Abstracts
Cat Scratch Disease (CSD) is an infectious disorder which appears after cat scratching particularly in children and adolescents. Bartonella henselae is the etiologic agent more frequently involved. There are only a few recent reports demonstrating the disease after transplantation, although the illness is not infrequent in immunologically competent people. Indeed CSD in transplant receptors has only been recently emphasized in the literature and it was concluded that fever and lymphadenopathy in patients who had been exposed to cats should prompt clinicians to maintain a suspicion for the infection. In this report CSD infecting a renal transplanted adolescent complaining of headache, blurred vision and fever, presenting a cat scratching lesion in the right arm, with a bilateral painful cervical lymphadenopathy was related. He also presented indirect immunofluorescency identifying that the two subtype's titles of Bartonella-henselae and quintana- were elevated. Treatment with doxicicline e rifampicin was introduced and the patient became asymptomatic in about 3 weeks.
adolescent; health care (public health); immunosuppression
A Doença da Arranhadura do Gato (DAG) é uma desordem infecciosa que surge após a arranhadela do animal, especialmente em crianças e adolescentes. Bartonella hanselae é o agente etiológico mais frequentemente envolvido. Há somente poucos relatos recentes demonstrando a doença após transplante renal, embora a mesma não seja infrequente em pessoas imunologicamente competentes. Na verdade, DAG em receptores de transplantes tem sido somente recentemente enfatizada na literatura e concluiu-se que a presença de febre e linfadenopatias em pacientes que estiveram expostos a contato com o animal deveriam sinalizar os clínicos a manter suspeita da infecção. Neste relato de DAG, é exposto o caso de um adolescente transplantado de rim queixando-se de cefaleia, visão borrosa e febre, apresentando cicatriz de arranhadura no braço direito, com linfadenopatia cervical bilateral dolorosa. Também apresentava imunoflorescência indireta identificando que os dois subtipos de Bartonella- a henselae e a quintana- estavam elevadas. Tratamento com doxiciclina e rifampicina foi iniciado e o paciente tornou-se assintomático em cerca de três semanas.
adolescente; avaliação de processos (cuidados de saúde); imunossupressão
Case report
A 16 year-old boy was born with a posterior urethral valve, vesico-uretheral reflux and a severe bilateral renal dysplasia. He was submitted to a gastrocystoplasty and a bladder catheterization was intermittently performed. He had initiated on CAPD in the first year of life, being submitted to cadaveric renal transplantations with 5 and 12 years-old. Currently he is being submitted to treatment with cyclosporine 50 mg BID, mofetil-mycophenolate 500 mg TID and prednisone 5 mg/day. Four years after the second transplantation he was admitted to the Hospital with a bilateral cervical lymphadenopathy beginning 7 days before, complaining of headache, blurred vision in the right eye and fever (38º-39 ºC) since the day before. When admitted he presented a scratching cat lesion in the right arm, 1 cm left cervical and 2 cm right supraclavicular lymphadenopathy, both very painful to palpation. Liver was about 3 cm below right costal board and the spleen was also palpable.
Urine and blood cultures were negative. EB virus, toxoplasmosis, cytomegalovirus, fungi and tuberculosis were also non-reagents. Liver function tests were within normal limits and the sedimentation rate was 32 mm. Indirect Bartonella IgM immunofluorescency was < 1:20 (normal < 1:16) and IgG 1:256 (normal < 1:64). Indirect immunofluorescency to identify the subtypes of Bartonella species was done. Bartonella henselae title was 1:2048 and Bartonella quintana equals 1:1024, both elevated. An abdominal CT showed increased liver size and splenomegaly, with no focal parenchymal lesions. Patient was evaluated by an ophthalmologist. Posterior uveitis in both eyes with papilledema and right eye hemorrhages were seen in the retinography (Figure 1). A supraclavicular lymph node biopsy demonstrated a pyogenic necrotizing adenitis, suggestive of CSD (Figure 2). Warthin-Starry method allowed visualizing the pleomorphic bacilli (Figure 3). Treatment with doxicicline e rifampicin was introduced and fever decreased 14 days after, headache disappeared nine days later and hepatospleno - lymphadenomegaly were not found at physical examination 2 months afterwards. Antibiotic therapy was maintained during 6 months.
Supraclavicular lymphonode biopsy demonstrated a supurative necrotizing adenitis, suggestive of CSD.
Supraclavicular lymphonode biopsy using the Warthin-Starry method allowed visualizing the pleomorphic bacilli.
Discussion
Cat Scratch Disease (CSD) is an infectious disorder which appears after cat scratching
particularly in children or young adults.11 Stechenberg BW. Cat Scratch Disease. In: Kliegmann RM, Behrman RE,
Jenson HB, Stanton BF. Nelson Textbook of Pediatrics, 18th ed.
