Osteomyelitis in Cat-Scratch Disease: A Never-Ending Dilemma—A Case Report and Literature Review

Received Oct 6, 2017; Revised Feb 15, 2018; Accepted Mar 7, 2018

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1. Background

Cat-scratch disease (CSD) is a common zoonosis caused by Bartonella henselae [1].

Affected children typically present with lymphadenitis after local cutaneous reaction at the scratch site.

Complications such as Parinaud’s oculoglandular syndrome, erythema nodosum, and granulomas in the liver and spleen occur in approximately 10% of immunocompetent children [2]. Bone involvement during CSD is rare, and skull localization is even more unusual [2–5].

We present a case of disseminated CSD with skull osteomyelitis and spleen involvement and perform a review of pediatric case studies of osteomyelitis associated with CSD to consolidate existing information on clinical presentation, diagnostic tools, therapy, and outcome.

2. Case Presentation

A 12-year-old girl presented with a 5-day history of fever, right lateral-cervical and submandibular lymphadenopathy, and frontoparietal headache. The past medical history was uneventful, and she had no pets at home and did not travel recently.

Physical examination revealed a 3 cm painful lateral-cervical swelling with overlying erythematous skin. White blood cell count was 16.2 × 10³/$\mu$L, with 12.8 × 10³/$\mu$L neutrophils, while C-reactive protein and erythrocyte sedimentation rate were normal. Oropharyngeal swab was negative. Ultrasound (US) confirmed the nature of the swelling (multiple reactive lymph nodes without central colliquation) and showed other reactive lymph nodes in the left cervical and bilateral inguinal regions. The girl was discharged with a 14-day course of amoxicillin-clavulanate, followed by improvement of cervical swelling and reduction of spiking fever.

After two days from the conclusion of antibiotic therapy, the patient presented to the Emergency Department suffering reoccurrence of severe headache and lymphadenopathy and was admitted for further investigation.

Physical examination was unremarkable, except for right cervical swelling and 2 cm left parietal-occipital swelling.

Complete blood cell count and inflammatory markers were normal; IgM and IgG positivity for Bartonella henselae was confirmed through immunofluorescence assay. Suspecting CSD, a new medical history was collected revealing that the child used to play with neighbor’s kittens.

Due to the clinical finding of scalp swelling, a cranial magnetic resonance imaging (MRI) with contrast was...