Acute Hepatitis in a 6 Year Old Boy: Who`s to Blame?

Background: Cat scratch disease (CSD) is a common infectious disease, caused by Bartonella Henselae, typically characterized by self-limited regional lymphadenopathy. CSD rarely causes disseminated illness, like hepatosplenic disease.

Hereditary spherocytosis’ (HS) presentation can vary from mild to severe depending on the degree of haemolysis and complications. HS can remain undetected until challenge by an infectious illness.

Case Report: A previously healthy 6-year-old boy, with family history of spherocytosis and exposure to cats, presented to our hospital with a 3-day history of fever, right cervical lymphadenomegaly, nonspecific rash, jaundice and choluria. He was previously medicated with amoxicillin/clavulanate for adenitis and suspected streptococcal tonsillitis. Laboratory test revealed: haemoglobin 11.1 g/dL; mean corpuscular volume 88 fl; mean corpuscular haemoglobin concentration (MCHC) 37.2 g/dL; reticulocytosis 0.21x10^6/uL; peripheral blood smear (PBS) with anisocytosis, toxic granulation and vacuolated neutrophils; C-reactive protein 1.17 mg/dL; hyperbilirubinemia (direct 3.21 mg/dL; indirect 5.28 mg/dL); aspartate aminotransferase 117 U/L; alanine aminotransferase 227 U/L; lactate dehydrogenase 578 U/L. Ultrasonography revealed mild splenomegaly and no parenchymal liver changes or structural cause of obstructive cholestasis. During hospital stay, there was an improvement in symptoms with supportive treatment followed by decreasing levels of aminotransferases and bilirubin. Serologic testing for putative infectious agents were negative. He was discharged four days later, asymptomatic. Post-discharge results were positive for Bartonella henselae IgM titers. No specific treatment was prescribed since the patient was asymptomatic by the time of results. Further studies on suspected spherocytosis were performed at a tertiary hospital.

Discussion: We considered a diagnosis of acute hepatitis due to infection of Bartonella Henselae, according to laboratory results, lymphadenomegaly and exposure to cats. Although there were no red blood cell abnormalities in PBS, HS is suspected because of a positive family history, increased MCHC and hemolysis.