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Cat-Scratch Disease**
STUDIES ON SERUM ALBUMIN
99
REFERENCES
1. Davson, H.: Physiology of the Ocular and Cerebrospinal Fluids. London, Churchill, 1956. 2. Adler, F. H.: Physiology of the Eye: Clinical Application. St. Louis, Mosby, 1959, ed. 3. 3. Lugossy, G. : The fluorescein permeability of the blood-aqueous barrier. Advances Ophth. IX, 53: 110, 1959. 4. Duke-Elder, W. S. : Quoted by Davson, H.1 5. Franceschetti, A., and Wieland, H.: Quantitative Bestimmung des Eiweissgehalt der intraokularen Flüssigkeiten mit dem Nephelometer. Arch. Augenh., 99:1, 1928. 6. Von Sallmann, L., and Dillon, B. : The effect of di-isopropyl fluorophosphate on the capillaries of the anterior segment of the eye in rabbits. Am. J. Ophth., 30:1244, 1947. 7. Von Sallmann, L., and Moore, D. H.: Electrophoretic patterns of concentrated aqueous humor of rabbit, cattle and horse. Arch. Ophth., 40:279, 1948. 8. A.M.A. Council on Drugs: New and Nonofficial Drugs. Philadelphia, Lippincott, Co., 1961. 9. DuBois, K. P., Schmalgemeier, D., and Plzak, G.: To be published. 10. Mazur, A. : An enzyme in animal tissues capable of hydrolyzing phosphorus-fluoride bond of alkyl fluorophosphates. J. Biol. Chem., 164:271 (July) 1946. 11. Kadin, M.: Systemic effects of Co-Ral and CoRalOx. Am. J. Ophth., 50:622, 1960. 12. : Studies on the toxicity and effect of dipterex in rabbits. Am. J. Ophth., 53:512, 1962. 13. : Unpublished data. 14. Jaenike, J. R., Schreiner, B. F., and Waterhouse, G: The relative volumes of distribution of IU1tagged albumen and high molecular weight dextran in normal subjects and in patients with heart disease. J. Lab. & Clin. Med., 49:172 (Feb.) 1957. 15. Peters, J. P.: The role of sodium in the production of edema, New England J. Med., 239:353, 1948. 16. Reeve, E. B., and Roberts, J. E.: The nature and rates of excretion of radioactive breakdown products of P " albumin in the rabbit. J. Gen. Physiol., 43:397, 1959. 17. Goldmann, H.: Fluorescein in der menschlichen Vorderkammer: Das Minutenvolumen des Men schen. Ophthalmologica, 123:277, 1950. 18. Weekers, R., et Delmarcelle, Y. : Hypotonie oculaire par reduction du debit de l'humeur aqueuse. Ophthalmologica, 125:425, 1953. 19. Langley, D., and MacDonald, R. K. : Clinical method of observing changes in the rate of flow of aqueous humor in the human eye: II. In glaucoma. Brit. J. Ophth., 36:499, 1952. 20. Kadin, M.: Effect of CoRalOx. Am. J. Ophth., 50:115, 1960. 21. Jaffe, N. S.: Cholinesterase in the aqueous of the eye. Arch. Ophth., 40:273, 1948. 22. Viikari, K.: Studies of the cholinesterase activity of the aqueous humor in man and some animals. Ann. med. exper. & Biol. Fenn., 33:Supp. 4, 1955.
CAT-SCRATCH J O S E P H E.
A L F A N O , M.D.,
DISEASE*
AND ARMANDO T.
PEREZ,
M.D.
Chicago, Illinois The domestic cat has long been known as a carrier of human disease. A m o n g those diseases transmitted by cats 1 to man are cat-scratch fever, tularemia, rabies, rat-bite fever, feline pneumonia ( v i r u s ) , diphtheria, tuberculosis, typhus, leptospirosis ( ? ) , ring worm, creeping eruption, favus, pasturellosis, plague ( ? ) and histoplasmosis ( ? ) . I n 1932, 2 ' 3 Foshay first recognized an * From the Department of Ophthalmology and the Department of Pediatrics, the Children's Me morial Hospital and the Northwestern University Medical School.
ulceroglandular disease entity following the scratch of a cat and referred to it as catscratch fever. H e described the disease as resembling a mild case of tularemia and felt that a cat contact was invariable. I n 1945, H a n g e r 2 ' 3 and Rose prepared an antigen from pus aspirated from a suppurative re gional lymph node in one of these cases. W h e n this material was injected intradermally, it produced an intense tuberculinlike reaction in H a n g e r who suffered from the disease and in patients of Foshay with this disease.
