eMedicine Specialties > Infectious Diseases > Skin and Soft-Tissue Infections

Catscratch Disease: Differential Diagnoses & Workup

Author: Stephen J Nervi, MD, Staff Physician, Department of Dermatology, University of Medicine and Dentistry of New Jersey, New Jersey School of Medicine
Coauthor(s): Rajendra Kapila, MD, MBBS, Associate Professor, Department of Medicine, UMDNJ, New Jersey Medical School; Roseanne A Ressner, DO, Fellow, Department of Infectious Diseases, Brooke Army Medical Center; Lynn L Horvath, MD, Clinical Assistant Professor of Medicine/Infectious Disease, University of Texas Health Science Center; Consulting Staff, Department of Infectious Disease, Brooke Army Medical Center; Joyce R Drayton, MD, Assistant Professor, Department of Internal Medicine, Division of Infectious Disease, Morehouse School of Medicine
Contributor Information and Disclosures

Updated: Jan 26, 2009

Differential Diagnoses

Blastomycosis
Sarcoidosis
Brucellosis
Sporotrichosis
Coccidioidomycosis (Infectious Diseases)
Syphilis
Histoplasmosis
Toxoplasmosis
Infectious Mononucleosis
Tuberculosis
Lyme Disease
Tularemia
Lymphogranuloma Venereum (LGV)
Nocardiosis
Plague

Other Problems to Be Considered

Lymphoma
Histiocytic necrotizing lymphadenitis (Kikuchi-Fujimoto disease)
Nontuberculous mycobacterial infection
Bacterial adenitis
Cutaneous anthrax
Erysipelothrix rhusiopathiae infection
Viral infections: orf (parapoxvirus), cowpox (orthopoxvirus)

Workup

Laboratory Studies

  • In addition to lymphadenopathy 10 mm or larger that persists for 3 or more weeks, 3 of 4 of the following criteria confirm the diagnosis of catscratch disease (CSD). In an atypical case, all 4 of the following criteria may be needed:
    • Contact with a cat, with or without a scratch mark or a regional inoculation lesion (skin papule, eye granuloma, mucous membrane)
    • Laboratory and radiology findings: Purified protein derivative (PPD) or serology negative for other infectious causes of adenopathy; sterile pus aspirated from node; polymerase chain reaction (PCR) assay positive for Bartonella; CT scan that reveals liver or spleen abscesses
    • Enzyme-linked immunosorbent assay (ELISA) positive for serum antibody to B henselae or indirect fluorescent antibody (IFA) assay serology test greater than 1:64; a 4-fold rise in titer between acute- and convalescent-phase specimens
    • Biopsy of node, skin, liver, bone, or eye granuloma showing granulomatous inflammation compatible with catscratch disease; positive Warthin-Starry silver stain finding
  • IFA testing (96% sensitive) and ELISA (71% sensitive) are used to detect serum antibody to B henselae. An antibody titer that exceeds 1:64 suggests recent Bartonella infection. Paired acute and convalescent sera (drawn 6 wk apart) showing a 4-fold or greater increase is confirmatory. With IFA and ELISA tests, some cross-reactivity may occur between Bartonella species (especially B henselae and B quintana) and other bacteria such as Chlamydia psittaci.
  • PCR is the most sensitive test and is able to differentiate between different Bartonella species, as well as subspecies and strains. However, this test is not readily available.
  • A presumptive diagnosis of infection with catscratch disease bacilli can be made with Warthin-Starry and Brown-Hopps gram-stained tissues.
  • Studies to rule out other common causes of regional adenopathy should be performed.

Imaging Studies

  • In patients with disseminated catscratch disease and persistent high fever, abdominal pain, and severe systemic symptoms, abdominal CT scanning may be helpful. Multiple hypodense lesions of the liver and spleen are the major manifestations seen on such scans. These lesions resolve or calcify after weeks to months.

