Case Description. A patient who had close contact with a cat subsequently developed a localized, suppurative cervical lymphadenitis. As B. henselae was identified in 1992, the authors were able to confirm the existence of CSD serologically. Surgical drainage resulted in a successful resolution of the disease process.

Clinical Implications. As patients with CSD may be seen in the dental office, an awareness of its symptomatology can prevent unnecessary dental intervention and facilitate early treatment.

It is estimated that 70,000 new cases of CSD occur each year.¹ Although systemic manifestations have been reported, CSD generally is considered to be a benign, self-limiting, granulomatous, suppurative regional lymphadenitis. Cats are a natural reservoir for the causative microorganism. Because infected cats rapidly develop antibodies, they appear healthy despite a bacteremia that can be present for at least 12 months.^2–4 A positive serology has been reported in up to 56 percent of North American cats.³ The etiologic organism, transmitted to humans by a cat’s scratch, lick or bite, was identified in 1992 by Regnery and colleagues⁵ as the gram-negative bacillus Bartonella henselae.

Because some patients who have CSD will be examined in the dental office, we present a case report and review of CSD to heighten dentists’ awareness of signs, symptoms and methods of diagnosis.

	CASE REPORT

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A healthy 4-year-old girl was referred to the Salivary Gland Center at Columbia University School of Dental and Oral Surgery in New York City by the pediatric emergency clinic at Columbia University because of a left submandibular swelling (Figure 1). A tentative diagnosis of submandibular sialadenitis had been made.

View larger version (121K): [in this window] [in a new window]   Figure 1. Clinical view of left submandibular swelling.

No trismus was present, and an intraoral examination revealed that the dentition was caries-free. There was no indication of any oral sepsis. We exerted extraoral pressure on the left submandibular salivary gland and noted a clear and adequate salivary flow exiting from the orifice of the left Wharton’s duct, thus effectively ruling out sialadenitis. A panoramic radiograph showed a normal dentition and no etiologic cause for the swelling. We prescribed penicillin.

When we questioned the girl’s mother, she indicated that the child had returned one month earlier from a four-week summer vacation. On the girl’s return, she had some scratches and a "large pimple," involving her left check and neck, which were gone when we examined her. The mother also indicated that the girl had played constantly with a pet kitten while on vacation. It was the kitten that was responsible for the scratches that were observed by the mother on the girl’s return.

A computed tomographic, or CT, scan or CI, revealed an enlarged, superficially located ovoid mass with a central necrotic area and a periphery of increased density (Figure 2). The submandibular salivary gland was normal in appearance but displaced slightly medially. We made a diagnosis of a suppurative enlarged lymph node. In view of the history, we thought that CSD was the cause.

View larger version (166K): [in this window] [in a new window]   Figure 2. Computed tomographic scan of the submandibular area. Left submandibular salivary gland (S) has been displaced medially. Note enlarged suppurative lymph node (arrows) with rim of increased density and central lucent area (A) representing pus accumulation. Because of head tilt, inferior border of mandible (M) is not symmetrically positioned.

While the patient was sedated, we drew blood for a serologic examination. The specimen was sent to the Centers for Disease Control and Prevention, or CDC, along with a presumed diagnosis of CSD. The CDC identified antibodies to B. henselae with a titer of 1:128 (normal < 1:64).

A significant improvement in the patient’s condition was evident when she returned two days later for postoperative care. We discontinued her penicillin use, which we had started seven days earlier at the time of the first visit. One week later, wound closure with the absence of drainage was evident.

The patient failed to return for further visits, but follow-up phone calls revealed that the wound had healed uneventfully.

	DISCUSSION

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In the case report that we discuss in this article, a medical history in a healthy child revealed no systemic diseases (neoplasm, tuberculosis, leukemia and so forth) that could be related to cervical lymphadenopathy. Furthermore, a suppurative lymphadenitis is unusual in such conditions. Because we had eliminated the oral cavity and submandibular salivary gland as instigators of the swelling, we searched for another infective cause.