100
JOSEPH E. ALFANO AND ARMANDO T. PEREZ
Debré4 after a visit with Foshay in 1947, began a study of similiar cases in France and published the first of his reports of this disease in January, 1950. He and his coworkers described this disease syndrome under the title of "La maladie des griffes de chat." These authors studied 10 cases, al though only one case was described in de tail. The case was that of a six-year-old child who, after contact with a cat, developed fever, inguinal adenopathy and a local folliculitis. Penicillin had no effect on the course of the disease, although they felt that aureomycin had shortened the course. Mollaret,5 in 1950 and 1951 collected and reported some additional cases. Greer and Keefer 1 were the first to pub lish a case in the American literature in 1951. Their case of cat-scratch fever was in a 36-year-old white man who presented the clinical picture of regional lymphadenitis, fever, malaise and a macular rash on both arms following a cat bite on the neck, which had two opened pimples. The Frei test was negative but the Foshay skin test for catscratch disease was positive. Lange,8 in 1951, reported three additional cases, unconfirmed by intradermal tests. Daniels and MacMurray 2 ' 8 reported 60 cases in 1952. Since this time, multiple case re ports have appeared both in the American and foreign periodicals. The occurrence of Parinaud's oculoglandular syndrome, caused by a cat-scratch, was first reported by Pesmé,7 De Lavergne, et al. 8 ' 9 and Clement, et al.10 Daniels and MacMurray 2 ' 3 also reported two cases which had been studied and verified, using the skin antigen, by Peterson. Cassady and Culbertson" reported four cases of this syn drome. Pesmé and Marchand's 7 case showed con junctivitis with preauricular swelling and fever in a six-year-old child who had been bitten by a cat. An intradermal test, with an antigen of cat-scratch fever obtained from the pus of lymph nodes of patients from Debré's laboratory, gave a positive reaction
both in this child and in a patient with Parinaud's syndrome one year after he had recovered. De Lavergne 8,9 reported a case of oculoglandular syndrome which showed a prolonged course. All the diagnostic tests for tularemia, tuberculosis, lymphogranuloma venereum and syphilis were negative but the intradermal test with cat-scratch anti gen gave a positive reaction. Cassady11 presented four cases of the ocu loglandular syndrome in which no etiologic agent could be ascertained because all tests, including the agglutination, and conjunctival cultures were negative. When the cat-scratch antigen became available, the patients were called back and all four gave a strongly positive skin reaction. The disease appears to affect both males and females equally. The majority of pa tients are under 20 years of age. Inoculation usually occurs after direct contact with a cat and is the result of a scratch, lick, bite or contamination with cat excreta. Since the cats in these cases are usually healthy ani mals, they probably transmit the disease passively. Their intradermal reactions to catscratch antigen are negative. According to Cassady and Culbertson,11 in cases of Parinaud's oculoglandular syn drome due to cat-scratch disease, the con junctiva is the site of the primary infection. The initial conjunctivitis with granulation is followed by regional lymphadenitis. Accord ing to these same authors, infection from cats by inhalation of infected material, trans mitted by the nasopharyngeal or faucial route, has been reported by Daniels and MacMurray. 2,8 They state that in Henry's case,12 a cat sneezing into the patient's face produced the oculoglandular syndrome. They also suggest that rubbing the eyes after handling a cat with a conjunctival infection might transmit the disease to the human conjunctiva. The initial lesion, present in about 50 per cent of the cases, may assume the form of a scratch, bite, papule, pustule, ulcer, scab or vesiclelike lesion at the point or place of
CAT-SCRATCH DISEASE contact. It usually appears three to seven days after a scratch. Enlargement of the lymph nodes may appear from three to as long as 42 days after the initial lesion. The nodes most frequently involved are the axil lary, then the nodes of the head and neck. Femoral and pectoral nodes are often strik ing in size becoming as large as a golf ball or small orange. Occasionally the nodes are nontender but usually they are tender, with swelling, heat and redness of the overlying skin. The glands are usually movable and suppuration with sterile pus formation is common. The enlargement of the nodes may persist from two weeks to six months. Systemic symptoms13 usually accompany the adenopathy and include malaise, ano rexia, weakness, lassitude, aching, chilly sen sations, headache, macular rash on the arms, trunk or chest, and fever. Lack of fever tends to signify lack of suppuration. Gen eralized lymphadenopathy, splenomegaly, meningo-encephalitis and Parinaud's oculoglandular syndrome can occur. Laboratory studies may reveal a mild leukocytosis with some elevation of the sedimentation rate. Thrombocytopenia""16 with purpura has been reported as occurring in this condition. Diagnosis can be made from the Foshay skin test. The technique for the preparation of the antigen is as follows: Aspirated sterile pus is diluted 1:5 with sterile, isotonic sodium chloride solution and heated to 56° C. for one hour on two con secutive days. After sterility is proved, 0.1 ml. is injected intradermally. After 48 hours, a positive test shows a central papule 0.5 to 1.0 cm. in diameter or an area of erythema 1.5 to 6.0 cm. in diameter, or both. The serum agglutinations for brucellosis and tularemia are negative and the heterophil agglutination test for infectious mononucleosis is negative. Serologie tests for lues are negative, as is the Frei intradermal test for lymphogranuloma venereum. Pathologic examination of the lymph node in these cases usually reveals a marked hyperplasia of the reticulo-endothelial cells
