Cat scratch disease A28.10

Authors: Prof. Dr. med. Peter Altmeyer, Prof. Dr. med. Martina Bacharach-Buhles

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Last updated on: 07.06.2021

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Benign inoculation lymphoreticulosis; Benign inoculative lymphoreticulosis; cat scratch disease; Cat scratch disease or fever; Cat scratch fever; Cat scratching lymphadenitis; Inoculation lymphoreticulosis benign; Maladie of the handle de Chat; Parinaud's oculoglandular syndromes

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Parinaud, 1889; Petzetakis, 1935; Debré, 1950; Mollaret, 1950;

Diane Hensel of Oklahoma first isolated the pathogen in 1990, and it was given her name.

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Worldwide occurring bacterial infectious disease with acute or sub-acute course and spontaneous healing, which is counted among the Bartonellosis. Inoculation of the pathogen often through cat scratches or bites.

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Bartonella spp. (gram-negative, pleomorphic, partly straight, partly curved, slender, monotrich flagellated rod bacteria that are genomically different). The natural reservoir of the bacteria is probably surface water (typical damp and puddle germ).

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Worldwide distribution, incidence peaks in late autumn and in the winter months.

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Infection with Bartonella (formerly Rochalimaea) henselae (small pleomorphic bacteria). Pathogenetically, infection with cutaneous lymphonodary primary complex occurs by exogenous inoculation, especially through cat scratch or bite lesions; however, infection is also possible through flea and tick bites. Infected target cells (endothelial cells) induce the release of growth factors (e.g. VEGF: vascular endothelial growth factor), which lead to endothelial cell proliferation.

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Mainly occurring in children and adults under 20 years of age.

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Mainly uncovered body parts, primary lesion in 50% of patients arms and hands.

Clinical features
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Incubation period usually 10 days (3-60 days).

General symptoms: Subfebrile temperature or fever, headache, muscle and joint pain, fatigue, loss of appetite; generalized lymphadenopathy, splenomegaly.

Integument: inconspicuous primary effect at the entry site of the pathogen: inflammatory reddening, ulcerous nodules. After about 6 weeks lymph node enlargement in the lymph drainage area, rarely melting and perforation of the affected lymph node = primary complex.

Optional: scarlatiniform, morbilliform, maculopustular exanthema, possibly erythema exsudativum multiforme, erythema nodosum. Inconstant also maculopapular, nodose or multiforme exanthema.

Ectopic and atypical course: Oral and pharyngeal involvement with acute tonsillitis and fever, swelling of the cervical lymph nodes and occasionally retropharyngeal and peritonsillar abscesses.

Conjunctival (oculo-glandular) form (Parinaud syndrome): Unilateral (follicular) conjunctivitis and indolent ipsilateral preauricular lymphadenitis and fever.

Mesenteric form: Adenitis mesenterica, granulomatous abscessed hepatitis and splenitis.

Thoracic form: Mediastinal lymph node swelling.

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(primary lesion and lymph nodes): Focal necroses with neutrophilic abscesses and surrounding granulomatous reaction. Later tuberculoid granulomas with star-shaped cystic necrosis.

Whartin-Starry silver impregnation and tissue gram staining according to Brown-Hopps: pleomorphic, comma-shaped to coccoid gram-negative bacterial clusters.

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Clinic, histology (skin or lymph nodes), PCR diagnostics (serum, skin), ELISA (serum).

Culture from skin swabs: B. henselae shows good growth on anaerobic blood agar and chocolate plates. Small, non-hemolytic, rough, dry, yellow to grey colonies grow there.

Differential diagnosis
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Primary tularemic complex; venereal infection; actinomycosis of the skin; primary tuberculous complex; brucellosis; sporotrichosis; infection with non-tuberculous (formerly: "atypical") mycobacteria;

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Occurrences may include encephalitis, encephalomyelitis, neuritis, neuroretinitis with acute amaurosis, pneumonia, splenomegaly, osteolytic changes, thyroiditis, glomerulonephritis, generalized swelling of lymph nodes.

Life-threatening courses can occur in immunocompromised patients.

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Usually spontaneous healing, possibly erythromycin (e.g. Erythromycin Filmtbl.) 3-4 times/day 500 mg p.o. or ciprofloxacin (e.g. Ciprobay) 2 times/day 500 mg p.o. over a period of 10-14 days.

