Swollen Lymph Nodes Not Only Symptom of Cat Scratch Disease

SWOLLEN LYMPH NODES ARE NOT THE ONLY SYMPTOM OF CAT SCRATCH DISEASE

Georgetown University otolaryngologist--head and neck surgeons suggest that other symptoms, such as facial paralysis and swollen eyelids, could result from an adverse encounter with a cat

New Orleans -- Cat scratch disease in a relatively common infectious disease that occurs in all age groups. Lymphadenenopathy, or swollen lymph nodes, is the prevailing symptom, generally caused from a kitten scratch or bite. In a previous study, cat scratch disease or fever was found to be the number two cause of lymphadenenopathy localized to the head and neck among 1,200 patients.

A team of Washington, DC- based otolaryngologist--head and neck surgeons contend that there are atypical symptoms of cat scratch disease that often go unrecognized. They have suggested that oculo glandular syndrome (painless eyelid swelling) and facial nerve palsy are two manifestations of the disorder that can often be confused with parotid malignancy (situated near the ear, denoting the parotid salivary gland). The consequence of this misdiagnosis leads to inappropriate patient management.

The etiology, clinical features, pathology, and management of two patients with the atypical symptoms were examined and described by the research team. The authors of the research, "Unusual Presentations of Cat Scratch Disease in the Head and Neck" are Alexander G. Chiu, MD, David A. Hecht, MD, Stephen A. Prendiville, MD, Christopher Mesick, MD, and Suzette Mikula, MD, all from the Georgetown University Medical Center, and Ziad E. Deeb, MD, at the Washington Hospital Center, Washington, DC.

The results were presented before the American Academy of Otolaryngology--Head and Neck Surgery Foundation Annual Meeting and Oto Expo being held September 26-29, at the Ernest N. Morial Convention Center in New Orleans, LA. At the gathering, the Academy's 11,000 members will have the opportunity to hear the latest research in the diagnosis and treatment of disorders of the ear, nose, throat, and related structures of the head and neck.

Methodology and results.

The two cases examined were:

A 23 year old caucasian female with a three week history of progressive painful right cheek swelling associated with oculo glandular syndrome recalled being scratched by a cat in the region of her right eye and chin five weeks earlier. An exam revealed a right-sided ptosis (drooping appearance), conjunctival congestion, and a firm right preauricular parotid mass which was tender to the touch.

A CT scan revealed diffuse enlargement of the parotid gland as well as an overlying gland. A biopsy of the right parotid gland was performed; clusters of branched pleomorphic bacilli within the inflammation were found, consistent with cat scratch disease. The symptoms were alleviated after one week of treatment.

A ten year old caucasian female complained of a two week history of left facial weakness. Her illness initially began as a left eye conjunctivitis followed by left-sided facial swelling and weakness. The patient also complained of a painful left neck mass. A physical examination revealed unilateral weakness of all facial nerve branches.

A CT scan confirmed posterior triangle adenopathy and a diffuse enlargement of her left parotid gland. The neck mass showed necrotizing granulomatous lymphadenitis with microabscess formation. Dieterle stain (used to demonstrate spirochetes and Leishman-Donovan bodies) showed small perivascular rod-like forms consistent with Bartonella. Ten days after treatment, the symptoms had decreased, and her face had returned to normal.

Conclusion:

Until 1983, the cause of cat scratch disease was unknown. Research found small, pleomorphic, argyrophilic bacilli in the lymph nodes of cat scratch disease sufferers; the organism was reclassified as Bartonella, believed to be the causative agent of the disorder.

Until very recently, the diagnosis of cat scratch fever has been made by clinical standards. A diagnosis required the presence of (1) a history of animal contact with a scratch or primary dermal/eye lesion; (2) regional lymphadenopathy in which all other causes have been ruled out; (3) a positive skin test; and (4) lymph node biopsy with histopathology consistent with the disorder.

If physicians encounter symptoms such as facial paralysis or a drooping eyelid, cat scratch disease should be considered as the cause. The study results recommend that a B.henselee IgM ElA be administered to the patient. If the test is negative, a Bartonella PCR assay using biopsied tissue should be the next step.

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Editor's Note: For a copy of this study or an interview with Dr. Chiu, contact Ken Satterfield at 703-519-1563 (through 9-21); 9/23-29, call the Annual Meeting Newsroom at 504-670-5409.