101
early in the disease, followed by the develop ment of focal granulomas with suppuration and necrosis. The etiology of this condition is not known at present although there is evidence which suggests that the disease may be due to a virus related to the lymphogranulomapsittacosis group. In the majority of cases the illness is mild and of short duration, although sup purating lymph nodes may persist for months and require surgical drainage. Be cause most patients recover spontaneously, the effect of antibiotic treatment is difficult to evaluate, although it is felt that chlortetracycline may accelerate recovery. The disease is rarely fatal. Differential diagnosis should include lymphopathia venereum, Hodgkin's disease, tularemia and other diseases involving the lymphatic system. Conditions which may produce Parinaud's oculoglandular syndrome must also be differentiated, including oculo glandular tularemia, leptothricosis, syphilis, tuberculosis and sporotrichosis. CASE REPORT
This 14-year-old white girl was first seen in the out-patient department, Children's Memorial Hos pital, with a history of a painful swelling in front of the right ear, below the right side of the jaw and on both sides of the neck. There was an as sociated swelling with closure of the right eye of four days' duration. Fever, exposure to contagion and trauma were denied. Birth and development were described as normal. She had received the usual vaccinations and immunizations. Past history revealed that she had had rubeola complicated by pneumonia at the age of three years and a tonsillectomy with an adenoidectomy at the age of nine years. Her parents and four siblings were in ap parent good health. A history of familial disease was denied. Interrogation revealed that she had been in re cent contact with a schoolmate who had had a posi tive Mantoux test. Further questioning revealed that there were four cats in her home and that one of them had scratched her on the right hand about one week before her difficulties began. She stated, however, that she had been scratched many times before by all four of the cats. She was not able to recall if there was a papule or ulcer at the site of the scratching. Physical examination revealed a well-developed white girl in mild distress and with asymmetry of
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JOSEPH E. ALFANO AND ARMANDO T. PEREZ
Fig. 1 (Alfano and Perez). Eversion of the right upper eyelid, showing a granular conjunctivitis with an ulcerated papular lesion measuring two mm. in diameter. There was some edema and neovascularization in the area surrounding the lesion. the face due to swelling of the right side of the face and neck. Examination of the right eye (fig. 1) showed marked blepharospasm. The lids were edematous and swollen. The palpebrai aperture was completely obliterated. The lids were tender to touch. There was a large tender preauricular node and an enlargement of the submaxillary nodes on the right. There was no suppuration. Separation of the lids revealed a severely hyperemic conjunctiva with granulations. The cornea was clear. There was an ulcerated, elevated, yellowcolored papular lesion on the conjunctiva of the upper lid. It measured two mm. in diameter. There was some edema and neovascularization of the area surrounding the papule. The fundus was normal. Examination of the left eye was completely nor mal. Examination of the ears, nose and throat was normal. There was bilateral enlargement of the cervical nodes which were freely movable and tender to touch. The remainder of the physical ex amination, including neurologic examination, was negative, excepting for two parallel red linear streaks on the dorsum of the right hand.
A white blood cell count performed at this time was within normal limits. She received one million units of penicillin intramuscularly and was told to return to the clinic in five days. Upon her return, there was accentuation of the eye findings, with in creased enlargement of the preauricular and sub maxillary nodes on the right side, although no sup puration of any nodes was present. Upon admission to the hospital the Frei and the Mantoux tests were negative. Blood agglutinations for brucellosis and tularemia were negative, as was the heterophil agglutination test. The Foshay skin test for cat-scratch disease was positive. Because of this a diagnosis of cat-scratch disease was made and the patient was placed on chlortetracycline, 200 mg. four times a day. Within five days the con dition of the eye and lymph nodes was much im proved; complete resolution occurred within the next three weeks. SUMMARY
A case of cat-scratch disease in a 14-yearold white girl is presented. I t was felt that a conjunctival papule on the superior palpebrae of the right eye may have been the point of entry. Cat-scratch fever is probably viral in origin and usually occurs after a scratch, bite or contact with cat excreta. T h e ini tial papular lesion at the site of contact is followed by regional adenopathy and, usu ally, a mild systemic reaction. P a r i n a u d ' s oculoglandular syndrome can occur if the conjunctiva is the inoculation site. I n most cases the illness is mild and of short dura tion and patients recover spontaneously. Chlortetracycline may accelerate the patients recovery. 303 East Chicago Avenue (11).
