Cat Scratch Disease – Heterogeneous in Clinical Presentation: Five Unusual Cases of an Infection Caused by Bartonella henselae

S. Weinspach; T. Tenenbaum; S. Schönberger; J. Schaper; R. Engers; J. Rueggeberg; C. R. MacKenzie; A. Wolf; E. Mayatepek; H. Schroten

doi:10.1055/s-0029-1233488

Klin Padiatr 2010; 222(2): 73-78
DOI: 10.1055/s-0029-1233488

Original Article

Cat Scratch Disease – Heterogeneous in Clinical Presentation: Five Unusual Cases of an Infection Caused by Bartonella henselae

Katzenkratzkrankheit – heterogen in der Klinischen Präsentation: Fünf ungewöhnliche Fälle einer Infection mit Bartonella henselae S. Weinspach¹ ^, ² , T. Tenenbaum¹ ^, ³ , S. Schönberger¹ ^, ² , J. Schaper⁴ , R. Engers⁵ , J. Rueggeberg¹ , C. R. MacKenzie⁷ , A. Wolf⁶ , E. Mayatepek¹ , H. Schroten¹ ^, ³

¹Department of General Pediatrics, University Children's Hospital, Heinrich Heine University Düsseldorf, Germany
²Clinic for Pediatric Oncology, Hematology and Clinical Immunology, University Children's Hospital, Heinrich Heine University Düsseldorf, Germany
³Pediatric Infectious Diseases, Department of Pediatrics, University Children's Hospital Mannheim, Germany
⁴Institute of Radiology, University Hospital, Heinrich Heine University Düsseldorf, Germany
⁵Institute of Pathology, University Hospital, Heinrich Heine University Düsseldorf, Germany
⁶Department of General and Visceral Surgery, University Hospital, Heinrich Heine University Düsseldorf, Germany
⁷Institute for Medical Microbiology and Hospital Hygiene, University Hospital, Heinrich Heine University Düsseldorf, Germany

Abstract

Background: Cat-scratch disease (CSD) is common in children, however the wide spectrum of the clinical presentation of CSD may lead to delayed diagnosis. An atypical presentation of CSD includes in its differential diagnosis diseases such as tuberculosis, other mycobacterioses, Epstein-Barr-Virus infection (EBV) or malignant disease. Since, in a small number of cases, these diseases may be present concurrently with an active CSD, it is important to consider CSD early in the differential diagnosis and order the appropriate tests. These tests include serology and, where possible, histology including molecular diagnostic methods on tissue specimens.

Patients and Method: We performed a case series of five patients treated in our hospital with a clinical diagnosis of cat-scratch disease, confirmed by serology. An analysis of the history and clinical symptoms associated specifically with an atypical presentation of CSD was performed.

Results: The clinical presentation of CSD no longer encompasses the original typical description from 1950, but rather presents with a wide spectrum of signs and symptoms, including the absence of a documented cat scratch, fever, primary lesions or peripheral lymphadenopathy. Low density lesions in spleen, liver and lymphnodes are typical findings in ultrasound, MRI, or CT. Ignoring CSD as a possibility in investigating possible malignancy or tuberculosis could lead to unneccesary hospitalisation and delay in the proper treatment.

Conclusion: CSD should also be considered in differential diagnosis of any patient with intraabdominal lymphadenopathy, abdominal pain and fever of unknown origin. A careful history is important however, often patients with CSD have no history of contact with cats. Therefore in atypical cases of CSD the finding of other clinical symptoms and performance of specific diagnostic tests is important. Our experience suggests that early serological testing for Bartonella henselae should be performed and may avoid invasive diagnostic procedures.

Zusammenfassung

Hintergrund: Die Katzenkratzkrankheit (CSD) ist im Kindesalter verbreitet. Das weite Spektrum in der klinischen Präsentation erschwert jedoch die Diagnose. Atypische Verläufe der CSD präsentieren sich klinisch häufig ähnlich schweren Krankheitsbildern wie Tuberkulose, anderen Mykobakterien, Epstein-Barr-Virus-Infektion (EBV) oder maligne Erkrankungen. In seltenen Fällen ist das gleichzeitige Auftreten dieser schweren Erkrankungen und CSD beschrieben. CSD frühzeitig in die möglichen Differenzialdiagnosen einzubeziehen und frühzeitige Diagnostik einzuleiten, ist daher sinnvoll. Diese Diagnostik umfasst die Serologie und, wenn möglich, histologische und molekulare Diagnostik aus Gewebeproben.

Patienten und Methode: Es wurde eine Fallserie mit 5 Fällen von atypischer CSD aus unserer Klinik erstellt. Wir untersuchten die Fälle serologisch gesicherter CSD auf spezifische anamnestische Hinweise und klinische Zeichen.

Ergebnisse: Das klinische Spektrum umfasst nicht nur die typischen Symptome entsprechend der Beschreibung von 1950, sondern umfasst ein weites Spektrum von klinischen Verläufen. Dies beinhaltet das Fehlen von Kratzspuren durch Katzen, Fieber, einer Primärläsion oder peripherer Lymphadenopathie. Echoarme Herde in Leber, Milz und Lymphknoten sind typische Befunde der Sonografie, im CT oder MRT. Die CSD als mögliche Diffferenzialdiagnose bei Verdacht auf Tuberkulose oder Malignomen zu ignorieren, kann zu unnötiger Hospitalisation und Verzögerungen der adäquaten Therapie führen.

Schlussfolgerung: CSD sollte differenzialdiagnostisch bei allen Patienten mit intraabdomineller Lymphadenopathie, abdominellen Schmerzen und unklarem Fieber berücksichtigt werden. Eine Infektion ist auch bei fehlendem Kontakt zu Katzen nicht ausgeschlossen Eine sorgfältige Anamnese ist wichtig, deshalb ist die Kenntnis wegweisender klinischer Symptome und die Durchführung gezielter Diagnostik bei atypischen Verläufen notwendig. Nach unseren Erfahrungen kann eine frühzeitige serologische Untersuchung auf Bartonella henselae eine invasive Diagnostik vermeiden.

Key words

CSD - lymphadenopathy - lymphadenitis - children - bartonella henselae

Schlüsselwörter

Katzenkratzkrankheit - Lymphknotenvergrößerung - Lymphadenitis - Kinder - Bartonella henselae

Full Text

References

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Correspondence

Dr. Sebastian Weinspach

Clinic for Paediatric Oncology,

Haematology and Clinical Immunology

University Children's Hospital

Heinrich Heine University

Düsseldorf

Moorenstraße 5

40225 Düsseldorf

Germany

Phone: 0211/811 82 97

Fax: 0211/811 65 39

Email: weinspach@med.uni-duesseldorf.de