Color Doppler Pseudolymphomatous Manifestations of the Cat Scratch Disease

Color Doppler
Pseudolymphomatous
Manifestations of the Cat Scratch
Disease

sis (IgG, IgM), while only in one case

biopsy and patothohystology analysis of
the lymph node is done.

Fahrudin Smajlovic, Muris Ibralic

Faculty of Health Sciences, Sarajevo, Bosnia and Herzegovina
Case report
SUMMARY

Cat Scratch Disease (CSD) is an infectious illness, caused by the Bartonella henselae bacterium. Besides the common infective symptoms, swelling in the axillary and cervical region is very common and is usually evaluated by
Color Doppler US (CDUS) (among other diagnostic methods). The aim of this work is to present ultrasound findings of the Cat Scratch Disease. During 2002 and 2003, we followed four patients (three male and one female) by
CDUS, with different manifestations of the disease. The average age of the patients was 12. In all four cases, the
local and generalized lymphadenopathy was found, and in two cases we found multiple focal hepatolienal lesions
as well. The enlarged lymph nodes were found, with heterogeneous echogenicity of the cortex, and increased
number of the hiluses, disturbed vascular structure and non specific hemodynamic. Hepatolienal lesions were
hypoechogenic, round, unclear outline, and poorly vascularised. CDUS has proved to be a very sensitive imaging
method in detection of pathomorphologic and hemodynamic changes of superficial lymph nodes and focal
lesions of visceral organs in CSD. Opposite to the high sensitivity, its specificity is much lower, because of similar
findings in lymphoma, TB lymphadenopathy and multiple visceral abscesses. Detailed anamnesis, clinical findings,
with laboratory and specific serological tests (IgG, lgM), US characteristics, sometimes percutaneous aspiration
biopsy as well, are crucial in determination of etiology of the disease.
Keywords: lymphadenopathy, Cat Scratch Disease, CDUS

1. INTRODUCTION
Cat scratch disease (CSD) is infectious illness caused by bacteria Bartonella henselae which is more often during the youngest decades of life. Injured
skin usually heals quickly and without
consequences, although in case of larger
damage complications can occur in form
of general inflammation symptoms (abdominal problems and localized swelling at the neck or axils) (1,2,3,4,5). Superficial tumefact is usually analyzed
with ultrasound, as reliable, simple diagnostic method. With it is possible in
short time period detect the nature of tumefact in this case presented as package of increased lymph nodes (5). Besides local, sometimes it is possible to
find generalized lymphadenopathy as
well as multiple, focal visceral manifestations of illness, so called hepatoplenomas (6,7,8,9,10,11). External patient appearance (alkalized swelling) and look
of ultrasound laringeographs, raises
doubt to lymphoma, so often patients
have wrong further diagnostic tests and
medical treatment (5,6,9). CSD diagnosis is set based on detailed anamnesis
data (previous scratch), serology tests,
increased number of antibodies for this
bacteria (IgM >1:64), as well as ultrasound, CT and pathohystology finding
after biopsy. Treatment with wide spec-

3. RESULTS
Tumefaction on a neck or axillary pit
was evident in all cases; painful, immobile, size up to several centimeters with
stretched skin. Ultrasound examination
of the swelling as its substrate is identified package of inflammatory enlarged
lymph nodes.
Altered lymph nodes were round in
shape, with decreased ration in length
and with, with clear border and usually
with hypoechogenic cortex. Doppler indicated existence of one or two hiluses
while the peripheral vascular branches
were without significant dislocation.
Hemodynamic of the affected lymph
nodes was featured with higher blood
flow velocities, as we found in case of
inflammatory, as well as malignant processes.
With the lymphadenopathy in 2
cases in liver and spleen we found sev-

trum antibiotics leads to

rapid healing, opposite
symptoms can remain
for several weeks, which
makes clinical symptoms
more complex as well as
differential diagnosis.

2. MATERIAL AND
METHODOLOGY
Du ring last t h ree
years with color Doppler ultrasound we examined, and then followed 4 patients with cat
scratch disease. Three of
them were male and one Figure 1. Large axillary tumefact
female patient, age between 5-22 years, in average of 12 years. All of
them were in details examined at the Clinical
Center of Sarajevo University, and one patient
was hospitalized. During the diagnostic process patients underwent
the standard procedures:
Chest and neck X-ray,
ECG, blood analysis, US
of the peripheral organs
and abdomen, as well as Figure 2. Significantly increases reactive lymph node with one,
specific serology analy- central hyllus. (BI10iO)
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Color Doppler Pseudolymphomatous Manifestations of the Cat Scratch Disease

