CAT SCRATCH DISEASE: NONBACTERIAL REGIONAL

LYM PHADEN IllS

The Study of 145 Patients and a Review of the Literature
A. M. Margileth, M.D.
Captain (MC), U.S. Navy, Retired

ABSTRACT. Of 145 patients with

nonbacterial Lymphadenopathy was most common in the ex-
lymphadenitis observed over a period of 10 years, tremities (57%), and head and neck (43%). Cat
115 had clinical cat scratch disease (CSD) with a scratch antigen was found to be a reliable diagnos-
positive cat scratch antigen skin test. In this group tic skin test. A negative test was found in 98% of
86% had a typical benign course of CSD; the re- control patients; a positive test was found in 94%
maining 16 (14%) had an atypical form. These un- of patients who were clinically suspected to have
usual forms were: Parinaud’s oculoglandular syn- CSD and a history of cat scratch.
drome in 7, encephalopathy in 3, atypical pneumo- Management consisted of reassurance, sympto-
nia in 2, and recurrent suppurative lymphadenopa- matic therapy, and closed aspiration of enlarged
thy in 1. Two typical cases occurred after a dog nodes if suppuration occurred. Antibiotics were not
scratch or bite, and one after a monkey scratch. effective. The disease is self-limited and has an ex-
The disease was most prevalent in late fall and cellent prognosis in the majority of patients. An
early winter; 80% of patients were under age 20 etiologic agent could not be isolated in this study.
years. Primary lesions were detected in 55%, node Until the causative agent is known, it will be diffi-
suppuration occurred in 26%, and lymphadenopa- cult to carry out preventive measures. Pediatrics,
thy lasted 2 weeks to 2 months in most patients. 42:803, 1968, NON-BACTERIAL LYMPHADENITIS, CAT
Symptoms were absent in 35% of cases. Fever oc- SCRATCH DISEASE, CAT SCRATCH SKIN TEST ANTIGEN,

curred in 26, and exanthem was present in 4%. OCULOGLANDULAR SYNDROME, ENCEPHALOPATHY.

C AT SQIATCH DISEASE, variously termed scratch disease (CSD ) using diagnostic

cat scratch fever, benign lymphoretic- criteria to be discussed. The purpose of this
ulosis, or nonbacterial regional lymphad- paper is to present the limitations of utiliz-
enitis, has been reported with increasing ing cat scratch skin test antigen in patients

frequency during the past 10 years. De- with benign lymphadenitis and to review
spite documentation of over 1,000 cases, the the unusual clinical manifestations encoun-
disease undoubtedly eludes detection more tered in 16 of the 115 patients who had pos-
often than not. Since the disease is benign itive cat scratch skin tests. The present
and self-limited in most instances, the clini- management of patients with CSD, includ-
cal diagnosis frequently is considered but ing a literature review, will be given.
not confirmed due to the limited supply of
SUBJECTS AND METHODS
cat scratch skin test antigen.
Following a previous study of 10 patients The patients were selected on the basis
in 1957,6 a prospective study was begun in that lymphadenopathy of unknown etiology
1958 to determine the diagnostic value and was present. Controls consisted of healthy
specificity of cat scratch antigen as a skin individuals or patients with a known cause
test in patients with benign nonbacterial for their lymphadenopathy with or without
regional lymphadenitis. Of 145 patients other systemic disease. The majority were
studied, 115 (79%) were found to have cat observed as outpatients at Naval Hospitals

(Received September 14, 1967; revision accepted for publication May 8, 1968.)
The opinions or assertions contained herein do not necessarily reflect the views of the Bureau of
Medicine and Surgery of the Navy Department or the naval service at large.
Formerly Chief Pediatrics, Naval Hospital, Bethesda, Maryland. PRESENT ADDRESS: Associate Pro-
fessor, Pediatrics, Ceorge Washington University School of Medicine, and Senior Attending Physician,
Children’s Hospital of the District of Columbia, 2125 13th Street, N.W., Washington, D.C. 20009.

PEDIATRICS, Vol. 42, No. 5, November 1968

803

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804 CAT SCRATCH DISEASE

in Chelsea, Massachusetts, or in Bethesda, gens were compared to Lot M in the same

Maryland. Some were seen at the Naval group of patients and produced a compara-
Hospitals, Oakland, California; Philadel- ble amount of skin induration (7 to 11
phia, Pennsylvania; and Jacksonville and mm ) after 48 to 72 hours.
Pensacola, Florida. Several physicians in Technique and Reading of Skin Test
private practice used the same cat scratch
The test was performed by the intracuta-
skin test antigens on a few patients and
neous injection of 0.1 ml of antigen using a
provided complete reports. Five patients
disposable, 25 gauge needle and a plastic
were studied at Children’s Hospital of the
tuberculin syringe. Interpretation has var-
District of Columbia.
ied according to certain writers. Kalter1#{176}
Antigen Preparation and Prier7 considered any area of erythema
with or without induration as a positive
Antigens were prepared by a method
test. We and others’5’8”12 have used the
similar to that described by Prier7 and
following criteria as indicative of a positive
Kunz.8 Material aspirated from a lymph
reaction: an area of induration of 5 mm or
node was immediately diluted: one part of
more with, or without, erythema in 48 to 72
pus to four parts of normal saline. This was
hours. Pustule formation may occur ( Fig.
shaken vigorously and stored in a freezer
1). An immediate flare reaction is often
( -20#{176}C After
). sterility tests (aerobic, an-
seen and may be followed by marked er-
aerobic bacteria, viruses, typical, and atypi-
ythema for 12 to 36 hours. As erythema de-
cal mycobacterium) were completed, the
creases a positive delayed tuberculin type
diluted mixture was incubated 24 hours at
reaction appears and persists for from 48
60#{176}C
on 3 consecutive days to destroy com-
to 96 hours in most patients. A doubtful re-
plement and hepatitis virus.8 A preservative
action is 4 mm to less than 5 mm of indura-
was not added. Following another negative
tion. A negative test is less than 4 mm of
bacterial culture, the antigen was used for
induration. The majority of tests were read
skin testing. Two lots of antigen have been
by the author after exact delineation of the
used for skin testing for 5 years without loss
degree of induration using ink marks.
of activity as was found by Kunz.8 Dispatch
Other skin tests-tuberculin ( PPD stan-
of the antigen via airmail has not affected
dard, atypical PPD, Tine), histoplasmin,
its activity.
coccidioidin, and blastomycin-were admin-
istered intracutaneously using disposable
Validity of Antigens
syringes and needles. All antigen solutions
The skin test antigen (Lot M) utilized
were freshly prepared. Ten millimeters or
for routine skin testing of the majority of
more of induration was considered a posi-
patients in the present study was obtained
tive reaction13’14 for PPD S or atypical
from one of the 10 patients reported8 in
PPD;#{176}5 TU or .0001 mg/0.1 ml was used
1957. Lot M was standardized in the pre-
for each tuberculin skin test.
vious study by comparing the skin test re-
Immunologic studies were performed in
sults in the same five patients to an antigen
the research laboratories of Admiral G. W.
provided by Dr. W. B. Daniels and Dr. F.
Calver, MC, USN, at the Naval Medical
G. MacMurray of Washington, D.C.#{176}Posi-
School and by Dr. J. A. Bellanti at George-
tive reactions to both antigens with com-
town University Medical School, Washing-
parable degrees of skin induration (6 to 11
ton, D.C. Dr. Bellanti used a standard im-
mm) were obtained in all five patients.
munoelectrophoretic cell and goat antihu-
During the present study two additional cat
* PPD Avian, Battey, Cause, S, and Y strains
scratch antigens were prepared from two
were obtained from Communicable Disease Cen-
adults with CSD: Case 1 (Lot B) resided
ter, Biological Preparation Laboratory, TB. Pro-
in Arlington, Virginia; the other patient gram, Atlanta, Georgia; courtesy of L. B. Edwards,
(Lot G) lived in Hawaii. These two anti- M.D.

