eMedicine Specialties > Dermatology > Bacterial Infections

Catscratch Disease: Differential Diagnoses & Workup

Author: Kerrie J Spoonemore, MD, PharmD, Clinical Instructor, Department of Dermatology, Pacific Medical Centers
Coauthor(s): Jill McKenzie, MD, Resident, Division of Dermatology, University of Washington School of Medicine; Gregory J Raugi, MD, PhD, Professor, Department of Internal Medicine, Division of Dermatology, University of Washington at Seattle; Chief, Dermatology Section, Primary and Specialty Care Service, Veterans Administration Medical Center of Seattle
Contributor Information and Disclosures

Updated: Apr 4, 2008

Differential Diagnoses

Atypical Mycobacterial Diseases
Nocardiosis
Coccidioidomycosis
Sarcoidosis
Cutaneous T-Cell Lymphoma
Sporotrichosis
Drug-Induced Pseudolymphoma Syndrome
Syphilis
Leishmaniasis
Lymphogranuloma Venereum
Mycobacterium Marinum Infection of the Skin

Other Problems to Be Considered

Consider all causes of subacute and chronic lymphadenopathy and include the following:

Infection with cytomegalovirus, human immunodeficiency virus type 1, or Epstein-Barr virus usually is associated with lymphadenitis at more than one site.

Consider the following additional diagnoses with the presence of persistent skin papules and regional lymphadenopathy:

Because the clinical manifestations of infection with B henselae are different in patients who are immunocompromised, an entirely different differential diagnosis is appropriate. Bartonella infection leads to vasculoproliferative lesions, namely bacillary angiomatosis (B henselae, Bartonella quintana) and peliosis (B henselae only). The clinical differential diagnosis includes malignant neoplasms (eg, Kaposi sarcoma, angiosarcoma) and benign reactive conditions (eg, pyogenic granuloma, angiolymphoid hyperplasia with eosinophilia).

Workup

Laboratory Studies

No specific guidelines are available for the diagnosis of CSD. The combination of clinical presentation and a history of exposure to a cat usually leads to the diagnosis. Studies can be used to support the diagnosis. Positive laboratory serology findings can confirm the diagnosis, but a negative result does not rule out disease. A biopsy of skin or lymph node with characteristic histopathology is also helpful when the diagnosis is in question. B henselae isolation from tissue has low yield.

Typically, the diagnosis is based on the presence of 3 of the 4 following criteria: 

  • Contact with a cat in association with a scratch or lesion of the dermis, eye, or mucous membrane
  • Positive skin test result for CSD
  • Regional lymphadenopathy in the absence of other causes as ascertained by PPD testing, serologic studies, and cultures of lymph node aspirates
  • Characteristic histopathology in a biopsy specimen of skin or lymph node

CSA skin testing, which uses a preparation derived from infected lymph node tissue of other infected humans, is similar to the intradermal tuberculin PPD procedure. The antigen test is no longer widely available because of concern for the potential transmission of hepatitis viruses, HIV, and prions.

Skin testing is no longer warranted and largely has been replaced by antibody titer testing using indirect immunofluorescent antibody, hemagglutination, and enzyme-linked immunosorbent assay techniques. Of patients suspected of having CSD, 88% have detectable antibody, versus 3% of healthy controls. The timing of immunoglobulin G and immunoglobulin M response is variable, and cross-reactivity between different Bartonella species may occur. In one study, 25% of patients remained immunoglobulin G seropositive for longer than 1 year. Antibody kinetics do not reliably predict severity or duration of disease. The prevalence of seropositivity in cats living in the same house as a human with CSD is 81%, versus 14-44% in unselected households.

Lymph node biopsy generally is not indicated in typical cases of CSD, given the associated morbidity and expense. Node aspiration in patients suspected of having CSD traditionally has been discouraged for fear of fistula formation.

Immunofluorescence testing on both serum and lymph node smears improves the sensitivity and specificity of CSD diagnosis to 97% (based on at least one positive test result). Additionally, consider performing a biopsy of skin or affected lymph node in cases of possible malignancy or in an unclear presentation in an immunocompromised host.

Finally, findings from the CBC count are usually normal, although a mild leukocytosis or eosinophilia may be present. The erythrocyte sedimentation rate may be mildly or moderately elevated. The PPD test should be nonreactive.

