Cat-Scratch Disease in an AIDS Patient Presenting with Generalized Lymphadenopathy: An Unusual Presentation with Delayed Diagnosis

Abstract

BACKGROUND Bartonella infection is the causative organism of cat-scratch disease (CSD), which typically presents with self-limited localized lymphadenopathy. In HIV-infected patients, Bartonella infection can cause systemic illnesses with significant morbidity and mortality manifesting as bacillary angiomatosis (BA), hepatic peliosis, splenitis, bacteremic febrile illness, and other organ involvement. To the best of our knowledge, there have been no reports of HIV-infected patients presenting with generalized lymphadenopathy caused by Bartonella infection. We report an unusual case of CSD presenting with generalized lymphadenopathy in an AIDS patient with advanced immunosuppression. CASE REPORT A 44-year-old woman with AIDS, advanced immunosuppression, and intermittent adherence to antiretroviral therapy and medical care, presented with cough and increased generalized tender lymphadenopathy. A lymph node biopsy 1 year earlier was non-diagnostic for tuberculosis, fungal infection, and lymphoproliferative disorders. She remained with generalized lymphadenopathy. A repeat biopsy with the addition of Warthin-Starry silver staining suggested the diagnosis of cat-scratch lymphadenitis. She responded well to a long course of azithromycin antibiotic therapy, with the resolution of lymphadenopathy. CONCLUSIONS Cat-scratch disease may present with prolonged generalized lymphadenopathy, an unusual presentation in HIV patients with advanced immunosuppression. Awareness of the possibility of CSD in a similar clinical scenario may prompt early recognition and management of this disease.

Figure 1.

Chest X-ray at presentation: (A) Frontal view, right hilar (arrow) opacities suggestive of lymphadenopathy; (B) Lateral view, subcarinal (arrow) opacities suggestive of lymphadenopathy.

Figure 2.

At presentation, contrast-enhanced CT scan of the neck, revealing bilateral cervical lymphadenopathy; the largest node was in the right supraclavicular region (arrow) with central low attenuation relative to periphery with enhancement.

Figure 3.

At Presentation, selected axial (A, B) and coronal (C) images from contrast-enhanced CT scan of the chest, demonstrating bilateral axillary (thick arrows), subcarinal (long arrows), and right hilar larger than left (short arrows) lymphadenopathy.

Figure 4.

One week after start of treatment, selected axial (A, B) and coronal (C, D) contrast-enhanced CT scan of the chest, demonstrating significant reduction in size of the right supraclavicular (arrow in C), bilateral axillary, hilar, and subcarinal lymphadenopathy, indicating a favorable response to treatment.

Figure 5.

One week after start of treatment, Axial contrast-enhanced CT image at level of lower pole of kidneys, demonstrating sub-centimeter and enlarged mesenteric lymph nodes (arrows).