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.

We describe a patient who presented with a massive chest-wall abscess after a severe debilitating illness that lasted 3 months. Steroid therapy, administered for 4 weeks, masked the slow development of an extensive axillary and chest-wall abscess. After multiple negative tests, the patient's prolonged illness was diagnosed as cat-scratch disease (CSD). An indirect fluorescent antibody test revealed that two convalescent serum samples were positive for IgG to Bartonella clarridgeiae, but no other Bartonella species. We also review 12 cases of severe chest and pulmonary disease due to CSD that were reported in the English-language literature. Thoracopulmonary findings associated with CSD, pathogenic mechanisms of bartonella infections, diagnostic criteria, and management of CSD are presented.

Antibiotic therapy for cat-scratch disease: clinical study of therapeutic outcome in 268 patients and a review of the literature.

During 24 months in an uncontrolled, retrospective study of 268 patients with cat-scratch disease (CSD), 202 were treated with 18 different antimicrobial agents. Criteria for antibiotic effectiveness were established. One or two antibiotics were taken separately for at least 3 to 5 days by 202 patients with CSD. Outcome was determined by follow-up examinations and telephone. Effectiveness of antibiotic therapy was based upon 3 or more days of therapy and clinical improvement of the patient with absence of and/or a decrease in malaise, fatigue, fever, headache, anorexia, lymphadenopathy and, in 90 patients, a declining or normal sedimentation rate. Of 18 different antimicrobials prescribed, 14 commonly used antibiotics were judged to be of little or no value in treatment of CSD. Four antimicrobials were efficacious. Efficacy of the three oral drugs in decreasing order was: rifampin 87%, ciprofloxacin 84%, trimethoprim-sulfamethoxazole 58%. Gentamicin sulfate intramuscular was 73% effective. Antibiotic therapy can be considered for patients with severe cat scratch disease. Conservative, symptomatic treatment is recommended for the majority of patients with mild or moderate CSD.

Cat scratch disease: no longer a diagnostic dilemma.

Cat scratch disease is a relatively common cause of localized lymphadenopathy with about 80% of cases occurring in children. This self-limited infection is caused by a small pleomorphic gram-negative bacillus that has been identified in ocular granulomas, skin and lymph node specimens. Unusual manifestations of the disease, such as the oculoglandular disease of Parinaud, encephalopathy, or severe systemic disease, occur in about 12% of patients. Management consists of symptomatic treatment, occasionally aspiration of a node or selected antibiotic therapy in moderate to severely ill patients. Persistence of adenopathy for several months in a generally healthy patient with gradual, spontaneous resolution of the enlarged node is the natural course.

Cat-scratch disease. Acute encephalopathy and other neurologic manifestations.

Seventy-six patients with neurologic complications of cat-scratch disease are discussed. Encephalopathy occurred in 61, while 15 had either cranial or peripheral nerve involvement. The average age of the patients with encephalopathy was 10.6 years (range, 1 to 66 years), and almost twice as many males as females were affected in contrast to patients with uncomplicated cat-scratch disease, in which the ratio was almost equal. Fever was not documented in 50% of patients with encephalopathy and only 26% had temperatures higher than 39 degrees C. Convulsions occurred in 46% and combative behavior in 40%. Lethargy with or without coma was accompanied by variable neurologic signs. Results of laboratory studies, including imaging of the central nervous system, were inconsistent and nondiagnostic. Biopsy tissue from 14 patients showed histopathologic findings compatible with cat-scratch disease. The "English-Wear bacillus" was demonstrated by the Warthin-Starry stain in 10 of 14 skin or lymph node specimens. Of the 15 patients without encephalopathy, two children with facial nerve paresis displayed cranial nerve symptoms and/or signs, 10 patients had cat-scratch disease neuroretinitis, and three women had peripheral neuritis. All 76 patients recovered within 12 months; 78% recovered within 1 to 12 weeks. There were no neurologic sequelae. Treatment consisted of control of convulsions and supportive measures. Commonly used antibiotics administered to more than half of the patients were apparently ineffective.

Cat-scratch disease. Isolation and culture of the bacterial agent.

A gram-negative bacterium or its cell wall-defective variants were isolated from lymph nodes of ten patients with cat-scratch disease. Cultured bacteria were morphologically identical to vegetative and wall-defective forms seen in human tissues. Three of seven patients with recent cat-scratch disease had fourfold or greater rises in antibody titer against the cultured bacteria; the remaining four patients had maximum titers of 1:32 to 1:128. Rabbit antiserum to cultured bacilli reacted in immunoperoxidase stains with vegetative and wall-defective cat-scratch disease bacilli in lymph node, skin, or conjunctiva and with vegetative or wall-defective bacteria isolated from ten patients. Vegetative bacteria produced lesions in the skin of an armadillo identical to early lesions in human skin. Vegetative bacteria were recovered from the lesions in the armadillo.

