GRANULOMATOUS HEPATITIS IN CAT SCRATCH DISEASE (CSD): A NEW SYNDROME WITH DEMONSTRATION OF THE CAT SCRATCH BACILLUS IN THE LIVER

Abstract

Three patients had an unusual presentation of CSD with visceral involvement. Two of the patients had no peripheral adenopathy. High lever (≥39°C) was present for more than 3 weeks in each case. Abdominal CT revealed focal hepatic defects in 2 patients and periportal and periaortic adenopathy in the third. At laparotomy, nodules were visible on the liver surfaces of all 3 patients and histologic examination revealed necrotizing granulomata. Using the Warthin-Starry silver stain, organisms consistent in appearance with the cat scratch bacillus were identified in the liver and a periaortic lymph node from one patient, in the liver from the second patient, and in the axillary lymph node of the third. This represents the first reported identification of the organism beyond the inoculation site-peripheral lymph node complex. In all 3 patients the clinical findings and abnormalities observed on imaging studies improved without specific therapy. A review of the surgical pathology files of Washington University revealed that these 3 patients were the only pediatric cases of granulomatous hepatitis diagnosed during the past 6 years. These findings indicate that CSD should now be included in the differential diagnosis of granulomatous hepatitis. The identification of CSD as a cause of granulomatous hepatitis in two of the patients in the absence of peripheral adenopathy suggests that the clinical spectrum of CSD may be broader than previously appreciated.