Catscratch Disease Treatment & Management

  • Author: Stephen J Nervi, MD; Chief Editor: Burke A Cunha, MD   more...
 
Updated: Nov 21, 2011
 

Approach Considerations

Controlled studies on treatment of catscratch disease (CSD) are lacking. Thus, treatment recommendations are based on case reports, reviews, a single controlled trial, and anecdotal data. Practice guidelines for the diagnosis and management of skin and soft-tissue infections, including CSD, have been established.[54]

For most patients with mild or moderate CSD, only conservative symptomatic treatment is recommended because the disease is self-limited. Administer antipyretics and analgesics as needed. Local heat may be applied to the involved lymph nodes.

Occasionally, lymph node aspiration is indicated for pain relief in patients with tender, fluctuant nodes. Use of antibiotics is controversial and not indicated for typical CSD in immunocompetent patients.

The role of corticosteroids in atypical CSD is somewhat controversial. Patients with neuroretinitis, encephalopathy with or without hemiplegia, and acute solid organ transplant rejection[55] have all been treated successfully with a combination of appropriate antibiotics and steroid therapy.

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Antibiotic Treatment

Antibiotics are not indicated in most cases of CSD, but they may be considered for severe or systemic disease. Reduction of lymph node size has been demonstrated with a 5-day course of azithromycin[56] and may be considered in patients with severe, painful lymphadenopathy; however, no reduction in the duration of symptoms has been shown. Immunocompromised patients should be treated with antibiotics because they are particularly susceptible to systemic disease and bacteremia

Margileth et al reported the results of therapy for catscratch antigen–proven CSD with 18 different antimicrobials in 268 adult and pediatric patients.[57] They concluded that the following 4 antibiotics were the most effective for patients with severe CSD:

  • Rifampin - Efficacy of 87%
  • Ciprofloxacin - Efficacy of 84%
  • Gentamicin intramuscularly - Efficacy of 73%
  • Trimethoprim/sulfamethoxazole (TMP-SMZ) - Efficacy of 58%

These agents were considered moderately to highly effective, producing reduction or resolution of lymphadenopathy, a declining erythrocyte sedimentation rate, and decreased inflammatory and constitutional symptoms within 3-10 days. Severe disease was defined as persistent high fever (>103.1°F [>39.5˚C]) with severe systemic signs (eg, malaise, fatigue, blindness, headache) and lymphadenitis.

A prospective, randomized, double-blind, placebo-controlled study by Bass et al showed that azithromycin administered for 5 days decreased lymph node volume as measured by ultrasonography within the first month of treatment. No other differences in clinical outcome were noted.[56] Musso et al[58] found that aminoglycosides were bactericidal and Ives et al[59] showed that clarithromycin and azithromycin were efficacious in CSD. (See Table 3, below.)

Table 3. Response to Medications (Open Table in a new window)

Ciprofloxacin



500 PO bid



Case Report



5 adults



"Dramatic improvement" in a few days; defined as resolution of symptoms (ie, malaise and pain)Holley[60]
Gentamicin



5 mg/kg/d IV/IM



Case Report



3 febrile children; 2 with hepatitis, 1 with painful regional lymphadenopathy



Resolution of fever and systemic symptoms in 1-2 daysBogue et al[61]
TMP-SMZ



6-8 mg TMP/kg/d PO



Uncontrolled retrospective study



60 patients with prolonged fever and systemic symptoms



58% effective, 7-day course (see above)Margileth[41]
Rifampin 10-20 mg/kg/d PO/IVUncontrolled retrospective study



60 patients with prolonged fever and systemic symptoms



87% effective, 7- to 14-day course (see above)Margileth[57]
Azithromycin



500 mg PO qd for 1 day, then 250 mg PO qd for 4 days



Prospective placebo-controlled, double-blind study



29 patients



80% of lymph node volume (as measured by ultrasonography) resolved in 30 days in 7 of 15 patients on azithromycin vs 1 of 15 control patients Bass et al[56]

Although data are lacking, patients with catscratch disease who are treated should receive treatment for 10-14 days. Immunocompromised patients may require much longer courses of therapy. No specific dose recommendations are available for treating CSD.