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 ARTICLES 805

man globulin (IgA, IgG and 1gM) antiserat

for quantitative determination of immuno-
globulins by the agar diffusion method.13
Admiral Calver’s laboratory utilized the
samef antisera.
Material aspirated from lymph nodes or
primary lesions was inoculated on blood,
EMB, or Endo agar and in thioglycolate
broth. These were observed for 5 days.
Three different media were used to detect
fungi; these were observed over 1 month at
25#{176}C. Two media (Petragnani, Lowen-
stein-Jensen) were observed for 8 weeks for
typical and atypical mycobacteria. Sodium
hydroxide or N acetyl-1-cysteine digestion
and concentration methods were used to
prepare the aspirates prior to inoculation of
the latter media.

Virus Studies
Virology studies were performed by Dr.
T. H. Weller at Harvard Medical School,
Dr. J. L. Sever at the Perinatal Research
Branch, National Institute of Health, FIG. 1. Positive cat scratch skin test at 72 hours
Bethesda, Maryland, and by Dr. E. Weiss, showing pustule formation and 10 mm induration.
Naval Medical Research Institute, Bethesda,
Maryland.
Aspirates obtained from the suppurative mus cultures ( Ma 117, MA 119)4 Another

lymph nodes in 11 patients were trans- aspirate ( Case 1 ) was passed in three cell
ported within ] to 2 hours to one of the culture lines ( WI-38, Mk-2, and AGMK),
aforementioned viral laboratories. One aspi- and hemagglutination tests were performed
rate was frozen immediately and stored at with chick, rat, and human “0” cells on
these culture lines; hemadsorption tests with
minus 80#{176}C,and studies were performed
within 48 hours; another was inoculated di- guinea pig cells were also performed with
rectly into a sucrose (.25 M) phosphate several of these cell culture lines. The cells

buffered solution (pH 7.0), prior to viral of the latter inoculated cultures (Case 1)

studies. The remaining aspirates were inoc- were tested on several occasions for the
ulated directly into six tissue culture lines: presence of interference by challenge with
WI-38, human embryonic diploid fibroblast, ECHO-il virus.
primary African green monkey kidney
Case Reports
(AGMK), secondary monkey kidney (MK-
CASE 1: RECURRENCE OF SUPPURATIVE LYMPH-
2), primary rabbit kidney and cornea, and
ADENOPATHY-In mid-December 1965, a 46-year-
primary ferret lung. In each case three old man received two deep scratches in his scalp
blind passages were made at 2 to 3 week when the family cat sprang onto his head. Three
intervals. weeks later tender swelling below the left parotid

Lymph node aspirate from one patient area, malaise, fever headaches,
(101#{176}F), and leth-
argy developed. Tetracycline was prescribed for
and saliva and nail clippings from the cat
10 days without improvement. Two cat scratch
in Case 1 were studied further using contin- skin tests were positive; other skin tests were nega-
uous African green monkey lung and thy-
Microbiological Associates, Bethesda, Mary-
f Hyland Laboratories, Los Angeles, California. land.

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806 CAT SCRATCH DISEASE

tive. Improvement was gradual during the next 2 creased and became fluctuant. The 3.5 ml of aspir-
months. Five months later malaise and headache ated, thick, yellow material was sterile for viruses,
recurred with tender swelling of the left superior bacteria, fungi, and mycobactena. Adenopathy
cervical nodes. On aspiration a fluctuant, lemon- subsided after 8 weeks. Results of cat scratch skin
sized mass yielded 35 ml of thick yellow pus. All tests using three antigens were positive : Lot M, 11
symptoms subsided. Cultures were negative for x 11mm; LotB,9 X 9mm; andLotG,7 X 7
fungi, mycobacteria, bacteria, and viruses. mm.
The patient remained well until October 1966, In summary, an illness characteristic of CSD ap-
when a mass of similar size recurred accompanied peared in a 5-year-old girl several days after she
by malaise and headache. After 35 ml of pus were was bitten by a dog.
aspirated, all symptoms subsided. Cat scratch anti- CASE 3: CAT SCRATCH DISEASE APPARENTLY

gen skin tests were positive. Cultures and other FROM A MONKEY SCRATCH-A 25-year-old Negro
skin tests were negative. Follow-up 6 months later received a scratch
from a laboratory monkey on
showed no recurrence. the right forearm. A pustule developed within 5
In summary, this was a typical case of CSD, days (Fig. 2). Excisional biopsy of the pustule was
with the exception that lymphadenopathy with done because of an increasingly tender, large,
suppuralion recurred following an asymptomatic grape-sized, right axillary node. Histological diag-
period of 5 months. Two children of the patient nosis was acute necrolizing vesicular dermatitis.
had CSD during the same period. Cultures from the primary lesion for bacteria,
CASE 2: CAT SCRATCH DISEASE APPARENTLY fungi, and mycobacteria were negative. All skin
FROM A Doc BITE-In a 5-year-old girl, a pustule tests at this time, including cat scratch antigen,
developed several days after a pet dog bit her on were doubtful or negative.
the left thumb. The lesion persisted 1 week, then The swelling of the axillary node persisted for 2
fever and left axillary lymphadenopathy ensued. months. Multiple skin tests repeated 5 weeks later
Fever (103#{176}F) lasted 3 to 4 days. Erythromycin was showed positive tests to cat scratch antigen and
given for 10 days without effect on the tender axil- PPD B ( 10 x 15 mm) and PPD C ( 11 x 12 mm).
lary swelling. Six weeks later the swelling in- Four days later a battery of atypical PPD skin
tests (Y 035, 269, 383, 452 Phlei, 463, 613 Platy,
and Avian strains ) were all negative. One year
later PPD B and G skin tests were negative; cat
scratch skin tests ( M, B Lots) were positive.
In summary, this was an example of CSD pro-
duced by a monkey’s scratch; this patient was the
only one whose skin tests were temporarily positive
for atypical PPD (Battey, Cause) antigens.
CASE 4: PNEUMONITIS ASSOCIATED WITH CAT

SCRATCH LYMPHADENOPATHY-A previously well

11-year-old boy developed fever ( 102#{176}F), cough,
and tender masses in his right arm in September
1958. Exposure to cats was frequent and he received
occasional scratches. Examination showed a 2 x 3
mm pustule over the lateral aspect of the right
wrist, 2.5 x 2.0 cm tender
a epitrochlear node,
and a 3 X 3 cm tender firm node in the right axilla.
His lungs were clear on auscultation; he was healthy
otherwise.
Routine laboratory studies and cultures were
normal; corrected sedimentation rate was 44 mm.
A cat scratch skin test was strongly positive during
the third week of illness. Cold agglutination tests
showed a fourfold rise (1:64 to 1:256) during a
2-week period. A patchy density was observed in
the right second interspace on the admission chest
x-ray; a second film
progressionshowedin 3 no
days. Seven days later no abnormal findings could
be seen by x-ray. During this period the patient
was mildly ill with fever and malaise which lasted
Fic. 2. Right forearm (Case 3): primary pustule 5 days; the nonproductive cough cleared in 14
following a monkey scratch 5 days previously. Bi- days on symptomatic therapy. The lymphadenopa-
opsy showed acute necrotizing vesicular dermatitis. thy subsided in 1 month.

