Cat scratch disease A28.10

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

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

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.

Bartonella spp. (gram-negative, pleomorphic, partly straight, partly curved, slender, monotrichous flagellated rod-shaped bacteria that differ genomically). The natural pathogen reservoir of the bacteria is probably surface water (typical wetland and puddle germ).

Infection with Bartonella (formerly Rochalimaea) henselae (small pleomorphic bacteria). Afipia felis is detected in <5% of cases.

Pathogenetically, infection with cutaneous lymphonodary primary complex occurs through exogenous inoculation, particularly cat scratch or bite lesions. However, infection is also possible through flea and tick bites.

Infected target cells (endothelial cells) induce release of growth factors (e.g. VEGF: vascular endothelial growth factor) leading to endothelial cell proliferation.

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.

(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.

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

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

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

The symptoms may include encephalitis, encephalomyelitis, neuritis, neuroretinitis with acute amaurosis, pneumonia, splenomegaly, osteolytic changes, thyroiditis, glomerulonephritis, and generalized lymph node swelling.

Life-threatening courses with scarlatiform or morbilliform exanthema (see figure) may occur in immunocompromised patients.

Usually spontaneous healing, if necessary 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.

In immunosuppressed patients, intravenous therapy with 2x1g erythromycin for 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.

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

The oculoglandular Parinaud syndrome is a special form of manifestation. Here, the inoculation takes place at the conjunctiva. Clinical manifestations include conjunctival granulomas and preauricular adenopathy (Domínguez I et al. 2019).

Unilateral lymphadenitis in cat scratch disease.

Bartonella henselae is a relatively rare pathogen that can be causative of a severe disseminated infectious disease in immunocompromised patients.

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

Sonographically, an irregular, circumscribed 5 cm x 4 cm, echo-poor mass with discrete blood flow presented.

Lymph node biopsy: Fine tissue showed granulomatous inflammation with central necrosis. Antibody detection of Bartonella antigen by PCR.

Laboratory: Nonspecific elevation of inflammatory values (CRP↑ leukocytosis) detectable.

The patient was diagnosed with cat scratch disease and was adjusted with erythromycin 1g/2x/day i.v. for 3 weeks. This resulted in complete healing.

This case highlights the classic presentation of this rare disease in an immunocompromised patient with cat scratch disease. Early antibiotic use should be done early in patients considered at risk.

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