Recent Advances in Diagnosis and Treatment of Cat Scratch Disease

Cat scratch disease unveils hidden breast carcinoma: A diagnostic twist

Cat scratch disease is a rare condition that can present with different clinical manifestations, including axillary lymphadenopathy. Here, we report the case of a 45-year-old female who presented with axillary lymphadenopathy attributable to a process of differential diagnosis to cat scratch disease. During the thorough investigation of her condition, a routine mammogram was performed, due to the unilateral axillary lymphadenopathy, revealing the presence of previously undiagnosed breast carcinoma in situ; in fact, a DCIS (invasive ductal carcinoma with spread to the ipsilateral axillary nodes) was incidentally found. This case highlights the importance of comprehensive differential diagnosis and a multidisciplinary approach in managing patients with atypical presentations of common diseases, given that other alarming but unrelated findings are visible.

Unusual presentation of cat scratch disease: case report

Cat scratch disease (CSD) is an infection caused by Bartonella henselae, presents with non-specific symptoms like lymphadenopathy, fever, and fatigue. It can progress to disseminated disease, leading to complications such as liver and splenic micro abscesses, osteomyelitis, encephalitis, and uveitis. Diagnosis is challenging due to varied presentations and limited tests. Treatment involves supportive care, with severe cases requiring antimicrobial therapy. In this report, we present a case of Cat scratch disease characterized by an atypical clinical manifestation, hepatosplenic and paravertebral involvement.

Cat-scratch disease: a rare cause of osteomyelitis

Cat-scratch disease is a zoonosis caused by Bartonella henselae, characterised by regional lymphadenopathy. Rarer presentations, such as osteomyelitis, can occur.We present an adolescent girl with severe right lumbar pain and fever, without animal contacts or recent travels. On examination, pain on flexion of torso, movement limitation and marked lordosis were noted, but there were no inflammatory signs, palpable masses or lymph nodes. Serological investigations revealed elevated inflammatory markers. Imaging revealed a paravertebral abscess with bone erosion. Several microbiological agents were ruled out. After a second CT-guided biopsy, PCR for Bartonella spp was positive. At this point, the family recalled having a young cat some time before. Cat-scratch disease was diagnosed, and complete recovery achieved after treatment with doxycycline and rifampicin.Cat-scratch disease is a challenging diagnosis in the absence of typical features. However, B. henselae must be investigated if common pathogens are ruled out and response to therapy is poor.

A Retrospective Analysis of Systemic Bartonella henselae Infection in Children

Systemic Bartonella henselae infection, also known as cat-scratch disease (CSD), presents a diagnostic challenge due to the variability of clinical manifestations and the potential for serological cross-reactivity with other organisms. This study aimed to retrospectively analyze the epidemiological, clinical, laboratory, and imaging characteristics of pediatric patients diagnosed with systemic B. henselae infection, to improve understanding and facilitate timely diagnosis and treatment. We conducted a 10-year retrospective study at the "Louis Turcanu" Children's Emergency Hospital and private clinics in Timisoara, Romania, reviewing records for confirmed cases of B. henselae infection from January 2014 to January 2024. The study adhered to the Declaration of Helsinki and received approval from the Institutional Review Board. Diagnostic criteria included contact with animals, prolonged fever, hematological and/or hepatosplenic manifestations, and positive serological tests for B. henselae. Nineteen pediatric patients were identified with a median age of 8.1 years. The majority were exposed to felines (94.7%), reflecting the disease's epidemiological profile. Clinical findings highlighted fever (47.4%), lymphadenopathy (78.9%), and less frequently, abdominal pain and headache (both 10.5%). Laboratory analyses revealed a mean hemoglobin of 12.6 mg/dL, WBC count of 13.1 × 103 cells/microliter, and platelet count of 340.6 × 103 per microliter. Significant findings included elevation in ESR and CRP in 47.4% and 21.1% of patients, respectively, and high seropositivity rates for B. henselae IgM (63.2%) and IgG (94.7%). Imaging studies demonstrated widespread lymphadenopathy and occasional splenomegaly and hepatic microabscesses. All patients received antibiotic therapy, with azithromycin being the most commonly used (94.7%). Co-infections with Epstein-Barr Virus, Cytomegalovirus, and Toxoplasma gondii were documented, indicating the complex infectious status of the patients. Systemic B. henselae infection in children predominantly manifests with fever and lymphadenopathy, with a significant history of exposure to felines. Laboratory and imaging findings support the diagnosis, which is further complicated by potential co-infections. Effective antibiotic therapy, primarily with azithromycin, underscores the need for comprehensive diagnostic and treatment strategies. This study emphasizes the importance of considering systemic B. henselae infection in pediatric patients with prolonged fever and contact with cats, to ensure timely and appropriate treatment.

Cat Scratch Disease of the Breast/Axilla: Recognition of a Rare Disease and Approaches for Differential Diagnosis

Cat scratch disease rarely presents as a breast or axillary mass mimicking carcinoma both clinically and radiologically. Diagnosing breast/axillary cat scratch disease is challenging due to its rarity and nonspecific findings. Here, we reported 2 patients with breast cat scratch disease and reviewed 14 patients with cat scratch disease involving breast/axilla from the past 30 years. It mainly affects women (median age: 48), consistently presenting as axillary lymphadenopathy, and demonstrates ipsilateral breast mass in half of patients (50%, 8/16). The breast mass was most commonly located in the upper outer quadrant (88%, 7/8), indicating the possibility of disease extension from axillary adenopathy. Around half of patients (56%, 9/16) reported cat exposure. Histologically, most patients (93%, 14/15) presented as necrotizing granulomas, with characteristic stellate-shaped necrosis in 5 patients. Although pathologic differential diagnoses between cat scratch disease and cancer are straightforward, distinguishing cat scratch disease from other granulomatous mastitis poses diagnostic challenges. Silver stains should be included in the diagnostic workup panel when highly suspecting cat scratch disease clinically. However, they were only able to highlight the causative microorganism in 54% (7/18) patients, and the gram stain was negative in all 12 tested patients. In contrast, polymerase chain reaction (PCR) for the causative microorganism was consistently positive in all 3 tested patients, while serologic test confirmed diagnosis in 85% (11/13) patients; 1 patient with negative serology showed a positive PCR result. Therefore, upfront PCR tests with or without serologic study should be considered to confirm the diagnosis of cat scratch disease in a timely manner.