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 ARTICLES 807

In summary, the association of nonbacterial doubtful; Group III consisted of 23 healthy

pneumonitis with cat scratch lymphadenitis, stud- controls; Group IV was 85 controls proven
ies negative for tularemia and brucella agglutina-
to have another disease.
tion, skin tests negative for PPD and histoplasmin,
and a benign clinical course suggest that this pa- Of 145 patients clinically suspected to
tient had cat scratch pneumonitis.’#{176}” However, have CSD, 115 ( Group I) had positive
pneumonitis due to M. pneumoniae cannot be reactions; 112 of these had typical or atypi-
ruled out since there was a rise in cold agglutinins. cal CSD; 2 had dog scratch or bite disease,
CASE 5: OCULOCLANDULAR AND ENCEPHALOPA-
and 1 had monkey scratch disease (Table
THY SYNDROME DUE TO CSD-A 12-year-old boy
showed conjunctivitis in the right eye in February
I). In the 115 patients with positive skin
1968. Six days later right preauricular tender aden- tests, 17 initially had a negative cat scratch
opathy occurred. After several days of oral penicil- test during the first 4 weeks of their illness;
lin and no improvement, a polypoid conjunctival however, a repeat skin test showed that
mass was removed. Histopathologic study showed
these 17 had converted. Of the 30 patients
a nonspecific inflammatory reaction. Moderate swell-
ing of the parotid gland with preauncular and sub-
in Group II, only a few could be recalled
auricular cervical tender adenopathy persisted. for repeat cat scratch skin tests; those re-
All laboratory studies and skin tests, including peated were negative.
those for CSD, were negative. The patient had fre- Twenty percent of the patients with
quent contact with four cats and had occasional
reactions showed a positive reaction for 2 to
scratches.
One week later grand mal seizures suddenly de- 7 days; 10% remained positive for 8 to 14
veloped followed by coma and fever (105#{176}F). days, and one positive test was indurated
Therapy consisted of intravenous fluids and ste- for an entire year ( Case 1 ) Four. tests were
roids, anticonvulsants, and an ice mattress. Spinal negative at 48 hours but became positive at
fluid analyses were normal. Cultures of blood
72 to 96 hours.
CSF, and an aspirate of the preauricular adenopa-
thy showed no growth of virus, bacteria, or fungi.
Patients Clinically Suspected of CSD
Multiple laboratory studies and x-rays of the skull
and chest were negative or normal. An EEG was Skin tests using cat scratch antigen per-
grossly abnormal.
After 18 hours seizures stopped; formed in 145 patients clinically suspected
the patient became alert during the next 3 days.
of CSD showed that 112 (79%) with a his-
During the following week the patient recovered
fully and was discharged on diphenylhydantoin tory of cat exposure were positive and 29
therapy. (20%) were negative ( Table I). Of the 87
Two weeks later the preauricular swelling and patients clinically suspected of CSD with
the cervical adenopathy had subsided. An EEC history of a cat scratch, 82 (94%) had a
was minimally abnormal. A repeat cat scratch skin
positive skin test; of 37 patients with cat
test (Lot B) was positive. Two months later the pa-
contact, only 25 (68%) had a positive skin
tient continued to receive anticonvulsant therapy
and was doing well in school. test. Five (28%) of those with no cat con-
In summary, this was a case of the oculoglandu- tact showed a positive skin test, whereas 13
lar syndrome of Parinaud which was followed in 1
(72%) had a negative test.
week by an acute severe encephalopathy appar-
ently due to CSD. Recovery was complete within 2 Controls
weeks; however, the EEC was abnormal for sev-
eral months. The 108 control patients consisted of two
groups-Group III, 23 healthy controls
RESULTS without adenopathy; and Group IV, 85 pa-
Skin Testing tients with or without adenopathy who
Skin testing was performed on 253 per- were proven to have another diagnosis
sons. Four groups were identified: Group 1 (Table II). About 50% of these patients
was 115 patients who had clinical CSD and had lymph node enlargement. There were
a positive skin test to cat scratch antigen; no primary skin lesions in either group. Of
Group II comprised 30 patients who were the 108 patients in these two groups, 42
suspected clinically of having CSD, but (39%) had no animal or cat contact, and
whose skin test for CSD was negative or only 25 (23%) had scratches (Table I).

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808 CAT SCRATCH DISEASE

TABLE I

SKIN TEST REACTIONS TO CAT SCRATCH ANTIGEN IN 50 PERSONS CLASSIFIED BY PRESENCE OR ABSENCE
OF CLINICAL CAT SCRATCH DIss&sE AND HISTORY OF CAT EXPOSURE

Category of Subject lndiridual8 Showing indicated Skin Reaction to Cat Scratch Antigen

Cat Positive Negative Doubtful

Scratch History of Cat >5 mm <4 mm 4 to <5 nun Total Patient?
Disease Expo8ure
Suspected Number % Number % Number % Number %
Scratcht 82 94 5 6 - - 87 100
Yes* Contact only 5 68 11 30 1 37 100
No contact 5 8 13 72 - - 18 100

Scratch - - zS 9 8 25 100
No Contact only 5 37 90 5 41 100
No contact - - 41 98 1 i 4 100

* All 142 patients had lymphadenopatliy.

t Patients not included: two with dog scratch; one with monkey scratch.
: Controls: Z3 well, no adenopathy; 85 ill, another diagnosis with or without adenopathy.

Two controls had positive tests : an infant current allergic keratitis and conjunctivitis
who died with an overwhelming plasmacy- of 7 years’ duration and a previous history
tosis and an 8-year-old child with severe re- of lymphadenopathy and cat contact. Nega-
tive reactions were found in 41 (98%) of
those with no cat contact.

