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Cat Scratch Fever

Cat-Scratch Disease

Cat scratch fever (cat scratch disease, inoculation lymphoreticulosis, subacute regional lymphadenitis) is an infectious disease of children and adolescents, caused by the bacterium Bartonella henselae.


Presentation

The signs and symptoms of the disease are mild to moderate and are usually self-limiting. They develop after an incubatory period of 1 to 2 weeks or even longer after the initial bite. The onset of the symptoms is gradual. The salient clinical features are swollen and painful lymph nodes (lymphadenopathy), in particular the axillary, cervical and inguinal lymph nodes [4]. There may be formation of erythematous vesicles or pustules at the initial site of infection (bite or scratch). The patient has low grade fever of about 101 F which may be associated with chills. Other non-specific symptoms such as malaise, loss of appetite and weight loss occur. The patient also feels pain in various regions of the body. These include abdominal pain, back ache, muscle aches, sore throat and headache.

In rare cases, the patient may have other severe symptoms. Encephalopathy along with seizures may develop in these patients [5]. They may also have involvement of the heart in the form of endocarditis. Involvement of the liver (granulomatous hepatitis) and spleen may also be seen [6] [7]. Occasionally, there may be osteomyelitis and osteolytic lesions of the bone [8] [9]. Joints may also be affected.

Involvement of the eyes and ears can also occur, including visual disorders, neuroretinitis and otic neuralgia. Other serious complications include involvement of the lungs, Parinaud’s syndrome and thrombocytopenic purpura.