A case report of diagnosis of cat-scratch disease using metagenomic next-generation sequencing

Cat-scratch disease (CSD) is an anthropozoonotic infection caused by Bartonella henselae, and it is one of the most common causes of lymph node infections in children and adolescents. B. henselae, belonging to the genus Bartonella, is a common human pathogen of human beings. CSD commonly develops as a result of cat scratches and bites or when injured skin comes into contact with cat saliva. The manifestation of CSD clinically differs for each patient based on their immune system. Individuals who have healthy immune systems generally manifest minimal clinical symptoms and do not necessitate any form of treatment. However, patients who have hypo-immunity require prompt medical attention due to the potential manifestation of severe symptoms that affect multiple systems of the body. Long latency and atypical clinical manifestations are characteristics of CSD. Bartonella isolation and identification are challenging procedures that require specialized equipment. There is no gold standard method for CSD diagnosis, and misdiagnosis and missed diagnosis rates are typically high. We present the case of a middle-aged male patient who developed fever, chills, anal distension, dizziness, and muscle pain for 10 days. The patient had a documented history of cat bites 1 month prior to the onset of symptoms. Following admission, he underwent an examination to determine superficial lymphadenopathy and hypoimmunity. Additionally, he had a fever during the disease. As the patient refused a needle biopsy of lymph nodes, metagenomic next-generation sequencing (mNGS) was employed and B. henselae was detected in the peripheral blood. The patient was diagnosed with CSD and treated with a combination of azithromycin and doxycycline. The fever symptoms were alleviated, and the patient was ultimately discharged. As a result of this case, we suggest that mNGS be used as a crucial supplementary diagnostic tool for individuals with compromised immune systems who may have CSD, especially when conventional diagnostic methods are inconclusive.

Atypical Cat Scratch Disease With Splenic Lesion Mimicking Kawasaki Disease in a Healthy 5-Year-old Girl

BACKGROUND

Atypical cat scratch disease (CSD) and Kawasaki disease (KD) are differential diagnoses of pediatric febrile illnesses. Diagnosing atypical CSD can be challenging because of its wide range of symptoms. However, its similarity to KD has rarely been addressed.

METHODS

We present the case of a 5-year-old girl with atypical CSD and splenic lesions who fulfilled the diagnostic criteria for KD. We also conducted a literature review of previous cases in which CSD was suspected alongside KD and detailed the diagnosis and treatment processes.

RESULTS

A previously healthy 5-year-old girl with prolonged fever and symptoms resembling those of KD was admitted to our hospital. There was no evidence of an abnormal coronary artery, and her condition did not improve after the initial treatment for KD and bacterial infection. A history of contact with cats and multiple granulomatous lesions in the spleen on abdominal ultrasonography led to a clinical diagnosis of atypical CSD. Trimethoprim-sulfamethoxazole treatment resulted in symptom resolution. Elevated serum Bartonella henselae IgG and IgM antibodies confirmed the diagnosis of CSD. In this case, we avoided second-line treatment for KD with an alternative CSD diagnosis. Additionally, we identified 4 documented cases of CSD presenting with KD-like features in the literature. Intravenous immunoglobulin was ineffective in all cases, including the present case.

CONCLUSIONS

In cases of atypical CSD where KD is suspected, actively seeking organ-specific symptoms may facilitate an early clinical diagnosis of CSD. Adopting this approach could yield multiple advantages, including reduced invasiveness for the patient and decreased healthcare-related expenditures.

Limitations of Serological Diagnosis of Typical Cat Scratch Disease and Recommendations for the Diagnostic Procedure

Introduction

Cat scratch disease (CSD) is the most common cause of bacterial infectious lymphadenopathy, especially in children, but its diagnosis still remains challenging. Serological assays are widely applied due to their simplicity and the non-invasive sampling. However, these techniques present several limitations, including not well-defined antigen preparation, assay conditions and cutoff titers, severe cross-reactions with other species and organisms, and the notably ranging seroprevalence in the normal population. The objective of this study is to review the literature in order to determine the best diagnostic procedure for the diagnosis of CSD.

Methods

Databases including PubMed, Medline, Google Scholar, and Google were searched to determine the best diagnostic procedure for the diagnosis of CSD. A total of 437 papers were identified and screened, and after exclusion of papers that did not fulfill the including criteria, 63 papers were used.

Results

It was revealed that sensitivities of serological assays varied from 10% to 100%. Indeed, more than half of the studies reported a sensitivity lower than 70%, while 71% of them had a sensitivity lower than 80%. Moreover, specificities of serological assays ranged from 15% to 100%, with 25 assays reporting a specificity lower than 90%.

Conclusion

It is considered that molecular assays should be the gold standard technique for CSD confirmation, and physicians are reinforced to proceed to lymph node biopsy in suspicious CSD cases.

Abdominal Lymphadenopathy: Hypothesize Cat-Scratch Disease and Avoid Abdominal Excisional Biopsy

The finding of lymphadenopathy is usually the consequence of a benign infection, although a neoplastic origin must always be excluded. Through a careful anamnesis, physical examination, and serological tests several differential diagnoses are frequently possible. Nevertheless, sometimes an excisional biopsy of superficial lymph nodes is required, which is the best means to reach a definitive diagnosis. More concerns arise when lymphadenopathy is only abdominal/retroperitoneal: percutaneous biopsy is often inconclusive and the excisional node biopsy becomes a surgical procedure, certainly indicated in case of malignancy but avoidable in case of inflammatory diseases. We present the case of a 30-year-old man with a deep iliac lymphadenopathy who was evaluated at the Hematological Unit of Sapienza University of Rome. The enlargement of an iliac lymph node is quite unusual for an infectious disease. Although symptoms such as pain, fever, and chills suggested it was the case, cat-scratch disease was not hypothesized. Radiological investigations did not exclude a malignant disease and a laparoscopic excisional biopsy was scheduled, but the slight improvement of his spontaneous symptoms suggested a careful follow-up. Given the lack of disappearance of lymphadenopathy, the lack of diagnosis, and an ipsilateral superficial (inguinal) lymph node with similar ultrasonographic and radiological features, the patient underwent biopsy, which disclosed a diagnosis of cat-scratch disease, avoiding more invasive surgical procedures.

