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Cat-scratch Disease STEPHEN A. KLOTZ, MD; VOICHITA IANAS, MD; and SEAN P. ELLIOTT, MD, University of Arizona, Tucson, Arizona Cat-scratch disease is a common infection that usually presents as tender lymphadenopathy. It should be included in the differential diagnosis of fever of unknown origin and any lymphadenopathy syndrome. Asymptomatic, bactere- mic cats with Bartonella henselae in their saliva serve as vectors by biting and clawing the skin. Cat fleas are respon- sible for horizontal transmission of the disease from cat to cat, and on occasion, arthropod vectors (fleas or ticks) may transmit the disease to humans. Cat-scratch disease is commonly diagnosed in children, but adults can present with it as well. The causative microorganism, B. henselae, is difficult to culture. Diagnosis is most often arrived at by obtaining a history of exposure to cats and a serologic test with high titers (greater than 1:256) of immunoglobulin G antibody to B. henselae. Most cases of cat-scratch disease are self-limited and do not require antibiotic treatment. If an antibiotic is chosen, azithromycin has been shown in one small study to speed recovery. Infrequently, cat-scratch disease may present in a more disseminated form with hepatosplenomegaly or meningoencephalitis, or with bacillary angiomatosis in patients with AIDS. (Am Fam Physician. 2011;83(2):152-155. Copyright © 2011 American Academy of Family Physicians.) ▲ Patient information: at-scratch disease (CSD) is the Although a history of exposure to cats is A handout on cat-scratch most common human infection important, it is not absolutely necessary to disease is available at caused by Bartonella species. make the diagnosis. http://familydoctor. 3 org/024.xml. CSD has worldwide distribution After contact with an infected kitten or C and has been described in all areas of North cat, patients can develop a primary skin America. In northern temperate zones, it lesion that starts as a vesicle at the inocu- occurs more often in August through Octo- lation site. A small number of patients do ber, usually in humid, warm locales. There not recall contact with cats or having skin are an estimated 22,000 new cases of CSD lesions. Regional lymphadenopathy develops per year in the United States.1 one to two weeks later and is usually ipsi- Bartonella henselae is the microorganism lateral. According to one study, 46 percent responsible for CSD. It is found in feline of patients develop lymphadenopathy of the erythrocytes and fleas, which can contami- upper extremities, 26 percent develop lymph- nate saliva and then be introduced into adenopathy of the neck and jaw, 18 percent humans through biting and clawing by cats. develop lymphadenopathy of the groin, and The cat flea, Ctenocephalides felis, is the vec- 10 percent develop lymphadenopathy of other tor responsible for horizontal transmission areas (pre- and postauricular, clavicular, and of the disease from cat to cat, and its bite can chest).4 In these patients, lymph nodes are also infect humans.2 In addition, tick bites swollen, tender, and may eventually suppu- may transmit the bacterium to humans. rate.4 Seventy-five percent of patients develop Approximately 50 percent of cats harbor aching, malaise, and anorexia, and 9 percent B. henselae and are entirely asymptomatic.3 develop low-grade fever.4 Lymphadenopathy can persist for several months. Musculo- Clinical Presentation skeletal manifestations, especially myalgia, CSD is commonly diagnosed in children, arthralgia, and arthritis, are common and but adults may also present with the disease. occur in more than 10 percent of patients.5 It should be suspected in patients with ten- Visceral involvement has been reported6 and der regional unilateral lymphadenopathy, usually presents as hepatosplenomegaly with especially if there is a history of exposure to or without lymphadenopathy.7 Prolonged kittens or cats. CSD causes local lymphade- fever of unknown origin in children has been nopathy in 85 to 90 percent of patients.4 The described.8,9 differential diagnosis includes other causes Rare cases of meningoencephalitis, endo- of unilateral lymphadenopathy (Table 1). carditis, and eye involvement have occurred Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright © 2011 American Academy of Family Physicians. For the private, noncommercial use of 152 Americanone Family individual Physician user of the Web site. All other rights reserved.www.aafp.org/afp Contact [email protected] for copyright questionsVolume and/or 83, Numberpermission 2 requests. ◆ January 15, 2011 SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence Clinical recommendation rating References Cat-scratch disease should be included in the differential diagnosis in any C 2, 3 patient with lymphadenopathy. The diagnosis of cat-scratch disease is usually confirmed by a history of cat C 3, 19 exposure and antibodies to Bartonella henselae. Most cases of cat-scratch disease are self-limited and do not require B 4, 21, 23 antibiotic therapy. If an antibiotic is chosen to treat cat-scratch disease, azithromycin B 22 (Zithromax) appears to be effective at reducing the duration of lymphadenopathy. