An uncommon cause of linfadenopathy in a kidney transplant patient: Cat-scratch disease
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kidney transplant patient: Cat-scratch disease" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "540" "paginaFinal" => "542" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Cláudia Bento, La Salete Martins, André Coelho, Manuela Almeida, Sofia Pedroso, Leonídeo Dias, Ramon Vizcaíno, António Castro-Henriques, António Cabrita" "autores" => array:9 [ 0 => array:3 [ "nombre" => "Cláudia" "apellidos" => "Bento" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 1 => array:3 [ "nombre" => "La Salete" "apellidos" => "Martins" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] 2 => array:3 [ "nombre" => "André" "apellidos" => "Coelho" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "affc" ] ] ] 3 => array:3 [ "nombre" => 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"referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Department of Nephrology, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal, " "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "Department of Nephrology, Hospital Geral de Santo António, Porto, Portugal, " "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] 2 => array:3 [ "entidad" => "Department of Clinical Pathology, Hospital Geral de Santo António, Porto, Portugal, " "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "affc" ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12474_16025_58474_en_f112474.jpg" "Alto" => 654 "Ancho" => 649 "Tamanyo" => 412771 ] ] "descripcion" => array:1 [ "en" => "Ganglion biopsy – Focus of necrosis, some surrounded by granulomatous inflammation in cortical region (H&E, original magnification x40)." ] ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Dear Editor,</span></p><p class="elsevierStylePara">Cat scratch disease (CSD) is an infectious disease that usually presents as a self-limiting illness characterized by regional lymphadenopathy, fever and constitutional symptoms in association with a cat scratch or bite.<span class="elsevierStyleSup">1-4</span> In most cases, Bartonella henselae is the etiologic agent and cats are important reservoirs.<span class="elsevierStyleSup">2-5</span></p><p class="elsevierStylePara">We report a case of CSD in a 38-year-old Caucasian female recipient of a deceased kidney transplant since 2006 due to chronic renal failure of unknown etiology. Her maintenance immunosuppressive treatment was mycophenolate mofetil and cyclosporine. She was also medicated with calcium carbonate, vitamin D, atenolol, folic acid, fluoxetine, omeprazole, ferrous sulfate.</p><p class="elsevierStylePara">Six years post transplantation the patient was admitted to the hospital with a 4-week history of asthenia, low fever, loss of weight and multiple painful cervical ganglions. There was no previous history of tuberculosis. She had close contact at home with cats. On physical examination, the patient had a temperature of 37,3ºC, pulse rate of 84/min, blood pressure of 134/88mmHg, respiratory rate of 16/min and pulse oximetry of 100% in ambient air. She had multiple bilateral painful ganglions only in cervical region (node size ≤4cm). There was no rash. Examination of the lungs, heart and abdomen revealed no abnormalities including hepatosplenomegaly. The graft was painless. Laboratory tests revealed a white blood cell count 11,81×10<span class="elsevierStyleSup">^3</span>/L (neutrophils 65,8%, lymphocytes 23,6%, monocytes 10%, eosinophils 0,1%), normochromic-normocytic anemia (Hgb 9,6g/dL); creatinine 1,2mg/dL (basal value), blood urea nitrogen 39mg/dL; protein C reactive 143mg/L; LDH, SGOT, SGPT, total bilirubin and alkaline phosphate without alterations. Ultrasound cervical ecography demonstrated multiple ganglion formations.</p><p class="elsevierStylePara">She was observed on admission by an otorhinolaryngologist who prescribed metronidazole plus amoxicillin and clavulanate for a nasopharynx´s infection. Serologies for Epstein-Barr virus, herpes virus, cytomegalovirus, toxoplasmosis, brucella, leishmania, and HIV infection were negative. Blood culture was sterile. Chest and abdominal CT scan without changes. Quantiferon test for tuberculosis was indeterminate. Peripheral blood cytometry and cytometry of ganglion did not showed immunophenotypic alterations compatible with lymphoma. An ganglion biopsy was performed and histological examination revealed reactive lymphadenitis with central necrosis (Ziehl neelsen was negative) alterations compatible with CSD (Figure 1 and Figure 2). She stopped the initial antibiotherapy on the 6th of internment (without improvement of complains) and began azithromycin 500mg on day one, followed by 250mg for four days. There has been a good clinic improvement with involution of ganglion swelling and resolution of the pain and fever. One month later the patient was asymptomatic, without any signs of recurrence.