REFERENCES
1. Greer, W. E. R., and Keefer, C. S.: Cat-scratch fever: A disease entity, New England J. Med., 244:545-548, 1951. 2. Daniels, W. B., and MacMurray, F. G.: Cat-scratch fever: Nonbacterial regional lymphadenitis, Ann. Int. Med., 37:697-713, 1952. 3. : Cat-scratch disease, AMA Arch. Int. Med., 88:736-751, 1951. 4. Debré, R., and Larry, M., Jammett, M. L., Costril, L., and Mozzieonacci P.: LaMaladie des Griffes de chat, Bull. hôp. Paris, 66:76-79,1950. 5. Mollaret, P., et al.: Documentation novelle sur l'adenopathie regional subacgué et spotanement curable. Presse med., 58:1353,1950. 6. Lange, H. L.: Cat-scratch fever: A report of three cases. J. Pediat., 39:431, 1951. 7. Pesmé and Marchand P.: Un noveau type de conjonctivite. J. Méd. Bourdeaux 127:127-129, 1950. 8. De Lavergne, V. et al.: La forme oculoganglionnaire de la lymphoreticulose benigne. Bull hôp. Paris, 67:985,1951. 9. : La forme oculoganglionnaire de la lymphoreticulose benigne d'innoculation. Bull. hôp. Paris, 67:985, 1951.
CAT-SCRATCH DISEASE
103
10. Clément, R., et al.: Formé oculaire de la lymplo-reticulose bëgigne dite des griffe du chat, Bull. hôp. Paris, 67:1108, 1951. 11. Cassady, J. V., and Culbertson, C. S.: Cat-scratch disease and Parinaud's oculoglandular syndrome: AMA Arch. Ophth., 50:68-74, 1953. 12. Henry, M.: Oculoglandular conjunctivitis due to leptothrix. J. Pediat., 37:535-544, 1950. 13. Rivers, T. M., and Horsfall, F. L.: Viral and Richettsial Infections of Man. Philadelphia, Lippincott, 1960, ed 3. 14. Belber, J. P., Davis, A. E., and Epstein, E. H.: Thrombocytopenic purpura associated with catscratch disease: Response of cat-scratch disease to steroid hormones. AMA Arch. Int. Med., 94:321-325, (Aug.) 1954. 15. Billo, O. E., and Wolff, J. A.: Thrombocytopenic purpura due to cat-scratch disease: Case reports of three brothers who were continuously exposed to 11 farm cats. J.A.M.A., 174:1824-1826 (Dec. 3) 1960. 16. Jim, R. T. S.: Thrombocytopenic purpura in cat-scratch disease. J.A.M.A., 176:1036-1038, 1961.
T R E A T M E N T : AN ETYMOLOGICAL N O T E THELMA CHAREN
West Hyattsville, Maryland "Random notes" might better have con veyed the importance of the ramblings set down here, a mere collection of tidbits re garding the etymology of words for medi cal treatment in various languages. I have made no attempt to array them in scholarly fashion and I offer no documentation be yond the standard language and etymologi cal dictionaries generally available. The simple bibliography will refer only to sources more obscure than those found in most ophthalmologists' libraries. These notes should give some insight into the meaning of words we see every day in medical liter ature but to which we give too casual thought. They are all words important to the goal of medicine: the treating of the patient and the healing of the disease by the practitioner of the art. The words treat and treatment and all related forms come through the French traiter from the Latin tractare, "to handle." Both French and Latin derivative pairs are used in English: treatise: tract; tractable: treatable; intractable: untreatable. This handXmg is itself actually basically the word hand, that is, "touching or feeling with the hand." This is precisely the same idea in manage: the Latin manus (hand) became the Italian mano whence maneggiare, "to
control by hand," or, in the more familiar French form, manage. The German count erpart for treatment or management is Be handlung which incorporates this very con cept of handling. The hand appears more importantly in the Greek derivative sur gery, that is, cheirourgia: the working by hand, the practice of any handicraft, and so the handicraft par excellence: cheirour gia. The Greek became chirurgia in Latin, thence it went to chirurgie in French and finally surgery in English. The same word cheir, hand, appears in chiropody and chiro practic. Since we have mentioned the Greek it will not be amiss to discuss at this point therapy with its European variants thérapie and terapia. The Greek noun therapon meant simply an "attendant" or "servant" and the verb (infinitive) therapeuein, "to wait on," "to serve," or "to attend." The general "serving" became the more spe cialized kind of waiting on, the therapeutic kind or therapeia, medical therapy. The serving or attending of the sick is inherent in this word which contrasts with the heal ing or curing concept of the derivatives of iaomai from which we get the word iater or iatros seen in iatrogenic, pediatrics, ephebiatrics, podiatry, psychiatry, geriatrics,