Splenomegaly
  • Physical examination for hepatomegaly and splenomegaly. The cultures obtained from the victim can reveal the presence of Bartonella through Warthin–Starry stain or a Brown-Hopp tissue Gram stain.[symptoma.com]
  • Other symptoms are sometimes present as well, including anorexia, splenomegaly, sore throat, parotid swelling, rash, and/or conjunctivitis.[web.archive.org]
  • A report from Canada describes CSD presenting as acute mastoiditis in a 6-year-old girl. [37] Less common symptoms are splenomegaly (11%), exanthems (4.5%), conjunctivitis (4.3%), and parotid swelling (1.4%).[emedicine.medscape.com]
  • Splenomegaly (Patients 1, 3, 4, 5, 6, and 8) and abdominal or retroperitoneal lymphadenopathy (Patients 1, 2, 4, 5, 6, and 8) were also detected clinically or by imaging studies.[doi.org]
  • Additional findings may include a temporary skin rash consisting of flat (macular) or raised (papular) lesions, and/or enlargement of the liver or spleen (hepatomegaly or splenomegaly).[rarediseases.org]
Cervical Lymphadenopathy
  • Gray-scale sonographic evaluation of cervical lymphadenopathy in cat-scratch disease. J Clin Ultrasound 2001 ;29: 140 – 5 Google Scholar Medline ISI 13. . Ridder, GJ, Richter, B, Laszig, R.[doi.org]
  • The causes of cervical lymphadenopathy, with special regard to CSD, were investigated in a study of 454 patients who presented with unclear masses in the head and neck from January 1997 through January 2001.[doi.org]
Inguinal Lymphadenopathy
  • Inguinal lymphadenopathy has been reported in 17% of cases. Lymphadenopathy can be moderately tender, with erythema and increased warmth of the overlying skin.[emedicine.medscape.com]
Cat Scratch
  • Cat scratch fever (cat scratch disease, inoculation lymphoreticulosis, subacute regional lymphadenitis) is an infectious disease of children and adolescents, caused by the bacterium Bartonella henselae.[symptoma.com]
  • Cat Scratch Disease ( Bartonella henselae Infection) What is cat scratch disease? Cat scratch disease (CSD) is a bacterial disease caused by Bartonella henselae.[web.archive.org]
  • Cat-scratch disease - Connecticut, 1992-1993. J Infect Dis 1995 ;172: 570 – 3 Google Scholar Medline ISI 12. . Ridder, GJ, Richter, B, Disko, U. Gray-scale sonographic evaluation of cervical lymphadenopathy in cat-scratch disease.[doi.org]
  • Swollen lymph node in armpit and cat scratch on hand What is cat scratch disease (CSD)? Cat scratch disease is a bacterial infection caused by Bartonella henselae bacteria.[cdc.gov]
  • Convert to ICD-10-CM : 078.3 converts directly to: 2015/16 ICD-10-CM A28.1 Cat-scratch disease Applies To Benign lymphoreticulosis (of inoculation) Cat-scratch fever ICD-9-CM Volume 2 Index entries containing back-references to 078.3 : ICD-9-CM codes[icd9data.com]
Fever
  • Typical feature of the disease is persistent low grade fever, hence the name cat scratch fever. Cat scratch fever is a condition that is transferred to man through bite, scratch or lick by cats infected with a certain bacteria.[symptoma.com]
  • For cats that do become sick, the illness usually consists of fever for 2-3 days, with the cat recovering on its own. Symptoms requiring veterinary care include fever, vomiting, lethargy, red eyes, swollen lymph nodes or decreased appetite.[cdc.gov]
  • Other members of the Bartonella species can cause Oroya fever and trench fever. See separate Bartonellosis article for more details.[patient.info]
Lymphadenopathy
  • According to one study, 46 percent of patients develop lymphadenopathy of the upper extremities, 26 percent develop lymphadenopathy of the neck and jaw, 18 percent develop lymphadenopathy of the groin, and 10 percent develop lymphadenopathy of other areas[aafp.org]
  • Table 1 Diagnoses for 454 patients with lymphadenopathy in the head and neck. Table 1 Diagnoses for 454 patients with lymphadenopathy in the head and neck.[doi.org]
  • Cervicofacial lymphadenopathy was the most common manifestation.[doi.org]
  • One to three weeks after the appearance of the primary lesion, regional lymphadenopathy appears, usually next to the inoculation site.[patient.info]
Malaise
  • Malaise, fatigue, and other constitutional symptoms occur in up to 30% of patients. Headache, sore throat, and anorexia are noted in approximately 13% of patients.[emedicine.medscape.com]
  • About 50% of patients will experience additional signs and symptoms including: fever malaise /fatigue headache nausea and vomiting sore throat rash stomach pains conjunctivitis Less common problems occur in about 10% of patients.[dermnetnz.org]
  • Other non-specific symptoms such as malaise, loss of appetite and weight loss occur. The patient also feels pain in various regions of the body. These include abdominal pain, back ache, muscle aches, sore throat and headache.[symptoma.com]
  • In more than half of cases in one study, systemic symptoms accompanied the lymphadenopathy. [ 3 ] These may include fever, malaise, headache and anorexia and often occur in immunocompromised patients.[patient.info]
Weight Loss
  • In August 2001, a girl aged 12 years was admitted to TCH after 3 weeks of intermittent fevers (101 --105.1 F [38.3 --40.6 C]), 2 days of right upper quadrant pain, and weight loss.[cdc.gov]
  • Other non-specific symptoms such as malaise, loss of appetite and weight loss occur. The patient also feels pain in various regions of the body. These include abdominal pain, back ache, muscle aches, sore throat and headache.[symptoma.com]
  • Although she had recently had a fever, she had suffered no weight loss, and intermittent headaches and mild eye pain were her only other symptoms.[web.archive.org]
