory Tests

  1. •

    Serologies: An IFA or EIA Bartonella serology (titer ≥1:64) is diagnostic. A PCR assay on tissue or blood is also available.

  2. •

    Lymph node biopsy: granulomatous inflammation consistent with CSD.

  3. •

    Warthin-Starry silver stain on biopsy can identify the bacteria.

  4. •

    Histopathologically, Warthin-Starry silver stain has been used to identify the bacillus.

  5. •

    Culture: B. henselae is a fastidious, slow-growing, gram-negative rod that requires specific culture techniques for tissue or blood.

  6. •

    Routine laboratory findings:

    1. 1.

      Mild leukocytosis or leukopenia

    2. 2.

      Infrequent eosinophilia

    3. 3.

      Elevated ESR or CRP

  7. •

    Abnormalities of bilirubin excretion and elevated hepatic transaminases are usually secondary to hepatic obstruction by granuloma, mass, or lymph node.

  8. •

    In patients with neurologic manifestations, lumbar puncture usually reveals normal CSF, although there may be a mild pleocytosis and modest elevation in protein.

  9. •

    CSD skin test is no longer used for clinical purposes.

Treatment

Nonpharmacologic Therapy

  1. •

    Warm compresses to the affected nodes

  2. •

    In cases of encephalitis or coma: supportive care

Acute General Rx

  1. •

    This disease is typically self-limited and generally resolves within 2 to 6 months. Most studies show no additional benefit from antibiotic therapy.

  2. •

    It would be prudent to treat severely ill patients, especially if immunocompromised, with antibiotic therapy, because these patients tend to suffer dissemination of infection and increased morbidity.

  3. •

    Bartonella is usually sensitive to a 5-day course of azithromycin (500 mg on day 1 followed by 250 mg for 4 days for weight >45.5 kg; 10 mg/kg on day 1 followed by 5 mg/kg for 4 days for weight <45.5 kg) or alternatively tetracycline, sulfa, and the quinolones can be used for 7 to 10 days.

  4. •

    Hepatosplenic disease, neuroretinitis, and endocarditis require longer courses of therapy.

  5. •

    Antipyretics and NSAIDs may also be used for lymphadenitis.

Disposition

Overall prognosis is good.

Referral

  1. •

    For diagnostic aspiration or excision in presence of regional lymphadenopathy, bone lesions, and mesenteric lymph nodes and organs

  2. •

    Infectious diseases specialist for organ involvement including endocarditis

  3. •

    To ophthalmologist for ocular granulomas

Pearls & Considerations

Comments

  1. •

    A presentation of this syndrome, especially in patients with HIV infection or impaired cellular immunity, may be fever of unknown origin.

  2. •

    Hepatic and splenic granulomas, coronary valve infections may offer few physical clues to diagnosis, emphasizing the need for a complete history.

  3. •

    CSD should be considered in the differential diagnosis of school-aged children presenting with status epilepticus.

  4. •

    Chronically immunocompromised patients considering the acquisition of a young feline should be made aware of the possible risk of infection.

  5. •

    No signs of illness may be apparent in bacteremic kittens.

Suggested Readings

  • S.A. Klotz, et al.: Cat-scratch disease. Am Fam Physician. 83 (2):152–155 2011 21243990

  • G. Psarros, et al.: Bartonella henselae infections in solid organ transplant patients: report of 5 cases and review of the literature. Medicine. 91:111–121 2012 22391473

  • K.M. Zangwill: Cat scratch disease and other Bartonella infections. Adv Exp Med Biol. 764:159–166 2013 23654065

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  1. Cat-Scratch Disease (Patient Information)

 

 

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