TABLE II Different Lots of Cat Scratch Antigen

DIAGNOSES IN 85 PATIENTS WITH AND WITHOUT
The validation of Lot M antigen by com-
ADENOPATHY SHOWING A NEGATIVE SKIN
TEST TO CAT SCRATCH ANTIGEN parison to a previously tested standard
antigen9 has been mentioned. A comparison
Diagno8is Confirmed Number of Lots G and B using M antigen as the
standard skin test revealed a 63% correla-
Adenitis and/or abscess (bacterial) 29
tion for G Lot and 80% for B Lot (Table
Neoplasm (benign or malignant) 1
III) . The skin induration was comparable
Mycobacterial cervical adenopathy
Atypical (Battey ; Avian 8; Gravis ) 7 for each antigen: Lot M, 5 to 11 mm; Lot
Typical 3 G, 5 to 10 mm; Lot B, 5 to 7 mm. The
Osteomyelitis (bacterial) 4 lower percent of correlation with Lot G
Encephalitis (etiology unknown) 4
may be due to the fact that Lots M and B
Collagen disorders (1 each : rheumatoid ar- 4
were obtained from patients living on the
thritis, chorea, erythema nodosum,
lupus erythematosis) eastern coast of the United States. In con-
Cat bite cellulitis (with or without nodes) 3 trol patients, skin tests using both antigens
Cystic hygroma S showed 100% correlation with all tests
Pneumonia (atypicalTBC 1) , 3
being negative.
Reticuloendotheliosus (atypical, eosinophilic 3
granuloma, Letterer-Siwe)
Other Skin Tests
Granuloma, subcutaneous, nonspecific
Infectious mononucleosis Multiple skin tests for the following dis-
Miscellaneous (1 each : Viremia, elliptocyto- 6 eases were negative for the number of pa-
sis, chronic glomerulonephritis, PPD
tients indicated: histoplasmosis, 57 of 57
converter, Neimann-Pick disease,
plasma cell disease) tested; coccidiomycosis, 25 of 25 tested;
blastomycosis, 13 of 13 tested; atypical PPD

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 ARTICLES 809

G, 41 of 42 tested; B, 41 of 42 tested; Avian, TABLE III

36 of 36 tested. PPD S was negative in 99 COs1PA1tISON OF Two l)IFFEIIENT CAT SCRATCH SKIN

of the 101 tested, and Tine was negative in TEST ANTIGENS WITh STANDARD M LOT ANTIGEN IN

26 of the 30 tested. The positive tuberculin PATIENTS WITH CLINICAL CSI) AND CONTROLS

tests occurred in adults.

Percentages Showing a Positive or
.Vegatire Reaction to Indicated A ntigen
Cat Scratch Skin Test Antigen Analysis Reaction’ Number
to Patient t

By serum electrophoresis Lots G and B Lot .11 Tested Lot C Lot B

after dilution and freezing were found to Positive .\egatire Positive Negative

contain moderate amounts of albumin but Positive 19 63 37 80 0

no detectable gamma globulin. Both adults Negative 7 - 100 - 100

from whom these antigens were obtained

‘Skin induration: Lot M, 5 to II mm; Lot G, 5 to 10 mm; Lot B
had normal serum immunoelectrophoretic 5 to 7 mm.
t All 19 positive reactors had lymphadenopathy; seven controls
studies. Immunoelectrophoretic studies on
had no adenopathy.
both antigens revealed normal quantities of
IgA and IgG in Lot B compared to normal
adult serum values.15 However, in Lot G, mm in 23, and unknown in 10. The lesion
IgG was very low ( <40 mg/100 ml). 1gM was located on the arm or hand in 50% of
could not be detected in either lot. Total patients, 29% were on the head or leg, 12%
protein values in Lot B was 42 gm/ 100 ml; were conjunctival, and 9% were on the
Lot G was 40 gm/ 100 ml. These high trunk or neck. The majority (67%) of le-
values may be the result of cellular break- sions persisted from 5 to 28 days; 33% per-
down and concentration following freezing sisted from 28 to over 50 days. No clinical
to minus 70#{176}C. signs other than lymphadenopathy were
present in 35% of patients. Twenty-six per-
Clinical Findings cent had fever (101 to 106#{176}F) lasting from
Only the 115 patients with CSD ( Group 1 to 17 days (Table IV, Fig. 4); 40% had
I ) were studied extensively. Details will not malaise lasting from 1 to 21 days; 3% expe-
be given for Group II patients. Eighty per- rienced parotid swelling; 4% exhibited a
cent of Group I patients were less than 20 nonpruritic macular or maculopapular rash
years old; 63 were males. Nearly 80% of
the patients had onset of disease during the
autumn or winter (Fig. 3). There were 80
siblings of the children in Group I; 10 of
these siblings in different families devel-
oped CSD. The same family cat was in-
volved in ii cases; 47 of 90 cats were kit-
tens. In five cases there was no cat or other
animal contact; a dog was the only source
of “scratch” (bite) in two other cases, and
in one patient CSD followed a monkey
scratch (Case 3).
In Group I, 95% of the patients had cat
scratch and contact; 73% had cat scratches
alone. Primary lesions occurred in 55% of
patients; 8% had two or more lesions. In
the 63 patients having a primary lesion
there was a papule in 28, a pustule in 24,
and a conjunctival lesion in 5. The lesion FIG. 3. Occurrence of cat scratch disease during
diameter was 1 to 5 mm in 30 cases, over 5 four seasons.

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810 CAT SCRATCH DISEASE

TABLE IV single sites were found in 44%. From the

INCIDENCE OF CLINICAL MANIFESTATIONS AND time of the scratch, or primary lesion, the
INTERVAL OR DURATION OF EACH IN 115 PATIENTS interval to onset of lymphadenopathy
WITH CAT DISEASE AND A POSITIVE SKIN TEST ranged from 5 days to 50 days ( Table IV).
Over 50% of the patients developed lymph-
Total Patients Range of Average
Clinical in Whom Inte, vol Interval adenopathy within 1 to 2 weeks follow-
Jfanifestation Feature or or ing a scratch or a primary lesion. The ma-
Obsereed Duration Duration
jority of enlarged lymph nodes were tender
Number % Days Days and located in the extremities or the head
Scratch to bubo 80 70 3-50 13 (Table V) . Multiple site involvement ( Fig.
Primary lesion to bubo 63 55 5-SO 1
5 ) was observed in 11 patients. Seventy
Suppurat.ion of bubo 30 6 3-180 1
Duration of bubo 114 99 14-S40 63 percent of the nodes measured between 1
1-17 3
Fever
Malaise
(101-106#{176}F) 30
48
6
40 i-ia 4
and 6 cm in diameter; nine ( 7%) were
Exanthem 5 4 3-5 4 greater than 6 cm in size. Lymphadenopa-
Parotid swelling 4 3 7-%8 15
thy lasted 2 weeks to 8 months and per-
sisted in 90% of the patients longer than 2
weeks, in 25% of the patients it persisted
longer than 2 months, and in 4% of the pa-
for 3 to 5 days; 5% had conjunctivitis; and
tients it persisted beyond 6 months. Aspira-
3% had grand ma! seizures (two of these pa-
tion of suppurative lymph nodes was per-
tients were comatose for a few days).
formed in 28 patients : one time in 17 cases,
Lymphadenopathy observed in all 145
twice in 7 cases, three in 3 cases, and four
patients ( Groups I and II) was tabulated
times in 1 case. The volume of pus varied
in the 115 patients in Group I. Single nodes
from 2 to 35 ml.
were observed in 56%, multiple nodes in
Atypical clinical findings in 16 patients of
Group I are noted in Table VI. Four pa-
TABLE V tients with preauricular or subauricular
lymphadenopathy and concomitant parotid
LOCATION AND TENDERNESS OF ENLARGED Lmta
NODES IN SINGLE AND MULTIPLE SITES IN hiS gland swelling were seen; two had red-
PATIENTS WITH CAT SCRATCH DISEASE AND A ness and puckering of Stensen’s duct; only
POSITIVE SKIN TEST normal saliva could be expressed. The ten-
der parotid swelling persisted a few days
Location Tender Non Tender Total
when the lymph node swelling was maxi-
Head: total 28 4 32
mal. Nonbacterial pneumonia ( Case 4 ) was
submental 13 4 17 observed in two patients with CSD.16’17
preauricular 13 - 13
occipital 1 - 1 Laboratory Data
subocular 1 - 1
Histopathological studies of 21 lymph
Neck: total 17 10 27
11 3 14
node biopsies in Group I patients revealed
anterior cervical
posterior cervical 6 5 11 7 which were diagnostic for CSD. Seven
trapezius - 2 2 were compatible with CSD and seven
Extremities: total 70 9 79 showed nonspecific inflammation. Hematol-
axillae 44 7 51
ogy studies were performed in 72 patients.
epitrochlear 12 1 13
inguinal 8 - 8 Two patients had an eosinophile count over
femoral 5 1 6 10%. The only test consistently abnormal in
popliteal 1 - 1 Group I was the sedimentation rate. It was
Total 115 23 138*
elevated in 17 of 25 patients. There were no
* Total number of enlarged nodes is greater than the patients with leucopenia and only two cases
number of patients since multiple site involvement was had a white blood count over 16,000; a
observed in 11 patients. complete blood count was normal in 57 pa-

