Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature. Cat Scratch Disease The first description in the literature of Cat Scratch Diseaseis credited to Henri Parinaud in 1889. Writing in the Frenchliterature, he described a case of conjunctival granulomatous inflammation with ipsilateral preauricular adenopathy, a syndrome which now bears his name. In 1931 Dr. Robert Debré describeda case of a boy with a cat scratch on his hand associated witha suppurative epitrochlear lymph node. He is credited with recognizing the cat as the vector of this illness and coined the term "catscratch disease". Foshay noticed similar cases in the United States and independently named the condition "cat fever". A series of 160 cases was reported by Daniels in 1954, stimulating interest in cat scratch disease in this country. A skin tes twas developed by Hanger and Rose in 1946. Cat scratch disease is primarily a disease of children and young adults. It is classically described as a "subacute regional lymphadenitis", and occurs worldwide with no racial or sex predilection. Although this disorder is strongly associated with cats, other animals have also been implicated. Reports may befound of transmission by dogs, rabbits, and monkeys. A few anecdotal cases have also been described involving transmission by porcupine quills and fish bones. A primary lesion will usually appear at the inoculation site,and, if carefully looked for, may be found in about 90% of cases. Appearing 1-2 weeks following inoculation, it is typically described as a nonpruritic erythematous papule, or possibly a vesicle or pustule. Resolution without scarring occurs within 2-3 weeks. A single proximal lymph node will enlarge in the majority of the cases, typically measuring 2-4 cm in diameter although occasionall ythe node may be much larger. Most commonly affected are the axillaryand epitrochlear nodes as well as the cervical or preauricularlymphatics. Generally this unilateral subacute regional lymphadenitisis associated with only slight tenderness unless suppuration occurs. In these 10-20% cases the node may be very painful with associated fever and malaise. The adenopathy will usually resolve withou tintervention in 2-3 months although occasionally the node may remain enlarged for up to two years. The cat is the healthy vector of this illness, and displays no signs of illness. Transmission occurs by scratching, biting,or possibly even licking. Kittens seem to be particularly common as vectors. Most authors agree that there is little risk to other family members and that it is not necessary to get rid of the cat. Several variants of cat scratch disease have been described. The first reported and most common is Parinaud's oculoglandula rsyndrome, which consists of a unilateral conjunctivitis associated with preauricular lymphadenopathy. The ocular lesion is generally a polypoid granular lesion of the palpebral conjunctiva, without corneal involvement. Resolution without sequelae is the usua lcourse, and surgical intervention is not recommended. Other variants of cat scratch include CNS involvement with the sudden onset o fseizures and coma several weeks following an otherwise typical course of cat scratch. Examination of the spinal fluid demonstrates only a mild pleocytosis. Fortunately most of these patients recover completely within 2-10 days. Several skin reactions have been reported, including erythema nodosum, erythema marginatum, anderythema multiforme. In immunocompromised patients disseminated disease may occur with involvement of the liver and spleen. A skin test has been used in the diagnosis of cat scratch fordecades. First developed by Hanger and Rose in 1946, aspirated material from a lymph node of a patient with known cat scratc hdisease was pasteurized, standardized, and tested for sterility. It was then injected subdermally in much the same manner as the PPD. Mentioned throughout the literature as an accepted diagnostic maneuver, it has never been available commercially. Although no documented cases of disease transmission have been reported, it is not frequently used today because of the theoretical risk of transmission of hepatitis and AIDS. The criteria most frequently listed in the literature to establishthe diagnosis of cat scratch disease include: 1) exposure to cats; 2) regional lymphadenitis; 3) a positive skin test; 4) elimination of other causes of lymphadenopathy; and, 5) compatiblehistologic features. The differential diagnosis includes bacterialadenitis, lymphogranuloma venereum, tuberculosis, atypical mycobacterial infections, tularemia, brucellosis, mononucleosis, syphilis, toxoplasmosis,fungal infection, sarcoidosis, and nodular lymphomas. All cultures and microbiologic stains of aspirated material will be negative. Although nonspecific, a mild eosinophilia and elevated ESR are frequently seen. Although biopsy is usually not needed in the typical case, it may be helpful in those cases in which the diagnosis is unclear, if there is no history of cat contact, or if other potentially serious and treatable disorders must be ruled out. The typical nonspecific histologic finding is necrotizing granulomas, usually without caseous degeneration. For decades efforts to identify the causative organism behind cat scratch disease had been fruitless. However in 1983, Dr. Daniel Wear of the Armed Forces Instituteof Pathology demonstrated pleomorphic coccobacilli using the Warthin-Starry silver impregnation stain. Reported in a landmark article in JAMA 1988, the organism was finally cultured in the laboratory and Koch's postulates fulfilled by English and Wear of the AFIP. As of November 1991, this bacteria has been named Afipia