Philadelphia: Saunders Elsevier; 2007.
Bartonella henselae is the etiologic agent more frequently
involved.22 Rostad CA, McElroy AK, Hilinski JA, Thompson MP, Drew CP, Denison AM, et
al. Bartonella henselae-mediated disease in solid organ transplant recipients: two
pediatric cases and a literature review. Transpl Infect Dis 2012;14:E-71-81. DOI:
http://dx.doi.org/10.1111/j.1399-3062.2012.00774.x
http://dx.doi.org/10.1111/j.1399-3062.20...
In immunologically competent
individuals the disease is benign and self-limited.33 Schutze GE. Diagnosis and treatment of Bartonella henselae infections.
Pediatric Infect Dis J 2000;19:1185-7. DOI:
http://dx.doi.org/10.1097/00006454-200012000-00014
http://dx.doi.org/10.1097/00006454-20001...
It has also been recognized in AIDS patients,44 Lamas CC, Mares-Guia MA, Rozental T, Moreira N, Favacho AR, Barreira J,
et al. Bartonella spp. infection in HIV positive individuals, their pets and
ectoparasites in Rio de Janeiro, Brazil: serological and molecular study. Acta Trop
2010;115:137-41. DOI:
http://dx.doi.org/10.1016/j.actatropica.2010.02.015
http://dx.doi.org/10.1016/j.actatropica....
but there are only a few reports demonstrating the disease after
kidney transplantation. Indeed the issue has been recently emphasized in the literature
and it was concluded that fever and lymphadenopathy in patients who had been exposed to
cats should prompt clinicians to maintain a suspicion for B. henselae
infection.22 Rostad CA, McElroy AK, Hilinski JA, Thompson MP, Drew CP, Denison AM, et
al. Bartonella henselae-mediated disease in solid organ transplant recipients: two
pediatric cases and a literature review. Transpl Infect Dis 2012;14:E-71-81. DOI:
http://dx.doi.org/10.1111/j.1399-3062.2012.00774.x
http://dx.doi.org/10.1111/j.1399-3062.20...
,55 Psarros G, Riddell J 4th, Gandhi T, Kauffman CA, Cinti SK, et
al. Bartonella henselae infections in solid organ transplant recipients: report of 5
cases and review of the literature. Medicine (Baltimore) 2012;91:111-21. DOI:
http://dx.doi.org/10.1097/MD.0b013e31824dc07a
http://dx.doi.org/10.1097/MD.0b013e31824...
In this report CSD infecting a renal transplanted adolescent is
presented.
Parinaud, in 1931, was the first to describe conjunctival inflammation with
lymphadenopathy after contact with an animal. Debré was the first to observe the
occurrence of a regional lymphadenopathy after a cat scratch.66 Debre R, Lamy M, Jammet ML, Costil L, Mozziconacci P. La maladie dês
griffes du chat. Bull Mem Soc Med Hop Paris 1950:66:76-9.
Bartonella henselae or more rarely Bartonella quintana
were identified as the causal agents of the disease in 1992.77 Regnery RL, Olson JG, Perkins BA, Bibb W. Serological response to
"Rochalimaea henselae" antigen in suspected cat-scratch disease. Lancet
1992:339:1443-5. PMID: 1351130 DOI:
http://dx.doi.org/10.1016/0140-6736(92)92032-B
http://dx.doi.org/10.1016/0140-6736(92)9...
The illness occurs more frequently in the autumn and at the beginning of the
winter.88 Kwochka KW. Fleas and related diseases. Vet Clin North Am Small Anim
Pract 1987;17:1235-62. Lymphadenomegaly is the most common
manifestation and appears two weeks after the inoculation and almost 15% of the lymph
nodes were found to be suppuratives. About 30% of the patients had fever above 38.5 °C,
headache and malaise. Lymphadenopathy localization depends on the site of inoculation.
The most common affected sites are axilla, epitrochlea, neck, supraclavicular and
submandibular areas.99 Carithers HA. Cat-scratch disease. An overview based on a study of 1,200
patients. Am J Dis Child 1985;139:1124-33. PMID: 4061408 DOI:
http://dx.doi.org/10.1001/archpedi.1985.02140130062031
http://dx.doi.org/10.1001/archpedi.1985....
In the first few weeks of
disease sedimentation rate is usually increased.11 Stechenberg BW. Cat Scratch Disease. In: Kliegmann RM, Behrman RE,
Jenson HB, Stanton BF. Nelson Textbook of Pediatrics, 18th ed.
Philadelphia: Saunders Elsevier; 2007.
Acute renal transplantation rejection reaction was also associated with CSD.1010 Dharnidharka VR, Richard GA, Neiberger RE, Fennell RS 3rd.
Cat scratch disease and acute rejection after pediatric renal transplantation.