Metagenomic next-generation sequencing may assist diagnosis of cat-scratch disease

Bartonella henselae, the pathogen that causes cat-scratch disease (CSD), is relatively rare in the clinic. CSD usually causes mild clinical manifestations, which self-heal in a matter of weeks. However, in immunocompromised patients, CSD may cause systemic disorders that can lead to critical illness. Due to the diversity of symptom signs and the lack of a golden standard for diagnosis, identifying atypical CSD in a timely manner presents a challenge. Metagenomic next-generation sequencing (mNGS), is a promising technology that has been widely used in the detection of pathogens in clinical infectious diseases in recent years. mNGS can detect multiple pathogens quickly and accurately from any given source. Here, we present a case of atypical CSD, which was diagnosed using mNGS. The patient manifested a fever of unknown infectious origin, and routine antibiotic treatment was ineffective. mNGS was employed to test the patient’s peripheral blood, which led to the detection of B. henselae. This was rarely seen in previous CSD reports. We surmised that the patient presented with atypical CSD and thus a targeted therapy was recommended. Crucially, the patient recovered rapidly. Based on this case study findings, we recommend that CSD should be included in the differential diagnosis for fever of unknown origin and that mNGS may be helpful in the diagnosis of CSD.

Hepatosplenic Cat Scratch Disease and Prolonged Fever: When To Add Corticosteroids?

The indications for use of corticosteroids for persistent fever in cat scratch disease are controversial. We report the case of a 5-year-old boy diagnosed with systemic cat scratch disease, who presented with fever for 28 days and focal hepatosplenic lesions. He did not show improvement despite antibiotic treatment for 4 weeks, however, he became afebrile 24 hours after the administration of corticosteroids.

CAT-SCRATCH DISEASE: 9 YEARS OF EXPERIENCE AT A PEDIATRIC CENTER

Background

A more complete understanding of the epidemiology, risk factors, and clinical features of cat scratch disease (CSD) in children could help guide patient care.

Methods

We conducted a retrospective analysis of children presenting to a tertiary pediatric hospital system in Atlanta, Georgia between January 1, 2010, and December 31, 2018 who had serology, PCR and/or cytopathological results consistent with a Bartonella henselae infection. We also retrospectively reviewed veterinary diagnostic results performed at the University of Georgia (UGA) from 2018-2020 to ascertain the burden of bartonellosis in companion animals within the state.

Results

We identified 304 children with CSD over 9 years with the largest proportion of diagnoses made during August (41/304, 13.5%) and September (47/304, 15.5%). The median age of child cases was 8.1 years (interquartile range (IQR) 5.4-12.1]; 156 (51.3%) were female; 242/262 (92.4%) reported feline exposure, while 55/250 (22%) reported canine exposure of those with exposure histories documented in the medical record. Although lymphadenopathy was present on physical examination in the majority of cases (78.8%), atypical presentations lacking lymphadenopathy were also common (63/304, 20.7%). Among children with radiographic imaging, 20/55 (36.4%) had splenomegaly and 21/55 (38.1%) had splenic and/or hepatic microabscesses. Among veterinary data, Bartonella seroprevalence was 12/146 (8.2%), all among canines, with a geographic distribution that spanned the state of Georgia.

Conclusion

Distinguishing clinical features of CSD included subacute regional lymphadenopathy in school-aged children in the late summer, almost all of whom had cat exposure. Atypical clinical manifestations of CSD were also commonly identified.

Case Report: Treatment of Severe Neuroretinitis and other Sequelae Associated with Cat Scratch Disease

SIGNIFICANCE

Severe vision loss from Bartonella neuroretinitis can best be treated to improve visual outcomes with a combination of systemic corticosteroids and antibiotics. Topical ketorolac 0.5% and difluprednate 0.05% are presented as a new adjunct therapy to potentially improve visual outcomes.

PURPOSE

This case illustrates severe posterior pole complications that can occur with cat scratch disease disseminated to the eye. Combination therapy with antibiotics and corticosteroids results in better visual outcomes. Topical treatment might further enhance visual outcome by preventing inflammatory damage without significant immunosuppression.

CASE REPORT

A 17-year-old male presented with right eye vision loss. He had been hospitalized two weeks prior for optic neuritis and treated with intravenous methylprednisolone. After 3 days vision had improved from 20/200 to 20/40. After positive serology for Bartonella henselae was obtained, he was released and treated with oral rifampin, doxycycline and prednisone. Sixteen days later he regressed to 20/200 and many more ophthalmic complications were observed. After discontinuation of rifampin, oral prednisone was continued for an additional two weeks and doxycycline was continued for approximately 3 weeks. Topical drops ketorolac 0.5% BID and difluprednate 0.05% QID were used for over 6 weeks before tapering after vision returned to normal.

CONCLUSIONS

Bartonella neuroretinitis associated with preretinal hemorrhage, vitritis and subretinal hemorrhage can be successfully treated with a combination of systemic medications and topical drops. Monotherapy with doxycycline is effective and well tolerated. Rifampin can cause rapid metabolization and reduction in plasma levels of both prednisone and doxycycline and should be avoided with combined therapy. Oral prednisone and topical difluprednate are recommended to quell initial inflammation during the first few weeks. The anti-inflammatory effects of doxycycline and topical ketorolac used for longer duration may be beneficial in preventing tissue damage without systemic immunosuppression and result in better visual outcomes.

Cat Scratch Disease as a Mimicker of Malignancy

Cat scratch disease (CSD) infrequently mimics malignancy. We reviewed 11 such cases at MD Anderson Cancer Center and an additional 36 reported from the literature. Breast cancer, sarcoma, and lymphoma were the most commonly suspected malignancies. Most patients were young, female, had prior cat exposure, and had no systemic symptoms. Regional lymphadenopathy was the most common finding.