ogy which requires pre- its. With often present retroperitoneal

cise differential diagno- lymphadenopathy, suspicion on tumor
sis (Figure 1). As men- etiology of the changes increases (Figtioned in case of CSD, ure 10).
besides local lymphadeBecause of the faction to suppress
nopathy, we can found infection lymph nodes are first to realso its generalized form, act, in that process they suffer certain
as well as multiple hep- changes. Good knowledge about the ulatosplenomas (10). Ex- trasonic features of the altered lymph
istence of other symp- nodes in case of etiologically different
toms and complications states is because of that essential. Towithin main disease as day we are able to distinguish in maFigure 3. Multiple peripheral lymphadenitis in CSD
neurorenithis, endocar- jority of cases normal lymph node from
ditis and encephalitis are the inflamated or with tumor altered
seldom (8).
one (7,9,12). Normal superficial lymph
It is considered their nodes, which can be optimally visualized
wider manifestation with the high frequency probes, are not
of CSD occurs as the larger than 1cm. They have sharp edges,
consequence of inad- ellipse shape, twice bigger longitudinal
equate treatment, eti- than transversal size (L/S ratio > 1.5-2).
ology oversight or de- Along longitudinal axis there is a hylcreased immunity of the lus of the lymph node with the main arpatients. Increased val- tery and vein with straight flow and surues of sedimentation rounding connecting tissue which forms
rate, lymphocytes, LDH its hypoechogenic response. Around the
etc, with coexisting ul- hyllus we found homogenous hypoechotrasound changes can genic cortex. From the main blood vesFigure 4. Clearly visible 2 hiluses in reactively altered peripheral
lead to wrong conclu- sels into the cortex are divided many
lymph node.
sion of lymphoma. As straight branches with angle under 60
ultrasound nowadays is degrees (Figure 5). Deviations from this
the most sensitive im- normal image can be found in case of ineral round, with unclear border, homogenous, hypoechogenic, poorly vascular- aging method for this type of analysis flammatory or more often tumor (metaized changes, size of 1 cm. Retroperito- of type, extension and content of the static) altered lymph nodes.
neal lymph nodes were also increased, superficial swelling its use in this and
Inflammatory, reactive lymph nodes
similar states is justiwhich is confirmed with CT scan.
In a clinical-laboratory findings we fied. Besides insight of
found increased sedimentation rate the echo anatomical fea(from 40 to 110), L (from 10 to 21) and tures of the swelling, adfibrinogen over 18, while the chest x-ray, ditional functional DopBP, blood glucose level, urea, creatinine pler analysis provides
and hepatic functions were regular. In- more certain etiology
creased number of antibodies to bacteria of the lesion (trauma,
Bartonella henselae (IgG Elysamaximal inflammation, congen1:1024. normal up to 64, IgM up to 1:40 ital, benign or malig normal in all cases). The pathohysto- nant). For example now
logical results of one lymph node biopsy we are able to distinindicated existence of non specific gran- guish with color Dop- Figure 5. Adequate peripheral vascular branches
ulomatose process. During and after the pler the type of changes
treatment, we followed with ultrasound between different structhe regression of size, with Doppler he- tures, by measuring size,
modynamic normalization in lymph shape, number of hiluses
nodes parallel to decrease of antibod- and values of vascular inies number. In 3 cases full recovery is dexes.
achieved after two weeks, while in one
Visceral manifestacase diagnosis and treatment lasted lon- tions of CSD are more
ger, for more than 5 months.
seldom, and it can occur in form of multi4. DISCUSSION
ple focal lesions in liver
Fast growing superficial tumor can and spleen, in different
Figure 6. Low resistance flow (RI=0.52) in case of acute
be caused by neoplastic inf lamma- number and size which lymphadenitisCSD
tion, traumatic and congenital etiol- looks like lymph depos302

MED ARH 2009; 63(5) Case reports

Color Doppler Pseudolymphomatous Manifestations of the Cat Scratch Disease

Figure 7. Multiple avascular hypoechogenic lesions in spleen

parenchymaCSD

with its size are not larger than 2cm, have

elliptic shape and most often, one (seldom two) central hiluses. Image of the
internal nodal blood vessels, as hyllus
(central) as well as peripheral branches,
in 98% of cases is typical with low resistance in flow. Cortex becomes wider
and has uniform hypoechogenic appearance. Doppler analysis detects increased
flow and increase in vascular parameters
which is more prominent in case of tumor processes. Smaller deviations from
the described appearance of inflamated
lymph nodes we can found in case of
TBC infection with dominated cortical heterogenocity caused with granulomas and peripheral increase of perfusion (11,12).
Primary or secondary altered by tumor lymph nodes are larger, often more
than 3cm. Lymphomas, regardless of
histological type, are presented in oval
shape, smaller L/S ration (around 1), hypoechogenic, excentric hiluses or completely invisible, and random distribution and number of blood vessels. Val-

Figure 8.Lymph node with numerous hiluses and star like formation of
blood vessels.

ues of vascular indexes in case of lymphomas are somewhat different so the Pi

is more than 1.3, and RI 0.72.
Metastatic lymph nodes reach the
largest size among all pathological
lymph nodes, often over 2.5 cm. Most
often they are with altered and asymmetric cortex, heterogenic aspect which
occurred due to tumor deposits and necrosis zones (13,14,15). Vascular map is
featured with many, chaotically spread
and dislocated capsule blood vessels
branches and many accessory hiluses.
Listed Doppler features of altered
lymph nodes with due to inflammation
or tumor indicated high diagnostic reliability, sensitivity of 96%, and specificity of 77%.

5. CONCLUSION
Ultrasound analysis of the fast
growing peripheral tumor in case
of CSD detects existence of increased lymph nodes packages.
Doppler features of the altered
lymph nodes first indicate inflammatory etiology of
changes.
Visceral manifestations of CSD in form of
hepatoplenomas and retroperitoneal lymphadenopathy look like lymph
deposits from which is
difficult to distinct them
even with other current
imaging methods.
Figure 9. Atypical angiography of metastatic changed lymph
Detailed anamnesis,
node
clinical features, laboratory tests and specific serology tests with CDS,
HCT, biopsy and pathohystology findings enables more rapid diagnosis.
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Corresponding author: Prof Fahrudin

Smajlovic, MD, PhD. Faculty of Health Sciences.
Bolnicka 25. 71000 Sarajevo, BiH.

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