Download Cat-scratch disease osteomyelitis from a dog scratch

Cat-scratch disease osteomyelitis from a dog
scratch
David Keret, Mihael Giladi, Yehudith Kletter, Shlomo Wientroub
From the Dana Children’s Hospital and the Tel-Aviv Medical Centre and the Sackler
Faculty of Medicine, Tel-Aviv University, Israel
steomyelitis is a rare manifestation of cat-scratch
disease in patients who do not have AIDS. The
clinical presentation and non-specific subacute course
of the disease make diagnosis difficult.
We present a child with osteomyelitis of a
metacarpal following a dog scratch. Bartonella
henselae was found to be the aetiological agent. The
bone healed after treatment with antibiotics. Increased
awareness and a comprehensive medical history are
needed to identify patients with suspected Bartonella
henselae osteomyelitis.
O
J Bone Joint Surg [Br] 1998;80-B:766-7.
Received 10 February 1998; Accepted 3 March 1998
Cat-scratch disease (CSD) is benign, self-limiting regional
lymphadenopathy. Bartonella (B.) henselae is considered
1
the principal aetiological agent. Contact with a cat, usually
in the form of a scratch or bite, has been reported in most
cases. About 10% of patients with CSD may present with
atypical manifestations, including encephalopathy, neuro1
retinitis, erythema nodosum, arthritis, and osteomyelitis.
The last is rare but when present is usually in the form of
2
osteolytic lesions.
The diagnosis of CSD is difficult since the clinical
presentation and histopathological examination of the
involved tissue are non-specific. The CSD skin test lacks
standardisation and carries a potential risk of transmitting
infectious agents. Cultures and Warthin Starry silver stain
have low levels of sensitivity. Polymerase chain-reaction
analysis of pus or lymph nodes is not available in most
laboratories. Serological assays, particularly an indirect
fluorescent antibody (IFA) test, have become the principal
1
method of diagnosis.
D. Keret, MD, Senior Orthopaedic Surgeon
S. Wientroub, MD, Professor and Head
Department of Pediatric Orthopaedics, Dana Children’s Hospital
M. Giladi, MD, Senior Infectious Diseases Consultant
Y. Kletter, PhD, Clinical Microbiologist
The Bernard Pridan Laboratory for Molecular Biology of Infectious
Diseases
Tel-Aviv Medical Centre, 6 Weizmann Street, Tel-Aviv 64239, Israel.
We present a case of CSD metacarpal osteomyelitis from
a dog scratch. Diagnosis was confirmed by the detection of
anti-B. henselae IgG by an enzyme immunoassay (EIA).
Case report
A nine-year-old boy was seen with a two-week history of pain
and swelling in the dorsal aspect of the left hand. He did not
recall any previous injury and denied exposure to cats or
kittens. Two months earlier he had been given a Maltese
puppy which frequently scratched, but did not bite his hands.
Physical examination revealed a tender swelling over the third
metacarpal, with limited movement of the metacarpophalangeal joint and multiple scratches on both hands (Fig. 1).
The total leucocyte count, the ESR and the C-reactive protein
level were within normal limits. Plain radiographs showed a
periosteal reaction along the neck and shaft of the third
99m
Tc bone scan showed increased
metacarpal (Fig. 2). A
uptake in the third metacarpal consistent with osteomyelitis. A
presumptive diagnosis of haematogenous osteomyelitis was
made and treatment with intravenous cloxacillin started. Due
to a severe allergic reaction this was changed to intravenous
clindamycin followed by oral clindamycin on discharge from
hospital. Review after three weeks of antibiotic therapy
revealed no clinical improvement. The possibility of Bartonella infection was raised by the association with animal
scratches, the lack of fever and toxicity, the normal values for
the leucocyte count, ESR and C-reactive protein which are
characteristically elevated in pyogenic osteomyelitis, and the
lack of response to anti-staphylococcal therapy. The serum
EIA was positive for anti-B. henselae IgG, and treatment was
changed to oral suspensions of trimethoprim (10 mg/kg/day)
plus sulphamethoxazole (50 mg/kg/day) and rifampin (20 mg/
kg/day). Marked clinical improvement was apparent within
two weeks which progressed further until six weeks when the
antibiotics were discontinued. The swelling of the left hand
resolved completely by six months. Review at one year
showed normal function and appearance with complete resolution of the radiological findings.