99
REFERENCES
1. Davson, H.: Physiology of the Ocular and Cerebrospinal Fluids. London, Churchill, 1956. 2. Adler, F. H.: Physiology of the Eye: Clinical Application. St. Louis, Mosby, 1959, ed. 3. 3. Lugossy, G. : The fluorescein permeability of the blood-aqueous barrier. Advances Ophth. IX, 53: 110, 1959. 4. Duke-Elder, W. S. : Quoted by Davson, H.1 5. Franceschetti, A., and Wieland, H.: Quantitative Bestimmung des Eiweissgehalt der intraokularen Flüssigkeiten mit dem Nephelometer. Arch. Augenh., 99:1, 1928. 6. Von Sallmann, L., and Dillon, B. : The effect of di-isopropyl fluorophosphate on the capillaries of the anterior segment of the eye in rabbits. Am. J. Ophth., 30:1244, 1947. 7. Von Sallmann, L., and Moore, D. H.: Electrophoretic patterns of concentrated aqueous humor of rabbit, cattle and horse. Arch. Ophth., 40:279, 1948. 8. A.M.A. Council on Drugs: New and Nonofficial Drugs. Philadelphia, Lippincott, Co., 1961. 9. DuBois, K. P., Schmalgemeier, D., and Plzak, G.: To be published. 10. Mazur, A. : An enzyme in animal tissues capable of hydrolyzing phosphorus-fluoride bond of alkyl fluorophosphates. J. Biol. Chem., 164:271 (July) 1946. 11. Kadin, M.: Systemic effects of Co-Ral and CoRalOx. Am. J. Ophth., 50:622, 1960. 12. : Studies on the toxicity and effect of dipterex in rabbits. Am. J. Ophth., 53:512, 1962. 13. : Unpublished data. 14. Jaenike, J. R., Schreiner, B. F., and Waterhouse, G: The relative volumes of distribution of IU1tagged albumen and high molecular weight dextran in normal subjects and in patients with heart disease. J. Lab. & Clin. Med., 49:172 (Feb.) 1957. 15. Peters, J. P.: The role of sodium in the production of edema, New England J. Med., 239:353, 1948. 16. Reeve, E. B., and Roberts, J. E.: The nature and rates of excretion of radioactive breakdown products of P " albumin in the rabbit. J. Gen. Physiol., 43:397, 1959. 17. Goldmann, H.: Fluorescein in der menschlichen Vorderkammer: Das Minutenvolumen des Men schen. Ophthalmologica, 123:277, 1950. 18. Weekers, R., et Delmarcelle, Y. : Hypotonie oculaire par reduction du debit de l'humeur aqueuse. Ophthalmologica, 125:425, 1953. 19. Langley, D., and MacDonald, R. K. : Clinical method of observing changes in the rate of flow of aqueous humor in the human eye: II. In glaucoma. Brit. J. Ophth., 36:499, 1952. 20. Kadin, M.: Effect of CoRalOx. Am. J. Ophth., 50:115, 1960. 21. Jaffe, N. S.: Cholinesterase in the aqueous of the eye. Arch. Ophth., 40:273, 1948. 22. Viikari, K.: Studies of the cholinesterase activity of the aqueous humor in man and some animals. Ann. med. exper. & Biol. Fenn., 33:Supp. 4, 1955.
CAT-SCRATCH J O S E P H E.
A L F A N O , M.D.,
DISEASE*
AND ARMANDO T.
PEREZ,
M.D.
Chicago, Illinois The domestic cat has long been known as a carrier of human disease. A m o n g those diseases transmitted by cats 1 to man are cat-scratch fever, tularemia, rabies, rat-bite fever, feline pneumonia ( v i r u s ) , diphtheria, tuberculosis, typhus, leptospirosis ( ? ) , ring worm, creeping eruption, favus, pasturellosis, plague ( ? ) and histoplasmosis ( ? ) . I n 1932, 2 ' 3 Foshay first recognized an * From the Department of Ophthalmology and the Department of Pediatrics, the Children's Me morial Hospital and the Northwestern University Medical School.
ulceroglandular disease entity following the scratch of a cat and referred to it as catscratch fever. H e described the disease as resembling a mild case of tularemia and felt that a cat contact was invariable. I n 1945, H a n g e r 2 ' 3 and Rose prepared an antigen from pus aspirated from a suppurative re gional lymph node in one of these cases. W h e n this material was injected intradermally, it produced an intense tuberculinlike reaction in H a n g e r who suffered from the disease and in patients of Foshay with this disease.