</p><p class="elsevierStylePara">This case report intends to illustrate that the investigation of an immunocompromised kidney transplant patient presenting with lymphadenopathy may constitute a challenge given the wide differential diagnosis possible. The presence of enlarged lymph nodes in those patients should lead to post-transplant lymphoproliferative disorders (PTLD) as a first hypothesis; however more benign and unsuspected causes must be the cause.</p><p class="elsevierStylePara">The risk of PTLD is associated with the degree of immunosupression, time post transplant and the presence of Epstein-Barr virus.<span class="elsevierStyleSup">6-9</span> Their incidence is approximately 30 to 50 times greater than in the general population and comprises a wide histological spectrum from hyperplastic appearing lesions, non-Hodgkin lymphoma or multiple myeloma histology.<span class="elsevierStyleSup">6,8</span></p><p class="elsevierStylePara">Regional lymphadenopathy is the hallmark of CSD in association with mild constitutional symptoms and a previous history of cat scratch or bite.<span class="elsevierStyleSup">1-3</span> In our case the investigation was wide and extensive once this disease can mimic the more common PTLD disease or others infectious causes.<span class="elsevierStyleSup">2-4</span> In addition to serological tests a lymph node biopsy was performed to exclude lymphoma or other malignant causes. It has been proposed that at least three of four criteria must be present to establish the diagnosis of CSD: a) cat or flea contact; b) negative serology for other causes of adenopathy or sterile pus aspirated from a node or a positive Bartonella PCR assay or liver or spleen lesions on CT scan; c) positive serology for Bartonella henselae (EIA or IFA≥1:64); d) biopsy showing granulomatous inflammation consistent with CSD or a positive Warthin-Starry silver stain.<span class="elsevierStyleSup">2,3,10</span> The diagnosis of CSD in our patient was based on the presence of a cat contact history, negative serology for other causes and a ganglion biopsy compatible with CSD (Figure 1 and Figure 2). Serologic methods for detection of Bartonella henselae were not available in our hospital and it was not possible to isolate this agent by culture. The treatment of this entity is recommended in immunocompromised patients due to high risk for disseminated and recurrent CSD.<span class="elsevierStyleSup">2,3</span></p><p class="elsevierStylePara">Although CSD had rarely been reported in kidney transplant patients it should be considered in the differential diagnosis of patients with lymphadenopathy and a history of cat exposure.<span class="elsevierStyleSup">5</span> The absence of easy complementary tests, the difficulty in isolating the bacteria and the need of tissue biopsy makes a difficult diagnosis.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflict of interest</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">The authors declare that they have no conflicts of interest related to the contents of this article.</p><p class="elsevierStylePara"><a href="grande/12474_16025_58474_en_f112474.jpg" class="elsevierStyleCrossRefs"><img src="12474_16025_58474_en_f112474.jpg" alt="Ganglion biopsy – Focus of necrosis, some surrounded by granulomatous inflammation in cortical region (H&E, original magnification x40)."></img></a></p><p class="elsevierStylePara">Figure 1. Ganglion biopsy – Focus of necrosis, some surrounded by granulomatous inflammation in cortical region (H&E, original magnification x40).</p><p class="elsevierStylePara"><a href="grande/12474_16025_58475_en_f212474.jpg" class="elsevierStyleCrossRefs"><img src="12474_16025_58475_en_f212474.jpg" alt="Ganglion biopsy – Focus of stellate aspect necrosis with epithelioid macrophages in the periphery (H&E, original magnification x100)."></img></a></p><p class="elsevierStylePara">Figure 2. Ganglion biopsy – Focus of stellate aspect necrosis with epithelioid macrophages in the periphery (H&E, original magnification x100).