Management of Infectious Lymphadenitis in Children

Lymphadenopathy is an irregularity in the size and texture of the lymph nodes, which is quite common in childhood. When the enlargement of lymph nodes is caused by inflammatory and infectious processes, it is called lymphadenitis. The main objective of this manuscript is to summarize the common infectious etiologies and presentations of lymphadenitis in children providing a management guide for clinical practice. PubMed was used to search for all of the studies published up to April 2021 using keywords such as "lymphadenitis" and "children". Literature analysis showed that the differential diagnosis for lymphadenitis in pediatrics is broad. Although lymph node enlargement in children is usually benign and self-limited, it is important to exclude malignant etiology. In most cases, history and physical examination allow to identify the correct diagnosis and start a proper treatment with a prompt resolution of the lymphadenopathy. However, particularly in the case of persistent lymphadenitis, determining the cause of lymph node enlargement may be difficult, and the exact etiology may not be identified despite extensive investigations. Further studies should develop and validate an algorithm to assist pediatricians in the diagnosis and timely treatment of lymphadenitis, suggesting situations in which a watchful waiting may be considered a safe approach, those in which empiric antibiotic therapy should be administered, and those requiring a timely diagnostic work-up.

[Bone involvement in cat scratch disease]

INTRODUCTION

Cat scratch disease caused by Bartonella henselae with bone involvement is a rare presentation.

CASE REPORT

We report a case of disseminated bartonellosis with multifocal osteomyelitis and multiple visceral involvement in an immunocompetent adult. Diagnostic confirmation was obtained by PCR on lymphadenopathy. In addition to our observation, 31 cases of bartonellosis with bone involvement were reported in the literature. Diagnosis is based on a combination of history, serology and PCR performed on tissue. The antibiotic treatment allows recovery in all cases.

CONCLUSION

Cat scratch disease in its systemic form with bone involvement is a rare and difficult diagnosis for the clinician and an invasive approach is often required to obtain the diagnosis.

Reactive Lymphadenopathies

Lymphadenitis in the pediatric population frequently is benign and self-limited, often caused by infections. In children with refractory symptoms, lymph node biopsy may be indicated to rule out malignancy or obtain material for culture. Acute bacterial infections typically show a suppurative pattern of necrosis with abscess formation. Viral infections are associated with nonspecific follicular and/or paracortical hyperplasia. Granulomatous inflammation is associated with bacterial, mycobacterial, and fungal infections. Toxoplasma lymphadenitis displays follicular hyperplasia, monocytoid B-cell hyperplasia, and clusters of epithelioid histiocytes. Autoimmune and noninfectious inflammatory disorders are included in differential diagnosis of lymphadenitis. Infectious mononucleosis and Kikuchi-Fujimoto lymphadenitis may mimic Hodgkin and non-Hodgkin lymphomas.

Bartonellosis in transplant recipients: A retrospective single center experience

BACKGROUND

Bartonellosis is a rare but challenging condition to diagnose with a spectrum of clinical presentations in the immunocompromised host.

AIM

To further characterize the presentation of Bartonella henselae (B. henselae) infections in solid organ and hematopoietic stem cell transplant recipients.

METHODS

We conducted a single-center retrospective study of all B. henselae testing for 5012 transplant recipients receiving care at a single institution between 2011 and 2018.

RESULTS

We identified 38 patients who underwent testing for B. henselae, and three of 38 were found to have bartonellosis. Two of the patients were renal transplant recipients who presented with visceral bartonellosis and symptoms concerning for post-transplant lymphoproliferative disorder. One autologous stem cell transplant recipient presented with cat scratch disease. We detail the clinical courses of these three cases and review the literature concerning the clinical presentations, differential diagnosis, and limitations of diagnostic tests for B. henselae infections in transplant recipients.

CONCLUSION

Although the incidence of B. henselae infection in transplant recipients is unknown, it merits inclusion in the differential diagnosis for fever of unknown origin in this population.

Hepatosplenic Cat Scratch Disease: Description of Two Cases Undergoing Contrast-Enhanced Ultrasound for Diagnosis and Follow-Up and Systematic Literature Review

Cat scratch disease (CSD) is a disease usually characterized by self-limited lymphadenopathy of the young man. Rarely CSD, however, can manifest itself as an unusual hepatosplenic form (HS-CSD) in immunocompetent patients. HS-CSD diagnosis is generally based on clinical features, imaging, and serologies, but sensitivity of serologies is very variable, like that of other diagnostic methods, as Warthin-Starry silver stain and isthology. Also there are no specific markers for the follow-up. The use of the CEUS (abdominal contrast-enhanced ultrasound) in HS-CSD is not previously described in literature examined, but we think that CEUS can be of help to diagnosis and follow-up of these patients, even after an initial CT scan, because it is a sensitive method, as seen in other diseases associated with granulomas, such as sarcoidosis. We describe 2 new cases of HS-CSD, and we performed a systematic review of the clinical cases reported in the past 10 years in the literature associated to an analysis of clinical, diagnostic, and therapeutic aspects of the disease.

Atypical bartonellosis in children: What do we know?

AIM

To characterise Bartonella infections in a paediatric population requiring hospital admission and review its treatment.

METHODS

Longitudinal observational retrospective data analysis of children and adolescents admitted with Bartonella infection at a paediatric tertiary hospital from 2010 to 2019.

RESULTS

We identified 16 cases of bartonellosis, with a mean age of 8.0 ± 4.5 years old, no sex predominance and 14 had contact with cats. Most of the cases occurred in fall and winter. Clinical presentations included osteomyelitis/arthritis (n = 9), hepatosplenic disease (n = 2), lymphadenitis (n = 2), neuroretinitis (n = 2) and encephalitis (n = 1). Clinical diagnosis was confirmed by serology (n = 16) and Bartonella DNA detection in patient's lymph nodes/hepatic lesion (n = 3). Therapeutic approach varied according to the clinical presentation: azithromycin in lymphadenitis, rifampicin plus ciprofloxacin in hepatosplenic disease, rifampicin and doxycycline in neuroretinitis, ceftriaxone in encephalitis and azithromycin, cotrimoxazole or rifampicin plus azithromycin, cefuroxime, ciprofloxacin or doxycycline in osteomyelitis/arthritis. Immunodeficiency was excluded in seven patients. Seven patients' cats were screened by veterinarians and treated when infected (n = 5).