Other Tests

  • Bartonella species are fastidious and difficult to culture. They can be isolated in either cell cultures or axenic media with blood-enriched agar plates.
  • The catscratch disease skin test is no longer recommended. The test is less sensitive, less specific, poorly standardized, not readily available, not approved by the FDA, and considered by some to be unsafe.

Procedures

  • If suppuration occurs, lymph node aspiration may be required. Avoid incision and drainage of nodes because chronic draining sinuses may result.

Histologic Findings

The primary inoculation lesion site consists of acellular areas of necrosis in the dermis with surrounding histiocytes and epithelioid cells. Lymphocytes and multinucleated giant cells can be found surrounding the histiocytes.

Findings in involved lymph nodes can be nonspecific but include lymphoid hyperplasia followed by stellate granulomas. The centers are acellular and necrotic with surrounding histiocytes and lymphocytes. Microabscesses can develop and become confluent at later stages.

Warthin-Starry staining of involved lymph nodes or primary inoculation skin sites may reveal chains, clumps, or clusters of pleomorphic B henselae bacilli.

More on Catscratch Disease

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

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Further Reading

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Keywords

catscratch disease, cat scratch disease, CSD, cat scratch fever, catscratch fever, Bartonella henselae infection, B henselae infection, Bartonella infection, bacillary angiomatosis, peliosis, verruga peruana, Parinaud's oculoglandular syndrome, Parinaud oculoglandular syndrome, Parinaud syndrome, neuroretinitis, acute encephalopathy, endocarditis, Bartonella endocarditis, subacute regional lymphadenitis, bartonellosis, catscratch antigen, CSA, atypical catscratch disease, atypical cat scratch disease, Rochalimaea henselae, R henselae

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Contributor Information and Disclosures

Author

Stephen J Nervi, MD, Staff Physician, Department of Dermatology, University of Medicine and Dentistry of New Jersey, New Jersey School of Medicine
Stephen J Nervi, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Sigma Xi
Disclosure: Nothing to disclose.

Coauthor(s)

Rajendra Kapila, MD, MBBS, Associate Professor, Department of Medicine, UMDNJ, New Jersey Medical School
Rajendra Kapila, MD, MBBS is a member of the following medical societies: American College of Physicians, American Medical Association, Infectious Diseases Society of America, and Infectious Diseases Society of New Jersey
Disclosure: Nothing to disclose.

Roseanne A Ressner, DO, Fellow, Department of Infectious Diseases, Brooke Army Medical Center
Roseanne A Ressner, DO is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine, Armed Forces Infectious Diseases Society, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Lynn L Horvath, MD, Clinical Assistant Professor of Medicine/Infectious Disease, University of Texas Health Science Center; Consulting Staff, Department of Infectious Disease, Brooke Army Medical Center
Lynn L Horvath, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, American Society for Microbiology, Armed Forces Infectious Diseases Society, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Joyce R Drayton, MD, Assistant Professor, Department of Internal Medicine, Division of Infectious Disease, Morehouse School of Medicine
Joyce R Drayton, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Preventive Medicine, American Holistic Medical Association, Infectious Diseases Society of America, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Medical Editor

John M Leedom, MD, Professor of Medicine, Keck School of Medicine, University of Southern California; Chief, Division of Infectious Diseases, Department of Internal Medicine, Los Angeles County, University of Southern California Medical Center
John M Leedom, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, American Society for Microbiology, Infectious Diseases Society of America, International AIDS Society, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

John W King, MD, Professor of Medicine, Section of Infectious Diseases, Louisiana State University Health Sciences Center; Director, Viral Therapeutics Clinics for Hepatitis; Consulting Staff, Department of Infectious Diseases, Overton Brook Veterans Affairs Medical Center
John W King, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Federation for Medical Research, American Society for Microbiology, Association of Subspecialty Professors, Infectious Diseases Society of America, and Sigma Xi
Disclosure: emedicine $50.00 author of chapter

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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