History

Fact Explanation
Fever Cat Scratch Disease (CSD) is caused by Bartonella henselae[1] infection. One third of patients can present with low-grade fever. Prolonged fever can herald a hepatic or splenic abscess. [1]
Presence of an erythematous papule Lymphadenopathy usually follows an erythematous papule at the inoculation site. These small papules can be most commonly observed on the scalp. [1]
Tender lymphadenopathy Lymph Nodes that drain the inoculation site become enlarged and tender.[1] Involved lymph nodes undergo the following changes: lymphoid hyperplasia, granulomatous changes ,microabscess formation, and suppuration.[1][5]
Temporary blindness This is due to Parinaud’s Oculoglandular syndrome (POS). This is an atypical presentation of the disease. Features are conjunctival, granuloma formation with preauricular lymphadenitis. Eye involvement is seen if patient's rub the eye after handling cats. [1]
Periorbital swelling, tearing and Redlining of the eyes Also due to Parinaud’s oculoglandular syndrome (POS).
Abdominal pain If associated with prolonged fever, it can be due to hepatic and splenic abscesses [1] or mesenteric infarction. [2]
Acute onset of alteration of consciousness with seizures Encephalopathy is a complication of CSD. [1]
Difficulty in breathing and pleuritic chest pain This is due to pneumonia and pleural effusion that are complications of CSD. [1] Dyspnoea can also be a feature of acute heart failure following endocarditis[2]
Persistent bone pain Can be accompanied by a discharging sinus. Occurs due to osteomyelitis which is a rare complication of the disease. [1]
Back pain aggravated on movement Paravertebral abscess. [1]
Solitary or multiple tender, red vascular papules or nodules This is due to cutaneous bacillary angiomatosis and it is seen in immunocompromised individuals. Systemic symptoms may also indicate extracutaneous manifestations or bacteremia.[1]
Sudden onset unilateral facial or limb weakness This occurs due to a stroke which can occur after embolisation from valvular vegetation. [2]
Acute onset oliguria, hypertension, lethargy and edema This is due to post- infectious glomerulonephritis with secondary renal failure. [2]
Cat scratch or bite in the recent past Cat scratch or a bite or any exposure to cat fleas should be elicited. The pathogenic bacteria is present in the cat's saliva and in its circulation. [4,5]
Living in a humid warm climate Cat flea infestations are higher in a warm humid climate. [3]
References
  1. ANDERSON BE, NEUMAN MA. Bartonella spp. as emerging human pathogens. Clin Microbiol Rev [online] 1997 Apr, 10(2):203-219 [viewed 07 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC172916
  2. MARTíN L, VIDAL L, CAMPINS A, SALVá F, RIERA M, CARRILLO A, SáEZ DE IBARRA JI. Bartonella as a cause of blood culture-negative endocarditis. Description of 5 cases. Rev Esp Cardiol (Engl Ed) [online] 2009 Jun, 62(6):694-7 [viewed 07 July 2014] Available from: doi:10.1016/S1885-5857(09)72235-2 Link:http://www.revespcardiol.org/en/bartonella-as-cause-of-blood/articulo/13139389/
  3. JACOMO V, KELLY PJ, RAOULT D. Natural History of Bartonella Infections (an Exception to Koch's Postulate) Clin Diagn Lab Immunol [online] 2002 Jan, 9(1):8-18 [viewed 08 July 2014] Available from: doi:10.1128/CDLI.9.1.8-18.2002
  4. REGNERY R, TAPPERO J. Unraveling mysteries associated with cat-scratch disease, bacillary angiomatosis, and related syndromes. Emerg Infect Dis [online] 1995, 1(1):16-21 [viewed 08 July 2014] Available from: doi:10.3201/eid0101.950103
  5. ZUMLA A, JAMES DG. Granulomatous infections: etiology and classification. Clin Infect Dis [online] 1996 Jul, 23(1):146-58 [viewed 08 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8816144