CONCLUSIONS

In these clinical presentations, where other infections may be involved, a high index of suspicion is necessary, with emphasis on the epidemiological context. The association of systemic forms with immunodeficiency did not occur in our study. The lack of recommendations for treatment of atypical infection makes the approach of these cases a challenge. Randomised control studies are essential to define the best approach in each case.

A Case of Atypical Bartonellosis in a 4-Year-Old Immunocompetent Child

In most cases, infection due to Bartonella henselae causes a mild disease presenting with a regional lymphadenopathy frequently associated with a low-grade fever, headache, poor appetite and exhaustion that spontaneously resolves itself in a few weeks. As the infection is generally transmitted by cats through scratching or biting, the disease is named cat scratch disease (CSD). However, in 5–20% of cases, mainly in immunocompromised patients, systemic involvement can occur and CSD may result in major illness. This report describes a case of systemic CSD diagnosed in an immunocompetent 4-year-old child that can be used as an example of the problems that pediatricians must solve to reach a diagnosis of atypical CSD. Despite the child’s lack of history suggesting any contact with cats and the absence of regional lymphadenopathy, the presence of a high fever, deterioration of their general condition, increased inflammatory biomarkers, hepatosplenic lesions (i.e., multiple abscesses), pericardial effusion with mild mitral valve regurgitation and a mild dilatation of the proximal and medial portion of the right coronary artery, seroconversion for B. henselae (IgG 1:256) supported the diagnosis of atypical CSD. Administration of oral azithromycin was initiated (10 mg/kg/die for 3 days) with a progressive normalization of clinical, laboratory and US hepatosplenic and cardiac findings. This case shows that the diagnosis of atypical CSD is challenging. The nonspecific, composite and variable clinical features of this disease require a careful evaluation in order to achieve a precise diagnosis and to avoid both a delayed diagnosis and therapy with a risk of negative evolution.

Systemic Cat-Scratch Disease: a "Troublesome" Diagnosis

Diagnosis of systemic cat scratch disease may be challenging. Here, we describe a case of an immunocompetent girl exhibiting fever and multifocal hepatosplenic abscesses. Diagnostic tests for Bartonella henselae infection (enzyme immunoassay and polymerase chain reaction) were found steadily negative and the diagnosis, suspected on the basis of the Margilet's criteria, was finally confirmed by indirect immunofluorescent antibodies.

Hepatosplenic Bartonellosis in an Immunocompetent Teenager: An Atypical Presentation of Cat-Scratch Disease

Infection with Bartonella henselae,a gram-negative coccobacillus, most frequently presents as cat-scratch disease (CSD) and often accompanies a recent history of cat bite or scratch. As compared to adults, teenagers and children or immunocompromised patients are predominantly affected by CSD. In immunocompetent individuals, CSD is typically a self-limiting clinical syndrome with complete resolution of febrile illness in two to four weeks with or without antimicrobial therapy. While most cases present with fever of unknown origin (FUO), previous reports have also documented atypical clinical presentation or systemic symptoms in few cases, including reports of hepatosplenic involvement. We present a case of visceral bartonellosis in an immunocompetent 15-year-old female, who presented with a six-week history of fever and abdominal pain with hepatosplenomegaly. She recovered completely after prolonged antibiotic treatment for six weeks with doxycycline and amikacin. We emphasize that in the workup of FUO, it may be pertinent to include bartonellosis as a differential especially in cases exhibiting hepatosplenomegaly on examination along with hepatosplenic lesions on imaging.

Cat Scratch Disease: The First Case Report in Republic of North Macedonia

Cat scratch disease (CSD) is the main clinical manifestation caused by Bartonella henselae in immuno-competent patients. The bacterium is transmitted to humans from cats via scratches or bites. In this case report, we are presenting to our knowledge the first etiologically confirmed case of CSD in our country. Here we describe the case of a previously healthy adult female patient presenting with fever and axillar lymphadenopathy over 1-month period. She underwent numerous clinical and paraclinical investigations for potential etiologies associated with lymphadenopathy and fever. Finally, serological testing for B.henselae was performed with titers for IgG 1:1024 and 1:160 for IgM, which confirmed the diagnosis. Five-day treatment with azithromycin resulted with good clinical response and complete recovery. We proved that CSD is a reality in our country and this report should raise awareness in medical doctors, especially infectious disease specialist. Also, CSD should be included in differential diagnosis in patients with fever of unkown origin (FUO), who are presenting with regional lymphadenopathy, with or without history of cat contact.

Pediatric Bartonella henselae Infection: The Role of Serologic Diagnosis and a Proposed Clinical Approach for Suspected Acute Disease in the Immunocompetent Child

BACKGROUND

Bartonella henselae serology is commonly used to diagnose cat-scratch disease (CSD). Titers above a threshold for positivity suggest either a recent or remote infection. Recent infection can be confirmed by a 4-fold rise in the convalescent titer in some cases. Many atypical presentations attributed to CSD utilize a low threshold for positivity without supportive evidence from convalescent sera or supplemental testing, raising a concern for the overdiagnosis of CSD.

METHODS

We conducted a retrospective chart review of immunocompetent pediatric patients at the Hospital for Sick Children, Toronto, spanning an 11-year period. A total of 154 cases were included with serologic titers ≥1:128. These were divided into 3 groups: group 1 = 1:128, group 2 = 1:256, and group 3 ≥ 1:512. Cases within groups were evaluated with respect to cat contact, clinical presentation, further testing, and final diagnosis.

RESULTS

One-third of patients with a titer of 1:128 had an alternative diagnosis. Most cases with a titer of 1:128 or 1:256 did not have convalescent serologic testing performed. Within these 2 groups, only 1 case had a 4-fold rise in the convalescent titer. A trend of decreasing number of cases with alternative diagnoses (P = 0.03) and increasing number of cases presenting with regional lymphadenopathy (P = 0.07) was associated with higher titers in group 3 compared with group 1.

CONCLUSION

Concerns about the serologic diagnosis of CSD include the use of low titers for positivity, incomplete diagnostic evaluation, and the lack of convalescent serologic testing. We propose a clinical guide to assist in managing suspected cases of CSD.

The development and spontaneous resolution of a full-thickness macular hole in bartonella henselae neuroretinitis in a 12-year-old boy

Purpose

To describe an unusual case of Bartonella henselae neuroretinitis complicated by macular hole (MH) development.