100
JOSEPH E. ALFANO AND ARMANDO T. PEREZ
Debré4 after a visit with Foshay in 1947, began a study of similiar cases in France and published the first of his reports of this disease in January, 1950. He and his coworkers described this disease syndrome under the title of "La maladie des griffes de chat." These authors studied 10 cases, al though only one case was described in de tail. The case was that of a six-year-old child who, after contact with a cat, developed fever, inguinal adenopathy and a local folliculitis. Penicillin had no effect on the course of the disease, although they felt that aureomycin had shortened the course. Mollaret,5 in 1950 and 1951 collected and reported some additional cases. Greer and Keefer 1 were the first to pub lish a case in the American literature in 1951. Their case of cat-scratch fever was in a 36-year-old white man who presented the clinical picture of regional lymphadenitis, fever, malaise and a macular rash on both arms following a cat bite on the neck, which had two opened pimples. The Frei test was negative but the Foshay skin test for catscratch disease was positive. Lange,8 in 1951, reported three additional cases, unconfirmed by intradermal tests. Daniels and MacMurray 2 ' 8 reported 60 cases in 1952. Since this time, multiple case re ports have appeared both in the American and foreign periodicals. The occurrence of Parinaud's oculoglandular syndrome, caused by a cat-scratch, was first reported by Pesmé,7 De Lavergne, et al. 8 ' 9 and Clement, et al.10 Daniels and MacMurray 2 ' 3 also reported two cases which had been studied and verified, using the skin antigen, by Peterson. Cassady and Culbertson" reported four cases of this syn drome. Pesmé and Marchand's 7 case showed con junctivitis with preauricular swelling and fever in a six-year-old child who had been bitten by a cat. An intradermal test, with an antigen of cat-scratch fever obtained from the pus of lymph nodes of patients from Debré's laboratory, gave a positive reaction
both in this child and in a patient with Parinaud's syndrome one year after he had recovered. De Lavergne 8,9 reported a case of oculoglandular syndrome which showed a prolonged course. All the diagnostic tests for tularemia, tuberculosis, lymphogranuloma venereum and syphilis were negative but the intradermal test with cat-scratch anti gen gave a positive reaction. Cassady11 presented four cases of the ocu loglandular syndrome in which no etiologic agent could be ascertained because all tests, including the agglutination, and conjunctival cultures were negative. When the cat-scratch antigen became available, the patients were called back and all four gave a strongly positive skin reaction. The disease appears to affect both males and females equally. The majority of pa tients are under 20 years of age. Inoculation usually occurs after direct contact with a cat and is the result of a scratch, lick, bite or contamination with cat excreta. Since the cats in these cases are usually healthy ani mals, they probably transmit the disease passively. Their intradermal reactions to catscratch antigen are negative. According to Cassady and Culbertson,11 in cases of Parinaud's oculoglandular syn drome due to cat-scratch disease, the con junctiva is the site of the primary infection. The initial conjunctivitis with granulation is followed by regional lymphadenitis. Accord ing to these same authors, infection from cats by inhalation of infected material, trans mitted by the nasopharyngeal or faucial route, has been reported by Daniels and MacMurray. 2,8 They state that in Henry's case,12 a cat sneezing into the patient's face produced the oculoglandular syndrome. They also suggest that rubbing the eyes after handling a cat with a conjunctival infection might transmit the disease to the human conjunctiva. The initial lesion, present in about 50 per cent of the cases, may assume the form of a scratch, bite, papule, pustule, ulcer, scab or vesiclelike lesion at the point or place of
CAT-SCRATCH DISEASE contact. It usually appears three to seven days after a scratch. Enlargement of the lymph nodes may appear from three to as long as 42 days after the initial lesion. The nodes most frequently involved are the axil lary, then the nodes of the head and neck. Femoral and pectoral nodes are often strik ing in size becoming as large as a golf ball or small orange. Occasionally the nodes are nontender but usually they are tender, with swelling, heat and redness of the overlying skin. The glands are usually movable and suppuration with sterile pus formation is common. The enlargement of the nodes may persist from two weeks to six months. Systemic symptoms13 usually accompany the adenopathy and include malaise, ano rexia, weakness, lassitude, aching, chilly sen sations, headache, macular rash on the arms, trunk or chest, and fever. Lack of fever tends to signify lack of suppuration. Gen eralized lymphadenopathy, splenomegaly, meningo-encephalitis and Parinaud's oculoglandular syndrome can occur. Laboratory studies may reveal a mild leukocytosis with some elevation of the sedimentation rate. Thrombocytopenia""16 with purpura has been reported as occurring in this condition. Diagnosis can be made from the Foshay skin test. The technique for the preparation of the antigen is as follows: Aspirated sterile pus is diluted 1:5 with sterile, isotonic sodium chloride solution and heated to 56° C. for one hour on two con secutive days. After sterility is proved, 0.1 ml. is injected intradermally. After 48 hours, a positive test shows a central papule 0.5 to 1.0 cm. in diameter or an area of erythema 1.5 to 6.0 cm. in diameter, or both. The serum agglutinations for brucellosis and tularemia are negative and the heterophil agglutination test for infectious mononucleosis is negative. Serologie tests for lues are negative, as is the Frei intradermal test for lymphogranuloma venereum. Pathologic examination of the lymph node in these cases usually reveals a marked hyperplasia of the reticulo-endothelial cells