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evi- dence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml. in immunocompetent patients.10-12 One neu- peliosis.13 Bacillary peliosis is caused only by rologic manifestation of CSD is encephalop- B. henselae and involves the liver and some- athy, which manifests as severe headache and times the spleen. Bacillary angiomatosis acute confusion one to six weeks after the can be caused by B. henselae and Bartonella onset of lymphadenopathy.10 Seizures may quintana, and usually involves the skin and occur, and occasionally patients have focal lymph nodes, but can also involve bone and neurologic deficits that are self-limiting, but internal organs. Lesions consist of single or can last up to one year. Parinaud oculoglan- multiple red to purple papules.13 Bacillary dular syndrome is the most common ocular angiomatosis was first described in patients manifestation12 and consists of granuloma- with AIDS with very low CD4 cell counts.14 tous conjunctivitis and ipsilateral periauric- Evidence for previous Bartonella infection ular lymphadenopathy. Neuroretinitis can is common in patients with human immu- occur in CSD and manifests as acute unilat- nodeficiency virus infection living in Rio eral visual field loss secondary to optic nerve de Janeiro, Brazil,15 and Bartonella infection edema and star-shaped macular exudates. was detected in 18 percent of febrile patients In immunosuppressed patients, B. hense- with human immunodeficiency virus infec- lae can cause bacillary angiomatosis and tion living in San Francisco, Calif.16 Diagnostic Testing The Bartonella species are difficult to cul- Table 1. Select Common Diseases ture, and culture is not routinely recom- That May Be Confused with mended. Serology is the best initial test and Cat-scratch Disease Unilateral Lymphadenopathy can be performed by indirect fluorescent assay or enzyme-linked immunosorbent assay. Although more sensitive than culture, Infectious causes serologic tests lack specificity because many Cytomegalovirus lymphadenopathy* asymptomatic persons have positive serology Epstein-Barr virus lymphadenopathy* because of previous (often asymptomatic) Group A streptococcal adenitis exposure.17 The percentage of the general Human immunodeficiency virus lymphadenopathy* population that has a positive serologic test Nontuberculous mycobacterial lymphadenitis varies widely, but appears to be higher in 17 Staphylococcus aureus adenitis cat owners. Immunoglobulin G titers less Toxoplasmosis lymphadenopathy* than 1:64 suggest the patient does not have Noninfectious causes current Bartonella infection. Titers between Malignancy (lymphoma, leukemia [in children]) 1:64 and 1:256 represent possible infec- tion; repeat testing should be performed in *—Usually diffuse lymphadenopathy. these patients in 10 to 14 days. Titers greater than 1:256 strongly suggest active or recent January 15, 2011 ◆ Volume 83, Number 2 www.aafp.org/afp American Family Physician 153 Cat-scratch Disease infection.18,19 A positive immunoglobulin M In a study from 1985, a single inves- test suggests acute disease, but production of tigator evaluating 1,200 patients with immunoglobulin M is brief. Immunoglobu- lymphadenopathy who were believed to have lin G has significant cross-reactivity between CSD found that antibiotics were rarely used.4 B. henselae and B. quintana. Polymerase Physicians today occasionally employ antibi- chain reaction can detect different Barton- otics in CSD. The results of one randomized ella species; specificity is very trial support the use of oral azithromycin Bacillary angiomatosis and high, but the sensitivity is lower (Zithromax) for mild to moderate disease peliosis have high rates than with serology. for five days (500 mg on day 1, followed by Consequently, when a child 250 mg daily for four more days for patients of relapse and should be or adult presents with unilat- weighing more than 100 lb [45.5 kg]; or 10 treated with a prolonged eral lymphadenopathy,3 the mg per kg on day 1, followed by 5 mg per kg course of antibiotics. physician should consider the for four more days for patients weighing 100 differential diagnoses
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