Observations

A full-thickness macular hole developed in a 12-year-old boy in association with serology-confirmed Bartonella henselae neuroretinitis. Following a period of observation, the MH closed without intervention.

Conclusion and importance

MH may occur as a complication of neuroretinitis secondary to Cat-Scratch Disease.

Multifocal hepatic abscesses in immunocompetent patient due to Bartonella henselae: Case report with review of literature

To the best of our knowledge, this is the first case of multifocal hepatic abscesses in a young immunocompetent adult from India, which was successfully treated with hepatectomy and short course of oral antibiotic regimen. Publishing further such case reports will provide more clarity regarding the clinical significance of the disease, including associated risk factors and appropriate treatment.

Disseminated Bartonella henselae disease mimicking Langerhans' cell histiocytosis

Bartonella henselae, the causative agent of cat-scratch disease, has been recognized to be responsible for a broad range of clinical syndromes. We report the case of a patient with disseminated B. henselae infection mimicking Langerhans cell histiocytosis at presentation and its successful management with neurosurgery, prolonged antibacterial therapy, and observation.

Chest Imaging of a rare case of cat-scratch disease in a 2-years-old baby

Cat-scratch disease (CSD) is usually a self-limiting infection that in the majority of cases occurs as lymphadenitis in children who have been scratched or bitten by a cat. Rarely, Bartonella henselae is cause of fever of unknown origin (FUO), with dissemination to various organs, mimicking an inflammatory rather than a lymphoproliferative disease. This manuscript will present a case of thoracic manifestations of CSD in an immunocompetent 2-years baby without history of cat contact, with fever of unknown origin, investigated by chest CT and MRI. (www.actabiomedica.it)

The cat did it: erythema nodosum and additional atypical presentations of Bartonella henselae infection in immunocompetent hosts

A healthy patient presented with painful skin lesions on the anterior surface of her legs. Erythema nodosum was diagnosed but all the usual causes were ruled out. The finding of bilateral enlarged axillary lymph nodes with necrosis and granulomas led to the diagnosis of Bartonella infection, an unusual cause of erythema nodosum. Imaging also revealed splenomegaly and small para-aortic lymph nodes. Up to one quarter of the patients with cat-scratch disease present atypically, a considerably higher prevalence than previously reported. A comprehensive review of the literature (PubMed, since inception, all languages) revealed a remarkable array of unusual presentations which are summarised and briefly discussed.

Lymphadenitis associated with cat-scratch disease simulating a neoplasm: Imaging findings with histopathological associations

The lymphadenitis associated with cat-scratch disease (CSD) is often confused with neoplasms by a number of radiologists and clinicians, and consequently, unnecessary invasive procedures or surgeries are performed. In the present study, the contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) findings of 10 patients (6 men and 4 women) with clinically and pathologically confirmed lymphadenitis associated with CSD were retrospectively analyzed (CT in 3 patients, MRI in 6 patients, and CT and MRI in 1 patient) at The Second Affiliated Hospital of Zhejiang University School of Medicine (Hangzhou, China) between January 2007 and November 2014. As a result, 17 enlarged lymph nodes were identified in 10 cases. The 5 nodes identified by CT scan exhibited relatively inhomogeneous isodensity to muscle, with patchy low density in the center. All 14 nodes identified by MRI scan exhibited homogeneous or heterogeneous isointensity to muscle or slightly increased intensity compared with that of muscle on T1-weighted images (T1WI), and homogeneous or heterogeneous hyperintensity on fat-suppressed T2WI. Following enhancement, all 17 enlarged lymph nodes associated with CSD demonstrated the following 3 different enhancement patterns: Moderate homogeneous enhancement (n=8), which was associated with histologically identified early disease stage; marked heterogeneous enhancement with no enhancement of the necrotic areas (n=4), and heterogeneous enhancement with progressively ‘spoke-wheel-like’ (defined as radiating enhancement from the center) enhancement of the patchy low-density area (n=1), which was associated with histologically identified intermediate disease stage; and astral low-density/hypointensity with marked enhancement (n=2) or a ‘rose flower’ sign (n=2), which was associated with histologically identified late disease stage. We hypothesized that the CT and MRI results of lymphadenitis in CSD may be associated with the pathological features. It may be suggested that the diagnosis of CSD may be formed when considering the characteristic CT and MRI features of astral low-density/hypointensity with marked enhancement or a ‘rose flower’ sign (defined as marginal petaloid enhancement) in the late disease stage, or the MRI results of homogeneous, moderate enhancement in the early disease stage, or the CT/MRI data of heterogeneous enhancement with non-enhancing area in the center in the intermediate disease stage, in solitary or multiple enlarged lymph nodes associated with general subcutaneous edema in the vicinity of the nodes on CT/MRI and with a history of cat exposure.

Cat-Scratch Disease in the United States, 2005-2013

Each year, this preventable disease affects about 12,500 persons, mostly those who live in the South and are 5–9 years of age.

Cat-scratch disease (CSD) is mostly preventable. More information about the epidemiology and extent of CSD would help direct prevention efforts to those at highest risk. To gain such information, we reviewed the 2005–2013 MarketScan national health insurance claims databases and identified patients <65 years of age with an inpatient admission or outpatient visit that included a CSD code from the International Classification of Diseases, Ninth Revision, Clinical Modification. Incidence of CSD was highest among those who lived in the southern United States (6.4 cases/100,000 population) and among children 5–9 years of age (9.4 cases/100,000 population). Inpatients were significantly more likely than outpatients to be male and 50–64 years of age. We estimate that each year, 12,000 outpatients are given a CSD diagnosis and 500 inpatients are hospitalized for CSD. Prevention measures (e.g., flea control for cats) are particularly helpful in southern states and in households with children.

Corticosteroid Treatment for Prolonged Fever in Hepatosplenic Cat-Scratch Disease: A Case Study

Hepatosplenic cat-scratch disease (CSD) may cause prolonged fever. We present the case of a 4-year-old boy with confirmed hepatosplenic CSD with fever lasting 3 months despite use of multiple different antimicrobial agents. The patient became afebrile soon after corticosteroid therapy was started. Our case indicates corticosteroids may be useful in patients with hepatosplenic CSD and prolonged fever.