Pediatr Transplant 2002;6:327-31. DOI:
http://dx.doi.org/10.1034/j.1399-3046.2002.01091.x
http://dx.doi.org/10.1034/j.1399-3046.20...
Ocular manifestations include neuroretinitis which is a syndrome presenting decreased
visual acuity producing optical nerve edema associated with macular exudates. Funduscopy
alterations may result from vasculitis through direct vessels invasion by the
bacteria.1111 Wong MT, Dolan MJ, Lattuada CP Jr, Regnery RL, Garcia ML, Mokulis EC, et
al. Neuroretinitis, aseptic meningitis, and lymphadenitis associated with Bartonella
(Rochalimaea) henselae infection in immunocompetent patients and patients infected
with human immunodeficiency virus type 1. Clin Infect Dis 1995;21:352-60. DOI:
http://dx.doi.org/10.1093/clinids/21.2.352
http://dx.doi.org/10.1093/clinids/21.2.3...
Those presenting neuroretinitis
usually had fever, malaise and unilateral blurred vision.1212 Grando D, Sullivan LJ, Flexman JP, Watson MW, Andrew JH. Bartonella
henselae associated with Parinaud's oculoglandular syndrome. Clin Infect Dis
1999;28:1156-8. DOI: http://dx.doi.org/10.1086/514756
http://dx.doi.org/10.1086/514756...
Ophthalmologic examination usually discloses a unilateral involvement with
diminished visual accuracy and afferent papillary defect. Retinal abnormalities may
include hemorrhages, cotton wool exudates, multiple retina lesions and exudates.
Differential diagnosis must include toxoplasmosis, malignant diseases-lymphoma and metastasis, granulomatous disease, tuberculosis, sarcoidosis and other infectious disease-pyogenic abscess and fungal infections.
CSD diagnosis has been based in the following findings: (A) Cat contact with a scratching lesion; (B) Negative serum tests for other causes of adenopathy, Bartonella positive Polymerase Chain Reaction and liver- splenic lesions in the CT. (C) Bartonella henselae positive serology (Elisa or Indirect Immunofluorescence) with a titer equal or greater than 1: 64 and (D) a biopsy showing granulomatous inflammation consistent with CSD or with a positive Warthin-Strarry coloration for the bacilli.11 Stechenberg BW. Cat Scratch Disease. In: Kliegmann RM, Behrman RE, Jenson HB, Stanton BF. Nelson Textbook of Pediatrics, 18th ed. Philadelphia: Saunders Elsevier; 2007. The reported patient presented all the required diagnosis criteria.
As previously related a rare significant cross reaction occurred for IgG between
B. henselae and B. quintana specimens, as occurred
in the reported patient.1313 Patel UD, Hollander H, Saint S. Clinical problem-solving. Index of
suspicion. N Engl J Med 2004;350:1990-5. PMID: 15128900 DOI:
http://dx.doi.org/10.1056/NEJMcps032937
http://dx.doi.org/10.1056/NEJMcps032937...
However, serology
still remains the most widely used method for the diagnosis of CSD because culture and
isolation are difficult to perform and are not yet easily available. Using indirect
immunofluorescency, an IgG titer above normal limits- as occurred in our patient-must be
considered positive for CSD.1414 Rolain JM, Didier R. Bartonella Infections. In: Goldman L, Schafer A.
Goldman's Cecil Medicine. 24th Ed. Philadelphia: Saunders Elsevier; 2012.
p.1906-11.
Histopathology of the involved lymph node demonstrated a lymphoid hyperplasia with acellular and necrotic centers, peripheral hystiocytes and lymphocytes around them suggestive of CSD and the positive Warthin-Starry test which showed small pleomorphic bacillus. Biopsy findings depend on the time of disease presentation. At the beginning they may demonstrate lymphoid hyperplasia, arteriolar proliferation and reticular cells hyperplasia. Subsequently granulomas appear, usually with central necrosis and giant multinucleated cells. Lately star-like infiltrates become visible: these are not pathognomonic but very specific.11 Stechenberg BW. Cat Scratch Disease. In: Kliegmann RM, Behrman RE, Jenson HB, Stanton BF. Nelson Textbook of Pediatrics, 18th ed. Philadelphia: Saunders Elsevier; 2007.
Treatment, especially for neuroretinitis, was initiated with doxicillin and rifampicin. The need for antibiotic therapy in immunocompetent individuals is not well established. However, in the immunosuppressed, antibiotics are formally indicated, improving the prognosis.
As CSD is not frequently described in immunosuppressed transplanted individuals-contrarily to what has been seen in immunocompetent people- this report would help physicians to become aware of this diagnosis, including it in the extensive list of opportunistic agents causing infection in the post-transplant phase. And finally the question: Cat Scratch Disease in kidney transplant receptors: is it a rare or still an under diagnosed pathology?
