Correspondence

Treatment of Cat Scratch Disease

N Engl J Med 1999; 340:1842-1843June 10, 1999

Article

To the Editor:

In their Image in Clinical Medicine, Giladi and Avidor (Jan. 14 issue)1 describe a 17-year-old boy who was treated with 14 days of oral ciprofloxacin for an infection with Bartonella henselae after being scratched on the neck by a cat. Unfortunately, they do not address the controversy regarding the use of quinolones in patients under the age of 18 years.

Clinicians should be aware that the manufacturer of ciprofloxacin states that the drug should not be used in children or adolescents. Arthropathy has been observed in the weight-bearing joints of immature laboratory animals, and a transient arthropathy has been reported in at least one 16-year-old who received high doses of the drug.2 Similar concern about the use of the drug in children is found in the product labeling approved by the Food and Drug Administration and contained in the Physicians' Desk Reference.3

The American Academy of Pediatrics states that the use of quinolones may be justified in those under 18 years of age

when no other alternative anti-infective agent is available or when other available agents would be less effective; however, the drugs should be used only after careful assessment of the risks and benefits for the individual patient and after these benefits and risks have been explained to the parents or caregivers.2

Brian J. Bohlmann, M.D., Ph.D.
University of Wisconsin Medical School, Madison, WI 53706

3 References

1. 1

   Giladi M, Avidor B. Cat scratch disease. N Engl J Med 1999;340:108-108
   Full Text | Web of Science | Medline

2. 2

   Drug information. Bethesda, Md.: American Hospital Formulary Service, 1998:639.
   

3. 3

   Physicians' desk reference. 53rd ed. Montvale, N.J.: Medical Economics, 1999:643-4.
   

To the Editor:

The recent Image in Clinical Medicine entitled “Cat Scratch Disease” might convey the misleading message that masses assumed to be caused by either B. henselae (cat scratch), as shown, or mycobacteria (e.g., Mycobacterium avium complex and others) should be treated with direct puncture and drainage. Such an erroneous approach frequently leads to a draining sinus with an avoidable scar. Conservative management (assuming cancer is unlikely) consists of an attempt to treat the mass with azithromycin1 and complete removal. In cases in which diagnostic biopsy, drainage, or both are considered to be necessary, it should be performed through a tunnel and not by the direct approach, as shown.

Juan N. Walterspiel, M.D.
Yale University School of Medicine, New Haven, CT 06520

1 References

1. 1

   Bass JW, Freitas BC, Freitas AD, et al. Prospective randomized double blind placebo-controlled evaluation of azithromycin for treatment of cat-scratch disease. Pediatr Infect Dis J 1998;17:447-452
   CrossRef | Web of Science | Medline

Author/Editor Response

Dr. Giladi and a colleague reply:

To the Editor: We agree with Dr. Bohlmann that the manufacturer's recommendations should be taken into account whenever a drug is prescribed. However, with respect to our patients with cat scratch disease, a few points should be clarified. First, the patient was 17 years and 6 months old, he appeared sexually mature and close to his adult height, and we thought that the risk of ciprofloxacin-induced arthropathy was extremely low. A recent review of data on children and adolescents (>7000 subjects) treated with quinolones concluded that the concern about arthropathy is not justified.1

Second, no antimicrobial therapy is required in the majority of cases of cat scratch disease, since adenopathy is usually self-limited.2 This patient was an exception. Among the several hundred patients with typical cat scratch disease that we have treated over the years, his was one of the most severe cases, characterized by recurrent, painful, and very disturbing suppurative lymphadenitis over a period of seven months. A course of antibiotic treatment seemed warranted.

Finally, when we first saw the patient in 1995, there were no prospective, comparative studies of any antimicrobial agents for cat scratch disease. A retrospective analysis by Margileth suggested rifampin, ciprofloxacin, and trimethoprim–sulfamethoxazole as effective oral agents for the treatment of cat scratch disease, with the last-named being the least effective.3 Because of the rapid emergence of resistant organisms, rifampin should not be used alone. Therefore, we elected to use ciprofloxacin in this patient.

We are less enthusiastic today about using ciprofloxacin in patients with cat scratch disease because of our impression that it does not modify the course of the disease, as was demonstrated in our patient, in whom new suppurative lymphadenitis continued to develop despite treatment with ciprofloxacin. Azithromycin may shorten the duration of lymphadenopathy, as was demonstrated in a small, prospective, comparative study published recently.4

In about 15 percent of patients with typical cat scratch disease, the affected lymph node undergoes suppuration and becomes exquisitely tender. Drainage with a large-bore needle usually results in the almost immediate relief of pain and also provides material for diagnosis.2,5 This procedure, in our experience (>50 patients over the past three years), does not result in a chronic draining sinus regardless of whether or not the needle is “tunneled” through normal skin. Repeated drainage through a needle was necessary in about one fifth of our patients. Incision and drainage are seldom necessary and may result in the development of a chronic sinus tract.

Michael Giladi, M.D.
Tel Aviv Medical Center, Tel Aviv 64239, Israel

Moshe Ephros, M.D.
Carmel Medical Center, Haifa 34368, Israel

5 References

1. 1

   Burkhardt JE, Walterspiel JN, Schaad UB. Quinolone arthropathy in animals versus children. Clin Infect Dis 1997;25:1196-1204
   CrossRef | Web of Science | Medline

2. 2

   Margileth AM. Cat scratch disease. Adv Pediatr Infect Dis 1993;8:1-21
   Medline

3. 3

   Margileth AM. Antibiotic therapy for cat-scratch disease: clinical study of therapeutic outcome in 268 patients and a review of the literature. Pediatr Infect Dis J 1992;11:474-478
   CrossRef | Web of Science | Medline

4. 4

   Bass JW, Freitas BC, Freitas AD, et al. Prospective randomized double blind placebo-controlled evaluation of azithromycin for treatment of cat-scratch disease. Pediatr Infect Dis J 1998;17:447-452
   CrossRef | Web of Science | Medline

5. 5

   Avidor B, Kletter Y, Abulafia S, Golan Y, Ephros M, Giladi M. Molecular diagnosis of cat scratch disease: a two-step approach. J Clin Microbiol 1997;35:1924-1930
   Web of Science | Medline