Discussion
Correspondence should be sent to Professor S. Wientroub.
©1998 British Editorial Society of Bone and Joint Surgery
0301-620X/98/58823 $2.00
766
Osteomyelitis is a rare complication of CSD. Only 11 cases
have been described in the English literature among
THE JOURNAL OF BONE AND JOINT SURGERY
CAT-SCRATCH DISEASE OSTEOMYELITIS FROM A DOG SCRATCH
767
Fig. 1
Four weeks after the first clinical
symptoms, the third ray of the left
hand shows considerable swelling in
the metacarpophalangeal region.
There are dog scratches on the right
hand.
Fig. 2
Radiograph of the left hand showing a periosteal reaction along the neck
and shaft of the third metacarpal.
patients who do not have AIDS, mainly in children and
young adults. The involved sites were the vertebrae in five
cases, and the skull, sternum, femur, humerus, ilium and
2
metatarsal in one case each. In contrast to the acute
presentation with fever, systemic toxicity, a leucocytosis
and a high ESR typically found in haematogenous pyogenic
osteomyelitis in this age group, CSD osteomyelitis is characterised by a subacute presentation with mild constitutional symptoms. Radiological findings are available in
only eight of the 11 previously reported cases; six had
osteolytic lesions, one an osteolytic lesion with marginal
2
sclerosis and one marginal sclerosis only.
Our case has several unique features. It is the first report
of CSD osteomyelitis in the metacarpal bone, and the first
showing a periosteal reaction instead of the more common
osteolytic lesions. The association between dog scratches
and B. henselae osteomyelitis in the absence of contact with
a cat strongly implicates the dog as responsible for trans3
mitting the infection. This has very rarely been reported.
VOL. 80-B, NO. 5, SEPTEMBER 1998
While B. henselae has never been cultured from a dog, a
new strain of Bartonella, B. berkoffii, was detected in the
4
blood and heart valves of a dog with endocarditis. This is
also the first report of the use of serum EIA to diagnosis B.
henselae osteomyelitis.
In the 11 previously published cases the diagnosis was
based on the clinical presentation, a history of contact with
a cat and either a positive skin test and/or a lymph node or
2
bone biopsy. At present, serology is the most commonly
used method for the diagnosis of CSD. The IFA test is
specific and sensitive, but EIA is reported to have compara5
ble sensitivity and specificity, the latter reaching 97%. EIA
technology is available in a larger number of clinical
microbiology laboratories than the IFA test. It is less
observer-dependent and less labour-intensive, and can be
an effective alternative to the IFA test for the diagnosis of
CSD.
Increased awareness and a comprehensive medical history are needed to identify patients with clinically suspected
B. henselae osteomyelitis. Accurate diagnosis has therapeutic and prognostic implications and the currently available serological tests make confirmation of the diagnosis
easier than in the past.
No benefits in any form have been received or will be received from a
commercial party related directly or indirectly to the subject of this
article.
References
1. Anderson BE, Neuman MA. Bartonella spp. as emerging human
pathogens. Clin Microbiol Rev 1997;10:203-19.
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bone scan. Clin Imaging 1995;19:106-8.
3. Fischer GW. Cat scratch disease. In: Mandell GL, Bennett JE, Dolin
RD, eds. Mandell, Douglas and Bennett’s principles and practice of
infectious diseases. Fourth edition, New York: Churchill Livingstone,
1995:1310-2.
4. Breitschwerdt EB, Kordick DL, Malarkey DE, et al. Endocarditis
in a dog due to infection with a novel Bartonella subspecies. J Clin
Microbiol 1995;33:154-60.
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disease. 33th Interscience Conference on Antimicrobial Agents and
Chemotherapy, 1997.