  • One patient presented with recurrent cervical lymphadenitis, whereas the other 2 patients experienced systemic symptoms with periodic fever, malaise, headache, and weight loss.[emedicine.medscape.com]
  • Weight loss of 4.5 to 16 kg (10 to 35 lb) and cachexia (exact weight loss unknown) were also seen. Hepatomegaly was present in every patient, sometimes manifested as abdominal distention.[doi.org]
Vomiting
  • Symptoms requiring veterinary care include fever, vomiting, lethargy, red eyes, swollen lymph nodes or decreased appetite. My daughter got scratched by the neighbor’s kitten and now my husband is worried about “cat scratch disease.”[cdc.gov]
  • About 50% of patients will experience additional signs and symptoms including: fever malaise /fatigue headache nausea and vomiting sore throat rash stomach pains conjunctivitis Less common problems occur in about 10% of patients.[dermnetnz.org]
  • […] characteristic swollen lymph nodes and papule at the inoculation site are accompanied by fever, malaise, headache, and/or extreme fatigue, rather like a bad case of the flu plus the headache phase of a migraine, sometimes accompanied by abdominal pain and vomiting[web.archive.org]
  • Infection with certain strains of Salmonella bacteria may cause high fever, abdominal pain, bloody diarrhea, nausea, vomiting, rash, and/or other symptoms and findings.[rarediseases.org]
Nausea
  • About 50% of patients will experience additional signs and symptoms including: fever malaise /fatigue headache nausea and vomiting sore throat rash stomach pains conjunctivitis Less common problems occur in about 10% of patients.[dermnetnz.org]
  • Infection with certain strains of Salmonella bacteria may cause high fever, abdominal pain, bloody diarrhea, nausea, vomiting, rash, and/or other symptoms and findings.[rarediseases.org]
  • However, she continues to experience occasional irritability, confusion, dizziness, nausea, and pain involving the shoulder, hip and the bottoms of her feet.[doi.org]
Loss of Appetite
  • Lower back pain, abdominal pain, loss of appetite and weight commonly develop in the patients. With proper treatment, the symptoms completely regress and patients can be completely cured.[symptoma.com]
  • Less common symptoms include loss of appetite, sore throat, and weight loss. In some cases chills, backache, and/or abdominal pain have been reported.[rarediseases.org]
Hepatomegaly
  • Physical examination for hepatomegaly and splenomegaly. The cultures obtained from the victim can reveal the presence of Bartonella through Warthin–Starry stain or a Brown-Hopp tissue Gram stain.[symptoma.com]
  • Hepatomegaly was present in all cases.[doi.org]
  • Additional findings may include a temporary skin rash consisting of flat (macular) or raised (papular) lesions, and/or enlargement of the liver or spleen (hepatomegaly or splenomegaly).[rarediseases.org]
  • Klinisch manifestiert sich die BA mit Fieber (93%), niedriger CD4-Lymphozytenzahl, kutanen oder subkutanen Läsionen (55%), Lymphadenopathie (76%), Hepatomegalie (50%) und Splenomegalie (33%) [140].[antibiotikamonitor.at]
Papule
  • It may compromise any tissue, especially the skin, presenting papules, nodules or angiomatous tumours. [ 4 ] A case of aseptic meningitis related to cat scratch disease has been reported.[patient.info]
  • Careful examination may reveal an inoculation papule in the majority of patients. Given the tendency to hold cats against one's chest, the lesion is found most often on the head or upper extremities.[emedicine.medscape.com]
  • A vesicle or an erythematous papule may form at the site of initial infection. Most patients also develop systemic symptoms such as malaise, decreased appetite, and aches.[en.wikipedia.org]
  • A crusted primary inoculation papule on the neck of a 4-year-old child. Note the adjacent lymphadenitis. This patient had contact with cats and had multiple scratches. Courtesy of Andrew Margileth, MD.[emedicine.medscape.com]
Headache
  • Additionally, a person with CSD may experience fever, headache, fatigue, and a poor appetite. Rare complications of B. henselae infection are bacillary angiomatosis and Parinaud's oculolandular syndrome.[web.archive.org]
  • In the acute phase, the characteristic swollen lymph nodes and papule at the inoculation site are accompanied by fever, malaise, headache, and/or extreme fatigue, rather like a bad case of the flu plus the headache phase of a migraine, sometimes accompanied[web.archive.org]
  • Generalized headache and transient nuchal rigidity are often present.[emedicine.medscape.com]
  • Other associated complaints include headache, chills, muscular pains, joint pains, arthritis, backache, and abdominal pain. It may take 7 to 14 days, or as long as two months, for symptoms to appear.[en.wikipedia.org]
  • About 50% of patients will experience additional signs and symptoms including: fever malaise /fatigue headache nausea and vomiting sore throat rash stomach pains conjunctivitis Less common problems occur in about 10% of patients.[dermnetnz.org]
Expressive Aphasia
  • aphasia (inability to talk), as well as combinations of these.[web.archive.org]
  • Acute onset, self-resolving, recurrent expressive aphasia has been reported. Neuroretinitis (Leber stellate neuroretinitis, Leber idiopathic stellate retinopathy, [45] Leber idiopathic stellate maculopathy) was first described in 1916.[emedicine.medscape.com]
Neuralgia
  • Involvement of the eyes and ears can also occur, including visual disorders, neuroretinitis and otic neuralgia. Other serious complications include involvement of the lungs, Parinaud’s syndrome and thrombocytopenic purpura.[symptoma.com]