References
-
1Stechenberg BW. Cat Scratch Disease. In: Kliegmann RM, Behrman RE, Jenson HB, Stanton BF. Nelson Textbook of Pediatrics, 18th ed. Philadelphia: Saunders Elsevier; 2007.
-
2Rostad CA, McElroy AK, Hilinski JA, Thompson MP, Drew CP, Denison AM, et al. Bartonella henselae-mediated disease in solid organ transplant recipients: two pediatric cases and a literature review. Transpl Infect Dis 2012;14:E-71-81. DOI: http://dx.doi.org/10.1111/j.1399-3062.2012.00774.x
» http://dx.doi.org/10.1111/j.1399-3062.2012.00774.x -
3Schutze GE. Diagnosis and treatment of Bartonella henselae infections. Pediatric Infect Dis J 2000;19:1185-7. DOI: http://dx.doi.org/10.1097/00006454-200012000-00014
» http://dx.doi.org/10.1097/00006454-200012000-00014 -
4Lamas CC, Mares-Guia MA, Rozental T, Moreira N, Favacho AR, Barreira J, et al. Bartonella spp. infection in HIV positive individuals, their pets and ectoparasites in Rio de Janeiro, Brazil: serological and molecular study. Acta Trop 2010;115:137-41. DOI: http://dx.doi.org/10.1016/j.actatropica.2010.02.015
» http://dx.doi.org/10.1016/j.actatropica.2010.02.015 -
5Psarros G, Riddell J 4th, Gandhi T, Kauffman CA, Cinti SK, et al. Bartonella henselae infections in solid organ transplant recipients: report of 5 cases and review of the literature. Medicine (Baltimore) 2012;91:111-21. DOI: http://dx.doi.org/10.1097/MD.0b013e31824dc07a
» http://dx.doi.org/10.1097/MD.0b013e31824dc07a -
6Debre R, Lamy M, Jammet ML, Costil L, Mozziconacci P. La maladie dês griffes du chat. Bull Mem Soc Med Hop Paris 1950:66:76-9.
-
7Regnery RL, Olson JG, Perkins BA, Bibb W. Serological response to "Rochalimaea henselae" antigen in suspected cat-scratch disease. Lancet 1992:339:1443-5. PMID: 1351130 DOI: http://dx.doi.org/10.1016/0140-6736(92)92032-B
» http://dx.doi.org/10.1016/0140-6736(92)92032-B -
8Kwochka KW. Fleas and related diseases. Vet Clin North Am Small Anim Pract 1987;17:1235-62.
-
9Carithers HA. Cat-scratch disease. An overview based on a study of 1,200 patients. Am J Dis Child 1985;139:1124-33. PMID: 4061408 DOI: http://dx.doi.org/10.1001/archpedi.1985.02140130062031
» http://dx.doi.org/10.1001/archpedi.1985.02140130062031 -
10Dharnidharka VR, Richard GA, Neiberger RE, Fennell RS 3rd Cat scratch disease and acute rejection after pediatric renal transplantation. Pediatr Transplant 2002;6:327-31. DOI: http://dx.doi.org/10.1034/j.1399-3046.2002.01091.x
» http://dx.doi.org/10.1034/j.1399-3046.2002.01091.x -
11Wong MT, Dolan MJ, Lattuada CP Jr, Regnery RL, Garcia ML, Mokulis EC, et al. Neuroretinitis, aseptic meningitis, and lymphadenitis associated with Bartonella (Rochalimaea) henselae infection in immunocompetent patients and patients infected with human immunodeficiency virus type 1. Clin Infect Dis 1995;21:352-60. DOI: http://dx.doi.org/10.1093/clinids/21.2.352
» http://dx.doi.org/10.1093/clinids/21.2.352 -
12Grando D, Sullivan LJ, Flexman JP, Watson MW, Andrew JH. Bartonella henselae associated with Parinaud's oculoglandular syndrome. Clin Infect Dis 1999;28:1156-8. DOI: http://dx.doi.org/10.1086/514756
» http://dx.doi.org/10.1086/514756 -
13Patel UD, Hollander H, Saint S. Clinical problem-solving. Index of suspicion. N Engl J Med 2004;350:1990-5. PMID: 15128900 DOI: http://dx.doi.org/10.1056/NEJMcps032937
» http://dx.doi.org/10.1056/NEJMcps032937 -
14Rolain JM, Didier R. Bartonella Infections. In: Goldman L, Schafer A. Goldman's Cecil Medicine. 24th Ed. Philadelphia: Saunders Elsevier; 2012. p.1906-11.
Publication Dates
-
Publication in this collection
Jul-Sep 2014
History
-
Received
11 Dec 2013 -
Accepted
13 Mar 2014