Letter to the Editor
Cat Scratch Disease During Adalimumab Therapy: A Case Report
Enfermedad por arañazo de gato durante el tratamiento con adalimumab: a propósito de un caso
Teresa Martins-Rochaa,
, Cândida Abreub, Alexandra Bernardoa, Miguel Bernardesa,c, Joanne Lopesd
Corresponding author
a Rheumatology Department, Centro Hospitalar de São João, Porto, Portugal
b Infectious Diseases Department, Centro Hospitalar de São João, Porto, Portugal
c Rheumatology Department, Faculty of Medicine of the University of Porto, Portugal
d Department of Anatomic Pathology, Centro Hospitalar de São João, Porto, Portugal
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Case Report" "tieneTextoCompleto" => true "saludo" => "To the Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "309" "paginaFinal" => "310" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Teresa Martins-Rocha, Cândida Abreu, Alexandra Bernardo, Miguel Bernardes, Joanne Lopes" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Teresa" "apellidos" => "Martins-Rocha" "email" => array:1 [ 0 => "teresa.asmr@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Cândida" "apellidos" => "Abreu" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Alexandra" "apellidos" => "Bernardo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" 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"identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Department of Anatomic Pathology, Centro Hospitalar de São João, Porto, Portugal" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Enfermedad por arañazo de gato durante el tratamiento con adalimumab: a propósito de un caso" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1411 "Ancho" => 2500 "Tamanyo" => 291422 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Contrast-enhanced CT scan of the abdomen reveals a hypodense splenic nodule near the splenic hilum. (B) Abdominal ultrasound of the spleen depicts the same lesion as a hypoechoic nodule without posterior acoustic enhancement. (C) Cytology from lymphadenopathy's fine needle aspiration suggestive of granuloma inflammation.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Cat scratch disease (CSD) is an infection caused by <span class="elsevierStyleItalic">Bartonella henselae</span> after exposure to infected fleas from cats. Commonly occurs in children and young adults with regional lymphadenopathy and presents a self-limited course.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> In patients under biological drugs the disease may be severe and disseminated. A differential diagnosis with more common granulomatous infections, like tuberculosis, should be considered in the field of immunosuppression.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The authors report the case of a 38 year-old man diagnosed with Ankylosing Spondylitis (AS) in 2000. He presented inflammatory back pain, anterior uveitis, enthesitis, bilateral sacroiliitis and positive HLA-B27. He was first treated with infliximab (2004–2009) and was after changed to adalimumab because of recurrent uveitis. Before infliximab, he had been treated with isoniazid for latent tuberculosis, following a positive tuberculin skin test.</p><p id="par0015" class="elsevierStylePara elsevierViewall">On December 2013, he referred asthenia and new onset of left axillar nodules lasting for two weeks without fever or other complaints. He had nodules around 30<span class="elsevierStyleHsp" style=""></span>mm limited to left axillar region, without skin lesions. The cardiopulmonary, abdominal and neurological examinations were unremarkable. He denied known contacts with tuberculosis patients. He was owner of a cat which frequently scratched him but he did not recall any special lesion. Adalimumab treatment was stopped and diagnostic workup was performed.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Except for Erythrocyte sedimentation rate (38<span class="elsevierStyleHsp" style=""></span>mm/1st hour) and C Reactive Protein (9.0<span class="elsevierStyleHsp" style=""></span>mg/L), no others relevant analytical findings were found. Quantiferon–Gold in Tube was negative and thoracic X-ray was normal. Axillar ultrasound examination revealed multiple hypoechoic nodules sized between 20–30<span class="elsevierStyleHsp" style=""></span>mm. After fine needle aspiration procedure, the cytology revealed granulomatous inflammation (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), being Ziehl Neelsen stain, culture for mycobacteria and PCR for: <span class="elsevierStyleItalic">Mycobacterium (tuberculosis, avium and intracellulare</span>), <span class="elsevierStyleItalic">Borrelia Burgdorferi</span> and <span class="elsevierStyleItalic">Nocardia</span> all negative. The PCR for <span class="elsevierStyleItalic">Bartonella</span> spp. was positive as were blood antibodies for <span class="elsevierStyleItalic">Bartonella henselae</span> (IgG titer 1:256; IgM <1:32). Due to CSD diagnosis, azithromycin was prescribed for 5 days. After one month, he presented complete regression of lymphadenopathies. Abdominal CT revealed splenic hypodense millimetric nodules and abdominal ultrasound showed two splenic nodules (11 and 8<span class="elsevierStyleHsp" style=""></span>mm); there was no previous exam to compare (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Regarding procedure risks, it was decided by a multidisciplinary team to avoid splenic biopsy and ciprofloxacin during 3 weeks was prescribed. Regular ultrasound examinations revealed stability of the splenic lesions. Adalimumab was re-started on September 2014 because of exacerbation of AS activity. After more than three years, he remains asymptomatic and abdominal ultrasound revealed slight reduction of splenic nodules (8 and 5<span class="elsevierStyleHsp" style=""></span>mm).