Clinical utility of whole body diffusion-weighted imaging in an immunocompetent adult with atypical cat scratch disease

BackgroundCat scratch disease (CSD) is an infectious disease caused by Bartonella henselae. CSD follows a typical course, characterized by regional lymphadenopathy. In atypical CSD, the lesions spread to systemic organs and can cause fever of unknown origin (FUO). A previous study showed the usefulness of whole-body magnetic resonance imaging (WB-MRI) with diffusion-weighted imaging (DWI) for limited areas in the diagnosis of FUO, but there are no studies on the clinical utility of whole-body DWI (WB-DWI). We herein report the case of an immunocompetent young man in whom contrast-enhanced CT-unidentifiable multiple liver abscess and osteomyelitis were successfully detected by WB-DWI. Follow-up with a liver biopsy helped confirm an atypical CSD diagnosis.Case presentationA 23-year-old previously healthy man was admitted for a 19-day history of high fever despite 3-day treatment by azithromycin. His physical examination was unremarkable and contrast-enhanced CT showed only a low attenuated area in the right lobe of the liver, indicating a cyst. WB-DWI revealed multiple nodular lesions of hypo-diffusion in the liver, spine, and pelvic region. The biopsy specimens of the liver abscess showed no evidence of tuberculosis/malignancy and the polymerase chain reaction (PCR) test of liver abscess aspirate showed positive findings for Bartonella henselae, confirming the diagnosis of CSD. He completed minocycline monotherapy for a total of 60 days without any deterioration.ConclusionsWB-DWI can be useful for the diagnosis of atypical CSD with hepatic and bone involvement, which can cause FUO in young immunocompetent adults.     

猫抓病15例的临床分析

目的了解猫抓病(cat scratch disease,CSD)的临床表现、诊断方法、治疗及预后。方法收集西南医科大学附属医院2016年1月-2019年6月收治的CSD病例,统计分析患者的临床资料。结果15例CSD患者,男9例,女6例,年龄10~67岁,中位年龄32岁。临床表现以局部淋巴结肿大、发热、伤口经久不愈常见,所有患者经活检病理结合流行病学史确诊,经治疗后预后均良好。结论CSD临床表现以局部淋巴结肿大为主,流行病学史结合活检病理是确诊的主要方法,抗菌药物联合手术为有效的治疗手段,预后多数良好。     

Exploring the seasonal and regional features of cat-scratch disease on the basis of anti-Bartonella henselae IgM/IgG positive rates in Japan

ObjectivesThis study aimed to explore the seasonal and regional features of cat-scratch disease (CSD) based on 15-years of test results for anti-Bartonella henselae IgG and IgM by immunofluorescence assay (IFA) performed as a laboratory specialized in diagnostic testing of CSD in Japan. A literature search was performed to put our findings in perspective.MethodsA total of 956 sera from patients suspected of CSD were submitted to our laboratory from nationwide. Seasonal changes in the monthly positive rates of IgG/IgM antibodies and regional distribution of the test specimens were analyzed.ResultsThe monthly positive rates of anti-B. henselae IFA of IgG and IgM were both significantly high between September and January and low between March and July. The seasonal pattern observed in this study was similar to the ones reported from US and France, which were analyzed from a clinical database (monthly incidence of CSD diagnosis) or from monthly positive rates of either B. henselae PCR or anti-B. henselae IFA. However, fluctuations in the IFA monthly positive rates in this study were more pronounced than other reports. Regarding regionality, the test specimens submitted to us for IFA were prominently more from southwestern areas than from northern/middle-northern areas of Japan. The distribution coincided well with the regional distribution of CSD case reports and with a known regional prevalence of Bartonella-species bacteremia among pet cats in Japan.ConclusionThese epidemiological features in Japan are of relevance in the clinical diagnoses of CSD.     