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 ARTICLES 811

tients. The differential white blood cell culture cells. A virus could not be grown
count revealed a moderate increase in neu- using saliva and nail clippings from the
trophiles in 15 patients. Chest x-rays on 46 family cat in Case 1. One aspirate studied
patients in Group I were normal. for mycoplasma organisms showed no
Sera from 12 patients were studied for growth.
abnormal globulins. Seven showed normal
Treatment Results
serum electrophoresis levels and five had
minimally abnormal globulin values: three Suppuration of the node occurred in 30
patients showed elevated alpha -1, two pa- patients; 28 nodes were aspirated (Table
tients had alpha -1 and gamma elevations, VII). This was immediately effective in re-
two patients had beta elevations, and one lieving local pain and malaise in 27 cases.
patient had a low alpha -2. Immunoelec- Chronic sinus drainage occurred in two pa-
trophoresis patterns were normal in four tients; one following a biopsy and one after
patients: IgA was decreased in one patient repeated aspiration. Reaspiration was nec-
to 60 mg/100 mi-normal for age, 112 ± 40 essary in 11 patients. Incision and drainage
mg. In each patient the abnormal eiectro- was done in four instances; biopsy of the
phoresis and immunoelectrophoresis values node was effective in relieving local pain in
returned to normali5 within one month of 20 of 21 patients. Moist soaks were effective
the diagnosis. Heterophile tests and aggluti- when applied to four of five primary lesions;
nation studies for syphilis, brucella, tula- two primary lesions were excised-one skin
remia, and febrile antibodies performed on (Case 3) and one conjunctival (Case 5).
many patients were consistently normal. Forty-five trials of single and combined
Cold agglutination tests in Case 4 were ab- anti-microbials were ineffective in 40 pa-
normal. tients.
Cultures of 30 lymph node aspirates, two
primary skin lesions, and one conjunctival COMMENTS
biopsy (Case 5) showed no growth of Epidemiologic Aspects
bacteria, fungus, or mycobacteria. Exten- The cat is merely the healthy vector of
sive study of 11 aspirates produced no cyto- the disease-causing agent. Also implicated
pathic effect in six different types of tissue as the source of the scratch or bite are dogs

SEIZURES 3

COUGH 3
0
a.
HEADACHE 6

MALAISE 46

PAROTID SWELLING 4

EXANTHEM 5

FEVER 30
z
5,
U) PRIMARY LESION 63

SCRATCHES 80

IS
LYMPHADENOPATHY

0 10 20 30 40 50 60 70 80 90 00 110 20

FIG. 4. Frequency of symptoms and signs in 115 patients with cat scratch
disease and a positive skin test.

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812 CAT SCRATCH DISEASE

TABLE VI al.19 reported the isolation of a virus from

ATYPICAL SYNDROMES OR FINDINGS IN 16 OF THE 115 one patient with benign lymphoreticulosis
PATIENTS WITH CAT SCRATCH DISEASE AND A in 1962. They classified the agent as a mem-
POSITIVE SKIN TEST ber of the Chlamydozoa ( ornithosis-lym-
phogranuloma venereum trachoma ) group.
Clinical Feature8 Patients
Antibody titers in his study were low and

Oculoglandular*
7 did not rise significantly enough to confirm
Parotid enlargement 4 the presence of an infectious virus in the
Pneumonia 2 monkeys and rabbits inoculated.
Encephalitis* 3
The observation by Turner, et al.20 that
Sinus drainage chronic 1
an hemagglutinating viral agent antigeni-
* Case 5 had both syndromes. cally related to herpes virus might be the
cause of CSD has not been confirmed. On
the basis of repeated negative skin tests for

and monkeys as well as thorns, codfish typical and atypical mycobacterium per-
bones, and wooden lin7 Skin tests formed on 41 patients with CSD ( Group
with cat scratch antigen performed on cats I ), we are in full agreement with Carith-

known to have transmitted the disease have ers,2 who found no indication that classified

been The disease is not trans- or unclassified mycobacteria were the cause
of CSD. The transiently positive skin tests
mitted from man to man,’8 and the patient
does not require isolation. for PPD Battey (nonphotochromogen ) and
In the 115 patients with clinical CSD
Gause ( scotochromogen ) in Case 3 were
undoubtedly due to the booster effect of re-
and positive skin tests ( Group I ), 10 sib-
peated skin testing with atypical PPD anti-
lings had CSD; in each case, the family cat
was incriminated. Three cases ( father, Case gens reported by Smith.13

1, son and daughter ) occurred in one fam-

Pathology
ily. An epidemic of cat scratch disease oc-
The majority of the 21 lymph nodes were
curred in the winters of 1955 and 1956 in
biopsied because of increasing size, a lack
the Minneapolis-St. Paul area,5 the second
of etiologic diagnosis, or because of pro-
recognized outbreak in North America. The
longed discomfort from painful swelling
first was recorded by Marshall in Nova
and inability of the patient, usually an
Scotia in 1954 and 1955. Household and in-
adult, to perform regular duties. Although
tra-city outbreaks have been recorded.5 In
the microscopic appearance of the diseased
this series and others,5’6 the highest mci-
node is nonspecific, it has been helpful, to-
dence was during autumn and the winter
gether with the history and skin test results,
months. The incubation period is variable: it
averages 3 to 10 days from the scratch or
in making a positive diagnosis. Three stages
progressing from reticulum cell hyperplasia
inoculation to the formation of a primary
to tubercie-like granuloma and abscess for-
skin lesion, there is an average of 13 days
mation have been described.2’ Careful in-
from the scratch to detection of adenopa-
terpretation must be made since an incor-
thy, and it averages about 12 days from
rect diagnosis of lymphoma may occur
the onset of the primary lesion to adenopa-
when excessive nodal hyperplasia is ob-
thy (Table IV).
served in a benign lymph node.22

