Cat scratch disease, bacillary angiomatosis, and other infections due to Rochalimaea

Cat scratch disease and acquired immunodeficiency disease: diagnosis by transmission electron microscopy

A 33-year-old, homosexual, cat-owning, African-American man with human immunodeficiency virus infection by positive serologic tests and acquired immunodeficiency syndrome by CD4 lymphocyte count alone (39 cells/mL) presented with a one-year history of intermittent fever, weight loss, and generalized lymphadenopathy. A malignant lymphoma was suspected clinically. Light microscopic study of a left inguinal lymph node biopsy specimen revealed effacement of the lymph node architecture by a diffuse infiltrate of large, atypical reticulum cells, loose, patchy granulomatous inflammation, diffuse hyaline fibrosis, diffusely proliferated blood vessels, and multifocal degeneration and necrosis. Lymph follicles were absent and lymphocytes were moderately depleted. Microorganisms were not seen in lymph node sections stained with special histochemical stains (including the Warthin-Starry stain). These light microscopic changes were considered suggestive of a malignant lymphoma, especially Hodgkin's disease. The diagnosis of cat scratch disease (CSD) became apparent only after transmission electron microscopic study of the lymph node revealed clusters of small, pleomorphic bacteria in degenerated collagenous tissue and in blood vessel walls. This case illustrates the value of transmission electron microscopy in making the diagnosis of CSD, especially when light microscopic changes are superimposed on those of late human immunodeficiency virus infection of the lymph node.

Benign lymphoproliferative disorders

OBJECTIVE

To provide a review of three benign lymphoproliferative disorders commonly encountered in nursing practice: (1) infectious mononucleosis, (2) cat scratch disease, and (3) sarcoidosis.

DATA SOURCES

Research studies, review articles, and book chapters pertaining to benign lymphoproliferative disorders.

CONCLUSIONS

Benign lymphoproliferative disorders may be associated with infections, autoimmune disorders, hypersensitivity reactions, and unknown causes. Most of these disorders are self-limiting; however, some are associated with significant morbidity and mortality.

IMPLICATIONS FOR NURSING PRACTICE

Benign as well as malignant lymphoproliferative disorders will be encountered with increasing frequency by nurses in ambulatory settings. Nurses need to have a basic knowledge of these disorders that present a diagnostic and management challenge.

Bartonella (Rochalimaea) infections: beyond cat scratch

Five species of Bartonella have been found to infect humans, henselae, quintana, elizabethae, bacilliformis, and vinsonii. The most common of these in North America are Bartonella quintana and Bartonella henselae, the agents of trench fever, bacillary angiomatosis, and parenchymal peliosis, and in the case of B. henselae cat-scratch disease. B. bacilliformis is endemic in Peru and Ecuador, where it causes oroya fever or Carrion's disease. New methods of diagnosing Bartonella infections have resulted in increased recognition of the many manifestations of these infections. Early recognition is crucial, as these are potentially fatal opportunistic infections that usually respond rapidly to appropriate antimicrobial therapy.

Evaluation of serological response to Bartonella henselae, Bartonella quintana and Afipia felis antigens in 64 patients with suspected cat-scratch disease

The serological response to Bartonella henselae, B. quintana, and Afipia felis was assessed by an indirect fluorescence antibody test (IFAT) in 64 patients with suspected cat-scratch disease (CSD) recruited from the Bordeaux area in France. Blood samples were collected from 57 patients with chronic lymphadenopathy who underwent lymph-node biopsy with suggestive histopathologic features of CSD, and from an additional 7 patients with suspected CSD who underwent surgical incision and drainage because of lymph-node tenderness. Of the patients, 31 were male and 33 female, with a median age of 27 years (range 2-89). 69.8% reported cat and/or dog contact. Of the 26/64 (40.6%) patients, serum samples were positive at a titer of 1:100 or more for immunoglobulin G (IgG) antibodies (17 only to B. henselae, 1 only to B. quintana, 3 only to Afipia felis, and 5 to both B. henselae and B. quintana). IgM or IgA antibodies were also detected in 10 patients with IgG antibodies to B. henselae. 11 (17.2%) of the 64 patient serum samples were positive at a low titer of 1:50. These data suggested that serological response assessed by standard IFAT is not enough to confirm a CSD diagnosis.

Serous retinal detachment of the macula associated with cat scratch disease

PURPOSE

We studied an unusual ocular manifestation of cat scratch disease.

METHODS

We examined a patient who had a serous retinal detachment of the macula with vision loss out of proportion to her retinal findings.

RESULTS

The patient was found to have cat scratch disease by antibody titers.

CONCLUSION

Cat scratch disease should be considered in patients with a serous neurosensory retinal detachment of the macula and a history of cat exposure or systemic signs or symptoms consistent with the disease.

An unusual presentation of cat scratch encephalitis

Cat scratch disease is an infectious illness that has been recognized since the 1880s; however, our understanding and knowledge of it is still evolving (1). It was not until 1991 that the etiologic species, Rochalimaea, was finally confirmed (2,3). Only recently have the breadth of its clinical spectrum and the population at risk been appreciated. We now realize that signs and symptoms that had been considered cardinal for diagnosis may be absent. Cat scratch disease was known to afflict primarily children and adolescent; however, the incidence of CSD is increasing in immunocompromised groups, such as AIDS and transplant patients (3,4). The recent discovery of the infectious agent and improved understanding of the disease process have led to new approaches in diagnosis and treatment. We present a report of a patient with cat scratch disease who presented with seizure and altered mental status secondary to encephalitis.