Cat-scratch Disease

Cat-scratch disease is a common infection that usually presents as tender lymphadenopathy. It should be included in the differential diagnosis of fever of unknown origin and any lymphadenopathy syndrome. Asymptomatic, bacteremic cats with Bartonella henselae in their saliva serve as vectors by biting and clawing the skin. Cat fleas are responsible for horizontal transmission of the disease from cat to cat, and on occasion, arthropod vectors (fleas or ticks) may transmit the disease to humans. Cat-scratch disease is commonly diagnosed in children, but adults can present with it as well. The causative microorganism, B. henselae, is difficult to culture. Diagnosis is most often arrived at by obtaining a history of exposure to cats and a serologic test with high titers (greater than 1:256) of immunoglobulin G antibody to B. henselae. Most cases of cat-scratch disease are self-limited and do not require antibiotic treatment. If an antibiotic is chosen, azithromycin has been shown in one small study to speed recovery. Infrequently, cat-scratch disease may present in a more disseminated form with hepatosplenomegaly or meningoencephalitis, or with bacillary angiomatosis in patients with AIDS.     

An unusual outcome in a child with hepatosplenic cat-scratch disease

Typical cat-scratch disease (Bartonella henselae infection) in an immunocompetent child is usually associated with a history of scratch, bite or intimate contact with a cat. Most patients develop a non-tender papule in the scratch line after three to ten days. This may persist for only a few days or as long as two to three weeks. During the next two weeks or more, regional lymph nodes that drain the area gradually enlarge and then slowly resolve in more than 10% of patients. The nodes develop overlying erythema and may suppurate. Atypical forms of cat-scratch disease occur in a minority of cases and are characterized by ocular or neurological manifestations, hepatosplenic involvement, vertebral osteomyelitis, endocarditis etc. Immunocompromised individuals with B. henselae infection may develop bacillary angiomatosis, bacillary peliosis, and relapsing bacteremia. There have been several reports of hepatosplenic granulomas caused by B. henselae in immunocompetent children. We report a case of a 6-year-old boy with the hepatosplenic form of cat-scratch disease. Despite early diagnosis and long-term antimicrobial treatment, splenectomy could not be avoided.     

超声造影评价子宫剖宫产瘢痕的应用价值

目的探讨超声造影（CEUS）评估子宫剖宫产瘢痕的应用价值。 方法选取2017年5月至2019年5月就诊于首都医科大学附属北京世纪坛医院,剖宫产术后6个月以上的患者75例行前瞻性诊断试验研究,所有患者均接受经阴道超声（TVS）及CEUS检查,其中11例接受宫腔水造影检查。与TVS和宫腔水造影对比,分析CEUS对剖宫产瘢痕憩室的检出率及诊断符合率。对CEUS与TVS两种方法测量瘢痕憩室形态学参数的结果进行比较。根据检查结果将病例分为瘢痕憩室组和完整瘢痕组,对比分析2组瘢痕部位的时间-强度曲线参数。 结果TVS检出瘢痕憩室40例,检出率为53.3%（40/75）;CEUS检出瘢痕憩室51例,检出率为68%（51/75）,2者间差异有统计学意义（χ²=40.336,P<0.05）。CEUS测量瘢痕憩室的深度、瘢痕残余肌层厚度平均值分别为（5.55±1.55）mm、（3.22±1.37）mm;与TVS的测量值（4.24±2.76）mm、（3.96±1.80）mm比较,差异均有统计学意义（t=4.463、6.480;P均<0.001）。瘢痕憩室组瘢痕部位的峰值强度及增强速率分别为（15.07±1.82）dB、（2.60±0.61）dB/s;均明显低于完整瘢痕组的（17.37±1.97）dB、（3.72±1.89）dB/s,差异均有统计学意义（t=4.961、-3.837;P均<0.001）。 结论CEUS对子宫剖宫产瘢痕憩室的检出能力优于TVS,时间-强度曲线参数（峰值强度、增强速率）可以通过造影剂微泡的灌注情况,反映瘢痕部位的微血管密度,对瘢痕愈合情况进行评估,CEUS在子宫剖宫产瘢痕评价中具有较好的应用前景。     