Workup

Physical examination for hepatomegaly and splenomegaly. The cultures obtained from the victim can reveal the presence of Bartonella through Warthin–Starry stain or a Brown-Hopp tissue Gram stain.

The following tests are also helpful:

  • Polymerase chain reaction (PCR)
  • Erythrocyte sedimentation rate (ESR)
  • Enzyme linked immunosorbent assay (ELISA)
  • Serological testing for indirect fluorescent antibody (IFA) of Bartonella (high titers of IgG greater than 1:256 are diagnostic)
  • Analysis of the cerebrospinal fluid (CSF)
  • Lymph node biopsy [10]
  • Electroencephalography (EEG)
  • Ultrasound
  • Computerized tomography (CT) and magnetic resonance imaging (MRI)
Bartonella Henselae
  • Bartonella henselae is a gram-negative organism. The infection by this organism evokes a suppurative granulomatous response in the infected patients.[symptoma.com]
  • Cat Scratch Disease ( Bartonella henselae Infection) What is cat scratch disease? Cat scratch disease (CSD) is a bacterial disease caused by Bartonella henselae.[web.archive.org]
  • Abstract OBJECTIVE: The bacteria Bartonella henselae has been known as the principal causative agent of cat-scratch disease (CSD) since 1992. It is an important cause of infectious lymphadenopathies in the head and neck.[doi.org]
  • Azad, Acquisition of the Cat Scratch Disease Agent Bartonella henselae by Cat Fleas (Siphonaptera: Pulicidae), Journal of Medical Entomology, Volume 33, Issue 3, 1 May 1996, Pages 490–495, Download citation file: Ris (Zotero) EndNote BibTex Medlars ProCite[doi.org]
  • Bartonella henselae was discovered a quarter of a century ago as the causative agent of cat scratch disease, a clinical entity described in the literature for more than half a century.[ncbi.nlm.nih.gov]
Afipia Felis
  • In 1983, the Warthin-Starry silver stain was used to discover a Gram-negative bacillus which was named Afipia felis in 1991 after it was successfully cultured and isolated.[en.wikipedia.org]
  • Afipia felis and Bartonella clarridgeiea have also been found in association with cat scratch fever. Cats are the vectors for this agent. Fleas are responsible for transmission of this agent to cats.[symptoma.com]
  • Bei den gleichen Patienten wurden keinerlei Antikörper gegen Afipia felis gefunden, und mittels molekularbiologischer Untersuchungen wurde B. henselae -DNA, jedoch keine Afipia felis -DNA in dem für den Hauttest eingesetzten Antigen nachgewiesen [152][antibiotikamonitor.at]
  • In 1988, English and collaborators ( 34 ) isolated and cultured a bacterium that was named Afipia felis in 1992.[doi.org]
Lymph Node Hyperplasia
  • Of these benign neoplasms, 20 were adenomas, 14 were cystic lesions, 14 were cases of lymph node hyperplasia, and 2 were neurinomas; in addition, there was 1 case each of neurofibroma, hemangioma, and lymphangiolipoma, and 7 other benign neoplasms were[doi.org]

Treatment

The symptoms are usually self-limiting and resolve spontaneously. The following medicines may be used:

  • Antipyretics: These are given to reduce fever.
  • Analgesics: They are administered to provide relief from pain.
  • Antibiotics: Immunocompromised patients can be given antibiotics. These include Trimethoprim-sulfamethoxazole, ciprofloxacin or azithromycin, gentamicin and rifampin.

Prognosis

Complete cure is possible within 2 to 6 months after therapeutic measures are taken. In immunocompromised patients, it may take longer but the prognosis is generally good.

Etiology

Infection with Bartonella henselae bacterium is responsible for the disease [3]. Afipia felis and Bartonella clarridgeiea have also been found in association with cat scratch fever. Cats are the vectors for this agent. Fleas are responsible for transmission of this agent to cats. Biting, scratching and even licking can transfer the bacterium to humans as saliva of the cats has also been found to contain the organism.

The transfer of the bacterium from cats’ bloodstream to the saliva has, however, not been explained as yet. The transfer of this disease from one human to another has not been proved as yet.

Epidemiology

The disease is common in children and in people under 21 years of age. Almost 25,000 cases of cat scratch disease surface every year. There is a seasonal tendency of the disease, with more cases emerging during the early summers and mid-winters.

Sex distribution
Age distribution

Pathophysiology

Bartonella henselae is a gram-negative organism. The infection by this organism evokes a suppurative granulomatous response in the infected patients. In immunocompromised states, it can trigger a vascular reaction followed by recruitment and proliferation of lymphocytes. The bacteria cause angiogenesis in the infected area via adhesin A involvement.

