Granulomatous Hepatitis in Three Children due to Cat-scratch Disease Without Peripheral Adenopathy

Malatack, J. Jeffrey

doi:10.1001/archpedi.1993.02160330039014

Cited by 53 publications

(33 citation statements)

References 15 publications

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“…However, certain CSD cases may present with atypical symptoms. Atypical CSD clinical presentations might include prolonged fever and multiple hepatosplenic lesions (2). On the other hand, multiple renal lesions are extremely rare in CSD (3).…”

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“…Subsequently, a diagno- sis of CSD can be confirmed by specific serological tests. Although the typical clinical presentation of CSD includes regional lymphadenopathy with fever, atypical clinical presentations of CSD include prolonged fever and hepatosplenic lesions in 0.3-0.7z of patients, most of whom are pediatric patients (2). Moreover, although liver enzyme levels are usually normal in atypical CSD, the ESR is often increased compared with the normal rate (4).…”

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Multiple Renal and Splenic Lesions in Cat Scratch Disease

et al. 2016

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SUMMARY: Cat scratch disease (CSD) is an infectious disease caused by Bartonella henselae. Atypical clinical presentations of CSD include prolonged fever and multiple hepatosplenic lesions. Furthermore, multiple renal lesions are extremely rare in CSD. An 11-year-old Japanese girl presented at our hospital with a prolonged fever of unknown cause after being scratched and bitten by a kitten. Abdominal computed tomography (CT) revealed multiple small, round hypodense lesions in both kidneys and the spleen. Based on her history and the CT results, her diagnosis was CSD. The diagnosis was confirmed by serological tests, which indicated antibodies against B. henselae. After treatment with azithromycin, her fever immediately improved. Careful history taking and imaging are essential for the diagnosis of atypical CSD. In CT images, not only hepatosplenic lesions but also renal lesions are important features indicative of a diagnosis of atypical CSD. Subsequently, a diagnosis of CSD can be confirmed by specific serological tests. This is the first reported Japanese case of multiple renal and splenic lesions in a patient with CSD. Although difficult to diagnose, an early diagnosis atypical CSD and appropriate treatment are important to prevent complications and the need for invasive examinations.Cat scratch disease (CSD), which is generally seen in children, is an infectious disease caused by Bartonella henselae, a gram-negative bacillus (1). Typical CSD is generally benign and self-limiting. CSD is characterized by regional lymphadenopathy with fever following a scratch or bite from a cat or kitten. However, certain CSD cases may present with atypical symptoms. Atypical CSD clinical presentations might include prolonged fever and multiple hepatosplenic lesions (2). On the other hand, multiple renal lesions are extremely rare in CSD (3). Here, we present the case of a child with atypical CSD, who had multiple renal and splenic lesions.A previously healthy 11-year-old Japanese girl presented to our hospital with a fever of unknown cause. Empiric antibiotics (oral clarithromycin 10 mg/kg/day for 9 days, oral minomycin 4 mg/kg/day for 5 days, and intravenous ceftriaxone 75 mg/kg/day for 5 days) were administered before she visited our hospital, but the fever persisted. She had a 1-month history of a persistent fever at night (her temperature rose to 39-409 C at night and dropped to 36-379 C during the daytime) after being scratched and bitten by a kitten.On physical examination, neck lymphadenopathy with minimal pain was observed. Routine laboratory test results, including a complete blood count, hepatic and renal function tests, and urinalysis, were normal; however, she had a high C-reactive protein level (4.57 mg/dL; reference range [rr], ＜0.27 mg/dL) and an increased erythrocyte sedimentation rate (ESR, 74 mm/h; rr, 5-15 mm/h). Serum immunoglobulin (Ig) A and IgM levels were normal; however, she had high IgG (1,921 mg/dL; rr, 870-1,700 mg/dL) and complement (C3, 186 mg/dL; C4, 38 mg/dL; and CH50, 50 U/mL; rr's, 65-135 mg...