When children and young adults are seen with a regional lymphadenitis, suspicion regarding the presence of CSD should be aroused. Because hugging a cat involves the cat’s being close to the person’s facial and cervical areas, scratches in these anatomical locations can result in a cervical lymphadenopathy whose size can approach 10 cm. The lymphadenopathy develops when the infectious organism is transported by macrophages from the site of inoculation to a regional lymph node. Within seven to 12 days, a pustule or papule appears at the site of the scratch. It soon heals, only to be followed by enlargement of the lymph node five to 50 days later.⁶ Spontaneous resolution of the lymphadenitis usually occurs over a period of weeks or months, but 10 to 35 percent of the infected nodes progress to suppuration.^2,7,8

Serology has proven to be a reliable method of diagnosing cat-scratch disease.

Infected patients may experience mild fever, fatigue, malaise and headaches, but these symptoms often are not present. However, more serious systemic manifestations—such as parotitis, osteomyelitis, hepatosplenomegaly and a variety of neurological conditions^4,9,10—have been reported to occur in 15 percent of the patients.¹¹

Serology has proven to be a reliable method of diagnosing CSD, and it is performed by the CDC using an indirect immunofluorescent antibody, or IFA, assay. If CSD is present, high titers of antibody will react to the B. henselae antigen. Titers of 1:64 and higher are considered positive. Our patient’s history, clinical examination and CT scan led us to make a tentative diagnosis of CSD. Final diagnosis, however, required the serologic results reported by the CDC.

In the past, a diagnosis of CSD was based on a history of contact with a cat, elimination of other causes of a lymphadenopathy and a characteristic pathological picture. Clinically early in the disease process, a granulomatous infiltration of a lymph node is present, followed by the development of necrosis. The Warthin-Starry silver stain can be used to highlight the culpable organism. In our case, B. henselae could not be cultured nor was it uncovered by the stain, and the pathological tissue specimen was not diagnostic. With the development of a specific IFA assay, serology has become the gold standard for the diagnosis of CSD.

The serologic test for CSD is positive in 90 percent of the patients.¹² Elevated serum titers can be found one to three weeks after the onset of the illness. The titers continue to rise for the first eight weeks and then gradually decrease over the next several months.¹³ Because of its practicality and accuracy, the IFA assay has been accepted as the best diagnostic technique. Culturing of B. henselae is time-consuming, and its isolation and growth often are not successful.² Although a polymerase chain reaction test is available, appropriate laboratory facilities and equipment are required. Because histopathologic diagnosis demands a surgical approach, the alternative and less aggressive diagnostic modalities seem to be the way to go.

Most of the enlarged lymph nodes will resolve spontaneously over several months.^14,15 Antibiotics usually are not necessary,^2,16 as the causative organism does not respond well to such therapy. Antibiotics are indicated in those few cases in which spread to systemic organs has occurred. A definitive antibiotic protocol has not been established, but gentamicin,² azithromycin,¹⁶ penicillin,¹⁷ ciprofloxacin¹⁴ and rifampin¹⁸ have been suggested.

When suppuration occurs, it is necessary to evacuate the pus. In the reported case, we made an incision, but we did not place a drain, because we wanted to avoid impeding the healing of the wound margins and to diminish scar formation. However, we no longer would advocate this therapeutic approach, as such an incision may lead to the development of a persistent sinus with significant scar formation. To negate this outcome, needle aspiration can be used. The needle is introduced best through the skin 1 to 2 cm away from the localized swelling. It then can be tunneled in a horizontal plane toward the fluctuation area, and the pus can be aspirated.^12,16 Repeat aspirations may be necessary to achieve success.

	CONCLUSION

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Patients with submandibular lymph node swellings are seen in dental offices. CSD should be considered among the possible causes of such swellings. The causative organism B. henselae has been identified, and an accurate serologic test has been devised. Knowledge of the disease will facilitate its diagnosis and treatment.

View larger version (132K): [in this window] [in a new window]   Dr. Mandel is the director, Salivary Gland Center; clinical professor, division of oral and maxillofacial surgery; and an assistant dean, Columbia University School of Dental and Oral Surgery, 630 West 168th St., New York, N.Y. 10032. Address reprint requests to Dr. Mandel.

View larger version (135K): [in this window] [in a new window]   Ms. Surattanont is a research assistant, Salivary Gland Center; and a senior dental student, Columbia University School of Dental and Oral Surgery, New York.

View larger version (130K): [in this window] [in a new window]   Dr. Miremadi is a senior resident, Oral and Maxillofacial Surgery, New York-Presbyterian Hospitals, New York.