Etiology
Clinical Features
Attempts to isolate an organism using
The usual history, clinical features, and
multiple culture media in this and other
duration are noted in Table IV and Figures
series18 have been fruitless. Chervonskii, et
2-S. One third of our patients had no symp-
§ Reference 15 cited by Warwick and Good.#{176} toms, the remainder exhibited fever (101 to

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 ARTICLES 813

) for
106#{176}F several days with malaise, head- experienced recurrent facial swelling. In
ache, and occasionally vomiting. Symptoms four of these children the facial swelling
were usually not manifested during the simulated parotid gland disease, but it was
early phase when a primary lesion might be due to preauricular lymphadenitis from
found. When lymphadenopathy was de- animal scratch. In patients reported to have
tected, the primary lesion or original had mumps on several occasions, the true
scratches could easily be overlooked be- diagnosis may well have been CSD or re-
cause of healing. Systemic manifestations current, noninfectious parotitis.
appeared as the lymph node became larger Encephalopathy due to CSD was ob-
and tender. Fever and malaise were usually served in three cases : an adult, I! age 25
maximal when node suppuration occurred. years, who made a complete recovery
When the abscessed node was aspirated, within 2 months; an infant who developed
symptoms quickly subsided. Individuals seizures several years following his acute
with indolent buboes usually had no symp- episode of CSD encephalopathy; and a
toms. 12-year-old child ( Case 5 ) . These patients
The physician must look2 for a healing met the criteria necessary to confirm a diag-
primary lesion ( papule, pustule, or con- nosis of cat scratch encephalopathy.1224
junctivitis ) distal to the regional adenopa- With the addition of these 3 cases to the 26
thy, and he must inquire about cat, dog, or cases previously reported,1 the frequency of
other animal licks, bites, or scratches. Often the major symptoms and signs found in 29
it is the neighbor’s or relative’s cat that is patients are: coma or convulsions ( grand
implicated. The physician should question mal, usually), or both, in 18 (62%); neuro-
the child directly. The benign and chronic logical abnormalities (meningitis, radiculi-
nature of the lymphadenopathy is charac- tis, polyneuritis, paraplegia) in 7 (24%);
teristic and in children should always alert lethargy or confusion, or both, with or
the physician to the probable diagnosis of
hR. H. Pollen, M.D., Kensington, Maryland, un-
CSD, and thus avoid a needless biopsy. En-
published data.
largement of the lymph node may be strik-
ing in an apparently healthy child.12

Atypical Clinical Findings TABLE VII

TREATMENT RESULTS IN 115 PATIENTS WITh CAT
Unusual or atypical syndromes or find-
SCRATCH DISEASE AND A POSITIVE SKIN TEST
ings were noted in 16 patients ( Table VI).
Five children and two adults had the ocu- Results of Therapy
loglandular syndrome of Parinaud. These Category of Therapy*
cases and four cases previously reported#{176} Effective Ineffectivell

total 11 patients personally observed in a

None 48 0
period of 10 years. Six of 34 cases observed
Aspiration of iiode 27 1
by Quillian, et al. had ocular involvement. Incision and drainage of node 3 1
Cat scratch disease should always be con- Biopsy of node 20 1
sidered at any age in a patient who has an Antibioticf 0 40
(single or combined)
ocular lesion ( pustular or conjunctival ) and
Moist soaks to primary lesion 4 1
preauricular lymphadenopathy. More than
30 patients have been reported with this * ISIany patients received more than one type of
syndrome. Figure 6 shows a patient with therapy.

multiple periauricular node involvement t Penicillin, 20; erythromycin, 3; tetracyclines, 16;

ampicillin, 2; chloramphenicol, 2; streptomycin, 1;
which persisted for 7 months.
kanomycin, 1.
Benign parotid and intraglandular lymph- Relief of tender adenopathy, malaise, and fever.
adenopathy (lymphosialadenopathy) was § Drainage of primary lesion with rapid healing.
reported in a study23 of 25 children who ii No relief after several days of therapy.

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 814 CAT SCRATCH DISEASE

without choreoathetosis and behavior disor- gen was available. Later use of two or three
der in 5 ( 17%). The duration of severe different antigens at the same time in-
manifestations usually last from 1 to 2 creased the chance of eliciting a positive re-
weeks with gradual recovery to a normal suit even though the correlation was low
status in 1 to 6 months. Abnormal spinal between Lots M and G in eliciting positive
fluid was reported in five patients; two of skin tests to each antigen in the same pa-
our patients had elevated cell counts and tient (Table III). Kalterio has shown that
protein. Thus, seven (24%) cases have had various lots of antigens may react differ-
pleocytosis or elevated protein, or both. ently and suggests that more than one
Electroencephalograms, as noted in our pa- agent may produce CSD. Pooling of several
tients, are usually abnormal. The onset of antigens may eliminate this problem as well
neurological manifestations usually devel- as the variation in intensity of induration.
ops within 1 to 6 weeks of the onset of ad- A negative skin test in patients not sus-
enopathy; the pathogenesis of these find- pected of having CSD, especially when re-
ings is unknown. peated 4 weeks later, provided more confi-
Other unusual manifestations of CSD dence that the patient did not have CSD
( not encountered in our series ) which have ( Table I) . With a history of cat contact
been reported are: thrombocytopenic pur- only the test was negative in 90% of control
pura,25 erythema nodosum,23’26 osteolytic le- patients and in 92% of those with a scratch.
sions,18’27 and mesenteric and mediastinal In those with no cat contact, it was nega-
adenitis.27 tive in 98%. A negative result emphasized
the need for further study of those patients
Skin Test Interpretation with lymphadenopathy. In rare instances
In the interpretation of a positive skin skin testing may be accompanied by a brief
test ( Table I ), one must remember that exacerbation of the disease for a few days;4
false positive reactions may occur in certain associated tenderness in the regional lymph
select groups as follows: veterinari- node was noted in three of our patients.
4,5,7,11 12 to 29%, and in healthy con- Rarely, an individual may not develop a
trols,5 0 to 7.5%. Warwick and Good5 re- positive skin test for 7 to 10 days after the
ported an overall incidence of positive skin antigen is applied.bO
reactions to CSD antigen to be 4.4% in well
Laboratory Data
persons. Their limit of confidence was 95%
for a positive test based upon six control or Multiple routine and special tests per-
family contact groups. In our study, posi- formed in this study and others2,4h1 have
tive skin tests occurred in 94% of 87 patients shown a few nonspecific abnormalities in
clinically suspected to have CSD and who blood counts, serum electrophoresis, corn-
had a history of cat scratches. Previous plement fixation, and agglutination studies.
studies,27 and ours, have shown that the The sedimentation rate (Wintrobe) was
time necessary to develop a positive intra- abnormal in 67% of Group I patients4 dur-
dermal reaction is about 1 month. Thus, it is ing the period of acute lymphadenitis.
reasonable to speculate that additional posi-
Diagnosis
tive skin tests would have been found if the
30 patients suspected to have CSD with Our diagnostic criteria for this syndrome
negative or doubtful skin tests could have were modified from those recommended by
had repeat tests. Warwick and Good.5 Regional lymphade-
Spaulding4 states that 10% of patients nopathy must be present during the course
with a typical clinical course of CSD will of the disease. Three out of four of the fol-
have negative skin tests using one or two lowing manifestations would confirm the
different antigens. During the beginning of diagnosis in a typical case, whereas all four
our study, only one lot of cat scratch anti- would be necessary in an atypical case: (1)

