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 Bacterial Diseases - CAT SCRATCH DISEASE

(Cat Scratch Fever, Benign Lymphoreticulosis, Benign nonbacterial Lymphadenitis, Bacillary Angiomatosis, Bacillary Peliosis Hepatis)

AGENT:

Controversial, it is not currently possible to definitively name the causative agent responsible for CSD. Felt to be either Afipia felis, a gram-negative rod or Rochalimaea henselae and Rochalimaea quintana. Both are members of class Proteobacteria and both are intracellular parasitic bacteria.

RESERVOIR AND INCIDENCE

Associated with domestic cats throughout the USA, and worldwide. Over 6000 cases annually. Seen more often in men than in women. Have seen clusters of infection within families within a 2 to 3 week period, suggesting that shedding by cats may occur periodically. Other sources of infection have included scratches from other species including dogs, squirrels, and goats and from wounds induced by crab claws, barbed wire, and plant material.

TRANSMISSION:

Ninety percent (90%) of patients have been exposed to a cat; 75% of these have been bitten, scratched, or licked. Most affected individuals are <20 years of age. 75-80% of the cases of CSD are diagnosed between September and February with a peak incidence in December.  4 to 6% of the general population and 20% of veterinarians have positive skin test reactions to CSD antigen.

DISEASE IN ANIMALS:

Subclinical

DISEASE IN MAN:

Different distinct syndromes exist:

Typical CSD:

A primary lesion, most common on neck or extremities, will develop in 50% of the cases and appear approximately 10 days after a bite or scratch. A pustule persists for 1-2 weeks. 10-14 days after the lesion appears, lymphadenopathy develops and usually regresses within 6 weeks. 30-50% of the enlarged nodes become suppurative. Of the approximately 65% who develop systemic illness, fever and malaise are the symptoms most often noted. The disease is usually benign and most patients recover spontaneously without sequelae within 2-4 months. Many unrecognized cases probably occur. Disease appears to confer lifelong immunity.

Atypical CSD:

The atypical forms of CSD, which constitute 11% of all cases, are extremely varied. The most common, representing 6% of all cases, is Parinaud's oculoglandular syndrome (POGS), or granulomatous conjunctivitis with preauricular adenopathy. Other, atypical presentations include tonsillitis, encephalitis, cerebral arteritis, transverse myelitis, radiculitis, granulomatous hepatitis and/or splenitis, osteolysis, atypical pneumonia, hilar adenopathy, pleural effusion, erythema nodosum, erythema annulare, maculopapular rash, thrombocytopenic purpura, and breast tumor. Bacillary Angiomatosis (Dermal BA) presents in several ways. The most common form is an enlarging red papule with some resemblance to a cranberry, often with a collarette of scale and sometimes with a suggestion of surrounding erythema. This type of lesion may be mistaken for pyogenic granuloma, unless fairly deep biopsy specimens are examined. These lesions begin as small papules and enlarge, occasionally becoming several centimeters in diameter and rarely ulcerating. They may be single or quite numerous. Another form of dermal BA is a deeper, subcutaneous nodule that appears flesh-colored and may be either fixed to subcutaneous tissues or freely mobile. Rarely BA may present as a dermal plaque. BA has been reported to occur in every organ system, including the brain, and is often difficult to differentiate from mycobacterial and fungal infections or malignancy without the use of biopsy. It is unclear if the personality changes, ranging from frank psychosis to depression, that have been described in association with BA represent CNS involvement or a neurotoxic product of this infection. Bacillary Peliosis Hepatis BPH, a vasoproliferative condition involving the liver of HIV-infected patients, is characterized by a proliferation of cystic blood-filled spaces surrounded by fibromyxoid stroma in which one can see bacteria similar to those seen in BA. Clinically these patients may or may not have visible bacillary angiomas. Their symptoms usually include fever, weight loss, and abdominal pain or fullness. Physical exam may reveal organomegaly. Laboratory studies usually demonstrate elevation of alkaline phosphatase and ç-glutamyltransferase levels out of proportion to those of aminotransferase and bilirubin.

DIAGNOSIS:

The sedimentation rate is elevated, the white blood cell count normal, and the pus from the nodes is sterile. ID skin testing with antigen prepared from the pus is positive. Excisional biopsy, usually performed to exclude lymphoma, confirms the diagnosis.

TREATMENT:

For CSD: Rifampin, ciprofloxacin, gentamycin, and trimethoprim-sulfa. Aspiration of suppurating nodes is recommended for relief of pain. Symptoms resolve without treatment in 2-4 months. BA and BPH respond to erythromycin, rifampin, or doxycycline. Therapy must be continue for 4-6 weeks to avoid relapse.

PREVENTION/CONTROL:

Education. Wash hands after handling cat. Wash cuts and scratches promptly and don't allow cat to lick open wound.