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Hanzalova I, Matter M. Peripheral lymphadenopathy of unknown origin in adults: a diagnostic approach emphasizing the malignancy hypothesis. Swiss Med Wkly 2024; 154:3549. [PMID: 39154257 DOI: 10.57187/s.3549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2024] Open
Abstract
The term lymphadenopathy refers to an abnormality in size, consistency or morphological aspect of one or several lymph nodes. Although lymphadenopathies are commonly observed in everyday clinical practice, the difficulty of differentiating benign and malignant disease may delay therapeutic approaches. The present review aims to update diagnostic algorithms in different clinical situations based on the currently available literature. A literature review was performed to assess current knowledge of and to update the diagnostic approach. A short clinical vignette was used as an example of a typical clinical presentation. This case of metastatic lymphadenopathy with incomplete patient history demonstrates how misleading such lymphadenopathy may be, leading to a delayed diagnosis and even a fatal outcome. Any lymphadenopathy persisting for more than 2 weeks should be considered suspicious and deserves further investigation. Precise clinical examination, meticulous history-taking and a search for associated symptomatology are still cornerstones for diagnosing the origin of the condition. The next diagnostic step depends on the anatomical region and the specific patient's situation. Imaging starts with ultrasound, while computed tomography (CT) and magnetic resonance imaging (MRI) allow assessment of the surrounding structures. If the diagnosis remains uncertain, tissue sampling and histological analyses should be performed. Except for head and neck loco-regional lymphadenopathy, there are no methodical guidelines for persistent lymphadenopathy. The present review clarifies several confusing and complex situations. The accuracy of fine needle aspiration cytology could be increased by using core needle biopsy with immunocytologic and flow cytometric methods. Notably, except in the head and neck area, open biopsy remains the best option when lymphoma is suspected or when inconclusive results of previous fine needle aspiration cytology or core needle biopsy are obtained. The incidence of malignant lymphadenopathy varies with its location and the various diagnostic strategies. In metastatic lymphadenopathy of unknown primary origin, European Society for Medical Oncology (ESMO) guidelines and modern methods like next-generation sequencing (NGS) may help to manage such complex cases.
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Affiliation(s)
- Ivana Hanzalova
- Department of Surgery, University Hospital and Lausanne University, Lausanne, Switzerland
| | - Maurice Matter
- Department of Surgery, University Hospital and Lausanne University, Lausanne, Switzerland
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López-Rueda S, Valente-Acosta B, Murillo-Zolezzi A, Moreno-Sánchez F, Hoyo-Ulloa I, Baquera-Heredia JJ. A Man in His Forties with Recurrent Cat-Scratch Disease. Case Rep Infect Dis 2024; 2024:4411133. [PMID: 38444733 PMCID: PMC10914428 DOI: 10.1155/2024/4411133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 02/05/2024] [Accepted: 02/22/2024] [Indexed: 03/07/2024] Open
Abstract
Cat-scratch disease (CSD) is a self-limited zoonotic infection transmitted by felines caused by the Gram-negative bacillus Bartonella henselae. It usually presents with lymphadenopathy and constitutional symptoms that resolve within eight weeks, with, or without antibiotic treatment. The diagnosis is made by serology, molecular diagnosis in a biopsy, or a positive culture. The recurrence or reactivation of B. henselae has rarely been reported. We present the case of a 45-year-old man with a history of CSD two years before who presented to the clinic with groin lymphadenopathy. The patient had a history of close contact with felines though no known risk exposure was reported. The diagnosis was made with a positive serology suggestive of recent infection along with histopathological changes suggestive of CSD. Subsequently, azithromycin was administered with complete resolution of symptoms.