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">We herein report, to our knowledge, the second case of CSD on adalimumab treatment. Splenic nodules raised the concern of splenic dissemination of the disease that we cannot certainly attribute to <span class="elsevierStyleItalic">Bartonella</span> infection since biopsy was not undertaken. Tuberculosis, being our first concern, was completely excluded. In a retrospective study of adverse event reports on TNFα blockers users, an increased risk of granulomatous infections, particularly tuberculosis, was documented, but only one case was caused by <span class="elsevierStyleItalic">Bartonella</span> infection.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> Later on, 10 CSD reports were described: seven patients were under TNFα blockers (one case on adalimumab), one case on abatacept and two on tocilizumab.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">3–11</span></a> The majority presented regional lymphadenopathy and had good therapeutic response, restarting biologics 2–3 months after. However, in three published cases, visceral infection presenting with mesenteric panniculitis, splenic nodules and, one of those, with liver granulomatosis, were documented.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">3,8,11</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">It should be stressed that new onset lymphadenopathy and granulomatosis in patients under biological therapies should raise the suspicion of CSD, particularly in the field of epidemiologic risk. The possibility of systemic dissemination should be kept in mind due to underlying immunosuppression.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of Interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of Interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1411 "Ancho" => 2500 "Tamanyo" => 291422 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Contrast-enhanced CT scan of the abdomen reveals a hypodense splenic nodule near the splenic hilum. (B) Abdominal ultrasound of the spleen depicts the same lesion as a hypoechoic nodule without posterior acoustic enhancement. (C) Cytology from lymphadenopathy's fine needle aspiration suggestive of granuloma inflammation.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0060" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cat-scratch disease: an overview based on a study of 1,200 patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "H.A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 32 | 29 | 61 |
| 2024 September | 36 | 24 | 60 |
| 2024 August | 51 | 34 | 85 |
| 2024 July | 40 | 26 | 66 |
| 2024 June | 36 | 31 | 67 |
| 2024 May | 36 | 23 | 59 |
| 2024 April | 36 | 28 | 64 |
| 2024 March | 29 | 28 | 57 |
| 2024 February | 27 | 19 | 46 |
| 2024 January | 26 | 21 | 47 |
| 2023 December | 23 | 25 | 48 |
| 2023 November | 26 | 28 | 54 |
| 2023 October | 17 | 18 | 35 |
| 2023 September | 83 | 33 | 116 |
| 2023 August | 24 | 11 | 35 |
| 2023 July | 23 | 23 | 46 |
| 2023 June | 25 | 22 | 47 |
| 2023 May | 24 | 18 | 42 |
| 2023 April | 27 | 8 | 35 |
| 2023 March | 37 | 16 | 53 |
| 2023 February | 38 | 19 | 57 |
| 2023 January | 20 | 19 | 39 |
| 2022 December | 47 | 26 | 73 |
| 2022 November | 31 | 24 | 55 |
| 2022 October | 51 | 24 | 75 |
| 2022 September | 39 | 18 | 57 |
| 2022 August | 40 | 44 | 84 |
| 2022 July | 28 | 25 | 53 |
| 2022 June | 35 | 26 | 61 |
| 2022 May | 44 | 35 | 79 |
| 2022 April | 62 | 33 | 95 |
| 2022 March | 41 | 48 | 89 |
| 2022 February | 38 | 29 | 67 |
| 2022 January | 44 | 38 | 82 |
| 2021 December | 37 | 38 | 75 |
| 2021 November | 38 | 40 | 78 |
| 2021 October | 28 | 40 | 68 |
| 2021 September | 21 | 43 | 64 |
| 2021 August | 23 | 39 | 62 |
| 2021 July | 18 | 18 | 36 |
| 2021 June | 15 | 33 | 48 |
| 2021 May | 26 | 33 | 59 |
| 2021 April | 71 | 79 | 150 |
| 2021 March | 31 | 30 | 61 |
| 2021 February | 26 | 13 | 39 |
| 2021 January | 23 | 16 | 39 |
| 2020 December | 28 | 20 | 48 |
| 2020 November | 22 | 15 | 37 |
| 2020 October | 12 | 15 | 27 |
| 2020 September | 53 | 22 | 75 |
| 2020 August | 15 | 22 | 37 |
| 2020 July | 17 | 12 | 29 |
| 2020 June | 12 | 10 | 22 |
| 2020 May | 19 | 11 | 30 |
| 2020 April | 10 | 10 | 20 |
| 2020 March | 1 | 1 | 2 |
| 2019 November | 1 | 0 | 1 |
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