Bartonella adhesin a mediates a proangiogenic host cell response

Bartonella henselae causes vasculoproliferative disorders in humans. We identified a nonfimbrial adhesin of B. henselae designated as Bartonella adhesin A (BadA). BadA is a 340-kD outer membrane protein encoded by the 9.3-kb badA gene. It has a modular structure and contains domains homologous to the Yersinia enterocolitica nonfimbrial adhesin (Yersinia adhesin A). Expression of BadA was restored in a BadA-deficient transposon mutant by complementation in trans. BadA mediates the binding of B. henselae to extracellular matrix proteins and to endothelial cells, possibly via beta1 integrins, but prevents phagocytosis. Expression of BadA is crucial for activation of hypoxia-inducible factor 1 in host cells by B. henselae and secretion of proangiogenic cytokines (e.g., vascular endothelial growth factor). BadA is immunodominant in B. henselae-infected patients and rodents, indicating that it is expressed during Bartonella infections. Our results suggest that BadA, the largest characterized bacterial protein thus far, is a major pathogenicity factor of B. henselae with a potential role in the induction of vasculoproliferative disorders.     

Cat scratch disease: analysis of 130 seropositive cases

 To clarify the clinical manifestations of cat scratch disease (CSD), we evaluated a total of 130 seropositive patients with CSD. The patients' ages ranged from 1 to 68 years; 103 (79.2%) were under 18 years of age. CSD occurred predominantly in the fall and winter months. Regional lymphadenopathy was noted in 110 (84.6%) of the cases, and the most common sites were the neck (33%), axillary (27%), and inguinal (18%) regions. One hundred of the patients (77%) had general symptoms, such as fever, headache, and malaise. The clinical manifestations of CSD showed a wide spectrum from typical or classical CSD, with regional lymphadenopathy, to atypical or systemic CSD. Of the 130 cases, 103 (79.2%) were typical CSD and 27 (20.8%) were atypical CSD. Atypical cases of CSD were commonly reported as fever of unknown origin (37.0%), neuroretinitis (22.2%), encehalopathy (14.8%), hepatosplenic granuloma (11.1%), and Parinaud's oculoglandular syndrome (7.4%). Fever of unknown origin or prolonged fever lasting more than 14 days was evident in 27 (20.8%) of the 130 cases in this study. Eleven of the 27 cases lacked lymphadenopathy. Our findings suggest that CSD is not a rare disease in Japan. The indirect fluorescent antibody (IFA) test to detect Bartonella species may provide a prompt diagnosis of CSD and facilitate appropriate therapy. Received: March 6, 2002 / Accepted: July 8, 2002     

Gray-scale sonographic evaluation of cervical lymphadenopathy in cat-scratch disease

PURPOSE: The aim of this study was to characterize the gray-scale sonographic findings in the lymph nodes of patients with cat-scratch disease (CSD). METHODS: We analyzed the sonograms of cervical lymph nodes in 41 patients with proven CSD between January 1997 and October 1999. RESULTS: A total of 222 involved lymph nodes were detected. Involved nodes were most commonly found in the middle cervical (58%), parotid (37%), upper cervical (37%), and submandibular (17%) regions. We found acute, chronic, or abscessed lymphadenopathy in 63%, 12%, and 24% of patients, respectively. The size of involved lymph nodes ranged from 12 x 4 mm to 35 x 26 mm. The largest involved node had a short axis/long axis ratio of 0.5 or more in 61% of patients. Useful features for the differential diagnosis included markedly decreased echogenicity (100%), normal surrounding tissues (100%), and the presence of an echogenic hilum (76%). Posterior sound enhancement was significantly associated with larger and abscessed lymph nodes. CONCLUSIONS: Despite the absence of a specific sonographic finding for CSD, gray-scale sonography can provide clues to the diagnosis of CSD in the proper clinical setting.     