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early in the disease, followed by the develop ment of focal granulomas with suppuration and necrosis. The etiology of this condition is not known at present although there is evidence which suggests that the disease may be due to a virus related to the lymphogranulomapsittacosis group. In the majority of cases the illness is mild and of short duration, although sup purating lymph nodes may persist for months and require surgical drainage. Be cause most patients recover spontaneously, the effect of antibiotic treatment is difficult to evaluate, although it is felt that chlortetracycline may accelerate recovery. The disease is rarely fatal. Differential diagnosis should include lymphopathia venereum, Hodgkin's disease, tularemia and other diseases involving the lymphatic system. Conditions which may produce Parinaud's oculoglandular syndrome must also be differentiated, including oculo glandular tularemia, leptothricosis, syphilis, tuberculosis and sporotrichosis. CASE REPORT
This 14-year-old white girl was first seen in the out-patient department, Children's Memorial Hos pital, with a history of a painful swelling in front of the right ear, below the right side of the jaw and on both sides of the neck. There was an as sociated swelling with closure of the right eye of four days' duration. Fever, exposure to contagion and trauma were denied. Birth and development were described as normal. She had received the usual vaccinations and immunizations. Past history revealed that she had had rubeola complicated by pneumonia at the age of three years and a tonsillectomy with an adenoidectomy at the age of nine years. Her parents and four siblings were in ap parent good health. A history of familial disease was denied. Interrogation revealed that she had been in re cent contact with a schoolmate who had had a posi tive Mantoux test. Further questioning revealed that there were four cats in her home and that one of them had scratched her on the right hand about one week before her difficulties began. She stated, however, that she had been scratched many times before by all four of the cats. She was not able to recall if there was a papule or ulcer at the site of the scratching. Physical examination revealed a well-developed white girl in mild distress and with asymmetry of
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JOSEPH E. ALFANO AND ARMANDO T. PEREZ
Fig. 1 (Alfano and Perez). Eversion of the right upper eyelid, showing a granular conjunctivitis with an ulcerated papular lesion measuring two mm. in diameter. There was some edema and neovascularization in the area surrounding the lesion. the face due to swelling of the right side of the face and neck. Examination of the right eye (fig. 1) showed marked blepharospasm. The lids were edematous and swollen. The palpebrai aperture was completely obliterated. The lids were tender to touch. There was a large tender preauricular node and an enlargement of the submaxillary nodes on the right. There was no suppuration. Separation of the lids revealed a severely hyperemic conjunctiva with granulations. The cornea was clear. There was an ulcerated, elevated, yellowcolored papular lesion on the conjunctiva of the upper lid. It measured two mm. in diameter. There was some edema and neovascularization of the area surrounding the papule. The fundus was normal. Examination of the left eye was completely nor mal. Examination of the ears, nose and throat was normal. There was bilateral enlargement of the cervical nodes which were freely movable and tender to touch. The remainder of the physical ex amination, including neurologic examination, was negative, excepting for two parallel red linear streaks on the dorsum of the right hand.
A white blood cell count performed at this time was within normal limits. She received one million units of penicillin intramuscularly and was told to return to the clinic in five days. Upon her return, there was accentuation of the eye findings, with in creased enlargement of the preauricular and sub maxillary nodes on the right side, although no sup puration of any nodes was present. Upon admission to the hospital the Frei and the Mantoux tests were negative. Blood agglutinations for brucellosis and tularemia were negative, as was the heterophil agglutination test. The Foshay skin test for cat-scratch disease was positive. Because of this a diagnosis of cat-scratch disease was made and the patient was placed on chlortetracycline, 200 mg. four times a day. Within five days the con dition of the eye and lymph nodes was much im proved; complete resolution occurred within the next three weeks. SUMMARY
A case of cat-scratch disease in a 14-yearold white girl is presented. I t was felt that a conjunctival papule on the superior palpebrae of the right eye may have been the point of entry. Cat-scratch fever is probably viral in origin and usually occurs after a scratch, bite or contact with cat excreta. T h e ini tial papular lesion at the site of contact is followed by regional adenopathy and, usu ally, a mild systemic reaction. P a r i n a u d ' s oculoglandular syndrome can occur if the conjunctiva is the inoculation site. I n most cases the illness is mild and of short dura tion and patients recover spontaneously. Chlortetracycline may accelerate the patients recovery. 303 East Chicago Avenue (11).