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Multiple Renal and Splenic Lesions in Cat Scratch Disease

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“…B. henselae infection has a high morbidity rate in immunocompromised individuals. Therefore, targeted antibiotic therapy is recommended in this group [6]. Conversely, the debate is open on whether antibiotics should be given to immunocompetent patients [2,6], and there are also doubts concerning the type of drug and the duration of the therapy [6].…”

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Prolonged follow up of seven patients affected by hepatosplenic granulomata due to cat-scratch disease

et al. 2007

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This study is a retrospective analysis of seven patients with hypoechogenic lesions in the liver and/or spleen due to Bartonella henselae, who were followed from 1998 through to 2005 by the Department of Pediatrics, Turin University. In addition to showing constitutional symptoms, four children had skin lesions suggestive of injuries inflicted by cats, and one child had a history of exposure to cats. The origin of the infection remained undefined in the other two patients. Humoral tests enabled a precise diagnosis in all children. Treatment with macrolides or combinations of two active antibiotics for at least 2-3 weeks led to the definitive clearance of infection, although residual intraparenchymal lesions persisted in five patients for several months or years. Conclusion B. henselae serology allows an easy diagnosis of multiple hepatosplenic granulomata, a clinical picture that appears to be under-recognized. Macrolides or a combination of two active antibiotics for 2-3 weeks leads to a rapid clinical response and a definitive clearance of infection.

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“…Among the atypical presentations of CSD, visceral granuloma, especially one without peripheral lymphadenitis, is an important differential diagnosis in the patients with sustained fever of unknown origin [1][2][3][4][5]. It resolves spontaneously in most cases.…”

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“…It resolves spontaneously in most cases. Although splenic lesion is occasionally described as "splenic abscess", its histopathological finding is necrotic granuloma with micro-abscess [4,5]. In contrast to peripheral lymphadenitis, it is rare that splenic granuloma caused by B. henselae suppurates and necessitates surgical intervention.…”

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Pyogenic splenic abscess in an infant with serological evidence of cat scratch disease

et al. 2006

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AbbreviationsCSD cat scratch disease PCR polymerase chain reaction CT computed tomographyPyogenic splenic abscess is a rare intraperitoneal infection caused by a variety of bacteria, with S. aureus and streptococci most commonly isolated. Splenectomy is indicated when it is resistant to antimicrobial therapy. We report on a pyogenic splenic abscess requiring repeated aspiration in an infant who was serologically diagnosed as having cat scratch disease (CSD). A 7-month-old boy was admitted to a general hospital due to intermittent low-grade fever of 2 weeks' duration, splenomegaly and multiple cystic lesions in the spleen detected by ultrasonography. Despite intravenous administration of cefotaxime on suspicion of splenic abscess, high fever persisted and the intrasplenic lesions expanded. Five days after admission, he was referred to our hospital. There was no history of the presence of a pet. On physical examination, anemia and splenomegaly were noted. There was a strong acute phase response indicated by white blood cell (WBC) count (24,350/μl), C-reactive protein level (117 mg/l) and erythrocyte sedimentation rate (83 mm/h). Microcytic hypochromic anemia [red blood cells (RBCs) 3.88×10 6 /μl, hemoglobin (Hb) 8.2 mg/dl, hematocrit (Ht) 27.9%] was also noted. Chest X-ray showed a small infiltration in the left lower lung field, adjacent to the diaphragm. Abdominal computed tomography revealed an enlarged spleen with multiple cystic lesions, indicating intrasplenic abscesses (Fig. 1a). The patient's immunological parameters, including immunoglobulin levels, IgG subclass levels, lymphocyte subsets, proliferation to phytohemagglutinin, NK activity, and phagocytic and bactericidal activities of neutrophils, were normal. As the cystic lesions continued to enlarge, despite the intravenous administration of panipenem/betamipron and ampicillin, ultrasonography-guided puncture and aspiration were performed on the 10th hospital day. Three abscess lesions yielded a total of 20 ml of odorless yellowish-white pus (Fig. 1b). Cytological and histological examination of the aspirated material showed abscess and necrotic tissue without atypical cells. Neither bacteria nor fungus was identified by microbiological examination [smear, histology including Gram, periodic acid-Schiff (PAS), acid-fast and Warthin-Starry staining, and culture]. After the first aspiration, despite sequential and combined administration of antibiotics including meropenem, clindamycin, doxycycline, tobramycin, rifanpin, azithromycin and clarithromycin, small, low-density areas suppurated to form new abscesses one after another, necessitating a total of six sets (three-to-eight punctures per set) of aspiration (Fig. 1c).

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Granulomatous Hepatitis in Three Children due to Cat-scratch Disease Without Peripheral Adenopathy

Cited by 53 publications

References 15 publications

Multiple Renal and Splenic Lesions in Cat Scratch Disease

Multiple Renal and Splenic Lesions in Cat Scratch Disease

Prolonged follow up of seven patients affected by hepatosplenic granulomata due to cat-scratch disease

Pyogenic splenic abscess in an infant with serological evidence of cat scratch disease

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