Cutaneous cryptococcosis and Kaposi's sarcoma occurring in the same lesions in a patient with the acquired immunodeficiency syndrome

A 34-year-old woman presented with a history of fever, malaise and skin lesions. A diagnosis of Kaposi's sarcoma and acquired immunodeficiency syndrome (AIDS) was established, and in addition, the skin lesion which was biopsied also demonstrated cryptococcal infection. Disseminated cryptococcosis was later confirmed and the disease ran a florid course. The co-existence of different diseases within the same lesion is a feature of human immunodeficiency virus (HIV) infection, this being the third documented case of simultaneous Kaposi's sarcoma and cutaneous cryptococcosis occurring at the same site in a patient with AIDS. The nature of this co-existence is discussed with reference to the pathogenesis of Kaposi's sarcoma.

Serology to Bartonella (Rochalimaea) henselae may replace traditional diagnostic criteria for cat-scratch disease

Bartonella (Rochalimaea) henselae has been identified as causative agent of cat-scratch disease (CSD). Employing an indirect fluorescence antibody test we found that 20 (100%) out of 20 children with suspected CSD had serum titres to B. henselae of > or = 512. By contrast, in all but one of the controls (n = 332) including subjects exposed to the same cats, patients with diseases other than CSD, and blood donors the antibody titres were < or = 256 (P < 0.001). However, significant regional differences in seroprevalence were noted. CONCLUSION. Serology to B. henselae may supplant traditional criteria for the diagnosis of CSD and prevent patients from unnecessary surgery.

Characterization of a 17-kilodalton antigen of Bartonella henselae reactive with sera from patients with cat scratch disease

A library of Bartonella (Rochalimaea) henselae DNA was constructed in the cloning vector lambda ZAPII and screened for expression of antigenic proteins by using a pool of sera from patients who had been diagnosed with cat scratch disease (CSD) and had antibodies to Bartonella spp., as determined by indirect fluorescent-antibody (IFA) assay. Ten immunoreactive phages were subcloned as recombinant plasmids by in vivo excision. All 10 recombinants expressed a protein of approximately 17 kDa when they were examined by immunoblot with the pool of human sera. Restriction endonuclease digestion of each recombinant plasmid indicated seven profiles, suggesting that cloning bias was not the reason for repeated isolation of clones expressing the 17-kDa antigen. The gene coding for the 17-kDa antigen was sequenced and shown to code for an open reading frame of 148 amino acids with a predicted molecular mass of 16,893 Da. The amino terminus of the deduced amino acid sequence was hydrophobic in nature and similar in size and composition to signal peptides found in gram-negative bacteria. The remainder of the deduced amino acid sequence was more hydrophilic and may represent surface-exposed epitopes. Further subcloning of the 17-kDa antigen as a biotinylated fusion protein in the expression vector PinPoint Xa-2 resulted in a 30-kDa protein that was highly reactive on immunoblots with individual serum samples from patients with CSD. The agreement between reactivity with the 30-kDa fusion protein on immunoblot analysis and the results obtained by IFA assay was 92% for IFA-positive sera and 88% for IFA-negative sera. The recombinant-expressed 17-kDa protein should be of value as an antigen for serologic diagnosis of CSD and Bartonella infections and warrants further study in attempts to develop a subunit vaccine to prevent long-term Bartonella infection in cats and the potential for further spread of these organisms to humans.

In vitro evaluation of the role of humoral immunity against Bartonella henselae

The contribution of humoral immunity against Bartonella henselae was evaluated by examining the in vitro bactericidal activity of sera and the ability of these microorganisms to activate complement and stimulate phagocytosis and an oxidative burst in polymorphonuclear leukocytes. The organism was killed by complement-mediated cytolysis. Complement activation preferentially proceeded by the alternative pathway. The presence of specific antibodies did not increase the serum bactericidal activity or complement activation. However, phagocytosis and the subsequent production of oxygen radicals, evaluated by flow cytometry, were significantly enhanced in the presence of bacteria previously opsonized with immune sera.

Seroepidemiological survey of Bartonella (Rochalimaea) henselae in domestic cats in Japan

A total of 199 domestic cat serum samples from 3 geographical areas (northeastern, central and southwestern) of Japan collected between 1992 and 1994 were examined for serum antibody against Bartonella henselae using an immunofluorescent assay. The antibody prevalence was 15.1% (30/199). A significant difference in the prevalence of B. henselae antibody was observed between the northeastern area (6.3%:3/48) and the central area (22.0:13/59) in Japan. There was no significant difference between the average age of seropositive cats (4.39 +/- 3.26 years) and that of seronegative cats (4.03 +/- 3.84 years), and also between the frequency of seropositive male cats (16.5%:15/91) and that of seropositive female cats (11.8:9/76). This is the first report of B. henselae antibodies in cats in Japan

Unraveling mysteries associated with cat-scratch disease, bacillary angiomatosis, and related syndromes

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.