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A 25-year-old female comes to you with the complaint of a painful rash over the right hand for 4 days, and a tender swelling in the right axilla for 2 days. The patient is a bank accountant, and has been in good health in the past. When asked about pets, she says that she has two cats. On examination, she has multiple vesicular and erythematous papules over the site that itches, and a tender suppurative right epitrochlear and axillary lymphadenopathy. What is the most appropriate management of this patient?
A. Watchful observation
B. Oral azithromycin
C. Oral penicillin
D. Topical corticosteroids
E. Oral cephalexin
F. Lymph node biopsy
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BBB,cat scratch fever by Bartonella Hensele
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is patient has a classic presentation of cat-scratch disease. Cat-scratch disease is an infectious disease caused by B. henselae, transmitted by a cat scratch or bite, or from a fleabite. It is commonly seen in young, immunocompetent individuals. It most commonly presents as a localized cutaneous and lymph node disorder near the site of inoculum, with a very rare involvement of the liver, spleen, eye or central nervous system. A local skin lesion evolves through vesicular, erythematous and papular phases, but can be pustular or nodular. Localized, regional lymphadenopathy, the hallmark of CSD, is tender and may be suppurative. The diagnosis of CSD is mainly based on clinical grounds and positive B. henselae antibody test, or a positive Warthin-Starry stain on a tissue specimen, which supports the diagnosis.
Most patients with CSD have a gradual resolution of symptoms, even without specific antibiotic therapy. However, a tender regional lymphadenopathy and systemic symptoms may be debilitating. A short course of antibiotic is recommended for all patients with CSD. Five days of azithromycin has been found to be particularly effective. Other options include a seven- to ten-day course of clarithromycin, rifampin, trimethoprim-sulfamethoxazole, or ciprofloxacin. Doxycycline has also been found to be effective.
(Choice A) Though most of the patients with CSD have a gradual resolution of symptoms, the tender regional lymphadenopathy can be debilitating, and thus, a short antibiotic course is recommended.
(Choice C and E) Oral penicillin or cephalexin is not effective in CSD, however, they may be used if staphylococci infection is suspected.
(Choice D) Topical corticosteroids are not effective for CSD.
(Choice F) Lymph node biopsy is indicated to rule out malignancy such as Hodgkin™s disease, if the presentation of CSD is atypical.
Educational Objective:
Most patients with CSD have a gradual resolution of symptoms, even without specific antibiotic therapy. However, a tender regional lymphadenopathy and systemic symptoms may be debilitating. A short course of antibiotic is recommended for all patients with CSD. Five days of azithromycin has been found to be particularly effective