Examination

Fact Explanation
Febrile patient This is usually a low grade fever. [1]
Presence of erythematous papules These small papules are commonly observed at the site of inoculation. [1]
Tender lymphadenopathy Causes a unilateral lymphadenopathy and usually one [4] or a few nodes are palpable[3]. Common sites of lymphadenopathy are axillary, head and neck, inguinal regions. [6]
Periorbital swelling, tearing and redlining of eyes This is due to Parinaud’s oculoglandular syndrome (POS).This is a rare presentation, it is associated with conjunctivitis, granuloma formation with preauricular lymphadenitis. [1]
Hepatomegaly There can be a tender hepatomegaly following hepatic abscesses or due to hepatic congestion following bacteremia.
Splenomegaly Mild splenomegaly can be present if there is splenic abscess formation.
Dull percussion note on respiratory examination Due to a pleural effusion. [1]
Coarse lung crackles and rhonchi Due to the presence of a pneumonic consolidation. [1]
Bilateral fine end inspiratory crackles Indicates acute heart failure following bacterial endocarditis and valvular insufficiency.[2]
New onset cardiac murmurs Due to bacterial endocarditis. This commonly causes mitral or aortic insufficiency. [1]
Confusion and low GCS CSD can cause encephalopathy. [1]
Cranial nerve palsies This is due to entrapment of cranial nerves within the cranium, due to meningeal inflammation. [1]
Neck stiffness If positive indicates meningitis, this occurs as passive stretching of the meninges causes spasm of the cervical musculature.
Limb weakness of paralysis Myelitis and ischemic stroke can follow cardiac embolization. [1]
Disc edema and exudates of the macula This is due to neuroretinitis. [1]
Bone tenderness, presence of discharging sinuses Osteomyelitis is a rare complication of CSD. [1], [7]
Solitary or multiple tender, reddish, highly vascular papules or nodules with a variable cutaneous distribution This is due to cutaneous bacillary angiomatosis and it is seen most commonly in immunocompromised individuals. [1]
References
  1. ANDERSON BE, NEUMAN MA. Bartonella spp. as emerging human pathogens. Clin Microbiol Rev [online] 1997 Apr, 10(2):203-219 [viewed 07 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC172916
  2. MARTíN L, VIDAL L, CAMPINS A, SALVá F, RIERA M, CARRILLO A, SáEZ DE IBARRA JI. Bartonella as a cause of blood culture-negative endocarditis. Description of 5 cases. Rev Esp Cardiol (Engl Ed) [online] 2009 Jun, 62(6):694-7 [viewed 07 July 2014] Available from: doi:10.1016/S1885-5857(09)72235-2 Link:http://www.revespcardiol.org/en/bartonella-as-cause-of-blood/articulo/13139389/
  3. VELHO PE, CINTRA ML, UTHIDA-TANAKA AM, DE MORAES AM, MARIOTTO A. What do we (not) know about the human bartonelloses? Braz J Infect Dis [online] 2003 Feb, 7(1):1-6 [viewed 08 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12807686
  4. SCHWETSCHENAU E, KELLEY DJ. The adult neck mass. Am Fam Physician [online] 2002 Sep 1, 66(5):831-8 [viewed 08 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12322776
  5. JACOMO V, KELLY PJ, RAOULT D. Natural History of Bartonella Infections (an Exception to Koch's Postulate) Clin Diagn Lab Immunol [online] 2002 Jan, 9(1):8-18 [viewed 08 July 2014] Available from: doi:10.1128/CDLI.9.1.8-18.2002
  6. REGNERY R, TAPPERO J. Unraveling mysteries associated with cat-scratch disease, bacillary angiomatosis, and related syndromes. Emerg Infect Dis [online] 1995, 1(1):16-21 [viewed 08 July 2014] Available from: doi:10.3201/eid0101.950103
  7. HULZEBOS CV, KOETSE HA, KIMPEN JL, WOLFS TF. Vertebral osteomyelitis associated with cat-scratch disease. Clin Infect Dis [online] 1999 Jun, 28(6):1310-2 [viewed 08 July 2014] Available from: doi:10.1086/514787

