Cat scratch disease (CSD) is usually a benign, self-limited lymphadenitis, characterized by suppurative granulomas. It can, however, produce a wide spectrum of clinical symptoms and cytologic changes and be the source of diagnostic dilemmas. Identification of pleomorphic bacilli (PB) with silver impregnation stains aids in the diagnosis, but this has not been well documented in cytologic preparations or in cases without the classic morphologic changes. We reviewed 13 aspirations from eight patients (aged 13-36 yr) occurring over a 15 mo time period, all clinically or cytologically suspicious for CSD. Sites included: axilla (6), parotid (3), epitrochlear (1), neck (1), submental (1), and intraclavicular (1) nodes. Neoplasia was initially suspected clinically in 38% of the cases. All but two patients had cat exposure on subsequent interview. The cytologic differential included bacterial abscess and lymphoproliferative disorders in 31%. Neither granulomas nor suppurative inflammation were seen in all cases. Changes included: granulomas (77%), PMNs (62%), dispersed epithelioid histiocytes (46%), and suppurative granulomas (38%). A modified silver stain (Modified Steiner, Sigma Diagnostics, St. Louis, MO) was performed on all specimens. Silver positive organisms were seen in 69% of cases and were not limited to those preparations with suppurative granulomas. Fine-needle aspiration biopsy (FNAB) is an effective method for diagnosing CSD despite its heterogeneous appearance; and, when combined with clinical information and silver staining, may obviate the need for excision.

Background: The average annual cost of inpatient stroke care in the United States exceeds $35 billion. The lack of clear recommendations for the use of transthoracic echocardiography (TTE) in patients with Acute ischemic stroke (AIS) has made this test a universal component of every stroke work-up. We evaluated the clinical utility and cost-effectiveness of TTE performed in patients with lacunar strokes. Methods: This is a single-center retrospective analysis of AIS patients from October 2015 through December 2017 (27 months). Brain MRI was used to select patients with a single acute/subacute lacunar infarct and no T2FLAIR evidence of previous cortical embolic strokes. Patients with cardiac symptoms (chest pain, shortness of breath, pedal edema) or an abnormal ECG (Atrial fibrillation, other arrhythmias, ST-T changes) on admission were excluded. Results of TTE were reviewed and their utility in decision making was evaluated. TTE associated costs were calculated. Results: Out of the 442 patients diagnosed with AIS in the given timeframe , 98 met the above criteria for inclusion. Mean age was 55 and 40 patients were female.TTE revealed no patients with an ejection fraction below 40%. Incidence of cardiac thrombus was 0%. Small patent foramen ovale was found in 5 (5.1%) patients, out of which none had right to left shunting or associated atrial septal aneurysm. Obtaining TTE did not change the management in any of the cases. Average cost of inpatient TTE was $2616, totaling $266,832 in all patients. Based on the current incidence of lacunar strokes (15-25%), this corresponds to approximately $500 million of nationwide spending annually. Conclusion: In AIS patients with no cardiac symptoms and normal ECG, it may be safe and clinically reasonable to obtain MRI brain before deciding about the need for TTE. If MRI shows a lacunar stroke, inpatient TTE done routinely may not change the management but adds up unnecessary cost to the healthcare system. Large multi-center studies are warranted.