Cat-Scratch Disease In Adult Hospitalized For Prolonged-Fever Associated With Multiple Lymphadenopathies and Weight Loss
Mr. A, born on December 7, 1993 (19 years old) was hospitalized from 10-12-2012 to 17-12-2012 in the Service of Medicine B-Hepato-Gastro-Enterology of Tulle Hospital Center, for adenopathy of internal-underside of left elbow with prolonged-fever. The medical antecedent revealed a complete vaccination, obesity and smoking. In the history of the disease, we noted a deterioration of general condition involving asthenia, anorexia and weight loss with a loss of 15 kgs weight during the last three months (previous weight 105 kg). The general condition deterioration syndrome worsened with the appearance of a significant swelling inside the left arm associated with alternating fever-apyrexia and night sweats. There was no antecedent of travel in the tropics, insect sting or bite. The patient was a butcher living with a kitten and was regularly scratched by it. He had no urinary or pulmonary functional signs.\nAt the day of hospitalization the physical examination confimed the deterioration of general condition (asthenia, anorexia, weight loss), the temperature was 38.5°C, weight 88 kgs, height 182 cm, blood pressure 120/70 mmHg, there was no neurological, pulmonary or cardiovascular signs. The abdomen was soft, compressible, painless and had no hepatosplenomegaly. Clinical examination funded a left submaxillary and axillary infra centimeter adenopathies. The clinical examination which was otherwise unremarkable, revealed also an adenopathy with 5 to 6 centimeters of diameter at the internal face of the left elbow. This adenitis was firm, painful, moving and warm.\nThe laboratory tests performed on the day of admission (Day-0: D-0) highlighted: leukocytosis with neutrophil polynuclear predominance [White Blood Cells (WBC): 19.9 Giga/L, neutrophils Polunuclear: 14.5 Giga/L, C-reactive protein (CrP): 18 mg/L] (Table ). The remaining biological assessment, chest and left elbow radiographs were unremarkable, while the left elbow echography showed altered inflammatory of internal elbow soft tissue, consisting of a fluid collection, surrounded by a subcutaneous infil-tration and lymph node swelling underlying. To complete medical and biological exploration, a thoracic-abdominal scanner highlighted several axillary, supraclavicular, mediastinal, hilar, iliac and inguinal centimeter lymph nodes.\nIn summary, this observation showed an impaired general condition syndrome in prolonged fever context with suppurative adenitis, weight loss and multiple lymphadeno-pathy in a young adult patient. The diagnostic hypotheses were rejected by the respective laboratory tests: toxoplas-mosis, infectious monocucléose, HIV-1, HIV-2, Bartonel-losis and Brucellosis serology were found to be negative. The intradermal reaction (IDR) to tuberculin and quantiferon assay was negative. The Cytomegalo virus (CMV) and Ebstein Barr virus (EBV) serologies were in favor of a pre-vious infection. As the Bartonellosis serology was negative, the diagnosis of Cat-scratch disease was based on the patho-logical analysis of the biopsy specimen of the lymph node excisional which showed necrotizing granulomatous inflam-mation with central necrosis surrounded by epithelioid cells and Langhans’ giant cells, strongly suggesting Bartonella henselae infection. The Ziehl coloration and cultures in search of Acido-Alcohol-Resistant Bacillus (AARB) were negative.\nTaking into consideration the bacteriological results, a bi-empiric antibiotic therapy covering pyogenic and atypic germs was initiated (Amoxicillin-Clavulanic Acid: 1g x 3 daily associated with Doxycycline: 2 x 100 mg daily). Due to intolerance (nausea and vomiting) the Doxycicline was replaced by azithromycin (250 mg daily). The clinical and biological outcomes were favorable although adenitis with 2 centimeters persisted for forty five days (D-45) after azithromycin treatment initialization (Table ), thus justifying the continuation of this antibiotic treatment during eight weeks. The patient was also reviewed in consultation at day-75 (D-75) after the beginning of treatment. Clinical examination showed an overall decrease of the node diameter, absence of superficial lymph nodes, night sweats and asthenia, recovery of appetizing and stable weight of 86 Kg.