The challenging diagnosis of hepatosplenic cat scratch disease in children

Abstract

Cat scratch disease (CSD) can present as a systemic disease in 5–10% of cases leading to various entities including hepatosplenic disease with abscesses detected at abdominal imaging in more than 50% of patients. We describe a challenging diagnosis of hepatosplenic CSD, and review of literature. A previously healthy 12 y.o. girl was admitted for prolonged fever. She lived in contact with a cat. She had already received a 7-day unsuccessful antibiotic therapy (amoxicillin-clavulanate/ceftriaxone). Clinical/laboratory examination showed hepatosplenomegaly and no enlarged lymph nodes, CRP = 44 mg/L; ESR = 110 mm/h. An abdominal ultrasound evidenced multiple intrahepatic/intrasplenic hypoechoic lesions compatible with abscesses. Tests for main causes of liver abscesses ruled out included antibodies for Bartonella Henselase (BH) (enzyme immunoassay, EIA), Francisella Tularensis, Echinococcus Granulosus, Brucella spp; Entamoeba Histolitica microscopic identification; Tubercolosis skin tests and interferon-gamma release assays. Cultures, bone marrow aspiration, and alphafetoprotein were also normal. Due to a cat-pet at home CSD was reconsidered. IgG/IgM anti-BH were retested by indirect fluorescence (IFA) and found positive (title > 1:64). BH blood polymerase chain reaction (PCR) was negative. Home cat was found colonized by BH. The combination of contact history, serological, clinical, and imaging criteria were considered compatible with hepatosplenic CSD (Margileth diagnostic criteria). She was prescribed a combination of Azithromycin/Doxycycline with progressive improvement of all parameters.