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Cat-Scratch Disease

(Cat-Scratch Fever)

by Larry M. Bush, MD, Maria T. Perez, MD

Cat-scratch disease is infection caused by Bartonella henselae. Symptoms are a local papule and regional lymphadenitis. Diagnosis is clinical and confirmed by biopsy or serologic tests. Treatment is with local heat application, analgesics, and sometimes antibiotics.

The domestic cat is a major reservoir for B. henselae (see also Overview of Bartonella Infections). The prevalence of B. henselae antibodies in US cats is 14 to 50%. About 99% of patients report contact with cats, most of which are healthy. The specific location of the organism in the cat is unclear; however, periods of asymptomatic bacteremia occur in cycles. Infection is spread to humans via a bite or scratch. The cat flea may be an additional vector. Children are most often affected.

Symptoms and Signs

Within 3 to 10 days after a bite or scratch, most patients develop an erythematous, crusted papule (rarely, a pustule) at the scratch site. Regional lymphadenopathy develops within 2 wk. The nodes are initially firm and tender, later becoming fluctuant, and may drain with fistula formation. Fever, malaise, headache, and anorexia may accompany lymphadenopathy.

Unusual manifestations occur in 5 to 14% of patients: Parinaud oculoglandular syndrome (conjunctivitis associated with palpable preauricular nodes) in 6%, neurologic manifestations (encephalopathy, seizures, neuroretinitis, myelitis, paraplegia, cerebral arteritis) in 2%, and hepatosplenic granulomatous disease in < 1%. Patients may also present with an FUO. B. henselae is one of the most common causes of culture-negative endocarditis. Severe disseminated illness may occur in patients with AIDS.

Lymphadenopathy subsides spontaneously within 2 to 5 mo. Complete recovery is usual, except in severe neurologic or hepatosplenic disease, which may be fatal or have residual effects.

Diagnosis

  • Acute and convalescent serologic testing or PCR testing

  • Sometimes lymph node biopsy

Diagnosis is typically confirmed by positive serum Ab titers (testing acute and convalescent sera 6 wk apart is recommended) or PCR testing of samples from lymph node aspirates.

Because similar lymphadenopathy may be caused by other infections (eg, tularemia, mycobacterial infection, brucellosis, fungal infection, lymphogranuloma venereum), testing for those organisms may be done if the diagnosis is not clearly cat-scratch disease. Lymph node biopsy may be done if cancer is suspected or if the diagnosis of cat-scratch disease needs to be confirmed. Diagnosis is suggested by characteristic histopathologic findings (eg, suppurative granulomas) or detection of organisms by immunofluorescence.

Immunocompromised patients and patients with systemic symptoms should also have blood cultures. Lymph node aspirates are rarely culture-positive. However, Bartonella sp can be isolated from cultures of lymph node biopsy specimens.

Treatment

  • Local heat and analgesics

  • Sometimes antibiotics for immunocompromised patients

Treatment in immunocompetent patients is local heat application and analgesics for this typically self-limited disease. If a lymph node is fluctuant, needle aspiration usually relieves the pain.

Antibiotic treatment is not clearly beneficial and generally should not be given for localized infection in immunocompetent patients. However, azithromycin, erythromycin, or doxycycline is often given to reduce adenopathy and perhaps decrease the risk of systemic spread. A fluoroquinolone, gentamicin, or doxycycline may be used for bacteremia in AIDS patients. Prolonged therapy (eg, weeks to months) is usually necessary for bacteremia to clear. In vitro antibiotic susceptibilities often do not correlate with clinical results; testing often shows sensitivity to trimethoprim/sulfamethoxazole (TMP/SMX) and cephalosporins, but except for 3rd-generation cephalosporins, these drugs are clinically ineffective.

Drugs Mentioned In This Article

  • Drug Name
    Select Trade
  • PERIOSTAT, VIBRAMYCIN
  • ERY-TAB, ERYTHROCIN
  • GENOPTIC
  • ZITHROMAX
  • No US brand name

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