Correspondence
Case 33-2002: A 28-Year-Old Woman with Ocular Inflammation, Fever, and Headache
N Engl J Med 2003; 348:474-476January 30, 2003
- Article
To the Editor:
A large variety of infectious agents are associated with fever, headache, and ocular inflammation, as discussed by Mushlin et al. in Case 33-2002 (Oct. 24 issue).1 Whenever lymphadenopathy is involved, cat scratch disease due to Bartonella henselae, which is endemic in the United States, Europe, Africa, Australia, and Japan, should be considered. Cats, particularly kittens, are the principal reservoir.2 Cat scratch disease generally follows a scratch, bite, or lick from a kitten. However, in a small percentage of patients, there is no history of contact with animals.3 Clinical features of cat scratch disease include lymphadenopathy, local cutaneous lesions, fever, malaise, headache, weight loss, emesis, splenomegaly, sore throat, rash, parotid swelling, and conjunctivitis.4 In rare cases, encephalopathy, arthralgias, and erythema nodosum occur.5 Patients with Parinaud's oculoglandular syndrome present with an ocular granuloma or conjunctivitis and preauricular lymphadenopathy. Thus, in patients, such as the woman described in Case 33-2002, who have lymphadenopathy and ocular involvement, cat scratch disease should be considered in the differential diagnosis and confirmed by a positive serologic test for B. henselae. Histopathological examination of involved tissue is a useful adjunct to serologic testing.6
6 ReferencesRenate Haberl, M.D.
Christoph Wenisch, M.D.
University Hospital Graz, A-8036 Graz, Austria
renate_haberl@gmx.at 1
Case Records of the Massachusetts General Hospital (Case 33-2002). N Engl J Med 2002;347:1350-1357
Full Text | Web of Science | Medline2
Koehler JE ,Glaser CA ,Tappero JW . Rochalimaea henselae infection: a new zoonosis with the domestic cat as reservoir. JAMA 1994;271:531-535
CrossRef | Web of Science | Medline3
Daniels WB ,MacMurray FG . Cat scratch disease: report of one hundred sixty cases. JAMA 1954;154:1247-1251
Web of Science | Medline4
Carithers HA . Cat-scratch disease: an overview based on a study of 1,200 patients. Am J Dis Child 1985;139:1124-1133
Web of Science | Medline5
Moriarty RA ,Margileth AM . Cat scratch disease. Infect Dis Clin North Am 1987;1:575-590
Medline6
Anderson BE ,Neuman MA . Bartonella spp. as emerging human pathogens. Clin Microbiol Rev 1997;10:203-219
Web of Science | Medline
To the Editor:
In Case 33-2002, prompt diagnosis and appropriate (glucocorticoid) treatment of a severe form of Löfgren's syndrome led to a satisfactory response. It may be important, however, to point out that most patients with Löfgren's syndrome are not that seriously ill. A much more common presentation is hilar or mediastinal adenopathy and septal panniculitis (erythema nodosum), often associated with inflammatory periankle or ankle monoarthritis or peripheral inflammatory polyarthritis.1,2 Moreover, sarcoidosis is only one of the causes of Löfgren's syndrome, which may occur without underlying sarcoidosis and with clinical features that resolve spontaneously,1-3 as discussed with reference to a similar case.4 Awareness of other associations could prevent overtreatment with glucocorticoids, cytotoxic drugs, and other agents in patients with milder forms of the disease.
4 ReferencesAnand N. Malaviya, M.D.
Clinic for Arthritis and Rheumatism, New Delhi 110 070, India
anand_malaviya@yahoo.com 1
Malaviya AN ,Francis IM ,Kaushik P ,Ayyash EH . Musculoskeletal manifestations with panniculitis -- a hospital based study on 62 patients in Kuwait. Rheumatol Int 1999;19:51-57
CrossRef | Web of Science | Medline2
Callen JP. Panniculitis. In: Maddison PJ, Isenberg DA, Woo P, Glass DN, eds. Oxford textbook of rheumatology. 2nd ed. Oxford, England: Oxford University Press, 1998:1450-6.
3
Elder D, ed. Lever's histopathology of the skin. 8th ed. Philadelphia: Lippincott-Raven, 1997:191-2.
