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

© Georg Thieme Verlag KG Stuttgart · New York

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
Further Information

Publication History

Publication Date:
29 September 2009 (online)

Also available at
    Permissions and Reprints

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

Literatur

  • 1 Anderson BE, Neuman MA. Bartonella spp. as emerging human pathogens.  Clin Microbiol Rev. 1997;  10 203-219
    PubMedGoogle Scholar
  • 2 Arisoy ES, Correa AG, Wagner ML. et al . Hepatosplenic cat-scratch disease in children: selected clinical features and treatment.  Clin Infect Dis. 1999;  28 778-784
    CrossrefPubMedGoogle Scholar
  • 3 Bass JW, Freitas BC, Freitas AD. et al . Prospective randomized double blind placebo-controlled evaluation of azithromycin for treatment of cat-scratch disease.  Pediatr Infect Dis J. 1998;  17 447-452
    CrossrefPubMedGoogle Scholar
  • 4 Bass JW, Vincent JM, Person DA. The expanding spectrum of Bartonella infections: II. Cat-scratch disease.  Pediatr Infect Dis J. 1997;  16 163-179
    CrossrefPubMedGoogle Scholar
  • 5 Benesch M, Kerbl R, Wirnsberger A. et al . Peripheral lymphadenopathy in childhood – recommendations for diagnostic evaluation.  Klin Padiatr. 2000;  212 277-282
    Article in Thieme ConnectPubMedGoogle Scholar
  • 6 Caponetti G, Pantanowitz L. Cat-scratch disease lymphadenitis.  Ear Nose Throat J. 2007;  86 449-450
    PubMedGoogle Scholar
  • 7 Chen TC, Lin WR, Lu PL. et al . Cat scratch disease from a domestic dog.  J Formos Med Assoc. 2007;  106 S65-S68
    PubMedGoogle Scholar
  • 8 Diederen BM, Vermeulen MJ, Verbakel H. et al . Evaluation of an internally controlled real-time polymerase chain reaction assay targeting the groEL gene for the detection of Bartonella spp. DNA in patients with suspected cat-scratch disease.  Eur J Clin Microbiol Infect Dis. 2007;  26 629-633
    CrossrefPubMedGoogle Scholar
  • 9 Dzelalija B, Petrovec M, Avsic-Zupanc T. Probable atypical cat scratch disease presenting as isolated posterior pancreatic duodenal lymphadenitis and abdominal pain.  Clin Infect Dis. 2001;  33 912-914
    CrossrefPubMedGoogle Scholar
  • 10 Dunn MW, Berkowitz FE, Miller JJ. et al . Hepatosplenic cat-scratch disease and abdominal pain.  Pediatr Infect Dis J. 1997;  16 269-272
    PubMedGoogle Scholar
  • 11 Euchtler KRB, Beyer H, Moser O. et al . Vermeintlich harmlose Erkrankungen als Leitsymptom eines Neuroblastoms: 3 Fälle.  Klin Pädiatr. 2008;  220 107 FV6
    PubMedGoogle Scholar
  • 12 Florin TA, Zaoutis TE, Zaoutis LB. Beyond cat scratch disease: widening spectrum of Bartonella henselae infection.  Pediatrics. 2008;  121 e1413-e1425
    CrossrefPubMedGoogle Scholar
  • 13 Fox JW, Studley JK, Cohen DM. Recurrent expressive aphasia as a presentation of cat-scratch encephalopathy.  Pediatrics. 2007;  119 e760-e763
    CrossrefPubMedGoogle Scholar
  • 14 Garcia CJ, Varela C, Abarca K. et al . Regional lymphadenopathy in cat-scratch disease: ultrasonographic findings.  Pediatr Radiol. 2000;  30 640-643
    CrossrefPubMedGoogle Scholar
  • 15 Hajjaji N, Hocqueloux L, Kerdraon R. et al . Bone infection in cat-scratch disease: a review of the literature.  J Infect. 2007;  54 417-421
    CrossrefPubMedGoogle Scholar
  • 16 Herremans M, Vermeulen MJ, Van de Kassteele J. et al . The use of Bartonella henselae-specific age dependent IgG and IgM in diagnostic models to discriminate diseased from non-diseased in Cat Scratch Disease serology.  J Microbiol Methods. 2007;  71 107-113
    CrossrefPubMedGoogle Scholar
  • 17 Jackson LA, Perkins BA, Wenger JD. Cat scratch disease in the United States: an analysis of three national databases.  Am J Public Health. 1993;  83 1707-1711
    CrossrefPubMedGoogle Scholar
  • 18 Jacobs RF, Schutze GE. Bartonella henselae as a cause of prolonged fever and fever of unknown origin in children.  Clin Infect Dis. 1998;  26 80-84