Differential Diagnoses

Fact Explanation
Cytomegalovirus infection Cytomegalovirus[1] [2] infection is usually asymptomatic but can produce a symptoms with fever, sore throat, malaise[2], skin manifestations and lymphadenopathy. Less commonly there can be haemolytic anemia, hepatitis or myocarditis.
Epstein-Barr infection Epstein-Barr infection[1][2] is common in adolescents.They present with fever and pharyngitis.There is a symmetrical and tender lymphadenopathy ( posterior cervical group) that occurs in the first week of the disease.[2] There may be hepatosplenomegaly. Rare complications such as meningoencephalitis, Guillain Barre syndrome and myocarditis can occur.[2]
Group A streptococcal adenitis Group A streptococcal adenitis [1], pharyngitis, tonsillitis and upper respiratory tract infections[2] can cause local cervical lymphadenopathy. Associated features such as fever, sore throat and upper respiratory symptoms such as sneezing, rhinorrhea can be present.
Human Immunodeficiency Virus (HIV) Symptoms of (HIV) [1][2] infection develop in the second week after infection. It starts with a generalised lymphadenopathy. Symptoms such as fever, pharyngitis, myalgias, arthralgias, headache, malaise, pruritic maculopapular rash can be present. There will be a history of risk factors such as unprotected intercourse, blood transfusion and IV drug abuse. [2]
Staphylococcus aureus adenitis Staphylococcus aureus adenitis[1] may occur following skin infections on the face and neck. [2]
Toxoplasmosis Toxoplasmosis infection[1][2] may be asymptomatic but lymphadenopathy (single lymph node posterior cervical triangle) and constitutional symptoms may be present. Less frequent symptoms and signs such as maculopapular rash, pharyngitis, or hepatosplenomegaly can be present.
Ulceroglandular tularaemia This occurs due to Francisella tularensis. This infectious disease is transmitted by rodents or ticks. Clinical findings such as skin ulcer with a sharp border (eschar) at the entry site and regional lymphadenopathy can be present.[2]
HSV type 1 infection HSV type 1 infection presents with fever, odynophagia (with pharyngitis), and tonsillar exudates.The cervical lymphadenopathy may last several weeks. [2]
Tuberculous lymphadenopathy This is a very common manifestation of extrapulmonary TB. Respiratory symptoms such as cough and haemoptysis may not be present. Slowly progressive painless and solitary lymph-node enlargement without significant systemic manifestations can be present. [2]
Localized lesions giving rise to local lymphadenopathy In the axilla local skin conditions, ulceroglandular conditions, breast cancer can cause lymphadenopathy. [2] Inguinal lymphadenopathy is usually reactive if smaller than 1 cm. Can also be caused by STDs. Cervical Lymphadenopathy may be a result of local lesions such as ENT infections or dental caries. [2]
Lymphoma Lymphoma[1][2] can present in a similar manner. Fever, generalized pruritus, loss of appetite, loss of weight and local or generalized lymphadenopathy can be seen.[2]
References
  1. KLOTZ SA, IANAS V, ELLIOTT SP. Cat-scratch Disease. Am Fam Physician [online] 2011 Jan 15, 83(2):152-5 [viewed 08 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21243990
  2. RICHNER S, LAIFER G. Peripheral lymphadenopathy in immunocompetent adults. Swiss Med Wkly [online] 2010 Feb 20, 140(7-8):98-104 [viewed 08 July 2014] Available from: doi:smw-12892

Investigations - for Diagnosis

Fact Explanation
Serology The antibodies produced against the pathogen can be tested for by performing indirect fluorescent assay or enzyme-linked immunosorbent assay. This is the best initial test. [1] [2]
Culture of Blood, lymph node aspirates, biopsy specimens of skin or other involved tissues. The Bartonella species is difficult to culture; there it is not routinely requested. Microscopic appearance of B. henselae is a curved, aerobic gram-negative bacillus which stains with silver.[1][2]
Polymerase Chain Reaction (PCR) PCR can detect different Bartonella species. It has a high specificity but the sensitivity is lower than with serology. [1][2]
Lymph node biopsy Lymph node biopsy is only needed in situations where lymph nodes don't involute and when diagnosis is uncertain. Specimens show lymphoid hyperplasia and stellate granulomas. [1][2]
Skin biopsy Bacillary angiomatosis causes cutaneous or subcutaneous lesions. Histopathologic examination (by light microscopy) may confirm the diagnosis. Characteristic lobular proliferation of vasculature is seen with hematoxylin and eosin stain. [2]
References
  1. KLOTZ SA, IANAS V, ELLIOTT SP. Cat-scratch Disease. Am Fam Physician [online] 2011 Jan 15, 83(2):152-5 [viewed 08 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21243990
  2. ANDERSON BE, NEUMAN MA. Bartonella spp. as emerging human pathogens. Clin Microbiol Rev [online] 1997 Apr, 10(2):203-219 [viewed 07 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC172916

