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Journal of Clinical Microbiology, June 2006, p. 2288-2290, Vol. 44, No. 6
0095-1137/06/$08.00+0     doi:10.1128/JCM.00239-06
Copyright © 2006, American Society for Microbiology. All Rights Reserved.

CASE REPORT

Isolation of Bartonella henselae DNA from the Peripheral Blood of a Patient with Cat Scratch Disease up to 4 Months after the Cat Scratch Injury

Mardjan Arvand1* and Susanne G. Schäd2

Institut für Medizinische Mikrobiologie, Virologie, und Hygiene,1 Klinik und Poliklinik für Dermatologie und Venerologie, Universität Rostock, Rostock, Germany2

Received 2 February 2006/ Returned for modification 16 March 2006/ Accepted 22 March 2006


   ABSTRACT
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 Abstract
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 References
 
We report the case of a girl with cervical lymphadenitis and a persistent primary lesion of cat scratch disease (CSD). Bartonella henselae DNA was isolated from plasma samples collected 3 and 4 months after the cat scratch, indicating that recurrent and long-term shedding of Bartonella DNA into peripheral blood may occur in typical CSD.


   CASE REPORT
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 Abstract
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A 5-year-old girl was referred to the outpatient clinic of the Department of Dermatology of our University Hospital with an 8-week history of an erythematous plaque on the right cheek (Fig. 1A and B). Physical examination was unremarkable, except for an enlarged right cervical lymph node (Fig. 1A). The body temperature was normal, and no fever was reported anamnestically. Laboratory findings, including white blood cell count, C-reactive protein, and erythrocyte sedimentation rate, were within normal ranges, except for an increased eosinophil count (11% or 0.91 x109/liter, absolute; normal range, 1 to 5%), which could be linked to a positive history of atopic disease with symptomatic allergic rhinitis. Ultrasonography revealed a moderately enlarged (15.9 by 8.8 by 15.4 mm), hypoechoic cervical lymph node. Serological tests for cytomegalovirus, Epstein-Barr virus, herpes simplex virus, human immunodeficiency virus, and toxoplasmosis did not reveal evidence for ongoing infection. Cultures of a swab taken from the skin lesion revealed no growth of bacteria or fungi. Careful evaluation of the patient's history revealed that she had been scratched on the right cheek by a 4-week-old kitten during a visit in Latvia 3 months before, and the resulting injury had been photographed by her father (Fig. 1C).


Figure 1
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  		FIG. 1. Cervical lymphadenopathy (A) (black arrow) and primary lesion on the right cheek (A and B) at the time of admission, 4 November 2004. (C) Cat scratch injury as documented by the patient's father on 4 August 2004.

 
Serology for Bartonella species was performed by indirect immunofluorescence assay (MRL, Cypress, CA), which revealed a Bartonella henselae immunoglobulin G (IgG) titer of 1,024 (cutoff, 64) but no detectable IgM antibodies. A lymph node biopsy was not performed because of the mild clinical course. Instead, a sample of citrated whole blood was subjected to PCR for B. henselae the day after admission. DNA was isolated from the plasma fraction by a QIAamp tissue extraction kit (QIAGEN, Hilden, Germany), and seminested PCR for the B. henselae htrA gene was performed by using the oligonucleotides CAT1 and CAT2 as outer primers and RH1 and CAT2 as inner primers (1, 2). A 391-bp fragment was amplified, and subsequent sequencing revealed 99.7% homology with the htrA sequence of the B. henselae Houston-1 isolate. Cat scratch disease (CSD) was diagnosed, and the patient was treated with oral erythromycin (40 mg/kg of body weight/day) for 3 weeks. Serology and PCR were repeated 4 weeks later and confirmed the previously obtained results (IgG titer of 2,048, positive PCR) (Table 1). Sonographic evaluation of the abdomen was performed and did not reveal any abnormalities in the liver or spleen indicative of abscess or granuloma formation. The patient was monitored until resolution of all signs, and serology and PCR were repeated at 1- to 2-month intervals. B. henselae DNA was cleared from peripheral blood 9 weeks after admission and remained undetectable thereafter (Table 1). The primary lesion gradually turned pale, and lymphadenitis resolved slowly. The Bartonella-specific IgG titer dropped to 64 in April 2005. The blood eosinophil count was still increased (0.87 x109/liter) at follow-up after 2 years, suggesting that the eosinophilia was most probably due to the atopic disease.


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  		TABLE 1. Results of serology for Bartonella-specific antibodies and PCR for the B. henselae htrA gene

 
Cat scratch disease is the most common manifestation of human infection with B. henselae. Typical CSD represents 86 to 95% of all cases and is characterized by chronic regional lymphadenopathy following a cat scratch (8). Atypical manifestations of CSD include involvement of various organ systems, such as the liver, spleen, and central nervous system, or prolonged fever in children (7, 9). Our patient presented with signs that were compatible with typical CSD, i.e., mild lymphadenopathy and a persistent skin lesion at the primary inoculation site. There were no signs of systemic disease nor any atypical manifestations. Human immunodeficiency virus was serologically excluded, and there were no signs or history of other types of immunodeficiency. Therefore, it is surprising that B. henselae DNA could be isolated from the peripheral blood of our patient as long as 4 months after infection.