For immunocompromised patients, intravenous therapy with 2x1g erthromycin over 3 weeks is recommended.

Alternatively Cotrimoxazole (e.g. Eusaprim) 2 times/day 2 Tbl. p.o., possibly in combination with Doxycycline 2 times/day 100-200 mg p.o.

External therapy
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Antiseptic compresses, e.g. with quinolinol, potassium permanganate or with synthetic tanning agents (e.g. ethacridine lactate/Tannolact®).

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Spontaneous healing within weeks to months.

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A special form of manifestation is the oculoglandular Parinaud syndrome. Here, inoculation takes place at the conjunctiva. Clinically, conjunctival granulomas and a preauricular adenopathy are clinically impressive (Domínguez I et al. 2019).

Case report(s)
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Unilateral lymphadenitis in cat scratch disease

Bartonella henselae is a relatively rare pathogen that can be the cause of a severe infection in immunocompromised patients.

A 76-year-old man with stable chronic lymphatic leukemia (CLL) presented with right-axillary, moderately painful lymphadenitis. At the same time he complained of general complaints such as: fever (up to 38.5C°), tiredness and headache. This was preceded by a cat bite on the ipsilateral finger.

Sonographically, an irregular, circumscribed 5 cm x 4 cm, low-echo mass with discrete blood flow was visible.

Lymph node biopsy: The histological findings were a granulomatous inflammation with central necrosis. Antibody detection of Bartonella antigen by PCR.

Laboratory: Non-specific increase of inflammation values (CRP↑ Leukocytosis) detectable.

The patient was treated with diagnosed cat scratch disease with erythromycin 1g/2x/day i.v. for 3 weeks. Thus a complete healing could be achieved.

This case underlines the classical presentation of this rare disease in an immunocompromised patient with cat contact. Early antibiotic use should be made at an early stage in patients considered at risk.

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  1. Balakumar A et al (2019) Isolated Axillary Lymphadenitis Due to Bartonella Infection in an Immunocompromised Patient. Cureus. 2019 Aug 21;11:e5456.
  2. Brenner DJ et al (1991) Proposal of Afipia gen. nov., with Afipia felis sp. nov. (formerly the cat scratch disease bacillus). J Clin Microbiol 29: 2450-2460
  3. Debré R et al (1950) Le maladie des griffes de chat. Bull med Soc Hôp Paris 66: 76-79
  4. Dolan ML et al (1993) Syndrome of Rochalimaea henselae adenitis suggesting cat scratch disease. Ann Internal Med 118: 331-336
  5. Domínguez I et al (2019) Isolated conjunctival granuloma as a first manifestation of Parinaud's
  6. oculoglandular syndrome: A case report. On J Ophthalmol Case Rep 14:58-60.
  7. Gonzalez BE et al (2003) Cat-scratch disease occurring in three siblings simultaneously. Pediatric Infect Dis J 22: 467-468
  8. Mirakhur B et al (2003) Cat scratch disease presenting as orbital abscess and osteomyelitis. J Clin Microbiol 41: 3991-3993
  9. Mollaret P et al (1950) Sur une adénopathie régionale subaiguë et spontanément curable, avec intradermo-réaction et lésions ganglionnaires particulières. Bull méd Soc Hôp Paris 66: 424-449
  10. Parinaud H (1889) Conjonctivite infectieuse transmise par les animaux. Ann Oculistique 101: 252-253
  11. Petzetakis M (1935) Monoadénite subaiguë multiple de nature inconnue. Soc méd Athènes, Seatzg of 16. 3. 1935, p 229
  12. Rolain JM et al (2003) Cat scratch disease with lymphadenitis, vertebral osteomyelitis, and spleen abscesses. Ann N Y Acad Sci 990: 397-403
  13. Wear DJ, Margileth AM, Hadfield TL et al (1983) Cat scratch disease: A bacterial infection. Science 221: 1403-1405
  14. Welch DF et al (1992) Rochalimaea henselae sp. nov., a cause of septicemia, bacillary angiomatosis, and parenchymal bacillary peliosis. J Clin Microbiol 30: 275-280


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