Investigations - Fitness for Management

Fact Explanation
Ultrasound scan of the abdomen This is needed in systemic CSD with hepatosplenic involvement. Scattered hypoechoic lesions are seen on ultrasound. [1]
CT scan of the abdomen Indicated in systemic CSD with hepatosplenic involvement. Hypodense lesions (liver and/or spleen) are seen on CT. [1]
Chest X-ray Pulmonary involvement, with pneumonic features (consolidations) and/or pleural effusion, can be seen. [1]
Cerebro Spinal Fluid (CSF) analysis Detection of B. henselae antibodies in the spinal fluid is suggestive of meningo-encephalitis. [2]
Bone X-ray Osteomyelitis can be identified with lytic lesions on x-ray. [1]
Echocardiography This is to diagnose bacterial endocarditis. Valvular vegetations will be seen. [3]
References
  1. OPAVSKY MA. Cat scratch disease: The story continues Can J Infect Dis [online] 1997, 8(1):43-49 [viewed 08 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3327336
  2. ANDERSON BE, NEUMAN MA. Bartonella spp. as emerging human pathogens. Clin Microbiol Rev [online] 1997 Apr, 10(2):203-219 [viewed 07 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC172916
  3. MARTíN LUISA, VIDAL LAURA, CAMPINS ANTONIO, SALVá FRANCISCO, RIERA MELCHOR, CARRILLO ANDRéS, SáEZ DE IBARRA JOSE I.. Bartonella as a Cause of Blood Culture-Negative Endocarditis. Description of 5 Cases. Revista Española de Cardiología (English Edition) [online] 2009 June, 62(6):694-697 [viewed 08 July 2014] Available from: doi:10.1016/S1885-5857(09)72235-2

Management - General Measures

Fact Explanation
Avoid provoking with cats This is to prevent scratches. [1] Cats saliva contains the pathogen and scratch can introduce the pathogen into the bloodstream. This is most important in immunocompromised individuals.[1]
Wash hands after handling cats Washing [1] clears the saliva of the cats that might contain the pathogenic bacteria.
Treat cats for fleas Fipronil and other spot-on treatments can be used[1] to treat the fleas who act as vectors of the disease.
Keep pet cats indoors and away from stray cats. This helps to minimize transmission among the cat population.
References
  1. Prevention-Cat scratch disease (CSD), Bartonella henselae.Centers for Disease Control and Prevention.[online]2013.[viewed 10 July 2014].Available form: http://www.cdc.gov/bartonella/prevention/index.html

Management - Specific Treatments

Fact Explanation
Azithromycin Antibiotics are indicated only in moderately ill patients (example: those with chest infections). [4] Otherwise CSD is a self limiting condition and no antibiotics are needed. [1][4] Azithromycin[1][3][4]inhibits bacterial protein synthesis and is bacteriostatic. It has good gram negative cover and less effective against gram positives. It is given orally in this condition.
Erythromycin or Doxycycline Erythromycin[1][3][4] inhibits bacterial protein synthesis and is bacteriostatic.It has good gram negative cover but is less effective against gram positives. It is given orally in this condition.It is given orally in this condition. Doxycycline[1][3] inhibits bacterial protein synthesis and is bacteriostatic. It has a broad spectrum action. It is given orally in this condition. This is used in managing Bartonella endocarditis. [2]
Rifampin Rifampin[1] is a bactericidal, broad spectrum antibiotic. It is given orally. It is an alternative for other antibiotics in CSD.
Ciprofloxacin Ciprofloxacin[1] is a bactericidal antibiotic with more gram negative cover.This is given orally in CSD. It is an alternative for other antibiotics in CSD.
Trimethoprim/sulfamethoxazole (Co-trimoxazole) Trimethoprim/sulfamethoxazole[1] (Co-trimoxazole) is a synergistic combination that acts as a bacteriostatic agent. It has broad spectrum activity. This can be given orally or intravenously. This is an alternative to other antibiotics in CSD.
Gentamicin Gentamicin [1][3][4]can be an alternative to other drugs mentioned. Intramuscular or intravenous routes can be used. This can be used as an alternative to other drugs in CSD.
References
  1. KLOTZ SA, IANAS V, ELLIOTT SP. Cat-scratch Disease. Am Fam Physician [online] 2011 Jan 15, 83(2):152-5 [viewed 08 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21243990
  2. MARTíN LUISA, VIDAL LAURA, CAMPINS ANTONIO, SALVá FRANCISCO, RIERA MELCHOR, CARRILLO ANDRéS, SáEZ DE IBARRA JOSE I.. Bartonella as a Cause of Blood Culture-Negative Endocarditis. Description of 5 Cases. Revista Española de Cardiología (English Edition) [online] 2009 June, 62(6):694-697 [viewed 08 July 2014] Available from: doi:10.1016/S1885-5857(09)72235-2
  3. OPAVSKY MA. Cat scratch disease: The story continues Can J Infect Dis [online] 1997, 8(1):43-49 [viewed 08 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3327336
  4. MARGILETH AM, BAEHREN DF. Chest-wall abscess due to cat-scratch disease (CSD) in an adult with antibodies to Bartonella clarridgeiae: case report and review of the thoracopulmonary manifestations of CSD. Clin Infect Dis [online] 1998 Aug, 27(2):353-7 [viewed 08 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9709886