Cat scratch disease during etanercept therapy in a rheumatoid arthritis patient

Cat scratch disease (CSD) is an infectious disorder caused by Bartonella henselae and characterized by fever and granulomatous lymphadenopathy. Immunosuppression is a risk factor for the development of atypical forms of the disease. We report the case of a 52-year-old woman who presented with fever and bilateral inguinal lymph node enlargement. She did not have apparent contact with animals. The patient was receiving etanercept therapy for rheumatoid arthritis. Lymph node biopsy demonstrated granulomatous lymphadenitis. She was successfully managed by discontinuing etanercept and by treatment with minocycline. She developed clinical remission and typical seroconversion. Infection with Bartonella should be considered in the differential diagnosis in rheumatoid arthritis patients with lymphadenopathy of unknown origin.

Epitrochlear cat scratch disease: unique imaging features allowing differentiation from other soft tissue masses of the medial arm

OBJECTIVE

Evaluate anatomic and imaging features of epitrochlear regional adenopathy secondary to cat scratch disease (CSD) to assist differentiation of CSD from other soft tissue masses at the elbow.

MATERIALS AND METHODS

Retrospective review of 24 confirmed cases of CSD. Patient demographics, clinical presentation and radiographic (R; n = 10), CT (n = 3), ultrasound (US; n = 5), and MR (n = 21) images were reviewed. Lesion location, size, number of masses, and intrinsic characteristics on R/CT/US/MR and presence of soft tissue inflammatory changes or adjacent bone or joint involvement were established through the consensus interpretation by four musculoskeletal radiologists.

RESULTS

The average patient age was 18.6 years. Mass location was anterior and superficial to the medial intermuscular septum (100 %) with the masses posterior or posteromedial to the basilic vein (92 %). Three or fewer lymph nodes were involved in 92 %. Masses were noncalcified with adjacent inflammatory change (R = 90 %, CT = 100 %). US showed hypoechoic soft tissue echogenicity masses with defined to minimally irregular margins (80 %) and preserved central hilar hypervascularity on Doppler (100 % of cases). On MR, masses were T1 isointense (62 %), T2 isointense (54 %), intermediate signal on T2 images with fat suppression (55 %), and had perilesional inflammatory changes (95 %), perilesional fluid collections (38 %), adjacent muscle edema (81 %), hyperintense cental hilar vascular enhancement (65 %) and occasional preserved central hilar fat (14 %).

CONCLUSION

Cat scratch disease is suggested by the characteristic location of a medial epitrochlear mass superficial to the brachial fascia and posterior to the basilic vein with surrounding inflammatory changes and preservation of hilar vascular architecture, hilar enhancement and occasional hilar fat.

Disseminated cat-scratch disease: case report and review of the literature

Cat scratch disease (CSD) can present as a systemic disease in 5-10% of cases and lead to various disease entities. A previously healthy 16-month-old boy presented with fever for 7 days without other obvious symptoms. Abdominal computed tomography scan demonstrated enlarged right inguinal lymph nodes and multiple small round hypodensities in the spleen. Despite antibiotic treatment for 1 week, the fever persisted and the intrasplenic lesions progressed. Inguinal lymph node biopsy confirmed CSD by immunohistochemistry staining. The diagnosis of CSD was also supported by a history of contact, imaging and serological findings. The patient recovered after treatment with azithromycin for a total of 5 weeks and, in serial follow-up, the hepatosplenic micro-abscesses resolved after 4th months.

Ultrasound imaging as the basis of a clinical diagnosis of systemic bartonellosis in a patient after bone marrow transplantation. A case report

Infections in immunocompromised patients after hematopoietic stem cell transplantation can have a severe and atypical course. Some opportunistic pathogens are difficult to detect in microbiological tests, and that is why treatment success depends on an accurate clinical diagnosis. This article presents a case of a 7-year-old girl with severe aplastic anemia treated with bone marrow transplantation with post-transplantation period complicated by persistent, hectic fever, with peak episodes of 39–40°C, lasting several weeks. Repeated microbiological tests failed to reveal the etiological agent, and empirical anti-infective treatment was ineffective. In the fourth week of fever, imaging showed multiple foci resembling abscesses in the patient's internal organs and, subsequently, in soft tissues. The characteristics of these changes and data concerning environmental exposure led to the clinical diagnosis of cat scratch disease (bartonellosis) with multi-organ involvement and enabled the targeted treatment to be implemented. Fever subsided and organ lesions regressed. In this case, repeated ultrasound imaging was the basic diagnostic tool that helped arrive at a correct diagnosis and implement effective treatment of this life-threatening complication after hematopoietic stem cell transplantation.

Cat Scratch Disease in a Renal Transplant Recipient

Cat scratch disease (CSD) is a disorder characterized by self-limited regional lymphadenopathy and fever. We reported a case of CSD in a kidney transplant recipient who presented with fever and lymphadenopathy. Lymph node biopsy demonstrated bacterial histiocytic lymphadenitis. The patient was diagnosed with CSD. Patient had good clinical improvement after treatment. Therefore, CSD should also be borne in mind for kidney recipients though CSD had been infrequently reported in this group.

Cat-scratch disease: Otolaryngologic manifestations and management

OBJECTIVE:

The bacteria Bartonella henselae has been known as the principal causative agent of cat-scratch disease (CSD) since 1992. It is an important cause of infectious lymphadenopathies in the head and neck. Nevertheless, CSD often remains unrecognized in cases of cervicofacial lymph node enlargement.

STUDY DESIGN:

Between January 1997 and May 2003, we conducted a prospective clinical study including 721 patients with primarily unclear masses in the head and neck.

RESULTS:

CSD was diagnosed by serology and molecular investigations in 99 patients (13.7%; median age 33 years). Cervicofacial lymphadenopathy was the most common manifestation. Atypical manifestation of CSD including Parinaud's oculoglandular syndrome, swelling of the parotid gland and erythema nodosum were diagnosed in 8.1%, 8.1%, and 2.0% of cases, respectively.

CONCLUSIONS:

Our results demonstrate that CSD is a major cause of enlarged cervicofacial lymph nodes and should therefore be included in the differential diagnosis of lymphadenopathy in the head and neck region.