Dermatologic manifestations and update of cat scratch disease.

Cat scratch disease is a relatively common cause of chronic (three weeks or longer) lymphadenopathy, with 80% of cases occurring in children and adolescents. This self-limited infection caused by a small, gram-negative, pleomorphic bacillus has been identified in ocular granuloma, skin inoculation lesions, and lymph node specimens. Dermatologic manifestations observed prospectively in 908 patients included primary cat scratch inoculation papules, pustules or rarely, vesicles. Occasionally, enanthematous mucous membrane (oral, ocular) primary inoculation lesions were observed. About 5% of patients have generalized macular, maculopapular, morbilliform, and rarely petechial, usually nonpruritic exanthem. Rarely, erythema nodosum or multiforme and ecchymoses with petechial rashes are seen. Thrombocytopenic purpura is extremely uncommon. Unusual manifestations such as the oculoglandular syndrome of Parinaud, encephalopathy, or severe systemic disease occur in about 10% of patients. Management consists of symptomatic treatment and occasional aspiration of a suppurative node. The disease usually resolves spontaneously in two to four months.

Cat scratch disease.

In summary, CSD is a relatively common cause of localized lymphadenopathy, with 80 per cent of cases occurring in children. This self-limited infection is caused by a small pleomorphic bacillus that has been identified in ocular granuloma, skin, and lymph node specimens. Unusual manifestations of the disease such as the oculoglandular disease of Parinaud, encephalopathy, or severe systemic disease occur in about ten per cent of patients. Management consists of symptomatic treatment and occasionally aspiration of a node that suppurates. The disease usually resolves spontaneously in 2 to 4 months.

Systemic cat scratch disease: report of 23 patients with prolonged or recurrent severe bacterial infection.

Over a seven-year period, we identified 23 patients who had prolonged or recurrent, severe, systemic, cat-scratch disease (CSD). Compared with the usual, benign course in 1,038 patients with typical CSD, the course in these 23 patients included prolonged (two or more weeks) morbidity (fever, malaise, fatigue, myalgia, arthralgia, skin eruptions, weight loss, and splenomegaly). Five patients with systemic CSD had either neuroretinitis, pleurisy, arthralgia or arthritis, splenic abscesses, and mediastinal masses or enlarged nodes of the head of the pancreas. Recurrent CSD in two of three adults was confirmed by finding typical CSD bacilli in lymph nodes removed during separate episodes. The majority of patients were adult males, and all patients recovered completely without sequelae. Histopathologic studies of five skin and 18 lymph node biopsy specimens were diagnostic. CSD bacilli were detected in lymph nodes from 15 patients and in the primary skin lesions of four patients. CSD bacilli were found in both skin and lymph nodes of three patients.

Cat scratch disease. A therapeutic dilemma.

Cat scratch disease, a relatively common infectious disease, is caused by a small gram-negative pleomorphic bacillus. The course of CSD is usually benign and self-limiting and is characterized by tender regional chronic (3 weeks or longer) lymphadenopathy and frequently preceded by a primary skin lesion following cat contact or scratches. Persistence of adenopathy for several months in a generally healthy patient with gradual spontaneous resolution of the enlarged node is the natural course.

Life-threatening cat-scratch disease in an immunocompromised host.

We describe a renal allograft recipient with cat-scratch disease in whom refractory hypotension, severe metabolic acidosis, pulmonary infiltrates, and encephalopathy developed. The patient first presented with a history of cat bites and scratches, fever, headache, and arthralgias. Four weeks later, the clinical presentation of septic shock suddenly developed in the patient. Cat-scratch disease was documented clinically and by finding delicate pleomorphic bacilli in Warthin-Starry silver stains of biopsy specimens taken from the primary inoculation site and regional lymph node. The administration of intravenous sulfamethoxazole and trimethoprim, erythromycin lactobionate, and tobramycin sulfate therapy correlated with recovery. Although cat-scratch disease is usually a benign, self-limited illness, this article illustrates its systemic nature, its potential for devastating complications in the immunocompromised host, and its possible response to vigorous antibiotic therapy.

Cat scratch disease bacilli in the conjunctiva of patients with Parinaud's oculoglandular syndrome.

Unilateral conjunctivitis with regional lymphadenitis has been designated Parinaud's oculoglandular syndrome (POGS). The cause has been attributed to various infectious agents, especially leptothrix and the unidentified agent of cat scratch disease (CSD). In 1983-84 the cause of CSD in lymph node and skin was established as small pleomorphic gram-negative bacilli. We now report identical bacteria in the conjunctival lesions of 9 of 24 patients with POGS. This confirms the belief that the CSD bacillus is a major cause of POGS.