The host’s immune system is activated. Following phagocytosis by macrophages, the internalized bacteria are circulated to the regional lymph nodes. The lymph nodes proximal to the site of infection show granuloma formation, suppuration and hyperplasia on biopsy. Biopsy findings also include stellate abscesses and leucocyte infiltrates. The macrophages release several inflammatory cytokines including interleukin-1 (IL-1) and tumor necrosis factor α (TNFα). These cause recruitment of neutrophils and more macrophages to the site of infection.

Helper T cells are activated by presentation of the invading bacterial antigens by macrophages and dendritic cells. TNF-gamma is produced by the activated helper T cells which triggers the release of NO locally. NO produced cytotoxic elements kill the bacteria. The inflammation and suppurative granulomation ultimately resolves.

In immunocompromised hosts, bacteria can evade the defense mechanisms involving vital organs like brain, retina and liver, leading to atypical manifestations of the disease.

Prevention

  • Cat bites and licks should be washed immediately.
  • Children should be made to wash their hands every time after playing with cats.
  • Going near or playing with pet cats should be avoided in case an individual is supporting an open wound or is suffering from an immunocompromised state (for example, diabetes, HIV, chemotherapy, organ transplantation)
  • Pet cats should be looked after. Their claws should be trimmed to avoid harboring the flea dirt. Flea products should be used.

Summary

Also known as cat scratch disease, bartonellosis or Teeny’s disease, cat scratch fever is a bacterial infection transferred to humans through biting, licking or scratching by infected cats [1] [2].

Bartonella henselae is the bacterium responsible for this condition. The cats are asymptomatic carriers of the agent. The bacterium is transferred to cats by fleas, Ctenocephalides fells. The fleas may also be responsible for direct transference of the bacteria to man. Typical feature of the disease is persistent low grade fever, hence the name cat scratch fever.

Patient Information

Cat scratch fever is a condition that is transferred to man through bite, scratch or lick by cats infected with a certain bacteria. People with pet cats at home are more susceptible to it.

The infected persons develop pustules at the site of scratch or bite. Low grade fever, generalized fatigue, muscle pain. Lower back pain, abdominal pain, loss of appetite and weight commonly develop in the patients.

With proper treatment, the symptoms completely regress and patients can be completely cured. Proper preventive measures should also be taken to avoid getting infected. Cats should be looked after and their hygiene should be maintained. They should be regularly checked for flea infestation. Hands should be washed with antibacterial soap and plenty of water immediately after playing with cats especially in children as their bodies have weaker defense mechanisms and are more susceptible to the disease. If open wounds are present on the skin, one should avoid going near the cats. With proper care, the disease can be prevented altogether.

References

Article

  1. Keefer CS, Greer W. Cat Scratch Fever. Transactions of the American Clinical and Climatological Association. 1950;62:151-164.
  2. Marshall CE. Cat scratch fever. Canadian Medical Association journal. Nov 1 1956;75(9):724-732.
  3. Blattner RJ. The etiology of cat-scratch fever. The Journal of pediatrics. Jun 1960;56:839-841.
  4. Guiyedi V, Haddad H, Okome-Nkoumou M, et al. Cat-scratch disease in adult hospitalized for prolonged-Fever associated with multiple lymphadenopathies and weight loss. The open microbiology journal. 2013;7:152-155.
  5. Stevens H. Cat-scratch fever encephalitis. A.M.A. American journal of diseases of children. Aug 1952;84(2):218-222.
  6. Laham FR, Kaplan SL. Hepatosplenic cat-scratch fever. The Lancet. Infectious diseases. Feb 2008;8(2):140.
  7. Incandela S, Raoult D, Vitale G, Micalizzi A, Mansueto P. Hepatosplenic cat-scratch fever with seropositivity for Bartonella quintana? The Lancet. Infectious diseases. Nov 2008;8(11):663.
  8. Herts BR, Rafii M, Spiegel G. Soft-tissue and osseous lesions caused by bacillary angiomatosis: unusual manifestations of cat-scratch fever in patients with AIDS. AJR. American journal of roentgenology. Dec 1991;157(6):1249-1251.
  9. Johnson JF, Lehman RM, Shiels WE, Blaney SM. Osteolysis in cat-scratch fever. Radiology. Aug 1985;156(2):373-374.
  10. Winship T. Pathologic changes in so-called cat-scratch fever; review of findings in lymph node of 29 patients and cutaneous lesions of 2 patients. American journal of clinical pathology. Oct 1953;23(10):1012-1018.

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Last updated: 2019-07-11 21:36