An 11-Year-Old Male With Vertebral Osteomyelitis and a Paraspinal Abscess

Cat Scratch Disease in Pediatrics: Who Has Systemic Involvement?

BACKGROUND

Bartonella henselae is the agent responsible for cat scratch disease (CSD). Although lymphadenopathy is typically the defining symptom, some patients develop potentially severe systemic compromise. It is unknown why some patients progress to systemic disease. The objective of this study was to describe the clinical, epidemiologic and laboratory characteristics of children with CSD and to analyze the differences between systemic versus localized infections.

METHODS

Patients were identified by a retrospective review of medical records at a tertiary pediatric care hospital in Buenos Aires, Argentina, from January 2012 to July 2021. A CSD case was defined as any patient who presented compatible clinical findings with a positive serologic test (IgG >1/64 or IgM immunofluorescence) for B. henselae.

RESULTS

A total of 197 patients were identified, with a median age of 8 years (range: 1-17.4 years). The most frequent clinical symptoms were fever and lymphadenopathy. Systemic involvement was present in 34.5% (n = 68) of patients and the most common presentation was splenic abscess (n = 51), followed by liver abscess (n = 23), chorioretinitis (n = 9), osteomyelitis (n = 5) and pneumonitis (n = 3). Patients with invasive disease more frequently presented with fever (79.4% vs. 50.3%) (P<0.001) and had higher C-reactive protein levels (24.9 vs. 6.7 mg/L) (P<0.001). Antibiotic therapy was administered to 95.9% (n = 187) of patients and most with systemic disease (77%) used combination treatment. Most patients recovered fully, and there were no reported deaths.

CONCLUSIONS

CSD must be considered a potential cause of lymphadenopathy. Patients with fever and elevated C-reactive protein should be evaluated to rule out systemic compromise.

Atlantoaxial instability secondary to Bartonella henselae osteomyelitis managed surgically by atlantoaxial instrumentation: A case report and systematic review

Cat scratch disease (CSD), caused by Bartonella henselae, may atypically present with vertebral osteomyelitis. Antibiotic regimens are tailored to presentation, which is markedly variable and not well defined for any atypical disease. In cases of spinal instability, the use of antibiotics alone may not be sufficient. Atlantoaxial instability caused by osteomyelitis is a rare complication of CSD. In this report, we describe the rare case of vertebral osteomyelitis complicated by atlantoaxial instability, requiring both antibiotics and atlantoaxial fusion. We discuss our case, surgical technique, rationale, and outcome. In addition, we conducted a systematic review of the literature of vertebral osteomyelitis in pediatric secondary to B. henselae. A 2-year-old child presented with a 2-month history of irritability, fever, and rigid neck pain along with a recent history of feline exposure. Physical examination revealed cervical tenderness and decreased range of motion. Computed tomography (CT) showed osteolysis of the right C1 lateral mass and pars articularis; T1-weighted magnetic resonance imaging with contrast showed enhancement around the right C1 lateral mass. The titer for B. henselae was high. A diagnosis of cat scratch osteomyelitis with cervical instability was made, for which the patient underwent surgery with atlantoaxial fusion. Postoperative imaging demonstrated resolution of the contrast-enhanced lesion. At 6-year follow-up, the patient showed no signs of residual complications from surgical intervention with a solid fusion. Our review revealed 44 cases of pediatric CSD vertebral osteomyelitis. Conservative management with antibiotic employed in 86% while antibiotics with surgical intervention in 14% of the cases. Surgical intervention was most often in the form of incision for drainage and decompression without fusion. Average follow-up 10 months with 86% achieved complete resolution. Cervical instability caused by osteolysis is a rare complication of CSD. This can subsequently lead to vertebral instability, requiring definitive surgical intervention.