Cervical Nodules in a Healthy 65 Year-old Woman

Abstract:  One month history of three nodules in the right posterior cervical area in a 65 year-old woman.

HPI:  The patient is an otherwise healthy, immunocompetent woman who has noted three slightly painful nodules that appeared in the right posterior nuchal area. She has a history of  scalp excoriations.  She has two cats, one of which sleeps with her.

O/E:  Initially, there were three firm nodules measuring 0.8 to 1.5 cm in diameter.  She has had superficial scalp erosions secondary to excoriation for about a year.

Clinical Photos (courtesy of Yoon Cohen, D.O.)

Scar is biopsy site

Lab:  CBC normal, Chemistries normal.  Chest Xray normal.  Cat Scratch serology drawn six weeks after onset:  Bartonella Henselae IgG 1:1280 and Bartonella Quintana IgG 1:640  (IgM negative for both. Negative is <1:320)

Pathology: (photomicrographs courtesy of Lynne Goldberg, M.D., Boston University Skin Path) Because this was thought to be lymphadenopathy, a deep incisional biopsy was performed.  To our surprise, no lymphatic tissue was seen.  Rather, the pathology showed stellate subcutaneous microabscesses with a surrounding lymphohistiocytic infiltrate and fibrosis.

Course:  The patient continues to feel well.  An abscess was drained and around 1 cc of viscous pus was withdrawn.  It has refilled.  Since the patient feels well, we have not prescribed antibiotics.

Diagnosis: Cutaneous abscesses in Cat Scratch Disease.

Discussion: There are no reports of cutaneous abscesses in patients with CSD.  It may be possible that the suppuration we noted occurred as a sequela to an infected lymph node.  A review of the medical literature was not helpful here.  Recommendations for antibiotic therapy of immunocompetent with no systemic signs or symptoms are equivocal and we have elected to observe our patient for the time being.  If we decide to recommendad treatment, it will probably be with erythromycin.

References:

1.  eMedicine.comhttp://emedicine.medscape.com/article/214100-overview:  Catscratch disease (CSD), also known as catscratch fever or subacute regional lymphadenitis, is a bacterial infection affecting lymph nodes that drain the sites of inoculation. Bartonella henselae, a gram-negative rod, is considered the principal etiologic agent. CSD is a common cause of chronic lymphadenopathy in children and adolescents.

Patients with CSD usually have a history of sustaining a scratch or bite from a cat (typically a kitten). The initial symptom is formation of a papule at the inoculation site, followed by solitary or regional lymphadenopathy within 1-2 weeks (see the images below). In most patients, the disease resolves spontaneously within 2-4 months.

2. Abscess-forming lymphadenopathy and osteomyelitis in children with Bartonella henselae infection.  Ridder-Schröter R, et. al. J Med Microbiol. 2008 Apr;57(Pt 4):519-24. doi: 10.1099/jmm.0.47438-0.

Abstract: Bartonella henselae is the agent of cat-scratch disease (CSD), a chronic lymphadenopathy among children and adolescents. A systemic infection is very rare and most of these cases are found in patients with immunodeficiency. Here, cases involving four children of 6-12 years of age are reported. In immunocompetent patients, infection affects skin and draining lymph nodes; however, prolonged fever of unknown origin as in the fourth patient indicated a systemic complication of CSD. Free full text.