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SALIVARY GLAND RED HERRINGS IV -- CAT SCRATCH DISEASE SEPT. 1997 Three red herrings (masseteric hypertrophy, phleboliths, and somatoform problems) have been reported previously in this Newsletter. A fourth red herring seen in the Salivary Gland Center (SGC), mimicking a sialadenitis or salivary gland tumor, is cat scratch disease (CSD). CSD is a benign self-limiting unilateral regional lymphadenopathy characterized by a necrotizing granulomatous inflammation. The responsible agent, now identified as Bartonella henselae, is a gram negative bacillus. The cat's paws probably acquire the organism from the soil and transmit it to humans, mostly children and young adults, via a scratch. Macrophages then transport the bacillus from the inoculation site to regional nodes. Within a week following the scratch, a papule develops followed by a regional tender lymphadenitis occasionally accompanied by fever and malaise. Since the unprotected head and neck areas are frequently scratched, lymphadenopathy often involves intraparotid, paraparotid, parasubmandibular and adjacent cervical lymph nodes. The intimate relation of these nodes to the salivary glands may lead to a misdiagnosis of sialadenitis or salivary gland neoplasm. Spontaneous resolution of the lymphadenopathy (3-4 months) can be expected, but progression to suppuration may occur. The SGC can readily differentiate salivary gland involvement from extraglandular lymphadenopathy. Clinical history and palpation are efficient diagnostic measures. Patients with CSD do not have accentuation of pain and swelling when eating. A clear saliva exiting from the suspected gland's duct, rather than a cloudy saliva signifying infection, is observed in an innocent salivary gland. Furthermore, imaging procedures are effective in diagnosing inflammatory or neoplastic salivary gland disease.
Treatment? Symptomatically mild cases require no intervention. Systemic manifestations of CSD mandate antibiotic therapy. Oral rifampin or ciprofloxacin are most effective. Suppurative progression may be managed by aspiration or excision of the offending node.
The Salivary Gland Center (SGC) was developed because a void existed in the diagnostic and comprehensive care of patients with salivary gland problems and/or secretory dysfunction. Since the diversity of these salivary conditions presents challenges to the clinician, the SGC is available for referrals. Louis Mandel, DDS Director, Salivary Gland Center (212) 305-9982
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Diagnosis
of CSD requires a history of a recent cat scratch and a negative
study for other causes of lymphadenopathy. Biopsy reveals granulomatous
lymphadenitis. The Warthin-Starry silver stain can identify the
culpable I bacillus in the lymph node. A skin test for CSD, prepared
from the pus of an I infected patient, is reliable but unlicensed.
Serology testing has recently become available.