</p>" "pdfFichero" => "P1-E572-S4663-A12474-EN.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12474_16025_58474_en_f112474.jpg" "Alto" => 654 "Ancho" => 649 "Tamanyo" => 412771 ] ] "descripcion" => array:1 [ "en" => "Ganglion biopsy – Focus of necrosis, some surrounded by granulomatous inflammation in cortical region (H&E, original magnification x40)." ] ] 1 => array:8 [ "identificador" => "fig2" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12474_16025_58475_en_f212474.jpg" "Alto" => 559 "Ancho" => 657 "Tamanyo" => 454691 ] ] "descripcion" => array:1 [ "en" => "Ganglion biopsy – Focus of stellate aspect necrosis with epithelioid macrophages in the periphery (H&E, original magnification x100)." ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Spach D, Kaplan S. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 2 | 6 |
| 2024 October | 53 | 53 | 106 |
| 2024 September | 58 | 34 | 92 |
| 2024 August | 69 | 63 | 132 |
| 2024 July | 64 | 39 | 103 |
| 2024 June | 89 | 50 | 139 |
| 2024 May | 64 | 32 | 96 |
| 2024 April | 65 | 40 | 105 |
| 2024 March | 56 | 27 | 83 |
| 2024 February | 57 | 30 | 87 |
| 2024 January | 77 | 35 | 112 |
| 2023 December | 32 | 32 | 64 |
| 2023 November | 37 | 39 | 76 |
| 2023 October | 52 | 33 | 85 |
| 2023 September | 29 | 35 | 64 |
| 2023 August | 36 | 33 | 69 |
| 2023 July | 46 | 33 | 79 |
| 2023 June | 51 | 26 | 77 |
| 2023 May | 47 | 42 | 89 |
| 2023 April | 41 | 20 | 61 |
| 2023 March | 38 | 20 | 58 |
| 2023 February | 46 | 14 | 60 |
| 2023 January | 56 | 24 | 80 |
| 2022 December | 59 | 34 | 93 |
| 2022 November | 66 | 41 | 107 |
| 2022 October | 64 | 54 | 118 |
| 2022 September | 43 | 38 | 81 |
| 2022 August | 58 | 52 | 110 |
| 2022 July | 44 | 51 | 95 |
| 2022 June | 46 | 32 | 78 |
| 2022 May | 59 | 37 | 96 |
| 2022 April | 62 | 55 | 117 |
| 2022 March | 80 | 53 | 133 |
| 2022 February | 80 | 51 | 131 |
| 2022 January | 49 | 28 | 77 |
| 2021 December | 55 | 35 | 90 |
| 2021 November | 44 | 38 | 82 |
| 2021 October | 36 | 39 | 75 |
| 2021 September | 35 | 34 | 69 |
| 2021 August | 36 | 43 | 79 |
| 2021 July | 42 | 34 | 76 |
| 2021 June | 20 | 29 | 49 |
| 2021 May | 34 | 45 | 79 |
| 2021 April | 68 | 61 | 129 |
| 2021 March | 44 | 34 | 78 |
| 2021 February | 54 | 18 | 72 |
| 2021 January | 42 | 19 | 61 |
| 2020 December | 31 | 20 | 51 |
| 2020 November | 31 | 15 | 46 |
| 2020 October | 15 | 20 | 35 |
| 2020 September | 25 | 11 | 36 |
| 2020 August | 50 | 14 | 64 |
| 2020 July | 27 | 8 | 35 |
| 2020 June | 29 | 15 | 44 |
| 2020 May | 40 | 9 | 49 |
| 2020 April | 30 | 16 | 46 |
| 2020 March | 52 | 15 | 67 |
| 2020 February | 64 | 15 | 79 |
| 2020 January | 56 | 14 | 70 |
| 2019 December | 51 | 20 | 71 |
| 2019 November | 35 | 15 | 50 |
| 2019 October | 26 | 14 | 40 |
| 2019 September | 31 | 23 | 54 |
| 2019 August | 12 | 11 | 23 |
| 2019 July | 22 | 23 | 45 |
| 2019 June | 26 | 30 | 56 |
| 2019 May | 28 | 25 | 53 |
| 2019 April | 38 | 45 | 83 |
| 2019 March | 45 | 24 | 69 |
| 2019 February | 33 | 16 | 49 |
| 2019 January | 33 | 20 | 53 |
| 2018 December | 93 | 48 | 141 |
| 2018 November | 107 | 13 | 120 |
| 2018 October | 97 | 14 | 111 |
| 2018 September | 80 | 16 | 96 |
| 2018 August | 48 | 21 | 69 |
| 2018 July | 61 | 13 | 74 |
| 2018 June | 69 | 17 | 86 |
| 2018 May | 53 | 18 | 71 |
| 2018 April | 103 | 7 | 110 |
| 2018 March | 63 | 5 | 68 |
| 2018 February | 87 | 8 | 95 |
| 2018 January | 66 | 6 | 72 |
| 2017 December | 64 | 9 | 73 |
| 2017 November | 62 | 11 | 73 |
| 2017 October | 40 | 7 | 47 |
| 2017 September | 47 | 11 | 58 |
| 2017 August | 41 | 12 | 53 |
| 2017 July | 42 | 16 | 58 |
| 2017 June | 46 | 18 | 64 |
| 2017 May | 62 | 9 | 71 |
| 2017 April | 40 | 11 | 51 |
| 2017 March | 50 | 22 | 72 |
| 2017 February | 58 | 10 | 68 |
| 2017 January | 28 | 7 | 35 |
| 2016 December | 68 | 6 | 74 |
| 2016 November | 80 | 4 | 84 |
| 2016 October | 108 | 10 | 118 |
| 2016 September | 116 | 2 | 118 |
| 2016 August | 160 | 0 | 160 |
| 2016 July | 175 | 5 | 180 |
| 2016 June | 123 | 0 | 123 |
| 2016 May | 149 | 0 | 149 |
| 2016 April | 105 | 0 | 105 |
| 2016 March | 99 | 0 | 99 |
| 2016 February | 122 | 0 | 122 |
| 2016 January | 93 | 0 | 93 |
| 2015 December | 132 | 0 | 132 |
| 2015 November | 88 | 0 | 88 |
| 2015 October | 116 | 0 | 116 |
| 2015 September | 76 | 0 | 76 |
| 2015 August | 78 | 0 | 78 |
| 2015 July | 121 | 0 | 121 |
| 2015 June | 56 | 0 | 56 |
| 2015 May | 65 | 0 | 65 |
| 2015 April | 11 | 0 | 11 |
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