Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 22-1992. A 6 1/2-year-old girl with status epilepticus, cervical lymphadenopathy, pleural effusions, and respiratory distress

[Bone involvement in cat scratch disease]

INTRODUCTION

Cat scratch disease caused by Bartonella henselae with bone involvement is a rare presentation.

CASE REPORT

We report a case of disseminated bartonellosis with multifocal osteomyelitis and multiple visceral involvement in an immunocompetent adult. Diagnostic confirmation was obtained by PCR on lymphadenopathy. In addition to our observation, 31 cases of bartonellosis with bone involvement were reported in the literature. Diagnosis is based on a combination of history, serology and PCR performed on tissue. The antibiotic treatment allows recovery in all cases.

CONCLUSION

Cat scratch disease in its systemic form with bone involvement is a rare and difficult diagnosis for the clinician and an invasive approach is often required to obtain the diagnosis.

Magnetic resonance imaging abnormalities in cat-scratch disease encephalopathy

A 23-year-old woman who presented with a branch retinal artery occlusion followed by encephalopathy showed, by brain magnetic resonance imaging, a nonenhancing lesion in the right parietal gray matter with normal diffusion-weighted imaging. Of 64 reported cases of cat-scratch encephalopathy with documented neuroimaging findings, only 12 (18.8%) have had abnormal imaging findings. The abnormalities have included cerebral white matter lesions, basal ganglia and thalamic lesions, and multifocal lesions in immunocompromised patients, but no gray matter lesions similar to those in this patient. The variety of neuroimaging findings supports multiple pathophysiologic mechanisms of central nervous system involvement in this disorder.

Cat-scratch disease: considerations for dentistry

BACKGROUND

Cat-scratch disease, or CSD, results from inoculation of the gram-negative bacillus Bartonella henselae via a cat's scratch. A regional lymphadenitis, which usually is cervical, develops and may progress to suppuration. It is necessary to differentiate CSD from other lymphadenopathies.

CASE DESCRIPTION

A patient who had close contact with a cat subsequently developed a localized, suppurative cervical lymphadenitis. As B. henselae was identified in 1992, the authors were able to confirm the existence of CSD serologically. Surgical drainage resulted in a successful resolution of the disease process.

CLINICAL IMPLICATIONS

As patients with CSD may be seen in the dental office, an awareness of its symptomatology can prevent unnecessary dental intervention and facilitate early treatment.

Cytologic features of necrotizing granulomatous inflammation consistent with cat-scratch disease

Approximately 2,000 cases of cat-scratch disease are reported annually. It is an uncommon cause of unilateral lymphadenopathy in children and adults. We present the cytologic features of necrotizing granulomatous lesions consistent with cat-scratch disease from various sites. Eleven cases from 10 patients with a mean age of 16 yr (range, 2-33 yr) were biopsied by fine-needle aspiration. All gave a history of previous exposure to cats. Two children had atypical presentations; one with multiple hypodense areas within the liver and spleen, and the other with features of encephalitis. Other locations included lymph nodes from axilla, inguinal, preauricular, and cervical areas, and other body sites such as the scapula and the parotid gland. Histologic staging of the inflammatory process was correlated with cytologic features. There were 5 cases of early features, 3 cases in the middle phase, and 3 cases in late stage. The differential diagnosis of each stage is discussed. The 2 children with atypical presentations are described in detail.

An analysis of lymph node DNA for possible bacterial agents of cat-scratch disease

Recent investigations have implicated Afipia felis and Rochalimaea henselae as possible agents of cat-scratch disease (CSD). We studied lymph nodes with necrotizing granulomas characteristic of CSD for A. felis and R. henselae DNA so that the relationship of these organisms to lymph nodes with necrotizing granulomas of unknown etiology might be better defined. We examined formalin-fixed, paraffin-embedded lymph node biopsies with necrotizing granulomas suggestive of CSD from 28 children obtained over the last 10 years. None had identifiable bacteria, fungi, or acid-fast organisms on routine staining. Pleomorphic bacillary structures consistent with the CSD bacillus were seen with the Steiner stain in 17 cases. We performed the polymerase chain reaction (PCR) on the extracted lymph node DNA with DNA primers for these organisms after demonstrating the presence of amplifiable DNA with c-K-Ras primers. R. henselae was identified in two samples. A. felis DNA was found in just one specimen. These putative CSD bacteria are infrequently associated with necrotizing granulomas using standard PCR techniques. It is possible that some of the patients did not have clinical CSD. The preservation of DNA or numbers of bacteria in the extracted sections may be inadequate for demonstration by DNA amplification methods. These bacilli may be responsible for a small proportion of these characteristic lesions of unknown etiology, or the typical CSD histology, including the presence of pleomorphic bacillary structures, may be nonspecific.

Coma associated with intense bursts of abnormal movements and long-lasting cognitive disturbances: an acute encephalopathy of obscure origin

We report six previously healthy children who several days after a prodromal illness had an acute encephalopathy that ran a biphasic course. It appears to constitute a recognizable syndrome with a good prognosis that can be differentiated from other encephalopathies of obscure origin as previously defined by Lyon et al. The active phase was dominated by coma or confusion and by abnormal movements, including disordered gesticulation and attacks of orofacial dyskinesia or limb dystonia associated with permanent rigidity and culminating in opisthotonic posturing. Repeated seizures were observed in only two patients. Permanent slow waves were recorded on the electroencephalogram in all patients, even during bursts of abnormal movements. Cerebrospinal fluid and results of serologic studies were normal throughout the course of the disease, and attempts at viral isolation and antiviral antibody detection yielded negative results. Brain imaging either showed no abnormalities or suggested a moderate degree of brain edema. The recovery phase, which extended for several weeks, was characterized by a rapid return of motor function and persistent behavioral and cognitive disturbances. Nonverbal reasoning recovered long before verbal expression returned to normal. Four patients eventually recovered fully, whereas two had mild sequelae.