REFERENCES
1. Greer, W. E. R., and Keefer, C. S.: Cat-scratch fever: A disease entity, New England J. Med., 244:545-548, 1951. 2. Daniels, W. B., and MacMurray, F. G.: Cat-scratch fever: Nonbacterial regional lymphadenitis, Ann. Int. Med., 37:697-713, 1952. 3. : Cat-scratch disease, AMA Arch. Int. Med., 88:736-751, 1951. 4. Debré, R., and Larry, M., Jammett, M. L., Costril, L., and Mozzieonacci P.: LaMaladie des Griffes de chat, Bull. hôp. Paris, 66:76-79,1950. 5. Mollaret, P., et al.: Documentation novelle sur l'adenopathie regional subacgué et spotanement curable. Presse med., 58:1353,1950. 6. Lange, H. L.: Cat-scratch fever: A report of three cases. J. Pediat., 39:431, 1951. 7. Pesmé and Marchand P.: Un noveau type de conjonctivite. J. Méd. Bourdeaux 127:127-129, 1950. 8. De Lavergne, V. et al.: La forme oculoganglionnaire de la lymphoreticulose benigne. Bull hôp. Paris, 67:985,1951. 9. : La forme oculoganglionnaire de la lymphoreticulose benigne d'innoculation. Bull. hôp. Paris, 67:985, 1951.
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10. Clément, R., et al.: Formé oculaire de la lymplo-reticulose bëgigne dite des griffe du chat, Bull. hôp. Paris, 67:1108, 1951. 11. Cassady, J. V., and Culbertson, C. S.: Cat-scratch disease and Parinaud's oculoglandular syndrome: AMA Arch. Ophth., 50:68-74, 1953. 12. Henry, M.: Oculoglandular conjunctivitis due to leptothrix. J. Pediat., 37:535-544, 1950. 13. Rivers, T. M., and Horsfall, F. L.: Viral and Richettsial Infections of Man. Philadelphia, Lippincott, 1960, ed 3. 14. Belber, J. P., Davis, A. E., and Epstein, E. H.: Thrombocytopenic purpura associated with catscratch disease: Response of cat-scratch disease to steroid hormones. AMA Arch. Int. Med., 94:321-325, (Aug.) 1954. 15. Billo, O. E., and Wolff, J. A.: Thrombocytopenic purpura due to cat-scratch disease: Case reports of three brothers who were continuously exposed to 11 farm cats. J.A.M.A., 174:1824-1826 (Dec. 3) 1960. 16. Jim, R. T. S.: Thrombocytopenic purpura in cat-scratch disease. J.A.M.A., 176:1036-1038, 1961.
T R E A T M E N T : AN ETYMOLOGICAL N O T E THELMA CHAREN
West Hyattsville, Maryland "Random notes" might better have con veyed the importance of the ramblings set down here, a mere collection of tidbits re garding the etymology of words for medi cal treatment in various languages. I have made no attempt to array them in scholarly fashion and I offer no documentation be yond the standard language and etymologi cal dictionaries generally available. The simple bibliography will refer only to sources more obscure than those found in most ophthalmologists' libraries. These notes should give some insight into the meaning of words we see every day in medical liter ature but to which we give too casual thought. They are all words important to the goal of medicine: the treating of the patient and the healing of the disease by the practitioner of the art. The words treat and treatment and all related forms come through the French traiter from the Latin tractare, "to handle." Both French and Latin derivative pairs are used in English: treatise: tract; tractable: treatable; intractable: untreatable. This handXmg is itself actually basically the word hand, that is, "touching or feeling with the hand." This is precisely the same idea in manage: the Latin manus (hand) became the Italian mano whence maneggiare, "to
control by hand," or, in the more familiar French form, manage. The German count erpart for treatment or management is Be handlung which incorporates this very con cept of handling. The hand appears more importantly in the Greek derivative sur gery, that is, cheirourgia: the working by hand, the practice of any handicraft, and so the handicraft par excellence: cheirour gia. The Greek became chirurgia in Latin, thence it went to chirurgie in French and finally surgery in English. The same word cheir, hand, appears in chiropody and chiro practic. Since we have mentioned the Greek it will not be amiss to discuss at this point therapy with its European variants thérapie and terapia. The Greek noun therapon meant simply an "attendant" or "servant" and the verb (infinitive) therapeuein, "to wait on," "to serve," or "to attend." The general "serving" became the more spe cialized kind of waiting on, the therapeutic kind or therapeia, medical therapy. The serving or attending of the sick is inherent in this word which contrasts with the heal ing or curing concept of the derivatives of iaomai from which we get the word iater or iatros seen in iatrogenic, pediatrics, ephebiatrics, podiatry, psychiatry, geriatrics,