Imaging Studies

Imaging procedures are not diagnostic in patients with CSD but may be helpful for excluding other conditions in the differential diagnosis. Atypical CSD may exhibit hepatic or splenic lesions, usually round or oval, ranging from 3-30 mm. They are hypodense on noncontrast CT scans. Injection of contrast material may yield hypodense, isodense, or marginally enhanced lesions when compared with normal parenchyma. These lesions have been observed to spontaneously resolve or calcify over weeks to months.

MRI has been used to diagnose multifocal bone marrow involvement in CSD that has shown negative results based on plain radiography findings, radionucleotide scintigraphy, and CT scanning. MRI is also considered more reliable for the assessment of soft tissue involvement and follow-up of boney lesions than plain radiography.

Procedures

Skin biopsy of the inoculation papule may be diagnostic. Additionally, biopsy of affected nodes is indicated only when attempting to establish a diagnosis other than CSD.

Aspiration of suppurating nodes is both a diagnostic and therapeutic procedure. Treat recurrence of suppuration by incision and drainage. The risk of fistulous sinus tract formation is small. This has been reported only in cases of atypical mycobacterial lymphadenopathy mistaken for CSD.

Histologic Findings

Skin

The dermis contains variously shaped (round, triangular, stellate) areas of necrosis or necrobiosis surrounded by an inner zone of palisading epithelioid histiocytes with a few multinucleated giant cells and an outer zone of lymphocytes. Organisms (visualized with the Warthin-Starry stain or the Brown-Hopp modification of the Gram stain) appear in the necrotic areas singly, in chains, or in clusters.

Lymph nodes

Focal areas of necrosis with neutrophilic infiltration occur near the germinal centers of lymph nodes. Organisms line the vascular sinuses. When necrosis is present, organisms may be seen within histiocytes as well as extracellularly in the necrotic areas and in the lumina of thrombosed blood vessels. Organisms are fewer in number in necrotic areas extensively infiltrated with neutrophils. With disease progression, granulomas may appear with central necrosis and multinucleated giant cells. Late findings include stellate microabscesses, which may fuse within suppurating nodes.

Liver

Hepatic parenchyma may be replaced by zones of organizing granulation tissue containing focal areas of granulomatous inflammation with stellate areas of central necrosis. The necrotic areas are infiltrated with neutrophils and are surrounded by palisading fibroblasts.

More on Catscratch Disease

Overview: Catscratch Disease
Differential Diagnoses & Workup: Catscratch Disease
Treatment & Medication: Catscratch Disease
Follow-up: Catscratch Disease
Multimedia: Catscratch Disease
References
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Further Reading

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Keywords

catscratch fever, cat scratch fever subacute regional lymphadenitis, bartonellosis, Bartonella henselae, B henselae, CSD, catscratch antigen, CSA

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Contributor Information and Disclosures

Author

Kerrie J Spoonemore, MD, PharmD, Clinical Instructor, Department of Dermatology, Pacific Medical Centers
Kerrie J Spoonemore, MD, PharmD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

Coauthor(s)

Jill McKenzie, MD, Resident, Division of Dermatology, University of Washington School of Medicine
Jill McKenzie, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, and American Medical Association
Disclosure: Nothing to disclose.

Gregory J Raugi, MD, PhD, Professor, Department of Internal Medicine, Division of Dermatology, University of Washington at Seattle; Chief, Dermatology Section, Primary and Specialty Care Service, Veterans Administration Medical Center of Seattle
Gregory J Raugi, MD, PhD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

Medical Editor

Carrie L Kovarik, MD, Assistant Professor of Dermatology, Dermatopathology, and Infectious Diseases, University of Pennsylvania School of Medicine
Carrie L Kovarik, MD is a member of the following medical societies: Alpha Omega Alpha
Disclosure: Nothing to disclose.

Pharmacy Editor

Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center
Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Van Perry, MD, Assistant Professor, Department of Medicine, Division of Dermatology, University of Texas Health Science Center
Van Perry, MD is a member of the following medical societies: American Academy of Dermatology and American Society for Laser Medicine and Surgery
Disclosure: Nothing to disclose.

CME Editor

Glen H Crawford, MD, Assistant Clinical Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Chief, Division of Dermatology, The Pennsylvania Hospital
Glen H Crawford, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Phi Beta Kappa, and Society of USAF Flight Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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