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Affiliation(s)
- Sara López-Rueda
- The American British Cowdray Medical Center, Sur 136 116, Alvaro Obregon, Mexico City 01120, Mexico
| | - Benjamin Valente-Acosta
- The American British Cowdray Medical Center, Sur 136 116, Alvaro Obregon, Mexico City 01120, Mexico
| | - Adrian Murillo-Zolezzi
- The American British Cowdray Medical Center, Sur 136 116, Alvaro Obregon, Mexico City 01120, Mexico
| | - Francisco Moreno-Sánchez
- The American British Cowdray Medical Center, Sur 136 116, Alvaro Obregon, Mexico City 01120, Mexico
| | - Irma Hoyo-Ulloa
- The American British Cowdray Medical Center, Sur 136 116, Alvaro Obregon, Mexico City 01120, Mexico
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The Hematologic Malignancy That Wasn't. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2023. [DOI: 10.1097/ipc.0000000000001178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Abdominal Lymphadenopathy: Hypothesize Cat-Scratch Disease and Avoid Abdominal Excisional Biopsy. HEMATO 2022. [DOI: 10.3390/hemato3040052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
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.
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Zhu M, Zhang S, Shi Q, Sun X, Zhang X, Wang H, Liu Y, Sun M. Swollen inguinal lymph nodes with low fever and night sweat: diagnosis and treatment of case of cat-scratch disease lymphadenitis with sinus formation. Heliyon 2022; 8:e10448. [PMID: 36097471 PMCID: PMC9463371 DOI: 10.1016/j.heliyon.2022.e10448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/19/2022] [Accepted: 08/22/2022] [Indexed: 11/30/2022] Open
Abstract
A 52-year-old woman complained of inguinal lymph node enlargement, low fever and night sweats for 20 days. After pathological biopsy and metagenomic sequencing, she was diagnosed as having Bartonella henselae infection. Her lymph nodes were accompanied by multiple ulcers in the affected area and sinus formation. Azithromycin was administered according to the Sanford Guide to Antimicrobial Therapy 2020, combined with wound repair and partial resection of inguinal lymph nodes. The patient showed good recovery after the operation. In all, lymphadenitis associated with B. henselae infection is difficult to diagnose. Lymphadenitis with suppuration and sinus formation needs multidisciplinary consultation. When the causal pathogen is unknown, metagenomic sequencing is recommended for a definite diagnosis.
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Goaz S, Rasis M, Binsky Ehrenreich I, Shapira L, Halutz O, Graidy-Varon M, Leibovitch C, Maisler N, Glikman D, Ephros M, Giladi M. Molecular Diagnosis of Cat Scratch Disease: a 25-Year Retrospective Comparative Analysis of Various Clinical Specimens and Different PCR Assays. Microbiol Spectr 2022; 10:e0259621. [PMID: 35262411 PMCID: PMC9045166 DOI: 10.1128/spectrum.02596-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 02/14/2022] [Indexed: 02/07/2023] Open
Abstract
Cat-scratch disease (CSD), caused primarily by Bartonella henselae, is a common etiology of infectious regional lymphadenopathy. Lymphadenopathy is preceded by a primary inoculation lesion and may progress to suppuration. Laboratory diagnosis of CSD is hampered by the limitations of available confirmatory tests. PCR, in general, is highly sensitive and specific; however, clinical sensitivity in CSD varies greatly between studies. We aimed to identify clinical specimens and PCR assays best suited for CSD diagnosis using a national CSD registry and a uniform case definition. Different clinical specimens and PCR assays, including conventional and real-time PCR, were evaluated. PCR was positive in 335/390 (86%) CSD patients and 425/482 (88%) PCR tests. The highest PCR sensitivity was achieved in lymph node pus aspirates (96%; n = 278 tests) followed by primary lesions (88%; n = 50), lymph node fine needle aspirations (85%; n = 46), lymph node biopsy specimens (73%; n = 91) and paraffin-embedded lymph nodes (59%; n = 17), (P < 0.001). Sensitivity was similar in all types of PCR assays studied. PCR negative predictive value of pus aspirate and lymph node biopsy specimen patient groups was 82% and 72%, respectively. Specificity was 100% based on 125 non-CSD patients with negative PCR. In conclusion, the specimen type rather than the PCR assay type has a major impact on CSD molecular diagnosis. We assume that the inadequate sensitivity of the biopsy specimens was due to sampling errors or the presence of inhibitory factors. Primary lesions should be sampled more frequently for CSD diagnosis. Physicians should be aware of the low PCR negative predictive value of lymph node biopsy specimens. IMPORTANCE Polymerase chain reaction (PCR) for the detection of Bartonella henselae is an important tool for the diagnosis of cat scratch disease (CSD); however, clinical sensitivity varies greatly between studies. The current study shows that the specimen type, with pus aspiration, fine needle aspiration, and primary inoculation lesion having significantly higher sensitivity than fresh or formalin-fixed paraffin-embedded lymph node biopsy specimen, rather than the type of the PCR assay, whether a conventional or a real-time assay, has a major impact on the performance of diagnostic PCR for CSD. The new data provide new tools for the clinical microbiologist when interpreting the results of the PCR assays. Primary inoculation lesions, although easily accessible, are often neglected and should be sampled more frequently for molecular diagnosis of CSD. Physicians should be aware that negative PCR, particularly if performed on fresh or paraffin-embedded lymph node biopsy specimens, does not exclude CSD.
