CONTINUING EDUCATION Human infection with Bartonella species Bruce A. Stewart Department of Medd Microbiology, The Royal London Hospital, London, UK ILLUSTRATIVE CASE HISTORY A 14-year-old Caucasian boy presented with a 4-week history of malaise, intermittent fever, tender lymph- adenopathy of the axillary and cervical nodes, and fatigue which had been interfering with his school work. He had previously been healthy, with no developmental problems or past medical history, except for tonsillectomy at the age of 8 years. On direct questioning, he denied loss of appetite or a reduction in weight; there had been no rash or other type of cutaneous lesion. His father, mother and two younger siblings were well and asymptomatic. He had last been on holiday with the entire family 4 months previously in Greece. Family pets included his father's tropical fish, a hamster, and an aging cat. Examination failed to detect any signs other than the lymphadenopathy. The patient was afebrile. Investi- gation revealed normal biochemistry, haemoglobin concentration and platelet count, but the total white cell count was raised, at 1 2 . 4 ~ 109/L, with a neutro- philia of 96%. The erythrocyte sedimentation rate was 39 mm/h. The chest X-ray was unremarkable. Histologic examination of a lymph node demon- strated caseating granulomata, and a specific stain confirmed the diagnosis. Routine cultures of blood and node homogenate were negative at 7 days, and the specimens were discarded. With appropriate management, the boy complete- ly recovered within the next 2 months. Corresponding author and reprint requests: Bruce A. Stewart, Department of Medical Microbiology, 37 Ashfield Street, The Royal London Hospital, London El IBB, UK Tel: +44 171 377 7249 Acccepted 22 June 1997 Fax: +44 171 377 7330 Thoughts on the case 0 What was the most likely diagnosis? How could investigation have been optimized? 0 What was the nature of the successful management? MULTIPLE-CHOICE QUESTIONS In each ofthe numbered questions, at least one, and up tojive, of the individual entries are correct. (The answers are at the end of this article.) 1. Regarding cat scratch disease (CSD) (a) The first reports of lymphadenopathy following animal contact date back to the 1880s. True/False generally accepted to be Bartonella henselae. True/False (c) The primary reservoir for the organism is the adult cat, especially if elderly or diseased. True/False infection to humans has been shown to be the cat flea. occur at age less than 21 years. (b) The causative organism is now (d) The vector of transmission of True/False True/False (e) Eighty per cent of cases of CSD 2. Concerning the clinical features and natural history of CSD (a) A history of contact with cats is essential to make the clinical diagnosis of CSD. True/False (b) It is not uncommon for the primary skin lesion not to be detected on clinical examination. True/False (c) Lymphadenopathy is almost always present. True/False (d) In the immunocompetent patient, CSD can lead to complications in almost every organ system. True/False 677
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