eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease
Catscratch Disease
Updated: Apr 28, 2009
Introduction
Background
Catscratch disease (CSD) was first described in the mid 20th century; the first individual with catscratch disease was a 10-year-old boy in Paris, France. The signs and symptoms of catscratch disease widely vary; regional adenopathy is the most common symptom.1 Many organ systems can be affected. A skin papule at the sight of inoculation often occurs prior to the development of adenopathy. Catscratch disease is the most common cause of chronic adenopathy in children. Typically, the incubation period is 3-10 days.
Kittens are more likely to transmit the infection than older cats. Owners of kittens younger than 12 months are 15 times more likely to develop catscratch disease than owners of adult cats. Fleas are also most likely vectors for disease. More than 90% of patients infected with catscratch disease have a recent history of contact with a cat, usually a kitten. Risk factors for catscratch disease include ownership of a kitten younger than 12 months, a scratch or bite from a kitten, and ownership of at least one cat with fleas. catscratch disease secondary to a dog bite has also been reported.2
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 spontaneously resolved 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.
Pathophysiology
Most cases of catscratch disease are caused by Bartonella henselae. The bacteria, formerly classified as Rochalimaea henselae, are slow-growing, fastidious, pleomorphic, gram-negative organisms. In addition to lymphatics, infection can affect the CNS, eyes, liver, spleen, bone, and lungs. Erythema nodosum and thrombocytopenia purpura have also been reported. The primary inoculation site and involved lymph nodes show a central area of avascular necrosis surrounded by lymphocytes. Histiocytes and giant cells are often present.
Frequency
United States
The incidence rate is believed to be at least 9.3 per 100,000 population or more than 22,000 cases of catscratch disease per year. In temperate climates, catscratch disease predominantly occurs in autumn and winter; in the tropics, seasonal changes in frequency of the disease are not observed. Hospitalization rates vary from 0.6-0.86 per 100,000 children. The median hospitalization charge for catscratch disease has been estimated to be $46,140, and annual expenses are estimated to be about $3.5 million.
International
Distribution of catscratch disease is worldwide. Incidence rates reflect cat populations in each country.
Mortality/Morbidity
Catscratch disease is usually self-limited and benign. Patients with prolonged courses of the disease usually fully recover. Reinfection is infrequent. Death caused by catscratch disease in patients who are immunocompetent is extremely rare.
Sex
CSD is observed more frequently in males than females. This probably reflects an increased risk of exposure to infected kittens and an increased risk of bites and scratches from the infected animal.
Age
Although some studies suggest that approximately 60% of cases of catscratch disease occur in patients younger than 20 years, older literature suggests that incidence in this age group may have been as high as 80%.
Clinical
History
- A history of contact with a cat, usually a kitten, in the previous 1-2 weeks is common in individuals with catscratch disease (CSD). The patient often remembers being bitten or scratched by the cat.
- The classic history of an individual with catscratch disease is a local rash followed by adenopathy.
- The rash is present in more than 90% of patients infected with the disease and usually lasts until adenopathy occurs, which is a period of 1-4 weeks.
- The rash consists of one or more red papules that are 0.5 cm or less in diameter and appear at the site of inoculation, which is often a cat scratch or bite.
- Lymphadenitis usually persists 4-6 weeks but can last one year or longer.
- Axillary nodes are most frequently affected, followed by cervical, submandibular, and preauricular nodes.
- Single node involvement occurs in more than one half of individuals with catscratch disease. The typical node size is 1-5 cm in diameter.
- Fever of unknown origin may be present in one third of patients with catscratch disease.
- Fatigue is also present in one third of patients with catscratch disease.
- Parinaud oculoglandular syndrome occurs in 2-3% of patients with catscratch disease.
- CNS findings are present in 5% of patients with catscratch disease and include headaches, mental status changes, seizures, myelitis, transient peripheral neuropathy, and retinitis.
Physical
- Skin lesions typically evolve from vesicular to erythematous papular lesions. Papules may have an overlapping crust. Soon after the onset of adenopathy, skin lesions may disappear.
- Affected lymph nodes are tender with red, warm, indurated skin over the nodes. Many of the lesions may suppurate. Occasionally, a sinus track may form. Nodes that drain may heal with scarring. Occasionally, node enlargement lasts 4-6 weeks.
