A Rash of Little Scabs
Fishman listened to the young man’s story and then examined him. The lump on his neck was obvious. She had seen it from the doorway. But it wasn’t tender and moved easily, the way lymph nodes are supposed to. The rash was also easily seen, but on his arms she noticed something different. “What’s this?” she asked, pointing to some dots that looked like tiny scabs. That’s from my cats, the patient replied. They had four at home. They liked to play and sometimes left marks.
After the exam, Fishman excused herself and went out to look for the senior resident she was working with, Dr. Neeharika Namineni. The resident had also seen the patient and reviewed his records. Fishman described what she found and went over the test results from the E.D. His thyroid was normal. He didn’t have antibodies for Lyme or the other tick-borne diseases frequently seen in the Northeast, anaplasmosis and babesiosis. He didn’t have any antibodies for H.I.V. Fishman paused. Still, he could have early H.I.V., at the stage before antibodies are present. It takes four to six weeks to develop a measurable number of antibodies to most infections. Moreover, an acute H.I.V. infection can start with a fever and a rash. So first she would like to send off a test to look for the H.I.V. itself, to make sure he wasn’t in the earliest stages of that infection. He also had these cat scratches. Could this be cat-scratch fever or toxoplasmosis? Each of those diseases can be transmitted from cats to humans through scratches; each can cause a febrile illness and enlarged lymph nodes. Finally, could this be evidence of a hidden cancer — maybe a testicular cancer — that had spread to his lymph nodes?
Namineni thought infection more likely, but certainly cancer was possible. Fishman added tests for these pathogens to their orders. If all the tests came back negative, they would look for a cancer.
The next morning they met with the attending for the patient, Dr. Lloyd Friedman. Again Fishman described the patient and her thoughts. Friedman’s eyes lit up when the young woman mentioned the cat scratches. “I’m betting on cat-scratch fever,” he announced enthusiastically once she finished her presentation. Friedman wondered aloud if that infection can cause ITP. A quick search of the internet turned up a single case report. So it was uncommon but still possible. Friedman doubled down. The scratches, the fever, the hugely swollen lymph node: This felt to him like cat-scratch fever.
The patient got several doses of intravenous immunoglobulin over the next few days. It did its job — his platelet count began to inch back toward normal, going from 2 to 6 to 15 to 30 to 60. The patient hadn’t felt sick since he got to the hospital, and the blood in his urine and the sores in his mouth cleared up after the first dose of immunoglobulin.
With his platelet counts improving — though still far from normal — the patient was safe (and eager) to leave the hospital. Even after he left, Fishman monitored the labs for results. It wasn’t toxoplasmosis. It wasn’t acute H.I.V. Finally, they got their answer: He had cat-scratch fever, an infection caused by a bacterium called Bartonella henselae. By then the patient’s symptoms were long gone. Even the swollen lymph node was barely visible.