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Affiliation(s)
- Sher Goaz
- The Bernard Pridan Laboratory for Molecular Biology of Infectious diseases, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Michal Rasis
- The Bernard Pridan Laboratory for Molecular Biology of Infectious diseases, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | | | - Lev Shapira
- The Bernard Pridan Laboratory for Molecular Biology of Infectious diseases, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ora Halutz
- Microbiology Laboratory, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Merav Graidy-Varon
- Microbiology Laboratory, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Cecilia Leibovitch
- Microbiology Laboratory, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | | | - Daniel Glikman
- The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
- Infectious Disease Unit, Padeh Poriya Medical Center, Tiberias, Israel
| | - Moshe Ephros
- Pediatric Infectious Disease Unit, Carmel Medical Center and the Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Michael Giladi
- The Bernard Pridan Laboratory for Molecular Biology of Infectious diseases, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Infectious Disease Unit, Tel Aviv Sourasky Medical Center, and The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Misleading Positive Serology for Cat Scratch Disease Following Administration of Intravenous Immunoglobulin. Pathogens 2022; 11:pathogens11020177. [PMID: 35215121 PMCID: PMC8876604 DOI: 10.3390/pathogens11020177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 01/23/2022] [Accepted: 01/25/2022] [Indexed: 02/01/2023] Open
Abstract
Cat scratch disease (CSD), caused by Bartonella henselae, usually presents as regional lymphadenopathy/lymphadenitis, known as typical CSD or as atypical CSD, which includes, among others, neurological manifestations. Serology for anti-B. henselae IgG antibodies is the most commonly used diagnostic tests for CSD. Intravenous immunoglobulin (IVIG) is given for an increasing number of medical conditions and may cause interference with serological testing. We report six patients with neurological manifestations and two patients with Kawasaki disease mimicking typical CSD, mistakenly diagnosed as CSD due to false-positive serology following IVIG therapy. Bartonella IgG serology was positive one to six days after IVIG administration and reverted to negative in seven of eight patients or significantly decreased (1 patient) ≤30 days later. In patients with CSD, IgG titers remained essentially unchanged 15–78 days after the positive serum sample. An additional eight patients treated with IVIG for various conditions were evaluated prospectively. All were seronegative one day pre-IVIG infusion, five patients demonstrated an increase in the IgG titers one to three days after IVIG administration, one interpreted as positive and four as intermediate, whereas three patients remained seronegative, suggesting that false seropositivity after IVIG therapy may not occur in all patients. Treatment with IVIG can result in false-positive serology for B. henselae. Increased awareness to the misleading impact of IVIG is warranted to avoid misinterpretation. Repeat testing can distinguish between true and false serology. Preserving serum samples prior to IVIG administration is suggested.