- Fever may be present in one third of patients with catscratch disease and may last 1-2 weeks. In a series of prolonged fever without a source, catscratch disease was one of the most common diagnoses.3
- Fatigue is also present in one third of cases and may persist for weeks to months.
- Parinaud oculoglandular syndrome, which is characterized by unilateral conjunctivitis and regional lymphadenitis, occurs in 2-3% of patients with catscratch disease.
- In these patients, the site of inoculation is usually the eyelid or conjunctiva secondary to a lick, scratch, or bite. Subsequent rubbing of the eye often leads to spreading.
- After a few weeks, the patient develops nonpurulent conjunctivitis, an ocular granuloma, or both. Preauricular adenopathy also develops.
- Physical findings involving the eye resolve in a few months without residual damage.
- CNS findings occur in 5% of patients with catscratch disease and include encephalitis, seizures, myelitis, peripheral neuropathy, and retinitis.
- Headaches and mental status changes occur 2-3 weeks after onset of the disease and are frequently the initial findings of the encephalopathy.4
- Patients with encephalitis may have seizures.
- Myelitis presents with extremity weakness, abnormal reflexes, sensory loss, and sphincter dysfunction.
- Bell palsy has been described in patients with catscratch disease.
- Acute onset, self-resolving, recurrent expressive aphasia has been reported.
- Other CNS findings include transient peripheral neuropathy and optic neuritis and neuroretinitis presenting as unilateral blindness.
- Recovery from CNS manifestations may be slow; some individuals with catscratch disease require one year or longer to recover from CNS manifestations.
- An individual with catscratch disease may present with a fever of unknown origin. Adenopathy may not be present. Abdominal pain may be the initial finding, along with fever, for hepatosplenic catscratch disease.
- Characterized by painful, tender, subcutaneous nodules on the skin, erythema nodosum may present 1-6 weeks after onset of adenopathy in less than 1% of patients with catscratch disease. These nodules resolve without sequelae.
- A transitory rash may occur early in the course of the disease. Most commonly, the rash is an evanescent maculopapular rash.
- Thrombocytopenia purpura is quite rare and is usually transient.
- Osteomyelitis, manifesting by fever and bone pain, has been reported.
- A few patients with catscratch disease have been described with osteolytic lesions but not true osteomyelitis. These patients do not have a fever or leukocytosis.
- Sites of node involvement are remote from the site of inoculation of B henselae, suggesting hematogenous spread. Biopsy of these lesions demonstrates granulomatous reactions.
- Endocarditis with immune-mediated manifestations has been described. Immunocompromised patients may present with insidious back pain due to vertebral osteomyelitis. Other findings in immunocompromised patients include cysts in the liver and spleen, painful tumors, angiomatosis, and peliosis.
- Back pain as the presenting symptom has been reported. In one case report, CT scanning revealed a soft tissue mass dorsal to the processi transversa L1-2, and MRI revealed a contrast-enhancing paraspinal mass with infiltration of the erector spinae consistent with inflamation.5 B henselae immunoglobulin (Ig)M antibody findings were positive. The patient spontaneously recovered after about one month.
Causes
- Catscratch disease appears to be caused by B henselae.
- Afipia felis, at one time thought to be a major etiologic agent of catscratch disease, has now been excluded as a significant cause.
- Disseminated illness occurs in less than 1% of patients with catscratch disease. It is manifested by persistent spiking fever, hepatosplenomegaly, and abdominal pain associated with diffuse granulomatous liver and spleen.
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| Follow-up: Catscratch Disease |
| Multimedia: Catscratch Disease |
| References |
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References
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Further Reading
Keywords
catscratch disease, CSD, cat scratch disease, cat-scratch disease, cat bite, benign inoculation lymphoreticulosis, benign inoculation reticulosis, cat-scratch fever, regional granulomatous lymphadenitis, regional adenopathy, , , erythema nodosum, thrombocytopenia purpura, Parinaud oculoglandular syndrome, myelitis, transient peripheral neuropathy, retinitis, encephalitis, Bell palsy, hepatosplenic catscratch disease, endocarditis, rash, skin rash, abdominal pain, kitten bite, kitten scratch, treatment, diagnosis, back pain