Somewhat paradoxically, patients with AIDS and bacillary angiomatosis-peliosis frequently respond to a variety of commonly used antibiotics. Response to erythromycin, isoniazid, rifampin, doxycycline, and ethambutol is reported by Koehler et al.[62, 63] If an immunocompromised patient has treatment relapse, then prolonged treatment (4-6 mo) is recommended, although this is based on anecdotal data.

Bartonella henselae is generally resistant to penicillin, amoxicillin, and nafcillin.

Patients with neurologic bacillary angiomatosis or ocular manifestations have improved with antibiotic therapy and supportive care or with supportive care alone. In patients with thoracic and/or pulmonary disease, especially in association with prolonged fever and systemic symptoms, a trial of oral TMP-SMZ, ciprofloxacin, or azithromycin 2-3 times daily for 7-21 days is recommended. In the rare case of a severely ill patient, intramuscular gentamicin 5 mg/kg/d may be effective within 72 hours; continue treatment for 6-8 weeks.

Normal doses of rifampin are 10-20 mg/kg/d orally every 12-24 hours, not to exceed 600 mg/d. Rifampin can cause hepatitis, particularly with underlying liver damage. Gastrointestinal, hematologic, and neurologic adverse effects are reported.

Importantly, because of the potential risk of arthropathy, caution should be used if considering the use of fluoroquinolones in patients younger than 18 years. Ciprofloxacin is not approved for administration in children. Additional adverse effects include gastrointestinal symptoms, dizziness, rash, seizures, headache, confusion, and tremors.

TMP-SMZ doses can include 8-12 mg/kg/d orally of TMP and 40-60 mg/kg/d orally of SMX every 12 hours. TMP-SMZ can cause rashes and, occasionally, Stevens-Johnson syndrome. Anemia and neutropenia may occur, and a mild decrease in platelet count is common.

The dose of intravenous gentamicin is 3-7.5 mg/kg/d orally every 8 hours. Serious toxic effects from these drugs are not common. Gentamicin may cause nephrotoxicity and ototoxicity. Aminoglycoside therapy is recommended for endocarditis.

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Treatment of Lymph Node Suppuration

If suppuration occurs, lymph node aspiration may be required. Aspiration of suppurating nodes is both a diagnostic and therapeutic procedure. Repeated aspirations may be performed if pus reaccumulates and pain recurs.

Treat recurrence of suppuration by incision and drainage. Although incision and drainage has been discouraged because it leaves a scar and may result in a draining fistula, the risk of fistulous sinus tract formation is small. This has been reported only in cases of atypical mycobacterial lymphadenopathy mistaken for CSD.

Surgical excision of an enlarged node is indicated when the diagnosis is in question or when repeated aspirations fail to relieve the patient's pain. Excision of a persistent ocular granuloma may be required.

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Follow-up

Immunocompetent patients and immunocompromised patients without evidence of systemic disease may be followed on an outpatient basis. Depending on severity, immunocompromised patients or patients with atypical manifestations of CSD may require hospitalization. If admission is required, frequent monitoring of the adenitis is indicated to evaluate for suppurative complications.

Outpatients should be instructed to return for a follow-up evaluation to ensure resolution of lymphadenopathy in 2-4 months. Patients should return to care sooner if their condition worsens or the lymph node starts to suppurate. Closely follow up patients for 6 months or until the lymphadenopathy resolves.

Neurologic complications can occur up to 6 weeks after inoculation. Instruct parents to seek medical attention if they notice any abnormal behavior in their children.

If the lymphadenitis does not resolve or if it progressively enlarges, surgical biopsy may be indicated to rule out neoplastic causes and to definitively diagnose catscratch disease.

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Deterrence/Prevention

Pet quarantine, disposal, or euthanasia is unnecessary. The ability of the animal to transmit the organism is transient.

Although doxycycline treatment of cats is associated with decreased B henselae bacteremia, this treatment has not been shown to reduce the risk of cat-to-human transmission.

The natural history of feline infection and infectivity remains unknown. Feline B henselae bacteremia has been reported to last from weeks to months, with 100-fold fluctuations in bacteremic levels and intermittent negative cultures.

Given the established link between flea infection and B henselae transmission, common sense measures seem prudent (eg, avoiding stray cats, keeping pets free of fleas).

Children should be taught how to handle pets gently. Any scratch or bite, especially from a kitten, should be brought to the attention of parents and carefully followed up.

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Consultations

Emergent consultation is not usually required for those with catscratch disease. Consider emergent or outpatient consultation in cases of diagnostic uncertainty or with specific organ system involvement as indicated.