A comprehensive review of the literature revealed 4 reports on isolation of B. henselae DNA from peripheral blood of CSD patients (4, 5, 10, 12). Information about the patients' immune status was available in 3 reports that found positive PCR results in 5 cases (4, 5, 10). Three patients were not immunocompromised. The time point of blood collection was not specified in 4 cases (4, 5), while in the remaining case of a 10-year-old girl, blood was collected 3 weeks after the onset of lymphadenopathy (10). Considering an incubation time of approximately 2 weeks for CSD (8), the interval between the cat scratch injury and isolation of Bartonella DNA from peripheral blood can be estimated to be about 5 weeks in that case. In contrast, the time point of the cat scratch was precisely documented in the case of our patient. To our knowledge, this is the first report that demonstrates the presence of B. henselae DNA in the peripheral blood of a CSD patient at two distinct time points and up to 4 months after infection. It is possible that the prominent and persistent primary lesion may have served as an additional focus for the release of B. henselae DNA into the peripheral blood in this patient.

Currently, the laboratory diagnosis of CSD is based on serology or PCR from lymph node biopsy specimens (1, 3, 11). A combination of serology and PCR-based approaches has been shown to increase the sensitivity and specificity of the tests (6). Evaluation of peripheral blood for Bartonella DNA represents an additional, noninvasive diagnostic tool that could be useful when lymphadenectomy or biopsy is not feasible or in cases with equivocal serological results. However, further studies are necessary to determine whether B. henselae DNA may be isolated from the peripheral blood of other patients with CSD.

In conclusion, this report documents the isolation of B. henselae DNA from the peripheral blood of a patient with typical CSD several months after the initial inoculation, suggesting that B. henselae DNA may be chronically shed into peripheral blood during the natural course of CSD.


   ACKNOWLEDGMENTS
 
We thank Yvonne Humboldt for skillful technical assistance and Ralf Ignatius for critical review of the manuscript.


   FOOTNOTES
 
* Corresponding author. Mailing address: Institut für Medizinische Mikrobiologie, Virologie, und Hygiene, Universität Rostock, Schillingallee 70, 18057 Rostock, Germany. Phone: 49 381 4945950. Fax: 49 381 4945902. E-mail: mardjan.arvand{at}med.uni-rostock.de. Back


   REFERENCES
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 Abstract
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 References
 

  1. Anderson, B., K. Sims, R. Regnery, L. Robinson, M. J. Schmidt, S. Goral, C. Hager, and K. Edwards. 1994. Detection of Rochalimaea henselae DNA in specimens from cat scratch disease patients by PCR. J. Clin. Microbiol. 32:942-948.[Abstract/Free Full Text]
  2. Arvand, M., R. Ignatius, T. Regnath, H. Hahn, and M. E. Mielke. 2001. Bartonella henselae-specific cell-mediated immune responses display a predominantly Th1 phenotype in experimentally infected C57BL/6 mice. Infect. Immun. 69:6427-6433.[Abstract/Free Full Text]
  3. Bergmans, A. M., J. W. Groothedde, J. F. Schellekens, J. D. van Embden, J. M. Ossewaarde, and L. M. Schouls. 1995. Etiology of cat scratch disease: comparison of polymerase chain reaction detection of Bartonella (formerly Rochalimaea) and Afipia felis DNA with serology and skin tests. J. Infect. Dis. 171:916-923.[Medline]
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  5. Del Prete, R., D. Fumarola, S. Ungari, L. Fumarola, and G. Miragliotta. 2000. Polymerase chain reaction detection of Bartonella henselae bacteraemia in an immunocompetent child with cat-scratch disease. Eur. J. Pediatr. 159:356-359.[CrossRef][Medline]
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  7. Jacobs, R. F., and G. E. Schutze. 1998. Bartonella henselae as a cause of prolonged fever and fever of unknown origin in children. Clin. Infect. Dis. 26:80-84.[Medline]
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  10. Maruyama, S., H. Kabeya, S. Nogami, H. Sakai, J. Suzuki, H. Suzuki, H. Sugita, and Y. Katsube. 2000. Three cases of cat scratch disease diagnosed by indirect immunofluorescence antibody assay and/or polymerase chain reaction of 16S rRNA gene of Bartonella henselae. J. Vet. Med. Sci. 62:1321-1324.[Medline]
  11. Sander, A., M. Posselt, N. Bohm, M. Ruess, and M. Altwegg. 1999. Detection of Bartonella henselae DNA by two different PCR assays and determination of the genotypes of strains involved in histologically defined cat scratch disease. J. Clin. Microbiol. 37:993-997.[Abstract/Free Full Text]
  12. Tsukahara, M., H. Iino, C. Ishida, K. Murakami, H. Tsuneoka, and M. Uchida. 2001. Bartonella henselae bacteraemia in patients with cat scratch disease. Eur. J. Pediatr. 160:316.[Medline]

Journal of Clinical Microbiology, June 2006, p. 2288-2290, Vol. 44, No. 6
0095-1137/06/$08.00+0     doi:10.1128/JCM.00239-06
Copyright © 2006, American Society for Microbiology. All Rights Reserved.



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