SOLITARY IDIOPATHIC CHOROIDITIS IN THE SETTING OF EXTENSIVE ANIMAL EXPOSURE

PURPOSE

To describe solitary idiopathic choroiditis in the setting of extensive animal exposure.

METHODS

A 56-year-old asymptomatic female equestrian with an extensive history of exposure to horses and dogs and a trapper of wild animals and rodents was discovered to have an amelanotic choroidal mass in the macular region and referred for suspicious atypical nevus.

RESULTS

Funduscopy revealed a deep yellow mass with overlying retinal pigment epithelial thinning and without visible subretinal fluid or lipofuscin. Mild hyperautofluorescence represented unmasking of scleral autofluorescence. Ultrasonography showed a 1.8-mm-thick echodense lesion. Enhanced depth imaging-optical coherence tomography disclosed a dense, elevated scleral mass with "volcanic" configuration, demonstrating choroidal compression and trace overlying subretinal fluid. These features were consistent with solitary idiopathic choroiditis/scleritis. Systemic evaluation for standard cat-related bartonellosis, tuberculosis, sarcoidosis, and syphilis were negative. Horse-, dog-, and rodent-related bartonellosis testing was not available. Observation was advised, and the findings remained stable at 6 months.

CONCLUSION

Solitary idiopathic choroiditis is best imaged on enhanced depth imaging-optical coherence tomography as a scleral lesion with "volcanic" configuration and often secondary to previous Bartonella infection. Serologic positivity for cat-related Bartonella decays over time, and testing for horse-, dog-, or rodent-related Bartonella is not commonly used.

Hepatosplenic Abscesses and Osteomyelitis of the Spine in an Immunocompetent Adult with Cat Scratch Disease

We present an 18-year-old, immunocompetent Austrian military conscript with cervical lymphadenopathy, fever, back-pain, and persistent inflammation markers despite two weeks of antimicrobial therapy with ampicillin/sulbactam. All specific laboratory investigations for identification of a specific etiology, including blood cultures and autoantibodies, were inconspicuous. Abdominal computed tomography showed multiple hypodense hepatosplenic lesions and osteomyelitis of the thoracic and lumbar spine with base plate fracture. Based on the patient's history, clinical presentation, and radiological findings, serology for cat scratch disease (CSD) was performed and high B. henselae specific IgM and IgG antibodies were detected. Due to its variety of clinical presentations, diagnosis of CSD is challenging, especially in the absence of a history of specific exposure. This case report shall remind the physician that cat scratch disease is a common disease, mainly presenting with fever and lymphadenopathy in young patients. Nevertheless CSD has many different and rare forms of presentations, including hepatosplenic lesions and bone involvement as shown in this case.

[Bartonella henselae vertebral osteomyelitis: report of a case]

Cat scratch disease (CSD) is caused by Bartonella henselae, with unknown prevalence and incidence in the Chilean paediatric population. Regional lymphadenopathy is the most common presentation, while atypical forms constitute a diagnostic challenge.

OBJECTIVE

To report a case of CSD with osteomyelitis and present guidelines regarding treatment.

CLINICAL CASE

An eight year-old patient, with prolonged febrile illness, back pain and neck stiffness. Laboratory studies highlight positive IgG for Bartonella henselae. The abdominal ultrasound showed splenic micro-abscesses, and the MRI showing vertebral lesions suggestive of osteomyelitis.

DISCUSSION

The diagnosis of atypical forms requires a high rate of suspicion, as in this case, in which the patient manifested the musculoskeletal symptoms simultaneously with the febrile syndrome, which led us to study possible complications of the disease. Current knowledge of the treatment of atypical or complicated CSD is derived from the observation of case studies, rather than randomized trials. It is suggested that antibiotic therapy is analysed individually, with the help of a specialist.

CONCLUSION

The importance of high clinical suspicion are emphasised and discussed, as well presenting some treatment options based on the evidence from the current literature.

The significance of Bartonella henselae bacterias for oncological diagnosis in children

Background

Cat-scratch disease (CSD) is a common infection in children; however, the wide spectrum of its clinical picture may lead to delayed diagnosis. An unusual presentation of CSD includes in the differential diagnosis malignant diseases, Epstein-Barr and cytomegalovirus infections, tuberculosis, and mycobacterioses. The diagnostic procedure is difficult, and it is important to consider CSD as the etiology of untypical lesion.

Patients and method

We present the analysis of 22 immunocompetent children treated with the clinical diagnosis of CSD in our hospital. Their ages were 2 to 16 years (mean 9.15 ± 2.2 years). Four of them presented classical papulas at admission time. Asymmetric, local lymphadenopathy was present in 16 patients. Five children, who presented an untypical course of CSD mimicking the oncological process, were analysed carefully. There were 3 patients with skull osteomyelitis, 1 with inflammation of the parotid gland, and 1 with an extra peripharyngeal mass. The diagnosis in these children was based on epidemiological, radiological, serological, and histological factors.

Results

About 25 % of children with bartonellosis present an untypical spectrum of symptoms, including the lack of documented cat contact, primary lesions, or peripheral lymphadenopathy. Radiological methods like USG, CT, MRI present the unspecific masses, but they are not enough to distinguish the Bartonella inflammatory and oncological process. The final diagnosis was based on a histological method with additional polymerase chain reaction test.

Conclusion

CSD should be considered in differential diagnosis of any patient with untypical lesions located on the head, neck, and upper extremities.

Cat-scratch disease: a wide spectrum of clinical pictures

The aim of this review is to present an emerging zoonotic disease caused by Bartonella henselae. The wide spectrum of diseases connected with these bacteria varies from asymptomatic cases, to skin inflammation, fever of unknown origin, lymphadenopathy, eye disorders, encephalitis and endocarditis. The reservoirs of B. henselae are domestic animals like cats, guinea pigs, rabbits and occasionally dogs. Diagnosis is most often based on a history of exposure to cats and a serologic test with high titres of the immunoglobulin G antibody to B. henselae. Most cases of cat-scratch disease are self-limited and do not require antibiotic treatment. If an antibiotic is chosen, however, azithromycin has been shown to speed recovery.