Consultation with an infectious disease specialist should be sought in cases of atypical catscratch disease or in cases of catscratch disease in immunocompromised patients. Consultation with a neurologist is indicated for patients with CNS involvement, and evaluation with an ophthalmologist may be needed in patients with any visual changes.

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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 Medical School

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)

Rose A Ressner, DO  Staff, Department of Infectious Diseases, Walter Reed Army Medical Center

Rose 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.

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.

Rajendra Kapila, MD, MBBS  Associate Professor, Department of Medicine, University of Medicine and Dentistry of New Jersey-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.

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.

Additional Contributors

Jeffrey Glenn Bowman, MD, MS Consulting Staff, Highfield MRI

Disclosure: Nothing to disclose.

Itzhak Brook, MD, MSc Professor, Department of Pediatrics, Georgetown University School of Medicine

Itzhak Brook, MD, MSc is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians-American Society of Internal Medicine, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, Armed Forces Infectious Diseases Society, Association of Military Surgeons of the US, Infectious Diseases Society of America, International Immunocompromised Host Society, International Society for Infectious Diseases,Medical Society of the District of Columbia, New York Academy of Sciences, Pediatric Infectious Diseases Society, Society for Ear, Nose and Throat Advances in Children, Society for Experimental Biology and Medicine, Society for Pediatric Research, Southern Medical Association, and Surgical Infection Society

Disclosure: Nothing to disclose.

Jack A Coleman, MD Consulting Staff, Franklin Surgical Associates

Jack A Coleman, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Sleep Medicine, American Bronchoesophagological Association, American College of Surgeons, American Laryngological Rhinological and Otological Society, American Society for Laser Medicine and Surgery, and Association of Military Surgeons of the US

Disclosure: Accarent, Inc. Honoraria Speaking and teaching

Joseph Domachowske, MD Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York Upstate Medical University

Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Dirk M Elston, MD Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Allan D Friedman, MD, MPH Chairman, Division of General Pediatrics, VCUH Health System; Professor of Pediatrics, Virginia Commonwealth University

Allan D Friedman, MD, MPH is a member of the following medical societies: American Academy of Pediatrics

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.

Robert M Kellman, MD Professor and Chair, Department of Otolaryngology and Communication Sciences, State University of New York Upstate Medical University

Robert M Kellman, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Neurotology Society, American Rhinologic Society, American Society for Head and Neck Surgery, Medical Society of the State of New York, and Triological Society

Disclosure: GE Healthcare Honoraria Review panel membership; Revent Medical Honoraria Review panel membership

John W King, MD Professor of Medicine, Chief, Section of Infectious Diseases, Director, Viral Therapeutics Clinics for Hepatitis, Louisiana State University Health Sciences Center; Consultant in Infectious Diseases, Overton Brooks 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; MERCK None Other

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.

John M Leedom, MD Professor Emeritus of Medicine, Keck School of Medicine of the University of Southern California

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.

Kim Lundstrom, MD Consulting Staff, Department of Otolaryngology-Head and Neck Surgery, Longmont Clinic

Kim Lundstrom, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery and American Medical Association

Disclosure: Nothing to disclose.

Gauri Mankekar, MBBS, MS, DNB, PhD Consultant Otorhinolaryngologist, Department of Otolaryngology, PD Hinduja National Hospital, India

Gauri Mankekar, MBBS, MS, DNB, PhD is a member of the following medical societies: Association of Medical Consultants of Mumbai, Association of Otolaryngologists of India, and Cochlear Implant Group of India

Disclosure: Nothing to disclose.

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.

Arlen D Meyers, MD, MBA Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society

Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation Unrestricted gift Unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo Consulting; Medvoy Ownership interest Management position; Cerescan Imaging Honoraria Consulting; GYRUS ACMI Honoraria Consulting

Van Perry, MD Assistant Professor, Department of Medicine, Division of Dermatology, University of Texas School of Medicine at San Antonio

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.

Gregory J Raugi, MD, PhD Professor, Department of Internal Medicine, Division of Dermatology, University of Washington at Seattle School of Medicine; 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.