    CrossrefPubMedGoogle Scholar
  • 19 Jameson P, Greene C, Regnery R. et al . Prevalence of Bartonella henselae antibodies in pet cats throughout regions of North America.  J Infect Dis. 1995;  172 1145-1149
    PubMedGoogle Scholar
  • 20 Kahr A, Kerbl R, Gschwandtner K. et al . Visceral manifestation of cat scratch disease in children. A consequence of altered immunological state?.  Infection. 2000;  28 116-118
    CrossrefPubMedGoogle Scholar
  • 21 Kusuhara K, Nakao F, Saito M. et al . Pyogenic splenic abscess in an infant with serological evidence of cat scratch disease.  Eur J Pediatr. 2007;  166 1289-1291
    CrossrefPubMedGoogle Scholar
  • 22 Lamps LW, Gray GF, Scott MA. The histologic spectrum of hepatic cat scratch disease. A series of six cases with confirmed Bartonella henselae infection.  Am J Surg Pathol. 1996;  20 1253-1259
    CrossrefPubMedGoogle Scholar
  • 23 Larsen CE, Patrick LE. Abdominal (liver, spleen) and bone manifestations of cat scratch disease.  Pediatr Radiol. 1992;  22 353-355
    CrossrefPubMedGoogle Scholar
  • 24 Li W, Raoult D, Fournier PE. Genetic diversity of Bartonella henselae in human infection detected with multispacer typing.  Emerg Infect Dis. 2007;  13 1178-1183
    PubMedGoogle Scholar
  • 25 Machi T. Cat scratch disease showing clinical picture resembling tuberculous lymphadenitis: a case report.  Kekkaku. 2001;  76 545-548
    PubMedGoogle Scholar
  • 26 Maman E, Bickels J, Ephros M. et al . Musculoskeletal manifestations of cat scratch disease.  Clin Infect Dis. 2007;  45 1535-1540
    CrossrefPubMedGoogle Scholar
  • 27 Margileth AM. Antibiotic therapy for cat-scratch disease: clinical study of therapeutic outcome in 268 patients and a review of the literature.  Pediatr Infect Dis J. 1992;  11 474-478
    PubMedGoogle Scholar
  • 28 Massei F, Gori L, Macchia P. et al . The expanded spectrum of bartonellosis in children.  Infect Dis Clin North Am. 2005;  19 691-711
    CrossrefPubMedGoogle Scholar
  • 29 Melikian AL, Mediannikov O, Kaplanskaia IB. et al . Bartonella infection in hematological practice.  Ter Arkh. 2007;  79 58-62
    PubMedGoogle Scholar
  • 30 Niedzielska G, Kotowski M, Niedzielski A. et al . Cervical lymphadenopathy in children – incidence and diagnostic management.  Int J Pediatr Otorhinolaryngol. 2007;  71 51-56
    CrossrefPubMedGoogle Scholar
  • 31 Ridder-Schröter R. et al . Abszedierende Lymphadenitis und Osteomyelitis durch Bartonella henselae Infektion.  Klin Padiatr. 2007;  219 112
    PubMedGoogle Scholar
  • 32 Rolain JM, Lepidi H, Zanaret M. et al . Lymph node biopsy specimens and diagnosis of cat-scratch disease.  Emerg Infect Dis. 2006;  12 1338-1344
    PubMedGoogle Scholar
  • 33 Sander A, Berner R, Ruess M. Serodiagnosis of cat scratch disease: response to Bartonella henselae in children and a review of diagnostic methods.  Eur J Clin Microbiol Infect Dis. 2001;  20 392-401
    PubMedGoogle Scholar
  • 34 Scolfaro C, Leunga GG, Bezzio S. et al . Prolonged follow up of seven patients affected by hepatosplenic granulomata due to cat-scratch disease.  Eur J Pediatr. 2007; 
    PubMedGoogle Scholar
  • 35 Schwarz SHG, Fiedler A, Beyer H. et al . Differenzialdiagnose abdomineller Lymphadenopathien bei Neugeborenen.  Klin Padiatr. 2008;  220 107
    PubMedGoogle Scholar
  • 36 Tsujino K, Tsukahara M, Tsuneoka H. et al . Clinical implication of prolonged fever in children with cat scratch disease.  J Infect Chemother. 2004;  10 227-233
    PubMedGoogle Scholar
  • 37 Wilson M. Persistent abdominal pain.  Clin Pediatr (Phila). 2005;  44 553
    CrossrefPubMedGoogle Scholar
  • 38 Windsor JJ. Cat-scratch disease: epidemiology, aetiology and treatment.  Br J Biomed Sci. 2001;  58 101-110
    PubMedGoogle Scholar

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

      >