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 ARTICLES 815

a history of animal ( usually a cat) contact, neously within 1 to 2 months in most cases.
scratch or a primary lesion; (2 ) aspiration Thus, management consists of reassurance,
of sterile pus from the node ( this would be analgesics for pain, and aspiration if sup-
a presumptive diagnostic test for CSD in puration occurs. Significantly, no active
addition to other appropriate laboratory therapy other than reassurance was effec-
studies to exclude other etiologic possibili- tive in 45 patients. Lack of response to anti-
ties); ( 3) a positive intradermal skin test to biotic therapy was one of the main rea-
cat scratch antigen, remembering that 3 to sons for patient referral (Table VII).
4% false positives occur and that using only Others4,h1,28 have noted the ineffectiveness
one lot of antigen may produce a false neg- of antibiotic therapy.
ative result in 10 to 20% of patients; (4) a Since node aspiration is simple ( an 18 or
biopsy of the enlarged node showing histo- 19 gauge needle ) and can be performed
pathology consistent with CSD, keeping in under local anesthesia, this procedure is
mind that 33% may not show changes typi- preferred to incision and drainage or
cal of CSD. biopsy which may result in chronic sinus
If skin responses to two different cat tract drainage. Aspiration also provides skin
scratch antigens and other studies are nega- test antigen material, relieves painful ade-
tive, a biopsy must be considered to rule nopathy, and the patient is symptom free
out a benign tumor or lymphoma. At least 4 within 24 to 48 hours, unless fluid recurs.
weeks’ time should elapse between repeat Application of moist soaks to the primary
skin tests unless new findings dictate other- lesion may effect drainage and shorten the
wise. The presence of tenderness favors cat duration of lymphadenopathy. Biopsy of
scratch adenopathy rather than lymphoma4 one conjunctival lesion in our study was
(Table V). A tumor was found in 17 out of
85 patients with other diagnoses ( Table
II).

Differential Diagnosis
Cat scratch disease should be considered
in all patients with persistent or chronic
lymphadenopathy. Other considerations are
lymphogranuloma venereum, tuberculosis
( typical, atypical), bacterial adenitis, hi-

laremia, brucellosis, histoplasmosis, coccid-

ioidomycosis, toxoplasmosis, infectious
mononucleosis, and benign or malignant
tumors.22 In the atypical forms of CSD one
must consider benign recurrent parotid
lymphosialadenopathy,23 Parinaud’s oculo-
glandular disease,#{176} encephalitis,1 pneumo-
nia,16’17 thrombocytopenic purpura,23 er-
ythema nodosum,26 osteomyelitis,2127 and
fluctuant lymphadenopathy simulating cys-
tic hygroma or a thyroglossal duct cyst.

Management and Therapy

No specific treatment is known. When a
firm diagnosis of CSD can be made, the
best therapy is reassurance that the ade- FIG. 5. Cat scratch lymphadenitis in multiple sites:
nopathy is benign and will subside sponta- left axillary and right subocular.

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816 CAT SCRATCH DISEASE

cyst was necessary after 3 years. The

course of this patient was similar to that of
Townsend,3#{176} who had a recurrence after 3
years.

SUMMARY

In a study of 145 patients suspected of

having cat scratch disease ( CSD ), or non-
bacterial lymphadenitis, 115 patients were
diagnosed as having CSD; 107 cases were
due to exposure to cats, 2 vere caused by
dogs, and 1 was caused by a monkey. There
was no animal contact in 5 cases. The re-
maining 30 patients exhibited all the clini-
cal manifestations of CSD but had a nega-
FIG. 6. Right ear: pre- and postauricular lymph- tive skin test; no other cause could be as-
adenopathy in a patient with Parinaud’s oculo- certained for the lymphadenopathy. Over
glandular syndrome due to cat scratch disease. 95% of the former group had cat scratch or
cat contact; only 55% in the latter group
had cat contact. In the clinical CSD group,
effective6 in shortening the duration of ad- 86% had a typical benign course of subacute
enopathy (Case 5). The efficacy of steroid nonbacterial lymphadenitis; 14% had an
therapy was not evaluated.28 atypical form. These were : Parinaud’s ocu-
Operative therapy may be necessary in loglandular syndrome in seven patients; en-
selected patients, particularly to remove the cephalopathy in three patients; atypical
primary lesion caused by a thorn or foreign pneumonia in two patients; and a recur-
body.1 In the adult unable to perform daily rence of suppurative lymphadenopathy
work, especially if node suppuration recurs after 3 years in one patient.
following repeated closed aspiration, surgi- The disease occurred most frequently in
cal excision may be indicated.29 the late fall and early winter months. Sex
distribution was nearly equal, 80% of the
Prognosis and Sequelae patients were under 20 years, and 10 cases
Complications and sequelae are almost occurred in siblings in different families.
nonexistent. In this study the infant with Primary lesions were detected in 55%, node
encephalopathy had a recurrence of sei- suppuration occurred in 26%, and lymphad-
zures 3 years after his acute episode of cat enopathy lasted 2 weeks to 2 months in the
scratch encephalitis. One death has oc- majority of patients. Symptoms were absent
curred during treatment of continued sei- in 35% of patients. Fever occurred in 26%,
zures with hypothermia.1 Sequelae from malaise occurred in 46%, and an exanthem
typical cases do not occur. Spontaneous and was found in 4%. The majority of enlarged
complete recovery occurs in the majority of lymph nodes were located in the extremi-
patients within 2 months; a rare case has ties (57%) and head and neck (43%).
been reported to have had chronic adenop- Eleven attempts to isolate a viral agent
athy for 2 years. Second attacks have not were unsuccessful. Multiple laboratory
been reported. However, we have followed studies were normal, except the sedimenta-
one child who had a recurrence of the same tion rate was usually elevated. A positive
preauricular adenopathy with chronic sinus skin test was found in 94% of patients who
tract drainage three years after the acute were clinically suspected of having CSD
episode of Parinaud’s oculoglandular form. and a history of cat scratch. A negative skin
Surgical excision of a preauricular inclusion test was found in 98% of 108 controls.