猫抓病诊断中浅表淋巴结病变的超声图像分析

目的了解猫抓病患者浅表淋巴结的超声图像表现.方法分析经病理证实的26例猫抓病患者的浅表淋巴结的超声图像.结果 26例中共有92枚淋巴结为超声波所检出.受累淋巴结主要位于颈部、耳后、腋下及腹股沟等部位,大小0.4 cm×0.3 cm～4.7 cm×2.1 cm.约81%患者的受累淋巴结短/长径之比≥0.5.有助于诊断CSD的超声图像表现包括受累淋巴结的回声较低(100%),淋巴结周围的组织正常(100%),高回声的淋巴结门结构存在(76.09%),较大的受累淋巴结或化脓淋巴结的后方回声增强.59.78%受累淋巴结内可显示彩色血流信号,其中43.48%可检出小动脉血流信号,平均RI为0.58.结论 CSD的超声改变缺乏特异性,但结合临床资料,浅表淋巴结超声检查仍有助于CSD的诊断.     

猫抓病性结肠淋巴结炎CT诊断

目的 提高对猫抓病性结肠淋巴结炎CT表现的认识。方法 回顾性分析二例猫抓病性结肠淋巴结炎的临床及CT表现。结果 二例均有猫接触史，除体表引流区域淋巴结肿大外，主要表现为结肠淋巴结炎并呈肿块样改变，CT增强扫描有明显强化，肠腔无狭窄改变及结肠黏膜无破坏。结论 结合病史，CT扫描对猫抓病性结肠淋巴结炎的诊断有很大价值。     

Laboratory diagnosis of Bartonella infections

Bartonella species are pathogens of emerging and reemerging significance, causing a wide array of clinical syndromes. In North America and Europe, they are increasingly recognized as a cause of culture negative endocarditis, neuroretinitis, and disease among homeless, HIV-infected, and other immunosuppressed individuals. In South America, bartonellosis continues to plague those in endemic regions and poses a significant threat to travelers in these areas. As the clinician is increasingly faced with these illnesses, which may be difficult to diagnose, laboratory techniques to confirm or refute the diagnosis are becoming increasingly important. Culture methods have improved over the past decade demonstrating increased sensitivity, but still require prolonged periods before isolation of the organism. Specimen handling, media selection, and growth conditions all may affect results and must be optimized in order to provide the highest likelihood of recovering the organism. Pure culture of the bacteria not only provides morphologic information, but also provides material for further diagnostic testing. Work with liquid media, which may provide a more rapid means of cultivation has shown some promise and should continue to be pursued. Improved blood culture techniques were a primary factor in the discovery of Bartonella endocarditis and continued improvements will likely demonstrate further clinical insights. Serologic testing for B henselae infections has become the cornerstone of clinical diagnosis, replacing the skin test that was poorly standardized and posed a potential risk to the patient. Immunofluorescence assays have been well characterized and validated in clinical trials, however they are not universally available. Vero cell cocultivated antigens appear to provide higher sensitivity and specificity when compared with agar-derived antigens. IFA assays are inherently difficult to perform, requiring significant expertise to provide reproducible results. On the contrary, enzyme immunoassays offer ease of use and a high level of reproducibility, however ideal antigens for use in the diagnosis of Bartonella infections have not been clearly identified. Continued work to define antigenic targets of the human response to infection and incorporation of these into a widely available EIA will provide a cost-effective tool for the clinician and epidemiologist alike. Due to the close phylogenetic relationship of B henselae and B quintana, differentiation between these species by serologic means may prove difficult. Molecular techniques including PCR offer high sensitivity and specificity, rapid availability of information, and the ability to differentiate Bartonella organisms at the highest level. Results of studies to date are promising and as methods are refined it will be important to conduct clinical studies to define the role of these assays. In disseminated Bartonella infections such as bacillary angiomatosis, peliosis, endocarditis, and urban trench fever, PCR currently offers the ability to establish the diagnosis when other tests may be unrevealing. For CSD, this technique should be used as a confirmatory technique when the diagnosis is unclear by other means. PCR analysis of blood specimens offers a minimally invasive approach to diagnosis, but clinical data are scarce and further studies are needed. As DNA microarrays move into the clinical arena, specific hybridization probes may allow improved identification and differentiation of Bartonellae at the molecular level.     

