Summary

Summary Following the observation, during more than 10 years, of subacute suppurating adenitides after cat scratches, we managed since 1947 to identify them with certainty with the help of the specific intradermalreaclion conceived by Lee Foshay. We described them first, in association with M. Lamy, M. L. Jammet, L. Costil, and P. Mozziconacci, in January 1950, under the name of Cat‐scratch fever (Maladie des grilles de chat). Shortly afterwards, many cases were reported in Fiance, Switzerland, the U.S.A. and a large number of countries, thus conforming, widening and completing our first findings. A description is given here of the disease on the basis of our 80 cases and of the whole of I he published cases, the number of which is well over 300. Cat scratch fever is found throughout the world, under all climates and in all age sections. A cat is the usual vector and inoculating agent; a contact with one or several cats was definitely established in 83 % of I lie cases. In 54 % the disease was inoculated by a cat scratch, and in 6 % by a cat bile, whereas only 13 % of the patients developped a lesion around an excoriation due to a thorn, to a metal or wood fragment, or insect sling. The existence of familial epidemics, at the origin of which a cat living with the family was always found, further substantiates the value of these statistical data. Nevertheless the Iransmission of the disease is only incomplelely known; 17 % of the patients had no conlact will) a cat and 27 % failed to remember an inoculating trauma. II. seems thai the cal's transmitting capacity does not exceed several days or weeks, himself being not affected. The source of the virus, its natural reservoir have not been discovered. Nevertheless, there must exist a reservoir, as siiggesleld by our report of an endemic of 12 cases transmitted during 5 years by The cals of a small town in the vicinity of Paris. Although cat‐scratch fever is certainly of infectious nature, the causative pathogen has not so far been identified. Mollaret, Reilly, Bust in and Tournier, have reported that the disease can be transmitted to men and monkeys and that if may unconstantly give a complement deviation with the antigen of lymphogranuloma venereum. These aulhors demonstrated the existence in monkeys and sometimes in men of cellular inclusions hearing evidence, in their opinion, of the existence of a virus; we failed to discover and to study these inclusions in our sections of human lymph nodes. We do not think that it is permitted to establish a full relationship with the viruses of the ornithosis‐lymphogranuloma venereum group, because of morphological differences and chiefly of the failure of inoculations on embryonic eggs. We report the results of our investigations carried out with ganglionic pus and nodes taken unfortunately fairly late; the cultures on various media, the inoculations on tissue cultures and on the yolk sac of incubated eggs and ultimately to various rodents and monkeys failed. On the contrary, the inoculation of crushed nodes to rodents treated with cortisone enabled us to obtain cutaneous lesions without adenopathies, transmissible in series of animals; their speeilily is not unquestionable. The typical form of Cat‐scratch fever associates a cutaneous lesion of inoculation, a regional adenitis and general manifestations. The duration of incubation ranges from two lo six weeks. Several nodes of a same group, most often the axillary one, are involved, or sometimes two connected groups; the adenitis is of very variable volume, either solid or fluclualing; it suppurates in 50 % of the cases. The inoculation lesion is lo be seen in one half of the patients, under the aspect of a small macula or papula, which is often precocious and transient but may appear again when the adenitis is formed. At this stage, a slight attack of fever lasting about ten days, is commonly seen. The course is always benign. The adenitis either disappears spontaneously or the pus is evacuated through a fistula possibly simulating tuberculosis; anyway, recovery is complete within several weeks or months, a protracted course being very uncommon. Laboratory examinations are necessary and an unquestionable diagnosis must, be based on a positive intradermal reaction. The injection of 110 of ml of diluted pus induces the formation, 3 or 4 days later, of a pinkish papula with a diameter of 6 mm or more, and sometimes a focal or systemic reaction. This test is specific and lasting; but some failures require the use of various different antigens. The complement deviation lest is not specific and sometimes non contributory. The examination of the sterile pus or of ganglionic smears, obtained by punctures, is of diagnostic, value, as well as the biopsy performed in several cases. The blood count in not much modified. On the basis of all these findings, it is possible lo differentiate catscratch fever from other subacute adenitides. In the absence of inoculations cutaneous lesions, adenitides due to common pyogenic organisms, tuberculous adenitis, Hodgkin's disease and lymphogranuloma venereum are to be discarded in the first, place; diagnosis with ganglionic tumors, acquired toxoplasmosis and giant follicular lymphadenopathy is more uncommon. If there is an adenitis associated with a skin lesion, tularemia and oilier pasteurella infections, sodoku and mycoses will he discussed. If there is a polyadenitis, infectious mononucleosis, brucelloses and sarcoidosis will be considered. Several clinical forms of cat‐scratch disease are known at present. These are symptom‐free forms, protracted forms, so called “pseudo‐venereal” inguinal forms, forms with superinfection of the adenilides by tubercle bacilli. A maculous eruption or true erythema nodosum may accompany the adenitis. Especially interesting are the ectopic forms of the disease: oro‐pharyngeal (associating tonsillitis or a pharyngeal abscess with a cervical adenitis); palpebral; conjunctival with pretragal adenitis assuming the aspect of Parinaud's conjunctivitis; mesenteric (abdominal adenitis simulating appendicitis); thoracic (with involvement of The mediastinal nodes or primary atypical pneumonia). The most special forms are those with neuromeningeal accidents: encephalitis, myelitis, nevrilis and meningitis. The number of cases, in which cat‐scratch fever is lo be suspected and the intradermal reaction resorted to, is ever and ever increasing. The diagnostic criteria of these forms are given with accuracy and if is reminded that in these forms, too, a eat is the usual carrier of virus. The pathological examination of a cat‐scratch fever adenitis usually shows several nodes of different volume, circumscribed by loose periadenitis and containing areas of suppuration of variable size. The microscopic study shows the disapperancc of The normal node pattern, which is replaced by an inflammatory granuloma with areas of reticular hyperplasia with large clear cells and oilier areas infiltrated by round cells, polymorphonuclears and some plasmocyles; The granuloma is later the seal of necrotic foci which melt into pus. Typically, there is a follicular‘ structure: lympho‐plasmocytie peripheral circle, area of epithelioid cells “en palissade” scattered with Langbans giant cells, necrotic centre. Stress is laid on the very marked reticular and endothelial hyperplasia and on the very early appearance of sclerosis at the periphery of the granuloma. This histological pattern is not specific of cat‐scratch fever and is related to aspects found in other ganglionic granulomas (tuberculosis, Hodgkin's disease, sarcoidosis, lympho‐granuloma venereum, infections and mycotic adenilides.) The skin lesion of inoculation is made of a granuloma similar to that of the node, with the same reticular hyperplasia. The action of treatment is difficult lo appraise because of the usually beneficial course. A puncture of the node permits The removal of the pus and is the first treatment to carry out. Antibiotics shoud be used if the adenitis or fever outlasts the puncture; aureomycin induced the cessation of the fever and accelerated the recovery of the adenitis in nearly all treated cases. Other authors obtained similar results with terramycin, chloramphenicol and erythromycin. If the adenitis is not cured by antibiotics, surgical removal may be indicated. Antibiotics will be given in all ectopic or complicated forms.