Epidemiology, clinical manifestations, and outcomes of Bartonella henselae infection in children

Background: Cat scratch disease (CSD) is a zoonotic illness caused by Bartonella henselae. Limited contemporary data from large pediatric series are available on the epidemiology, clinical manifestations, and outcomes of CSD.

Methods: This is a retrospective record review of children diagnosed with CSD who were evaluated in the Emergency Center (EC) or admitted at Texas Children’s Hospital (TCH) from 1/1/10 to 12/31/15.

Results: 130 patients with CSD required 80 EC visits and 93 admissions (7 ICU). Mean age was 8.1 yrs (1.3-17.9 yrs), and 74 patients (57%) were male. Seventy-four patients (57%) presented in July-September. 103 (79%) had cat exposure documented (34% with scratches), and 5 had family members with recent CSD. Common presenting symptoms included lymphadenopathy (77%), fever (55%), and abdominal pain (21%).

115 patients (88%) had positive serology and 26 (20%) had positive Bartonella PCR. Thirty patients underwent biopsy; necrotizing granulomatous inflammation was the most common finding followed by suppurative necrosis and reactive lymphoid tissue.

83 patients (64%) presented with lymphadenitis: cervical/ submental 27, axillary 19, inguinal 14, epitrochlear 13, pre/postauricular 6, supraclavicular 3, and infraclavicular 1. Nineteen (23%) underwent incision and drainage (I&D). Of those with documented follow-up (34), the average time to resolution with trimethoprim/sulfamethoxazole (TMP/SMX) or azithromycin therapy was 7.3 wks (2-16 wks) vs. 8 wks (3-16 wks) with no therapy (NS). Time to resolution after I&D was 4 wks (2.5-10 wks) (p=0.02).

Other presentations included: 11 hepatosplenic (HS) CSD, 9 systemic febrile illness/ fever of unknown origin (FUO), 9 meningoencephalitis (7 status epilepticus, 2 ataxia), 7 neuroretinitis, 5 myositis/ soft tissue mass, 3 Parinaud oculoglandular syndrome, 2 vertebral osteomyelitis, and 1 pulmonary nodules. Mean duration of fever for HS-CSD and FUO was 45 days (8-90 days). All patients with HS-CSD received therapy with azithromycin + rifampin, doxycycline + rifampin, or TMP/SMX +/- rifampin. Only 4 patients with meningoencephalitis returned to baseline prior to discharge; others improved by 3-6 months post-infection. Five neuroretinitis patients had sequelae at 1 year after diagnosis.

Conclusion: CSD is common with a wide variety of clinical presentations and can cause significant morbidity in children.