Bartonella-associated infections in HIV-infected patients

Two species of the gram-negative bacilli Bartonella, B. henselae and B. quintana, cause disease in HIV-infected patients. If untreated, infection can be fatal. Manifestations include bacillary angiomatosis (BA), bacillary peliosis hepatis (BP), bacteremia, or a combination of these. BA and BP present as lesions, but bacteremia may be subacute and persist for months without diagnosis. Additionally, patients may acquire cat scratch disease (CSD), but this is more common in immunocompetent patients. BA lesions are usually vascular, friable, and bleed profusely when traumatized. They may be confused with Kaposi's sarcoma (KS), pyogenic granuloma, lymphoma and various subcutaneous tumors and infections. Lesions may affect almost any organ, and appear as angiomatous papules, dry scaling lesions, subcutaneous nodules, cellulitic plaques or deep, highly vascularized, soft tissue masses. Patients may have osseus BA lesions (frequently affecting the long bones); hepatic and/or splenic lesions; bacteremia; or endocarditis. To diagnose infection, lesions should be biopsied and examined. Hematoxylin and eosin staining reveal histopathologic changes; darkly staining organisms are evident after Warthin-Starry silver staining; and electron microscopy allows visualization of the bacillus. An indirect immunofluorescence antibody test (IFA) detects bartonella-specific IgG antibodies. Treatment with erythromycin for at least three months is recommended, or with doxycycline if erythromycin is not well-tolerated. Severely ill patients should receive IV doxycycline with either gentamicin or rifampin for at least four months. To prevent infection, HIV-infected people should avoid traumatic cat contact and exposure to the body louse.     

Motivating factors influencing choice of major in undergraduates in communication sciences and disorders

The purposes of this study were to determine: (1) whether background factors influence the choice of Communication Sciences and Disorders (CSD) as an academic major; (2) what motivates students to major in CSD; (3) the relationship between motivation to pursue CSD as a major and the attractiveness of the major; and (4) whether motivation influences the perceived value of a career in CSD. A survey of 143 undergraduates was created and administered to assess motivational factors that influence the choice of major. The participants had diverse ethnic/racial and cultural backgrounds and were enrolled in CSD courses in the Liberal Arts College of St John's University, a US American Institution in Queens, New York. Preliminary analyses indicated that ethnic/racial background and family income had no statistically significant relationship to motivations, attractiveness of CSD as a major, or career value of CSD as a major. Students scored highest on Intrinsic motivation factor (e.g., enjoy interacting with people) and the lowest on Science motivation (e.g., interested in science). Student confidence (e.g., in reaching career goals) was an important predictor in the perception of the career value of a CSD. Results of this study provide further insight into curriculum development and recruiting strategies.     

Bartonella henselae survives after the storage period of red blood cell units: is it transmissible by transfusion?