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Maria HKSD, Gazzoli E, Drummond MR, Almeida ARD, Santos LSD, Pereira RM, Tresoldi AT, Velho PENF. Two-year history of lymphadenopathy and fever caused by Bartonella henselae in a child. Rev Inst Med Trop Sao Paulo 2022; 64:e15. [PMID: 35195167 PMCID: PMC8853666 DOI: 10.1590/s1678-9946202264015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 01/20/2022] [Indexed: 08/30/2023] Open
Abstract
We report the case of a 6-year-old boy that presented with enlarged lymph nodes
on his neck. He complained of tiredness and discouragement, which worsened
during feverish periods. There were no relevant laboratory test abnormalities
and serological tests were not reactive. Bartonella henselae
DNA was detected by species-specific nested polymerase chain reaction. After
treatment, the patient progressed with no fever or lymphadenopathy.
Bartonellosis is a group of infectious diseases caused by bacteria of the genus
Bartonella. This case report is a useful reminder to
clinicians that long-term fever of unknown origin can be related to B.
henselae infection, even if the specific serology is not
reactive.
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Affiliation(s)
| | - Emily Gazzoli
- Pontifícia Universidade Católica de Campinas, Brazil
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Laboratory Diagnosis of 37 Cases of Bartonella Endocarditis Based on Enzyme Immunoassay and Real-Time PCR. J Clin Microbiol 2021; 59:JCM.02217-20. [PMID: 33731411 DOI: 10.1128/jcm.02217-20] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 03/08/2021] [Indexed: 12/15/2022] Open
Abstract
Bartonella spp., mostly Bartonella quintana and B. henselae, are a common cause of culture-negative endocarditis. Serology using immunofluorescence assay (IFA) and PCR performed on cardiac tissues are the mainstays of diagnosis. We developed an enzyme immunoassay (EIA) and a novel multiplex real-time PCR assay, utilizing Bartonella genus-specific, B. henselae-specific, and B. quintana-specific SimpleProbe probes, for diagnosis of Bartonella endocarditis. We aimed to evaluate the performance of these assays. Thirty-seven patients with definite endocarditis, 18 with B. henselae, 18 with B. quintana, and 1 with B. koehlerae, were studied. Diagnosis was confirmed by conventional PCR and DNA sequencing of surgical cardiac specimens. Similar to the case with IFA, anti-Bartonella IgG titers of ≥1:800 were found in 94% of patients by EIA; cross-reactivity between B. henselae and B. quintana precluded species-specific serodiagnosis, and frequent (41%) but low-titer cross-reactivity between Coxiella burnetii antibodies and B. henselae antigen was found in patients with Q fever endocarditis. Low-titer (1:100) cross-reactivity was uncommonly found also in patients with brucellosis and culture-positive endocarditis, particularly Enterococcus faecalis endocarditis. Real-time PCR performed on explanted heart valves/vegetations was in complete agreement with results of sequence-based diagnosis with characteristic melting curves. The genus-specific probe identified five additional endocarditis-associated Bartonella spp. at the genus level. In conclusion, EIA coupled with a novel real-time PCR assay can play an important role in Bartonella endocarditis diagnosis and expand the diagnostic arsenal at the disposal of the clinical microbiologist. Since serology remains a major diagnostic tool, recognizing its pitfalls is essential to avoid incorrect diagnosis.
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McNeil JC. Acute Hematogenous Osteomyelitis in Children: Clinical Presentation and Management. Infect Drug Resist 2020; 13:4459-4473. [PMID: 33364793 PMCID: PMC7751737 DOI: 10.2147/idr.s257517] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 12/01/2020] [Indexed: 12/16/2022] Open
Abstract
Acute hematogenous osteomyelitis (AHO) is a common invasive infection encountered in the pediatric population. In addition to the acute illness, AHO has the potential to create long-term morbidity and functional limitations. While a number of pathogens may cause AHO, Staphylococcus aureus is the most common organism identified. Despite the frequency of this illness, little high-quality data exist to guide providers in the care of these patients. The literature is reviewed regarding the epidemiology, microbiology and management of AHO in children. A framework for empiric therapy is provided drawing from the available literature and published guidelines.
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Affiliation(s)
- J Chase McNeil
- Department of Pediatrics, Section of Infectious Diseases, Baylor College of Medicine, Houston, TX, USA
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