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
Autor para correspondencia
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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"apellidos" => "Bernardo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Miguel" "apellidos" => "Bernardes" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 4 => array:3 [ "nombre" => "Joanne" "apellidos" => "Lopes" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Rheumatology Department, Centro Hospitalar de São João, Porto, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Infectious Diseases Department, Centro Hospitalar de São João, Porto, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Rheumatology Department, Faculty of Medicine of the University of Porto, Portugal" "etiqueta" => "c" "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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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 2 | 3 | 5 |
| 2024 Octubre | 36 | 35 | 71 |
| 2024 Septiembre | 67 | 18 | 85 |
| 2024 Agosto | 71 | 36 | 107 |
| 2024 Julio | 71 | 25 | 96 |
| 2024 Junio | 52 | 31 | 83 |
| 2024 Mayo | 69 | 36 | 105 |
| 2024 Abril | 55 | 45 | 100 |
| 2024 Marzo | 48 | 30 | 78 |
| 2024 Febrero | 62 | 35 | 97 |
| 2024 Enero | 46 | 24 | 70 |
| 2023 Diciembre | 46 | 20 | 66 |
| 2023 Noviembre | 57 | 32 | 89 |
| 2023 Octubre | 54 | 30 | 84 |
| 2023 Septiembre | 68 | 37 | 105 |
| 2023 Agosto | 45 | 7 | 52 |
| 2023 Julio | 54 | 27 | 81 |
| 2023 Junio | 34 | 27 | 61 |
| 2023 Mayo | 54 | 27 | 81 |
| 2023 Abril | 23 | 8 | 31 |
| 2023 Marzo | 63 | 30 | 93 |
| 2023 Febrero | 55 | 23 | 78 |
| 2023 Enero | 58 | 18 | 76 |
| 2022 Diciembre | 71 | 38 | 109 |
| 2022 Noviembre | 44 | 20 | 64 |
| 2022 Octubre | 68 | 38 | 106 |
| 2022 Septiembre | 59 | 38 | 97 |
| 2022 Agosto | 49 | 60 | 109 |
| 2022 Julio | 40 | 44 | 84 |
| 2022 Junio | 40 | 36 | 76 |
| 2022 Mayo | 48 | 39 | 87 |
| 2022 Abril | 77 | 44 | 121 |
| 2022 Marzo | 90 | 42 | 132 |
| 2022 Febrero | 97 | 31 | 128 |
| 2022 Enero | 71 | 32 | 103 |
| 2021 Diciembre | 53 | 36 | 89 |
| 2021 Noviembre | 40 | 36 | 76 |
| 2021 Octubre | 55 | 48 | 103 |
| 2021 Septiembre | 60 | 37 | 97 |
| 2021 Agosto | 35 | 40 | 75 |
| 2021 Julio | 34 | 27 | 61 |
| 2021 Junio | 39 | 41 | 80 |
| 2021 Mayo | 52 | 57 | 109 |
| 2021 Abril | 114 | 92 | 206 |
| 2021 Marzo | 77 | 30 | 107 |
| 2021 Febrero | 51 | 17 | 68 |
| 2021 Enero | 53 | 28 | 81 |
| 2020 Diciembre | 51 | 26 | 77 |
| 2020 Noviembre | 41 | 25 | 66 |
| 2020 Octubre | 34 | 14 | 48 |
| 2020 Septiembre | 83 | 40 | 123 |
| 2020 Agosto | 85 | 28 | 113 |
| 2020 Julio | 30 | 16 | 46 |
| 2020 Junio | 29 | 15 | 44 |
| 2020 Mayo | 76 | 29 | 105 |
| 2020 Abril | 43 | 23 | 66 |
| 2020 Marzo | 63 | 24 | 87 |
| 2020 Febrero | 1 | 0 | 1 |
| 2019 Diciembre | 1 | 2 | 3 |
| 2019 Noviembre | 1 | 0 | 1 |
| 2019 Octubre | 2 | 0 | 2 |
| 2019 Junio | 0 | 1 | 1 |
| 2019 Mayo | 49 | 31 | 80 |
| 2019 Abril | 75 | 23 | 98 |
| 2019 Marzo | 57 | 24 | 81 |
| 2019 Febrero | 28 | 14 | 42 |
| 2019 Enero | 40 | 25 | 65 |
| 2018 Diciembre | 53 | 52 | 105 |
| 2018 Noviembre | 0 | 15 | 15 |
| 2018 Octubre | 0 | 7 | 7 |
| 2018 Septiembre | 0 | 6 | 6 |
| 2018 Agosto | 0 | 11 | 11 |
| 2018 Julio | 0 | 7 | 7 |
| 2018 Marzo | 0 | 16 | 16 |
| 2018 Febrero | 0 | 25 | 25 |
| 2018 Enero | 0 | 11 | 11 |
| 2017 Diciembre | 0 | 21 | 21 |
| 2017 Noviembre | 0 | 30 | 30 |
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