[Parotid involvement in cat scratch disease: a differential diagnosis with increased significance]

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.

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.

Unusual otolaryngological manifestations of certain systemic bacterial and fungal infections in children

OBJECTIVE

Systemic bacterial and fungal infections may sometimes present local manifestations within otolaryngological district whose early detection may be useful in establishing a correct diagnosis and more appropriate treatment. This paper reviews certain systemic bacterial and fungal diseases presenting ENT manifestations in the pediatric population from an otolaryngological perspective.

METHODS

A medline searching for specific issues was performed in order to achieve more information as possible with regards to ENT manifestation of systemic bacterial and fungal infections. Limits for pediatric age were used. Two separate sections for bacterial and fungal disease are included. The section on systemic bacterial infections considers cat-scratch disease, Lyme borreliosis, actinomycosis, Lemierre's syndrome and congenital syphilis, and the section on systemic fungal infections includes candidiasis, aspergillosis and histoplasmosis.

CONCLUSIONS

Pediatricians and ear, nose and throat (ENT) specialists, approaching head and neck disorders in children, should therefore consider them among the possible differential diagnoses. This means that physicians need to recognize the first head and neck manifestations of systemic infections promptly in order to be able to treat them efficaciously and avoid the dangerous systemic spreading of the infective process.

The bacteriology of salivary gland infections

The parotid gland is the salivary gland most commonly affected by inflammation. However, infection of the salivary glands can occur in any of the glands. The most common pathogens associated with acute bacterial infection are Staphylococcus aureus and anaerobic bacteria. The predominant anaerobes include: anaerobic Gram negative bacilli (eg, pigmented Prevotella and Porphyromonas); Fusobacterium spp; and Peptostreptococcus spp. In addition, Streptococcus spp (including Streptococcus pneumoniae) and aerobic and facultative Gram-negative bacilli (including Escherichia coli) have been reported. Aerobic and facultative Gram-negative bacilli are often seen in hospitalized patients. Organisms less frequently found are Haemophilus influenzae, Treponema pallidum, Bartonella henselae, and Eikenella corrodens. Mycobacterium tuberculosis and atypical mycobacteria are rare causes of infection. The choice of antibiotics should be guided by identification of the etiologic agent.

[Cat-scratch disease localisation in the parotid gland]

INTRODUCTION

Cat scratch disease is an infection due to Bartonella henselae. It is one of the principal causes of benign chronic adenopathy in children or young adults.

CASE REPORT

A 36-year-old woman presented with a left parotid pre-auricular swelling suggesting a pleiomorphic adenoma. The history and complementary tests (ultra sonography, MRI, cytopuncture, B. henselae serology) led to a diagnosis of cat scratch disease. Doxycilline was efficient within 15 days.

DISCUSSION

The parotid localization of cat scratch disease is very rare. When a patient presents with parotid swelling, the distinction between a tumor and lymph node is not easy. Performing complementary tests can be in balance with a quicker but sometimes inappropriate surgical indication. The diagnosis is made even more difficult because of delayed specific serologic tests as for B. henselae.

Parotid mass due to cat scratch disease

Cat scratch disease (CSD), due to Bartonella henselae, is a self-limited chronic lymphadenopathy. A previously healthy 22-year-old woman presented with a palpable painful swelling in the right submandibular region accompanied by enlarged cervical lymph nodes. A diagnosis of B. henselae infection was made according to her personal history that divulged frequent contacts with cats and to a high titre of immunoglobulin G (IgG) and IgM antibodies for this agent. The patient improved within 1 month without the requirement of antibiotic treatment or surgery. The CSD should always be included in the differential diagnosis of all equivocal masses in the neck, especially in young individuals. In addition, it is important that a meticulous personal history is obtained.

Okuloglanduläres Syndrom nach Parinaud

Two cases of Parinaud's oculoglandular syndrome, which represents an ocular manifestation of cat-scratch disease, are reported. The symptoms are subacute and include unilateral conjunctivitis and pre-auricular lymphadenopathy. Diagnosis primarily relies on the recognition of suggestive clinical signs in conjunction with positive serologic testing. In most cases, therapy is not necessary.

B-mode sonographic criteria for differential diagnosis of cervicofacial lymphadenopathy in cat-scratch disease and toxoplasmosis

BACKGROUND

Our purpose was to evaluate different sonographic parameters of cervicofacial lymphadenopathy caused by cat-scratch disease (CSD) and toxoplasmosis.

METHODS

By use of high-resolution B-mode sonography a total of 552 lymph nodes in the head and neck were detected between January 1997 and December 2001. There were 71 patients (422 lymph nodes) with CSD and 19 patients (130 lymph nodes) with toxoplasmosis. Sonographic variables, including 20 sonomorphologic features along with age and gender, were analyzed with multivariate logistic regression.

RESULTS

Heterogenous lymph nodes were more often found in CSD (p =.003), and nonsharp nodal borders showed a significant association with CSD (p =.0005). Multivariate analysis identified sharpness of borders (p =.0001), S/L ratio (p =.0006), and type of lymphadenopathy (acute, abscessed, chronic) (p =.0006) as most significant for differentiating between CSD and toxoplasmosis.

CONCLUSIONS

These results provide significant and useful criteria for ultrasonographic differentiation between CSD and toxoplasmosis.

Role of cat-scratch disease in lymphadenopathy in the head and neck

Bartonella henselae is the causative agent of cat-scratch disease (CSD), which usually manifests as acute regional lymphadenopathy. The causes of cervical lymphadenopathy, with special regard to CSD, were investigated in a study of 454 patients who presented with unclear masses in the head and neck from January 1997 through January 2001. Sixty-one patients (13.4%) experienced CSD; 54 (11.9%) had primary lymphadenopathy due to other infectious agents, and 41 (9.0%) had lymphadenopathy that occurred in association with primary infections of other organs. For 171 patients (37.7%), the cause of the cervical lymph node enlargement could not be found. B. henselae DNA was detected in extirpated lymph nodes only during the first 6 weeks of lymphadenopathy, which indicates that the results of polymerase chain reaction strongly depend on the duration of illness. CSD should be included in the differential diagnosis of adenopathy in the otorhinolaryngologic patient population, to avoid unnecessary treatment.

Gray-scale sonographic evaluation of cervical lymphadenopathy in cat-scratch disease

PURPOSE

The aim of this study was to characterize the gray-scale sonographic findings in the lymph nodes of patients with cat-scratch disease (CSD).

METHODS

We analyzed the sonograms of cervical lymph nodes in 41 patients with proven CSD between January 1997 and October 1999.

RESULTS

A total of 222 involved lymph nodes were detected. Involved nodes were most commonly found in the middle cervical (58%), parotid (37%), upper cervical (37%), and submandibular (17%) regions. We found acute, chronic, or abscessed lymphadenopathy in 63%, 12%, and 24% of patients, respectively. The size of involved lymph nodes ranged from 12 x 4 mm to 35 x 26 mm. The largest involved node had a short axis/long axis ratio of 0.5 or more in 61% of patients. Useful features for the differential diagnosis included markedly decreased echogenicity (100%), normal surrounding tissues (100%), and the presence of an echogenic hilum (76%). Posterior sound enhancement was significantly associated with larger and abscessed lymph nodes.

CONCLUSIONS

Despite the absence of a specific sonographic finding for CSD, gray-scale sonography can provide clues to the diagnosis of CSD in the proper clinical setting.