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Arch Pediatr Adolesc Med. 2009;163(1):86.

Denouement and Comment: Cat-Scratch Disease
Shortly after the biopsies were performed, the child's father was available to provide additional history. The father was scratched by the family's kitten shortly after its acquisition 1 month before. He was given penicillin prophylaxis. He developed a fever and axillary lymphadenopathy 1 week later, a course of illness that suggested cat-scratch disease.

Pathologic specimens demonstrated small, rodlike organisms on Warthin-Starry staining of the lymph node (Figure 3B, inset). The B henselae genome was detected by polymerase chain reaction testing of the muscle tissue. Convalescent B henselae serology remained at the same titers (IgM < 1:16; IgG, 1:128) as during the acute phase of the illness. Cat-scratch disease is a well-known cause of fever and lymphadenopathy in children. The causative agent, B henselae, is a pleomorphic, aerobic, gram-negative bacterium commonly found in the oral flora of cats and kittens as well as other animals.¹

View larger version (201K): [in this window] [in a new window] [as a PowerPoint slide]   Figure 3. A, Histologic section of the lymph node biopsy specimen showing effacement of normal lymph node architecture and replacement by granulomatous inflammation characterized by an outer rim of small lymphocytes and collections of epithelioid histiocytes with a pale eosinophilic appearance surrounding areas of suppurative necrosis (arrows) (hematoxylin-eosin staining, original magnification x100). B, Histologic section of the needle biopsy specimen of left pelvic tissue showing a dense mixed inflammatory infiltrate composed of lymphocytes (far right) and collections of palisading epithelioid histiocytes (white arrows) surrounding areas of suppurative necrosis (black arrows) (hematoxylin-eosin staining, original magnification x100). Inset, Warthin-Starry silver staining was performed and showed a few small rod-shaped organisms (arrow) (original magnification x1000).

CLINICAL MANIFESTATIONS

Lymphadenopathy or lymphadenitis develops in regional lymph nodes following inoculation by a cat scratch or bite. Bacterial spread can occur through contiguous or hematogenous routes. Suppurative complications of B henselae, while uncommon, have been described in the literature.^2-5 Bone infection occurs in 0.17% to 0.27% of known cases of cat-scratch disease; the pelvic girdle is the second-most-common site of osteomyelitis after the vertebral column. Approximately 12% of patients with B henselae osteomyelitis have concomitant lymphadenopathy.⁶ Myalgia is a common complaint in children with cat-scratch disease,⁷ though myositis is infrequently described. Our patient had significant myositis visualized on magnetic resonance imaging adjacent to the area of osteomyelitis.

DIAGNOSIS

Bartonella serology is the most commonly used diagnostic test, with a sensitivity as high as 88% and a specificity of 97%, compared with patients with a clinical presentation consistent with cat-scratch disease and one other positive diagnostic test result (culture, skin testing, or polymerase chain reaction). Acute-phase titers are normal in as many as 75% of infected patients and should be repeated in the convalescent phase for diagnosis. Bartonella polymerase chain reaction has become an added tool in the diagnosis of this elusive infection. The literature indicates that although sensitivity of the assay may be low (43%-76%), specificity is high, even reaching 100% compared with combined clinical, histologic, and serologic evidence.⁸

TREATMENT

In the immunocompetent host, cat-scratch disease is a self-limited process. Treatment of suppurative B henselae infections has not been adequately evaluated. One review of 47 cases of osteomyelitis caused by B henselae suggested that the prognosis for recovery is excellent irrespective of antimicrobial selection.⁶

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AUTHOR INFORMATION
Correspondence: Eric J. Haas, MD, Pediatrics A, Soroka University Hospital, Beersheva 84101, Israel (haase{at}email.chop.edu).

Accepted for Publication: August 23, 2008.

Author Contributions: Study concept and design: Haas and Ernst. Acquisition of data: Ernst. Analysis and interpretation of data: Ernst. Drafting of the manuscript: Haas and Ernst. Critical revision of the manuscript for important intellectual content: Ernst. Administrative, technical, and material support: Haas and Ernst. Study supervision: Ernst.

Financial Disclosure: None reported.

REFERENCES
1. Florin TA, Zaoutis TE, Zaoutis LB. Beyond cat scratch disease: widening spectrum of Bartonella henselae infection. Pediatrics. 2008;121(5):e1413-e1425. FREE FULL TEXT 2. Abdel-Haq N, Abuhammour W, Al-Tatari H, Asmar B. Disseminated cat scratch disease with vertebral osteomyelitis and epidural abscess. South Med J. 2005;98(11):1142-1145. FULL TEXT | WEB OF SCIENCE | PUBMED 3. Heye S, Matthijs P, Wallon J, van Campenhoudt M. Cat scratch disease osteomyelitis. Skeletal Radiol. 2003;32(1):49-51. WEB OF SCIENCE | PUBMED 4. Mirakhur B, Shah SS, Ratner AJ, Goldstein SM, Bell LM, Kim JO. Cat scratch disease presenting as orbital abscess and osteomyelitis. J Clin Microbiol. 2003;41(8):3991-3993. FREE FULL TEXT 5. Ridder-Schröter R, Marx A, Beer M, Tappe D, Kreth HW, Girschick HJ. Abscess forming lymphadenopathy and osteomyelitis in children with Bartonella henselae infection. J Med Microbiol. 2008;57(pt 4):519-524. FREE FULL TEXT 6. Hajjaji N, Hocqueloux L, Kerdraon R, Bret L. Bone infection in cat-scratch disease: a review of the literature. J Infect. 2007;54(5):417-421. PUBMED 7. Maman E, Bickels J, Ephros M; et al. Musculoskeletal manifestations of cat scratch disease. Clin Infect Dis. 2007;45(12):1535-1540. PUBMED 8. Hansmann Y, DeMartino S, Piémont Y; et al. Diagnosis of cat scratch disease with detection of Bartonella henselae by PCR: a study of patients with lymph node enlargement. J Clin Microbiol. 2005;43(8):3800-3806. FREE FULL TEXT

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