Diagnostic Considerations
Consider all causes of subacute and chronic lymphadenopathy. However, infection with cytomegalovirus, human immunodeficiency virus type 1, or Epstein-Barr virus usually is associated with lymphadenitis at more than one site. In patients with persistent skin papules and regional lymphadenopathy, consider leishmaniasis, Nocardiosis, and fungal infections.
Because the clinical manifestations of infection with Bartonella 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 differential diagnosis includes malignant neoplasms (eg, Kaposi sarcoma, angiosarcoma) and benign reactive conditions (eg, pyogenic granuloma, angiolymphoid hyperplasia with eosinophilia).
Differential Diagnoses
-
Atypical Mycobacterial Diseases
-
Leishmaniasis
-
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 cat scratch 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 cat scratch 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 cat scratch 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 cat scratch 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.
Tables
Sign or Symptom |
Percentage, % |
Average Duration, d |
Adenopathy |
100 |
14-180 |
Adenopathy only |
52 |
14-180 |
Inoculation site |
59-93 |
7 |
Fever >101°F (38.3°C) |
32-60 |
6 |
Malaise/fatigue |
29 |
13 |
Headache |
13 |
4 |
Anorexia, weight loss, emesis |
14 |
5 |
Splenomegaly |
12 |
11 |
Sore throat |
5 |
2 |
Rash |
5 |
8.5 |
Parotid swelling |
2 |
- |
Conjunctivitis |
4.5 |
- |
Clinical Feature |
Margileth, n = 1174, % |
Carithers, n = 1200, % |
Typical presentation |
88.4 |
95 |
Inoculation lesion (skin, eye, mucous membrane) |
58.6 |
|
Unusual presentation |
11.6 |
5 |
Parinaud oculoglandular syndrome |
6.3 |
4 |
Encephalopathy |
2.3 |
0.25 |
Systemic disease, severe, chronic |
2 |
|
Erythema nodosum |
0.6 |
0.42 |
Atypical pneumonia |
0.2 |
|
Breast tumor |
0.2 |
|
Thrombocytopenic purpura |
0.1 |
0.08 |
Ciprofloxacin 500 PO bid |
Case Report 5 adults |
"Dramatic improvement" in a few days; defined as resolution of symptoms (ie, malaise and pain) |
Holley [68] |
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 days |
Bogue et al [69] |
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 [48] |
Rifampin 10-20 mg/kg/d PO/IV |
Uncontrolled retrospective study 60 patients with prolonged fever and systemic symptoms |
87% effective, 7- to 14-day course (see above) |
Margileth [65] |
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 [64] |