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Barry J Sheridan, DO Chief Warrior in Transition Services, Brooke Army Medical Center

Barry J Sheridan, DO is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Kerrie J Spoonemore, MD, PharmD Clinical Instructor, Department of Dermatology, University of Washington

Kerrie J Spoonemore, MD, PharmD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Russell W Steele, MD Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Michael J Wells, MD Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

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.

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Papulopustular lesions of a primary inoculation site on the hand of a 16-year-old patient. These lesions had been present for approximately 3 weeks. A catscratch antigen skin test was positive with 15-mm induration. No treatment was administered, and her condition resolved spontaneously in 2.5 months. Courtesy of Andrew Margileth, MD.
A crusted primary inoculation papule on the neck of a 4-year-old child. Note the adjacent lymphadenitis. This patient had contact with cats and had multiple scratches. Courtesy of Andrew Margileth, MD.
This 13-year-old girl developed fatigue and malaise after being licked and scratched by a cat. The typical conjunctival granuloma was accompanied by a parotid mass and intraparotid adenitis. No treatment was administered, and all her signs and symptoms resolved in 3 months. Courtesy of Andrew Margileth, MD.
This 9-year-old boy developed catscratch disease (CSD) encephalitis and a papular pruritic dermatitis after sustaining cat scratches and developing regional lymphadenitis. He was in a coma for 4 days but experienced a complete and rapid recovery within 3 weeks. Biopsy of the skin rash revealed nonspecific changes. The CSD antigen skin test result was positive. Courtesy of Andrew Margileth, MD.
This 2.5-year-old boy was recovering from catscratch disease acquired 10 months before when he developed this neck abscess over a period of 3 weeks. Biopsy revealed caseating granulomas; acid-fast bacillus and Warthin-Starry stain results were negative. Courtesy of Andrew Margileth, MD.
This 10-year-old child had contact with dogs but not cats. The impressive lymphadenitis had been present for 5 weeks and was not tender. Pathologic examination of a biopsy specimen of the lymph node revealed nonspecific changes. She had a positive catscratch disease skin test result and negative purified protein derivative skin test results. Treatment with cephalexin was administered with a good response. Complete resolution occurred in 4.5 months. Courtesy of Andrew Margileth, MD.
Warthin-Starry stained sections of lymph node showing chains and clusters of organisms. Courtesy of Andrew Margileth, MD.
Table 1. Clinical Manifestations of CSD[4]
Sign or SymptomPercentage, %Average Duration, d
Adenopathy10014-180
Adenopathy only5214-180
Inoculation site59-937
Fever >101°F (38.3°C)32-606
Malaise/fatigue2913
Headache134
Anorexia, weight loss, emesis145
Splenomegaly1211
Sore throat52
Rash58.5
Parotid swelling2-
Conjunctivitis4.5-
Table 2. Clinical Manifestations of Atypical CSD[14, 3]
Clinical Feature Margileth,



n = 1174, %



Carithers,



n = 1200, %



Typical presentation88.495
Inoculation lesion (skin, eye, mucous membrane)58.6
Unusual presentation11.65
Parinaud oculoglandular syndrome6.34
Encephalopathy2.30.25
Systemic disease, severe, chronic2
Erythema nodosum0.60.42
Atypical pneumonia0.2
Breast tumor0.2
Thrombocytopenic purpura0.10.08
Table 3. Response to Medications
Ciprofloxacin



500 PO bid



Case Report



5 adults



"Dramatic improvement" in a few days; defined as resolution of symptoms (ie, malaise and pain)Holley[60]
Gentamicin



5 mg/kg/d IV/IM



Case Report



3 febrile children; 2 with hepatitis, 1 with painful regional lymphadenopathy



Resolution of fever and systemic symptoms in 1-2 daysBogue et al[61]
TMP-SMZ



6-8 mg TMP/kg/d PO



Uncontrolled retrospective study



60 patients with prolonged fever and systemic symptoms



58% effective, 7-day course (see above)Margileth[41]
Rifampin 10-20 mg/kg/d PO/IVUncontrolled retrospective study



60 patients with prolonged fever and systemic symptoms



87% effective, 7- to 14-day course (see above)Margileth[57]
Azithromycin



500 mg PO qd for 1 day, then 250 mg PO qd for 4 days



Prospective placebo-controlled, double-blind study



29 patients



80% of lymph node volume (as measured by ultrasonography) resolved in 30 days in 7 of 15 patients on azithromycin vs 1 of 15 control patients Bass et al[56]
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