[A new example of cat scratch diseases; excision of the focus and infected lymph node; spectacular recovery].
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The authors present a clinical case of cat's scratch disease, with lymphadenitis and inoculation pustule. A series of observations are made on the importance of anamnesis, histopathologic examination, elimination of other clinical entities with lymphadenopathic manifestations, for determining the diagnosis. The recent investigations are aimed at identifying the etiologic agent. The treatment of the disease is symptomatic.
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Acute right hemiplegia and transient expressive aphasia occurred in a 7-year-old girl a few days after nonspecific constitutional symptoms and the appearance of a large right submandibular lymph node. Biopsy of this node and lack of other evident cause suggested a diagnosis of cat-scratch disease. Carotid arteriography showed a localized arteritis of the supraclinoid part of the left internal carotid artery and the left middle cerebral artery, involving also some lenticulostriate vessels. Computerized tomography demonstrated infarction in the left internal capsule. The size of this infarct and the angiographic abnormalities improved 6 weeks after onset, and coincided with clinical recovery. Cat-scratch disease may have caused the localized arteritis.
We describe the isolation and cultural characteristics of a Gram-negative bacillus that is very similar to the presumed etiologic agent of cat scratch disease. The organism was isolated from a tibial lesion of a male patient who had been hospitalized for severe necrotizing pancreatitis. The significance of the isolate in this patient remains uncertain.
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Bartonella henselae has only recently been isolated, characterized, and found to be the principal cause of cat-scratch disease (CSD). The availability of specific serologic investigations has allowed the recognition of a spectrum of ocular CSD syndromes that previously were ill defined and considered idiopathic. The primary inoculation complex causing regional lymphadenopathy is represented in the eye by Parinaud's oculoglandular syndrome; B. henselae is the most common cause. Leber's neuroretinitis has been identified for 80 years, and new data suggest that it is commonly a manifestation of CSD; the extent of the association remains to be determined. CSD optic neuritis is also described. The vitreoretinal manifestations include anterior uveitis, vitritis, pars planitis, focal retinal vasculitis, a characteristic retinal white spot syndrome, Bartonella retinitis, branch retinal arteriolar or venular occlusions, focal choroiditis, serous retinal detachments, and peripapillary angiomatous lesions. The pattern of ocular disease in AIDS-associated B. henselae infections is poorly delineated; unusual manifestations include conjunctival and retinal bacillary angiomatosis. The benefit of antimicrobial therapy for CSD in immunocompetent individuals has been difficult to establish, partly because most infections are self limited. Empirically, azithromycin, ciprofloxacin, rifampin, parenteral gentamicin, or trimethoprim-sulfamethoxazole provide the best therapeutic choices to minimize damage to the eye.
It has been suggested that plasmacytoid monocytes (PMOs) play an essential role in T-cell-dependent immune response. Indeed, numerous PMOs are found in close topographical association with epithelioid cell granulomas in hypersensitivity-type granulomas, such as tuberculosis and sarcoidosis. The key pathologic process in cat scratch disease (CSD) usually involves a B-cell-associated granulomatous reaction. Histologically, CSD appears to exhibit a histopathologic diversity, including suppurative lesions without epithelioid cell granulomas (early lesion), in which the microabscesses were surrounded by monocytoid B-cells (MBCs), suppurative granulomas containing MBCs (intermediate lesion), and suppurative granulomas without MBCs (late lesion). However, the presence or absence of PMO in CSD has not been studied previously. We examined 14 cases of CSD. In early lesions, numerous clusters of PMO were detected in the MBCs. In intermediate lesions, both MBCs and PMOs were found to be decreased in number, while late lesions contained no or only a few MBCs and PMOs. Overall, these findings suggest that PMOs may play a role in MBC-associated granulomatous response and in hypersensitivity granulomatous response. Moreover, the association with MBCs and PMOs indicates a functional relationship of MBCs with PMOs in the formation of suppurative lesions in CSD.
The identification of the causative organisms of cat scratch disease (CSD) has been elusive. The demonstration of Warthin-Starry stain-positive pleomorphic bacilli in lymph nodes of patients with CSD and recent serologic and epidemiologic data suggest an etiologic role of Rochalimaea henselae in CSD. The authors studied lymph node biopsy specimens of 46 patients with illnesses clinically consistent with CSD and found pleomorphic bacilli in 15 (33%). The organisms were labeled by polyclonal rabbit antibodies induced by outer surface proteins of R henselae. This finding further supports the possibility of an important role of R henselae in the pathogenesis of CSD.
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