A female child aged 11 years and four months old was admitted to the hospital for "recurrent fever with cough for 15 days". Fifteen days before admission, the child had a recurrent fever after vomiting as the primary manifestation, and chills and shivers accompanied the high fever, and the blood cell content in the hospital and ours indicated an increase in leukocytes (11.53×109/L) and CRP (> 10 mg/L). After treatment with piperacillin-sulbactam infusion (Frequency and dosage were unknown) and cough suppression in the hospital, the fever peak decreased, and the child was brought to our hospital. The blood cell count in our hospital indicated elevated CRP and erythrocyte sedimentation rate. Therefore, the child was admitted to our department with a " fever of unknown origin, sepsis, and bronchitis". She said she was scratched by a cat on her left wrist two months ago and bled, which was not treated then.
Physical Examination
The physical examination on admission showed a clear consciousness, a red rash on both lower extremities with itching, no subcutaneous bleeding, and no enlarged superficial lymph nodes. The heart, lungs, abdomen, and neurological examination were not special.
Ancillary Tests
A small pelvic effusion and enlarged left inguinal lymph nodes were observed on CT before admission. Blood cell count showed that WBC was 10.5×109/L, N was 59.9%, HGB was 104 g/L, PLT was 320×109/L, and CRP was 36.4 mg/L. The assessments of renal function, urine and stool routine, and autoantibodies were not abnormal. The evaluations of Rheumatoid factors and ferritin indicated 606 IU/ml of ASO, 34.79 mg/L of hs-CRP, and 2.6 g/L of a1-AG, and the rest were generally normal. TORCH infectious pathogens tests indicate 1.57 of HSV-IgM. The rest of the values are approximately normal. The purified protein derivative (PPD) tuberculin skin test, Mycoplasma pneumonia, Chlamydia pneumonia, nucleic acid-based detection of respiratory pathogens, T-SPOT, human parvovirus B19 antibody, CCP-IgG, blood culture, and cerebrospinal fluid culture were all negative. Bone marrow examination and cardiac ultrasound showed no abnormalities. Chest CT showed small nodular shadows in the upper lobe of the right lung and the lower lobe of both lungs, primarily chronic inflammation, and ground glass density nodular shadows in the dorsal segment of the lower lobe of the right lung. MRI of the head showed no significant abnormalities in the brain parenchyma, but a mucosal thickening of the left mastoid was detected.
Treatment
After admission, cefoperazone sodium, sulbactam sodium, and azithromycin were given to fight the infection. However, the fever was still recurrent after five days of use, with complaints of headache during the fever. But there was no special neurological examination, so she was given cranial MRI, lumbar puncture, bone marrow aspiration, and metagenomics next-generation sequencing of the whole blood. Cerebrospinal fluid cytology showed 50×106/L of nucleated cells, 6.0% of neutrophils, 78% of lymphocytes, and 16.0% of monocytes. Cerebrospinal fluid biochemistry, cerebrospinal fluid smear, and pathogenic nucleic acid of cerebrospinal fluid were not significantly abnormal.
Given that the child was considered to have meningitis and was treated with multiple antibiotics in another hospital, the child was treated with vancomycin and ceftriaxone sodium for anti-infection and acyclovir for antiviral treatment. After 5-day treatment, the child still had a recurrent fever. The metagenomics next-generation sequencing of the whole blood showed Bartonella henselae, so the diagnosis of cat scratch disease was confirmed. The temperature was normalized after one day of rifampicin and prednisone acetate, and doxycycline was added after one week of treatment. After two weeks of rifampicin + doxycycline + prednisone acetate treatment, the child's temperature was normal, the red rash on both lower limbs subsided, and the pharynx was slightly red. The routine blood tests showed 8.3×109/L of WBC, 70.6% of N, 126 g/L of HGB, 405×109/L of PLT, and CRP < 0.5 mg/L; Biochemistry showed no abnormality of liver and kidney function. She was discharged after 23 days of hospitalization. She was advised to continue taking rifampicin, doxycycline, and prednisone acetate orally for four weeks after discharge, during which hepatic and renal function was rechecked every week, and medication was adjusted according to the results. After four weeks of follow-up by telephone, the child's body temperature remained normal, weight increased significantly, and the dose of prednisone tablets was adjusted on an outpatient basis.