Penile chancre: an unusual presentation of cat-scratch disease

Cat-scratch disease (CSD) is an infectious disorder that begins in the skin but classically spreads to the adjacent lymph nodes. Bartonella henselae is the predominant but not the sole cause of CSD; in 1995, Clarridge et al. isolated a new Bartonella species.1 Bartonella species have been characterized as arthropod-transmitted haemotropic Gram-negative bacteria of small mammals, fish and birds. Human exposure to Bartonella occurs after contact with a cat.2 The micro-organism enters the skin through a scratch or previous site of injury.3–5 CSD begins with a papule or pustule that develops in 3–14 days along the initial scratch line. These papules and pustules typically develop within a few days of the scratch. This stage of disease is followed 5–50 days later by the development of a regional lymphadenopathy (> 90% of patients) in nodes proximal to the scratch. CSD is a self-limiting condition and normally resolves without treatment. Patients may have fever, headache and malaise but most patients generally feel well. A few patients with CSD demonstrate unusual presentations. They develop lesions in other locations that present more serious health concerns. Atypical manifestations of CSD include tonsillitis, encephalitis, cerebral arthritis, granulomatous hepatitis, osteolysis, pneumonia bacillary angiomatosis and oculoglandular syndrome of Parinaud.6,7 We describe an atypical presentation of CSD. A 40-year-old man presented a large painless erosion on the distal shaft of the penis, lymphadenopathy of both groins and axilla, fever (38 °C), headache and malaise (Fig. 1). The serologic tests specific for syphilis, hepatitis B and C, and human immunodeficiency virus were normal. Other causes of lymphadenopathy were negative, too. Laboratory tests indicated increased values of erythrosedimentation rate, white blood cell count, aspartate-aminotransferase and alanine-aminotransferase. Two to three days later, the chancre was resolved while suppurative lymphadenitis of the right groin appeared. The culture of the fine needle aspiration from the right groin lymph node was negative for fungal and bacterial infections. The histopathological examination of the surgical specimen showed architectural disarrangement with foci of necrosis in the paracortical zone, surrounded by a palisade of epithelioid histiocytes associated with epithelioid granulomas. Immunohistochemical analysis with monoclonal antibody (ABCAM 1 : 5) demonstrated occasional positivity in the cytoplasm of histiocytic epithelioid cells