Cat-scratch disease is infection caused by the gram-negative bacterium Bartonella henselae. Symptoms are a local papule and regional lymphadenitis. Diagnosis is clinical and confirmed by biopsy or serologic tests. Treatment is with local heat application, analgesics, and sometimes antibiotics.
(See also Overview of Bartonella Infections.)
The domestic cat, particularly kittens, is a major reservoir for Bartonella henselae. The prevalence of B. henselae antibodies among cats in the United States is greater in warm, humid areas and higher among feral animals (1).
Almost all patients with cat-scratch disease report contact with cats, frequently young cats or kittens, most of which are healthy. The specific location of the organism in the cat is unclear; however, periods of asymptomatic bacteremia occur in cycles. Infection is spread to humans via a bite, lick, or scratch.
The cat flea transmits infection among cats and may be the cause of disease in humans who have not had contact with cats. Other arthropods (eg, ticks, lice, mosquitoes) may also harbor diverse Bartonella species and have been proved to serve as vectors of human disease. Children are most often affected.
General reference
1. Chomel BB, Abbott RC, Kasten RW, et al. Bartonella henselae prevalence in domestic cats in California: risk factors and association between bacteremia and antibody titers. J Clin Microbiol. 1995;33(9):2445-2450. doi:10.1128/jcm.33.9.2445-2450.1995
Symptoms and Signs of Cat-Scratch Disease
Within 3 to 10 days after a bite or scratch, most patients with cat-scratch disease develop an erythematous, crusted, painless papule (rarely, a pustule) at the scratch site.
Regional lymphadenopathy develops within 2 weeks. The nodes are initially firm and tender, later becoming fluctuant, and may drain with fistula formation. Fever, malaise, headache, and anorexia may accompany lymphadenopathy.
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Unusual manifestations occur in 11 to 12% of patients and are more likely to occur in adults:
Parinaud oculoglandular syndrome (conjunctivitis associated with palpable preauricular nodes) (accounts for approximately 50% of atypical cases)
Neurologic manifestations (encephalopathy, seizures, neuroretinitis [causes acute unilateral vision loss], radiculitis, myelitis, paraplegia, cerebral arteritis) in 2%
Hepatosplenic granulomatous disease in < 1%
Patients may also present with a fever of unknown origin. B. henselae is one of the more common causes of culture-negative endocarditis, usually in patients with predisposing valvular heart disease. In immunosuppressed patients, B. henselae can cause bacillary angiomatosis and peliosis hepatis. Severe disseminated illness may occur in patients with AIDS.
Lymphadenopathy subsides spontaneously within 2 to 5 months. Complete recovery is usual, except in severe neurologic or hepatosplenic disease, which may be fatal or have residual effects.
Diagnosis of Cat-Scratch Disease
Acute and convalescent serologic testing or polymerase chain reaction (PCR) testing
Sometimes lymph node biopsy
Diagnosis of cat-scratch disease is typically confirmed by positive serum antibody titers (testing acute and convalescent sera 6 weeks apart is recommended) or PCR testing of samples from lymph node aspirates.
Because similar lymphadenopathy may be caused by other infections (eg, tularemia, mycobacterial infection, brucellosis, fungal infection, lymphogranuloma venereum), testing for those organisms may be done if the diagnosis is not clearly cat-scratch disease.
Lymph node biopsy may be done if cancer is suspected or if the diagnosis of cat-scratch disease needs to be confirmed. Diagnosis is suggested by characteristic histopathologic findings (eg, suppurative granulomas) or detection of organisms by immunofluorescence. Warthin-Starry silver stains also may be used to demonstrate the bacteria; the combination of the stain with immunohistochemistry is highly sensitive (1).
Immunocompromised patients and patients with systemic symptoms should also have blood cultures (which require prolonged incubation). Lymph node aspirates are rarely culture-positive. However, Bartonella species can be isolated from cultures of lymph node biopsy specimens. Special culture media are often required.
Diagnosis reference
1. Peng J, Fan Z, Zheng H, Lu J, Zhan Y. Combined Application of Immunohistochemistry and Warthin-Starry Silver Stain on the Pathologic Diagnosis of Cat Scratch Disease. Appl Immunohistochem Mol Morphol. 2020;28(10):781-785. doi:10.1097/PAI.0000000000000829
Treatment of Cat-Scratch Disease
Local heat and analgesics
Antibiotics for immunocompromised patients and sometimes for patients with systemic disease
Treatment of cat-scratch disease in immunocompetent patients is with local heat application and analgesics for this typically self-limited disease. If a lymph node is fluctuant, needle aspiration usually relieves the pain.
1) and to perhaps decrease the risk of systemic spread.
Treatment reference
1. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America [published correction appears in Clin Infect Dis. 2015 May 1;60(9):1448. Dosage error in article text]. Clin Infect Dis. 2014;59(2):e10-e52. doi:10.1093/cid/ciu444
