Ataxia following an altercation... with a cat
© Defres et al; licensee BioMed Central Ltd. 2008
Published: 23 September 2008
Cat scratch disease is caused by infection with Bartonella henselae of which cats serve as the natural reservoir. The disease is typically characterized by self-limiting regional lymphadenopathy. Although rare, < 2% of cases, a wide range of neurological manifestations have been described including encephalopathy, cerebellar ataxia, radiculitis and transverse myelitis. We present a 30 year old immunocompetent man who was admitted to the medical admission unit with a 4 day history of fever and headache. Examination findings were negative for any meningism and only revealed a temperature of 38.6 and an enlarged right epitrochlear lymph node. His 5th digit on his right hand was inflamed at the site of a previous cat scratch 8 weeks prior. He underwent excision biopsy of the lymph node and commenced azithromycin thereafter. Within 2 days his fever had completely settled, however, he developed left sensorineural hearing loss, opthalmoplegia and some nocturnal agitation. CT head at this point excluded any space occupying lesions including abcesses. The following day he was found to have an ataxic gait. Neurological findings showed unremarkable limbs with the exception of limb ataxia. Cranial nerve examination revealed limited abduction bilaterally with associated nystagmus in the contra-lateral eye. In addition there was a left facial weakness involving both the upper and lower face and left sided sensorineural hearing loss. Clinically there was a concern of a Bickerstaff's brainstem encephalitis secondary to the cat scratch disease. Other infections were excluded. His neurological conditions continued to deteriorate over the following 48 hours, becoming progressively encephalopathic and ataxic and he was given a course of intravenous immunoglobulin. His neurological problems gradually resolved over the next 7 days. Later serology and PCR from the lymph node confirmed infection with Bartonella species.
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