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 ARTICLES 817

Treatment consisted of reassurance, 9. Daniels, W. B., and MacMurray, F. G. : Cat

symptomatic therapy, and closed aspira- scratch disease. J.A.M.A., 154:1247, 1954.

tions of the enlarged lymph node if suppur-

10. Kalter, S. S. : Cat scratch disease. Texas J.
Med., 59:956, 1963.
ation occurred. The latter procedure was 11. Brooksaler, F. S., and Sulkin, S. E. : Cat scratch
simple and was both therapeutic and diag- disease. Post-grad. Med., 36:366, 1964.
nostic. Warm moist compresses hastened 12. Blattner, R. J. : Cat scratch disease. In Nel-
regression of persistent primary lesions. An- son, W. E., ed : Textbook of Pediatrics, ed.
8. Philadelphia: W. B. Saunders, Co., p.
tibiotics are not recommended, and surgical
574, 1964.
excision should be reserved for those cases
13. Smith, D. T. : Diagnostic and prognostic sig-
not responding to repeated closed aspira- nificance of the quantitative tuberculin tests:
tion. The disease is self-confined and has an influence of subclinical infections with atyp-
excellent prognosis, with a rare exception of ical mycobacteria. Ann. Int. Med., 67:919,
post-encephalitic seizures or recurrence of 1967.
14. Palmer, C. E., and Edwards, L. B. : Sensitivity
lymph node suppuration and spontaneous
to mycobacterial PPD antigens with some
drainage. laboratory evidence of its significance. Tub-
Cat scratch disease is common and it is erkuloza, 17:193, 1966.
difficult to prevent because of increasing 15. Bellanti, J. A., Artenstein, M. S., and Buescher,
numbers of pets in the home ( 24 million in E. L. : Ataxia-teliangiectasia: Immunologic
and virologic studies of serum and respira-
this country) The patient
. with CSD does
tory secretions. PEDIATRICS, 37:924, 1966.
not require isolation or quarantine. CSD 16. Marini, C., and Tonelato, V. : A case of benign
will be recognized more frequently if skin lymphoreticulocytosis with pleural pulmon-
testing with cat scratch antigen is carried arv manifestations and nodular erythema.
out in all instances of persistent benign Acta Paediat. Lat., 12/2:161, 1959.
17. Sheldon, G. C., and Smellie, H. : Cat scratch
lymphadenopathy.
disease with pneumonia. Brit. Med. J., 2:
446, 1957.
REFERENCES
18. Horsfall, F. L., Jr., Jr., and Tamm, I. : Viral
1. Courtois, G., Saint Martin, M., and Gaba, E.: and Rickettsial Infections of Man, ed. 4.
Complications neurologiques de la maladie Philadelphia: J. P. Lippincott Co., pp. 1164-
des griffes de chat. Un. Med. Canada, 94: 1166, 1965.
728, 1965. 19. Chervonskii, V. I., Terskikh, I. I., and Bekles-
2. Carithers, H. A. : Unclassified mycobacteria in hova, A. Y. : Isolation and study of agent
the etiology of cat scratch fever: A skin of benign lymphoreticulosis (cat scratch
test evaluation. PEDIATRICS, 31 : 1039, 1963. fever) in man. Fed. Proc. (Transl. Suppi.),
3. Quillian, W. W., Lancaster, J. W., and Quil- 23:T992, 1964.
han, W. W., II: Cat scratch disease. A clini- 20. Turner, W., Bigley, N. J., Dodd, M. C., An-
cal concept. Analysis of thirty-four cases. derson, C. : Hemagglutinating virus isolated
J. Florida Med. Ass., 49:389, 1962. from cat scratch disease. J. Bact., 80:430,
4. Spaulding, W. B., and Hennessy, J. N.: Cat 1960.
scratch disease: Study of eighty-three cases. 21. Naji, A. F., Carbonell, F., and Barker, H. J.:
Amer. J. Med., 28:504, 1960. Cat scratch disease. Amer. J. Clin. Path.,
S. Warwick, W. J., and Good, R. A.: Cat scratch 38:513, 1962.
disease in Minnesota. I. Evidence for its epi- 22. Ackerman, L. V., and Butcher, H. R., Jr.:
demic occurrence. II. Family epidemics. III. Surgical Pathology, ed. 3. St. Louis: The
Evaluation of skin test. Amer. J. Dis. Child., C. V. Mosby Co., pp. 511, 836, 1964.
100:228, 236, and 241, 1960. 23. Blatt, I. M.: Chronic and recurrent inflamma-
6. Margileth, AM.: Cat scratch disease as a cause tions about the salivary glands in 25 chil-
of the oculoglandular syndrome of Parinaud. dren. Laryngoscope, 76:917, 1966.
PEDIATRICs, 20:1000, 1957. 24. Steiner, M. M., Vuckovitch, D., and Hadawi,
7. Prier, J. E.: Cat scratch fever. Ann. N.Y. Acad. S. A.: Cat scratch disease with encephale-
Sd., 70:650, 1958. opathy. J. Pediat., 62:514, 1963.
8. Kunz, L. J.: Nonbacterial regional lympha- 25. Jim, R. T. S.: Thrombocytopenic purpura in
denitis (cat scratch fever). Stability of the cat scratch disease, J.A.M.A., 176:146,
intradermal test antigen. New Eng. J. Med., 1961.
265:591, 1959. 26. Young, D. L.: Cat scratch disease: cause of

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818 CAT SCRATCH DISEASE

erythema nodosum and splenomegaly. Texas scratch disease: Recurrence after three years.
J. Med., 57:278, 1961. Amer. J. Dis. Child, 110:213, 1965.
27. Rauschkolb, R. R.: Cat scratch disease. A se-
lective review. Arch. Derm., 79:674, 1959. Acknowledgement
28. Eckhardt, W. F., and Levine, A. I.: Cortico- I am indebted
to Doctors D. W. Bailey, B. Ci-
steroid therapy of cat scratch disease. Arch. lento, L. Hemmings, C. R. Krill, Jr., G. W. Mella,
Intern. Med., 109:139, 1962. D. Pascoe, and J. A. Washington for referring their
29. Small, W. J.,and Sniffen, R. C.: Nonbacterial patients and providing clinical records. The author
regional lymphadenitis (cat scratch fever): is grateful to D. W. Delaney, M.D., Felix Heald,
Surgical treatment. New Eng. J. Med., 255: M.D., and R. H. Parrott, M.D., for critical review
1029, 1956. of the manuscript, and to Misses N. Weyant and
30. Townsend, E. H., Jr., and Cravitz, L.: Cat C. Bierer for typing the manuscript.

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CAT SCRATCH DISEASE: NONBACTERIAL REGIONAL LYMPHADENITIS:
The Study of 145 Patients and a Review of the Literature
A. M. Margileth
Pediatrics 1968;42;803
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007.
Copyright © 1968 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005.
Online ISSN: 1098-4275.

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 CAT SCRATCH DISEASE: NONBACTERIAL REGIONAL LYMPHADENITIS:
The Study of 145 Patients and a Review of the Literature
A. M. Margileth
Pediatrics 1968;42;803

The online version of this article, along with updated information and services, is located on
the World Wide Web at:
/content/42/5/803

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication,
it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked
by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village,
Illinois, 60007. Copyright © 1968 by the American Academy of Pediatrics. All rights reserved. Print
ISSN: 0031-4005. Online ISSN: 1098-4275.

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