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A case of cervical lymphadenitis
We all have different systems to get the same work done. In medical school, we started collecting lists, flow sheets, notepads, abbreviations, fine-point pens and habits to keep the relevant information needed for caring of our patients.
Looking back, I can see how I progressively refined my own method. I am an index card person. Almost invariably I keep a 3" x 5" card where I put a patient sticker on the top, write the pertinent history below and jot down the labs on the back. After a month in the consultation service, I file those cards. Doing some clean-up, I came across this brief case that I would like to share with you.
About this case and barking dogs
My card reads that this was a 21-month-old who had developed a “small bump” to the right side of the neck that worsened progressively over three months. The patient had fevers as high as 103°F. At the beginning of the illness, his pediatrician prescribed clindamycin — an appropriate empiric therapy for acute lymphadenitis in the methicillin-resistant Staphylococcus aureus era — but the child developed an urticarial reaction (common in ~7% of cases) and for that reason, the therapy was switched to amoxicillin-clavulanate.
Symptoms progressed, and after a second round of antibiotics he presented to us.
On review of systems, the patient denied cough or difficulties breathing or swallowing, but there was a 2-lb weight loss noted. He lived with his parents and two siblings. His parents were Mexican, and relatives visited regularly. In addition, he had three kittens and two cats.
The physical examination was significant for a golf ball-sized mass in the right cervical area, somewhat tender, non-mobile and non-fluctuant. There was a preauricular adenopathy with violaceous color changes of the overlying skin.
His labs were significant for a white blood cell count of 23.5 cells/mL (41% segs, 15% bands), hemoglobin 9.2 g/dL and platelet count of 670,000/mL. Electrolytes and liver enzymes were normal. Lactate dehydrogenase was 672 and uric acid 4.0.
What is the etiologic agent for this disease?
- Mycobacterium tuberculosis
- Atypical mycobacteria
- Bartonella henselae
- Methicillin-resistant Staphylococcus aureus
- Lymphoma
The answer is Bartonella henselae.
I was absolutely convinced that this was a case of atypical mycobacterial disease. With negative TB history or contacts, negative chest films and TST, the likelihood for TB wasn’t as high. I realized that if it barks and has four legs, it may not be a dog after all.
The patient underwent an incisional biopsy. Simultaneously, we received the Bartonella henselae titers back: 1:512 (B. quintana, commonly cross-reacting, 1:8192). The histopathology revealed areas of focal necrosis that were pathognomonic.
The initial empiric therapy consisted of clarithromycin and rifampin. I did not see him in follow-up, and thus cannot attest on his subsequent course of therapy.
A blood culture obtained at admission was sterile. Routine aerobic, anaerobic, fungal and mycobacterial cultures (the great four) on the surgical specimen were negative as well. Now, a few words on cat-scratch disease (CSD).
I was relatively naive on CSD until coming to Houston but we see lots of CSD cases here. Sheldon Kaplan, MD, and colleagues published a review of 19 cases that presented at Texas Children’s, describing clinical and therapeutic aspects of hepatosplenic CSD, where abdominal pain, liver and spleen abscesses are the hallmark of the disease.
Incidentally, I was on service with Dr. Kaplan when we evaluated a teenager with a fever of unknown origin where a detailed exam revealed some lip edema. However, the patient spilled the beans and helped us to diagnose hepatosplenic cat-scratch fever when he offered that his brother had thrown the kitten onto his face two months prior. The unique story deserved to be shared!
CSD is a self-limited disease that resolves in one to two months (not on this patient!), but antibiotics can contribute to accelerate recovery. Oral azithromycin, quinolones, trimethoprim-sulfamethoxazole and rifampin can be used, although the duration of therapy is unclear. Fortunately, CSD has an excellent prognosis and leaves no sequelae behind.
I recently adopted a kitten that I have named Frida, and I’ve been checking my armpit daily but so far no nodes. I love cats, and I hope you enjoyed this brief case. I will bring more next time. Until then, be well.