felis. The usual infection with cat scratch is self-limited and no specific treatment is necessary. Spontaneous resolution is expected in 2-3 months. Reports may be found in the literature concerning the effectiveness of various antibiotics including gentamicin,ciprofloxacin (not to be used in children), and Bactrim, however their use is not widely accepted. Aspiration may be helpful fo rthose cases in which suppuration occurs. Incision and drainage carries the reported risk of sinus tract formation and formal node excision may be preferable. Case Presentation A two-year-old white male presented with a four week history of an enlarging left cervical lymph node, which became progressively erythematous and tender over the previous two weeks despite oral antibiotics. A small scratch probably received from a cat was noted on the child's chin. A subtotal excision of the node was performed, and all cultures and microbiologic stains of the necrotic material obtained were negative. Histologic sections demonstrated necrotizing granulomatous inflammation. Pleomorphicbacilli were seen with the Warthin-Starry stain. This lesio healed rapidly, however a left parotid mass developed two months later. Incision and drainage yielded only pus, with no discernable lymphatic tissue. Again, all cultures and microbiologic stains were negative. The adenopathy has resolved and the child has had no further difficulties. Bibliography Bogue CW, et al: Antibiotic therapy for cat-scratch disease? JAMA 1989;262:813-16. Brenner DJ, Hollis DG, Moss CW, et al: Proposal of Afipiafelis sp. nov. (formerly the cat scratch disease bacillus),Afipia clevelandensis sp. nov. (formerly the ClevelandClinic Foundation strain), Afipia broomeae sp. nov., andthree unnamed genospecies. J Clin Microbiol 1991;29:2450-2460. Carithers HA: Cat-scratch disease: notes on its history. AmJ Dis Child 1970;119:200-203. Carithers HA: Diagnosis of cat-scratch disease. Pediatrics1985;76:325-6. Carithers HA: Oculoglandular disease of Parinaud: a manifestationof cat-scratch disease. Am J Dis Child 1978;132:1195-1200. Carithers HA, Margileth AM: Cat-scratch disease: acute encephalopathyand other neurologic manifestations. Am J Dis Child 1991;145:98-101. Collipp PJ: Cat-scratch disease therapy. Am J Dis Child 1989;143:1261. Delahoussaye PM, Osborne BM: Cat-scratch disease presentingas abdominal visceral granulomas. J Inf Dis 1990;161:71-78. Eisenstein BI: New opportunistic infections - more opportunities. N Engl J Med 1990;323: 1625-27. English CK, et al: Cat-scratch disease: isolation andculture of the bacterial agent. JAMA 1988;259:1347-52. Gerber MA, et al: The aetiological agent of cat scratchdisease. Lancet 1985;June 1, 1236-39. Hadfield TL, et al: Is Rothia Dentocariosa the cause ofcat scratch disease? Lancet 1985;September 28:720-21. Heroman WM, McCurley WS: Cat scratch disease. OtolaryngolClin North Am 1982;15:149-58. Holley HP: Successful treatment of cat-scratch disease with ciprofloxacin. JAMA 1991;265:1563-65. Kirkpatrick CE, Glickman, LT: Cat-scratch disease and the roleof the domestic cat: vector, reservoir, and victim? MedicalHypotheses 1989;28:145-49. LeBoit PE, et al: Bacillary angiomatosis: the histopathologyand differential diagnosis of a pseudoneoplastic in patients withhuman immunodeficiency virus disease. Am J Surg Path 1989;13:909-20. Malatack JJ, et al: Cat-scratch disease without adenopathy. J Pediatrics 1989;114:101-104. Margileth AM: Cat scratch disease: a therapeutic dilemma. Vet Clin North Am 1987;17:91-103. Margileth AM: Cat scratch disease: nonbacterial regional lymphadenitis. Pediatrics 1968;42:803-18. Margileth AM: Safety of Cat-scratch skin test material. PediatrInfec Dis 1984;3:281-282. Margileth AM, et al: Cat-scratch disease: bacteria atthe primary inoculation site. JAMA 1984;252:928-31. McQueen WJ, Johnson JT: Cat-scratch disease of the submandibularregion. J Laryngol Otol 1981;95:1169-72. Miller-Catchpole R, et al: Cat scratch disease: identificationof bacteria in seven cases of lymphadenitis. Am J Surg Path1986;10:276-81.
Moss CW, et al: Cellular fatty acid composition of anunidentified organism and a bacterium associated with cat scratchdisease. J Clin Micr 1990;28:1071-74. Schlossberg D, et al: Culture-proved disseminated cat-scratchdisease in acquired immunodeficiency syndrome. Arch InternMed 1989;149:1437-39. Schwartzman WA, et al: Epithelioid angiomatosis or catscratch disease with splenic and hepatic abnormalities in AIDS: case report and review of the literature. Scand J InfectDis 1990;22:121-33. Shinall EA: Cat-scratch disease: a review of the literature. Pediatr Derm 1990;7:11-18. Small WT, Sniffen RC: Nonbacterial regional lymphadenitis ("cat-scratchfever"): evaluation of surgical management. NEJM 1956;255:1029-33. Spires J, Smith RH: Cat-scratch disease. Otolaryngol HeadNeck Surg, 1986;94:622-27. Tolan, RW, et al: Unusual systemic, pseudomalignant manifestationsof cat-scratch disease in siblings. Pediatr Infect Dis J 1990;9:913-16. Verhoeff, FH: Parinaud's conjunctivitis; a mycotic disease dueto a hitherto undescribed filamentous organism. Arch Ophthalmol1913;17:345-51. Wear DJ, et al: Cat scratch disease bacilli in the conjunctivaof patients with Parinaud's oculoglandular syndrome. Ophthalmol1985;92:1282-87. Wear DJ, et al: Cat scratch disease: a bacterial infection. Science 1983;221:1403-4. Yagupsky P, Sofer S: Cat-scratch encephalopathy presenting asstatus epilepticus and lymphadenitis. Pediatr Emerg Care1990;6:43-5. Grand Rounds Archive | Department Home page BCM Public | BCM Intranet | Privacy Notices | Contact BCM | BCM Site Map | ©2001-2006 Baylor College of Medicine
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