Radiological Case of the Month FREE

DURING THE early fall, a previously healthy 10-year-old child had a fever (temperature, 39.4°C) and upper respiratory tract symptoms of cough and rhinorrhea. No abnormalities were seen on a chest radiograph. His fever persisted despite a 10-day course of clarithromycin. On reexamination the patient was found to have acute otitis media and sinusitis, which were treated with the combination drug, amoxicillin–clavulanate potassium for 10 days. He continued to have a low-grade fever, malaise, and exudative tonsillitis, and developed generalized lymphadenopathy, night sweats, and, abdominal, back, and flank pain 5 weeks after the onset of illness. Urine culture and Epstein-Barr Virus titers were negative. Abdominal radiographs showed no abnormalities, but an abdominal ultrasound examination showed cystic lesions in the liver. He was subsequently referred for further evaluation.

The patient had a history of upper respiratory tract infections. The patient's history also revealed that he had been exposed to many animals including chickens, turkeys, salamanders, dogs, cats, rats, tarantulas, and sheep. Both parents and 2 siblings were healthy except for a history of respiratory allergies.

On physical examination, the patient was noted to have hepatomegaly and generalized lymphadenopathy. Preliminary laboratory test results showed a total white blood cell count of 11.0×10³ cells/mm³, a hemoglobin count of 130 g/L, a hematocrit of 0.37, and a platelet count of 289×10⁹/L. The patient's liver enzyme, amylase, and electrolyte values were within the normal range. An abdominal computed tomographic scan (Figure 1), with contrast, showed high-attenuation nodular fluid–containing lesions of soft tissue density that were diffusely distributed in the liver. The largest lesion measured 2.2 cm in diameter. A computed tomographic scan of the sinuses showed pansinusitis. A chest computed tomographic scan showed irregular soft tissue densities in the posterior lung bases bilaterally representing areas of atelectasis. Multiple serologic examinations were obtained including those for human immunodeficiency virus, hepatitis A, B, and C, cytomegalovirus, Echinococcus sp, Entamoeba histolytica, Toxocara sp, Mycoplasma, Toxoplasma, and alpha₁-fetoprotein. A single photon emission computed tomographic technetium Tc 99m sulfur colloid liver-spleen scan was performed to differentiate between focal nodular hyperplasia and hepatic adenomas (Figure 2). The procedure demonstrated multiple "cold" liver defects and splenomegaly. A single photon emission computed tomographic red blood cell liver scan tagged with ^99m Tc microlite showed no hemangiomas.

The patient continued to have a low-grade fever. He was treated for his sinusitis with intravenous cefotaxime sodium. On the third day in the hospital, a liver biopsy was performed. Necrotizing granulomas, extensive neutrophilic infiltrates, and plasma cells were present. Gram stains and special stains for acid-fast bacteria and fungus showed no microorganisms. A Steiner-Steiner stain for cat-scratch disease revealed elements highly suspicious, but not definite, for Bartonella henselae. Tissue specimens cultured for bacteria, acid-fast bacteria, and fungus were negative. Polymerase chain reaction on liver tissue revealed B henselae DNA. There was no evidence of Bartonella quintana DNA.

Serologic test results were all negative except for B henselae and titers of IgG of 110 optical deurity (OD) and IgM of 36 OD (cutoff 12 OD). Bacterial urine and blood cultures were negative for organisms. Purified protein derivative testing gave negative results with positive tetanus controls. An absolute CD4 cell count performed initially showed 0.43×10⁹/L.