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Authors present a 7-year-old patient with cat-scratch disease during which he developed a "grand mal" convulsive status with severe intracranial hypertension requiring epidural monitoring and energetic treatment. Outcome was favourable, without neurologic sequelae. Review etiology and diagnostic criteria of this disease pointing out atypical forms of presentation is made.
The cases of 2 siblings with cat scratch disease are described who presented with symptoms suggestive of acute febrile gastroenteritis. The first patient, a 7.5-y-old girl, developed mesenteric lymphadenitis, hepatosplenic granulomas and osteolytic bone lesions only late in the course of her protracted illness. Her 3-y-old brother had a shorter, self-limited illness without complications. Cat scratch disease is often unrecognized and the full spectrum of its clinical manifestations remains to be investigated.
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Cat-scratch disease (CSD), a bacterial infection caused by Bartonella henselae, has emerged as a relatively common and occasionally serious zoonotic disease among children and adults. To illustrate the spectrum of clinical manifestations of CSD observed during a 1-year period, Texas Children's Hospital (TCH) in Houston reviewed the medical records of 32 children evaluated at TCH during September 2000-August 2001 whose antibody titers indicated recent Bartonella infection. This report summarizes the evaluations of these cases and highlights four manifestations of infection with this pathogen in children. The findings emphasize that although CSD is generally a mild, self-limited illness, the differential diagnosis often includes more serious conditions (e.g., lymphoma, carcinoma, mycobacterial or fungal infection, or neuroblastoma) that might result in protracted hospital stays and lengthy treatments before diagnosis. Timely assessment of CSD is important, particularly when invasive diagnostic measures are being considered.
BACKGROUND: Parinaud oculoglandular syndrome is uncommon. Most cases are caused by cat scratch disease (CSD), recently discovered to be associated with the pathogen Bartonella henselae. Before isolation of the micro-organism, diagnosis relied on the presence of characteristic clinical features. However, atypical cases could cause diagnostic problems. With the development of an indirect fluorescent antibody test and polymerase chain reaction (PCR) assay, oculoglandular CSD can be diagnosed readily. METHODS: The authors report a case of atypical Parinaud oculoglandular syndrome in a 51-year-old woman who presented with an inferior conjunctival forniceal mass extending into anterior orbital tissues. Blood and operative tissue specimens were obtained for routine screening and histopathologic analysis but more specifically for serologic analysis, culture, and PCR assay for B. henselae. Computed tomography was performed to delineate the mass. RESULTS: Cultures for B. henselae were negative. Initial serologic analysis demonstrated a low IgG response without detectable IgM, but 1 month later had undergone a fourfold rise in IgG, again without detectable IgM. Histopathologic analysis showed a nonspecific necrotizing granulomatous inflammation consistent with but not diagnostic of CSD. Polymerase chain reaction assay for B. henselae was strongly positive. Computed tomographic scan showed a preseptal and anterior orbital inflammatory process. CONCLUSIONS: Cat scratch disease due to B. henselae should be suspected in patients with atypical conjunctival inflammation associated with regional lymphadenopathy. PCR assay is extremely useful in establishing the diagnosis. The PCR assay offers the additional advantage of early diagnosis because the test is positive early in the disease. Antibiotic therapy remains controversial. In this case, surgical excision hastened resolution of the conjunctival inflammation. However, the lymphadenopathy responded poorly to antibiotics.
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OBJECTIVE: To determine the efficacy of azithromycin in the treatment of patients with typical cat-scratch disease. DESIGN: Prospective, randomized, double blind, placebo-controlled clinical trial. SETTING: Large military medical center and its referring clinics. PATIENTS: Active duty military members and their dependents with laboratory-confirmed, clinically typical cat-scratch disease. INTERVENTION: Study participants assigned by randomization to treatment with oral azithromycin or placebo for 5 days. OUTCOME MEASURES: Lymph node volume was calculated using three dimensional ultrasonography at entry and at weekly intervals. The ultrasonographer was blinded to the treatment groups. Endpoint evaluations were predetermined as time in days to 80% resolution of the initial total lymph node volume. RESULTS: Demographic and clinical data showed that the azithromycin and placebo treatment groups were comparable at entry although the placebo group tended to be older. Eighty percent decrease of initial lymph node volume was documented in 7 of 14 azithromycin-treated patients compared with 1 of 15 placebo-treated controls during the first 30 days of observation (P = 0.026). After 30 days there was no significant difference in rate or degree of resolution between the two groups. CONCLUSIONS: Treatment of patients with typical cat-scratch disease with oral azithromycin for five days affords significant clinical benefit as measured by total decrease in lymph node volume within the first month of treatment.
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A retrospective study of lymph node biopsy specimens from nine patients with the clinical findings and histologic features of cat scratch disease was undertaken to determine whether the recent report by Wear et al. that pleomorphic bacteria are present in the lymph nodes of cat scratch disease could be confirmed. In seven of our nine cases, pleomorphic bacteria were demonstrated with the Warthin-Starry (WS) silver stain. These were gram-negative with the Brown-Hopps tissue Gram stain and were almost at the limit of microscopic resolution. Lymph node specimens from 13 additional patients with nonspecific lymphadenitis who had neither clinical nor histologic findings of cat scratch disease were studied similarly; in none of these were bacteria demonstrated with the WS silver stain. After examining the distribution of the organisms and the related morphologic features in cat scratch disease, we conclude that demonstration of pleomorphic, gram-negative, WS-positive bacteria in the appropriate clinical and histologic setting can firmly establish the diagnosis of cat scratch disease.
The search for the infectious agents responsible for cat-scratch disease, bacillary angiomatosis, and related syndromes has a long and often circuitous history. Recognition of the etiologic agents and a new understanding of the fundamental features of the epidemiology and natural history of modern day Bartonella (formerly Rochalimaea)-associated diseases culminate a multipartite story that combines clinical medicine, traditional microbiology, and novel technological approaches to solve a long-standing enigma.