Bartonella henselae is the agent of cat scratch disease and bacillary angiomatosis. Blood donors can be asymptomatic carriers of B. henselae and the risk for transmission by transfusion should be considered. The objective of this study was to demonstrate that B. henselae remains viable in red blood cell (RBC) units at the end of the storage period. Two RBC units were split into two portions. One portion was inoculated with B. henselae and the other was used as a control. All units were stored at 4 degrees C for 35 days. Aliquots were collected on a weekly basis for culture in a dish with chocolate agar, ideal for the cultivation of this agent. Samples were collected on days 1 and 35 and taken for culture in Bact/Alert R blood culture bottles. Aliquots taken simultaneously were fixed in Karnovsky's medium for subsequent electron microscopy evaluation. Samples from infected bags successfully isolated B. henselae by chocolate agar culture, although Bact/Alert R blood culture bottles remained negative. Bartonella spp. structures within erythrocytes were confirmed by electron microscopy. The viability of B. henselae was demonstrated after a storage period of RBC units. These data reinforce the possibility of infection by transfusion of blood units collected from asymptomatic blood donors.     

Cortical spreading depression in migraine.

Cortical spreading depression (CSD) is associated with a dramatic failure of brain ion homeostasis as well as efflux of excitatory amino acids from nerve cells and increased energy metabolism. There is strong clinical and experimental evidence to suggest that CSD is involved in the mechanism of migraine. This paper will, based on the experience related to the detection of CSD in humans, discuss pitfalls and possible strategies for detection of CSD in man. Development of reliable methods for detection of CSD in humans will determine the extent to which the large body of experimental findings from animal studies of CSD can be applied to the investigation and treatment of human brain disease. The paper is based on the experience that has been gained from two decades of studies of CSD in relation to clinical neurological diseases.     

Discovery and analysis of Bartonella henselae antigens for use in clinical serologic assays

The antibody response to Bartonella henselae has been studied in a number of mammals; however, the human response needs to be further studied. After natural infection, humans have antibody reactivity to a large number of B. henselae proteins. We used a proteomic approach to identify antigenic proteins of B. henselae to determine their capacity to elicit a human antibody response. Comparing patient sera by Western blot analysis demonstrated significant amounts of reactivity to B. henselae. The immunofluorescence assay (IFA)-positive sera identified several protein spots of interest. However, a consistent reactivity to a single spot by all sera was not observed. Three of these spots demonstrated reactivity in 71%, 64%, and 64% of positive sera tested with negligible reactivity to the negative sera. These proteins were identified as GroES, BepA, and GroEL. Most IFA-positive sera demonstrated reactivity to GroES, GroEL, and BepA. The usefulness of these proteins for a clinical serologic assay is discussed.     

Atypical manifestation of cat‐scratch disease: isolated epigastric pain in an immunocompetent, 12‐year‐old child

We present a 12‐year‐old immunocompetent girl with hepato splenic cat‐scratch disease (CSD). Her sole inaugural complaint was isolated epigastric pain. She fully recovered, with normalized abdominal CT scan following 2 weeks course of Azythromycin^®. CSD should be included in differential diagnosis in children with epigastric pain, especially in those with domestic pets.     

Cardiovascular evaluation of adolescents and young adults. Salient aspects of the examination

Cardiac findings in adolescents and young adults are usually normal, and most murmurs and other abnormalities that are found are benign. However, the primary care physician needs to obtain a complete personal and family history and perform a thorough physical examination to rule out cardiovascular disease and its precursors. Of primary concern are a personal or family history of syncope, family history of sudden death, and several pathologic murmurs such as those caused by mitral valve prolapse and hypertrophic cardiomyopathy. The physician may need to reassure the patient until a definitive diagnosis is made and can also provide accurate information on cardiac disease prevention.     

Munchausen syndrome presenting as acute spinal cord injury

A 30-year-old woman was diagnosed to have Munchausen syndrome, simulating acute spinal cord injury, a rarely reported neurologic presentation. For nearly seven years she traveled widely over two continents, taking serious medical risks in order to prolong her illness. She was discovered after recovering partial voluntary lower extremity function under the influence of Pentothal (thiopental sodium). Information about her personal and medical background was found to be untrue. Confidentiality requirements prevented the transfer of critical medical information and delayed the diagnosis. Corroboration of the details of personal and medical history may lead to earlier diagnosis and prevent unnecessary medical intervention.