A 3-year-old girl is brought to the clinic for evaluation of a lump on her left axilla. Her parents first noticed the lump 3 days ago; they placed cold compresses on the mass with no relief. The mass is now tender to the touch but has not changed in size or had any discharge. The patient had a fever a few weeks ago but it resolved after several days; she is otherwise healthy. Immunizations are up to date. She attends day care and has 2 dogs and a kitten at home. Temperature is 37.8 C (100 F). The child is alert and appears in no acute distress. Examination of the axilla shows a warm, tender, mobile left axillary lymph node that is approximately 2 cm (0.8 in) in diameter. Cardiac examination reveals no murmurs. The lungs are clear to auscultation bilaterally. The abdomen is soft, nontender, and without hepatosplenomegaly. The left index finger has a small erythematous, painless papule on the dorsal aspect. Both hands and arms have several superficial linear abrasions. In addition to clindamycin, which of the following is the most appropriate pharmacotherapy for this patient?

Question

A 3-year-old girl is brought to the clinic for evaluation of a lump on her left axilla.  Her parents first noticed the lump 3 days ago; they placed cold compresses on the mass with no relief.  The mass is now tender to the touch but has not changed in size or had any discharge.  The patient had a fever a few weeks ago but it resolved after several days; she is otherwise healthy.  Immunizations are up to date.  She attends day care and has 2 dogs and a kitten at home.  Temperature is 37.8 C (100 F).  The child is alert and appears in no acute distress.  Examination of the axilla shows a warm, tender, mobile left axillary lymph node that is approximately 2 cm (0.8 in) in diameter.  Cardiac examination reveals no murmurs.  The lungs are clear to auscultation bilaterally.  The abdomen is soft, nontender, and without hepatosplenomegaly.  The left index finger has a small erythematous, painless papule on the dorsal aspect.  Both hands and arms have several superficial linear abrasions.  In addition to clindamycin, which of the following is the most appropriate pharmacotherapy for this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf87_efbe_8f63_fb0a6d5a1b04_MD0005_00 This patient's localized papule and regional lymphadenopathy following cat exposure are consistent with cat-scratch disease (CSD). CSD is caused by Bartonella henselae, a fastidious gram-negative bacillus carried by the majority of cats, especially kittens. B henselae can be transmitted by a scratch or bite, or (rarely) by a flea. In many cases, patients do not recall a specific scratch or bite. Patients typically have a skin lesion that can be erythematous, papular, or nodular. Fever is present in <50% of cases. Regional lymphadenopathy follows within 1-2 weeks; it is the hallmark of CSD and can be the presenting sign if the skin lesion goes unnoticed. Affected lymph nodes are tender and erythematous; suppuration is less common. Cat exposure and symptoms consistent with CSD are usually sufficient to make a clinical diagnosis. Mild cases in healthy patients often self-resolve within 1-4 months; however, azithromycin is effective against B henselae and has been shown to decrease the length and severity of symptoms. In unclear cases, antistaphylococcal and streptococcal coverage (eg, clindamycin) may be added to empirically treat the most common organisms causing lymphadenitis. (Choices A and C) Several antibiotics have in vitro activity against Bartonella, including penicillins (eg, amoxicillin) and third-generation cephalosporins (eg, cefdinir), but are not proven to improve clinical outcomes. (Choice D) Cephalexin is a first-generation cephalosporin that treats staphylococcal and streptococcal skin infections but has no activity against most gram-negative pathogens, including Bartonella. (Choice E) Doxycycline (plus rifampin) treats neurologic manifestations of CSD in patients age >8. However, prolonged doxycycline is avoided in young children due to the risk of dental staining, and this patient has no neurologic findings. Educational objective: Cat-scratch disease generally presents with a cutaneous lesion and regional lymphadenopathy following a cat scratch or bite. Azithromycin treatment can reduce the length and severity of symptoms. References: Cat-scratch disease. (http://www.ncbi.nlm.nih.gov/pubmed/21243990)

A 3-Year-Old Girl Is Brought to the Clinic for Evaluation