4
Case Records of the Massachusetts General Hospital (Case 4-2001). N Engl J Med 2001;344:443-449
Full Text | Web of Science | Medline
To the Editor:
As usual in the Case Records, an excellent clinician made an excellent diagnosis in a timely manner. Unfortunately, the clinical diagnosis of erythema nodosum on the patient's legs was made without consideration of the possibility of a clinical look-alike, subcutaneous sarcoidosis.1 It is possible that if the patient had been seen by a dermatologist, a scar elsewhere on the body might have been found, and a biopsy specimen could have been examined for the presence of noncaseating granulomas.2 A biopsy of either a leg nodule or a scar elsewhere on the body would be much less invasive than a lymph-node biopsy. Although Sutton's law would guide us to a variety of sites, the ATM is an easier place to go than the bank's headquarters.
2 ReferencesDaniel M. Siegel, M.D.
SUNY Downstate Medical Center, Brooklyn, NY 11203
cyberdoc@alum.rpi. edu 1
Requena L ,Requena C . Erythema nodosum. Dermatol Online J 2002;8:4-4
Medline2
English JC III ,Patel PJ ,Greer KE . Sarcoidosis. J Am Acad Dermatol 2001;44:725-743
CrossRef | Web of Science | Medline
To the Editor:
Good medical practice usually dictates performing appropriate tests to establish a diagnosis and then proceeding with indicated treatment. But Dr. Mushlin suggests this course of action for meningitis, which represents an important exception to the rule.
Early antibiotic treatment of fulminant bacterial meningitis reduces mortality and long-term neurologic complications. In the United Kingdom, the chief medical officer recommends immediate treatment with parenteral antibiotics in all suspected cases.1 Diagnostic tests such as computed tomography are not routinely necessary2 and can delay treatment.3 Furthermore, the provision of high-dose antibiotics does not alter the diagnostic accuracy of lumbar puncture performed one to two hours later.4 Therefore, whenever there is a suspicion of bacterial meningitis, one should remember the exception to the rule and provide prompt, early antimicrobial therapy.
4 ReferencesOmar M. Pirzada, M.B., B.S.
Royal Hallamshire Hospital, Sheffield S10 2JF, United Kingdom
pirzada@madasafish.com 1
Donaldson L. Meningococcal infection. No. PL/CMO(99)1. London: Department of Health, 1999. (Accessed January 10, 2003, at http://www.doh.gov.uk/cmo/letters.htm.)
2
Hasbun R ,Abrahams J ,Jekel J ,Quagliarello VJ . Computed tomography of the head before lumbar puncture in adults with suspected meningitis. N Engl J Med 2001;345:1727-1733
Full Text | Web of Science | Medline3
Talan DA ,Zibulewsky J . Relationship of clinical presentation to time to antibiotics for the emergency department management of suspected bacterial meningitis. Ann Emerg Med 1993;22:1733-1738
CrossRef | Web of Science | Medline4
Quagliarello VJ ,Scheld WM . Treatment of bacterial meningitis. N Engl J Med 1997;336:708-716
Full Text | Web of Science | Medline
Author/Editor Response
Haberl and Wenisch are correct in mentioning cat scratch disease as a possibility in the differential diagnosis of fever, headache, and lymphadenopathy.
I concur with Malaviya's remarks about Löfgren's syndrome. I did not mean to imply that sarcoidosis was the only cause of that syndrome. In our experience, my colleagues and I rarely need to treat patients who have Löfgren's syndrome with corticosteroids. However, in this case, I speculated that the degree and duration of disability warranted therapy, which is usually promptly salubrious and short-term.
Regarding Siegel's comments, I thought that the surest path to a diagnosis was a lymph-node biopsy. Although skin sarcoidosis could have been the cause of the patient's illness, I thought it was statistically much more likely that these lesions were erythema nodosum. Therefore, the debate in my mind, and with my consultants, was not whether to perform a biopsy of a node, but where to do so.
I certainly agree with Pirzada's remarks about the urgency of providing antibiotic therapy in cases of bacterial meningitis. Indeed, I state this clearly in the discussion of the case. But since the patient did not present with a new, fulminant headache and fever, and since the cerebrospinal fluid contained three lymphocytes per cubic millimeter, with normal glucose and protein levels, I would not have administered antibiotics. A case could certainly be made that the cerebrospinal fluid might have these features very early in the course of fulminant meningitides, only to become dramatically abnormal within a few hours. However, I would accept the extremely low risk and not provide treatment in this situation unless the evolution of the illness had been very rapid and explosive.
Stuart B. Mushlin, M.D.
Brigham and Women's Hospital, Boston, MA 02115
smushlin@partners.org
