We report a 10-year-old girl with a 3.0- by 3.5-cm giant hepatic granuloma caused by Bartonella henselae. Such a solitary and large granuloma associated with B. henselae infection has not been previously reported. We believe that B. henselae infection is a consideration in the differential diagnosis of a large hepatic mass.
There have been several recent reports of hepatosplenic granulomas caused by Bartonella henselae.1–5 In these patients imaging studies revealed the presence of multiple hepatic and splenic lesions. We report a girl with a giant hepatic granuloma caused by B. henselae infection mimicking hepatic tumor.
A 10-year-old girl had a persistent fever of 38–39°C for 12 days, accompanied by back pain, headache and neck pain. She had no regional lymphadenopathy. She was treated with cefaclor, sparfloxacin and clindamycin for 10 days and gradually defervesced. On the 11th day a 3.0- by 3.5-cm mass was palpated in the left upper abdomen. The leukocyte count was 8.2 ×10 6 /l; C-reactive protein 3.9 mg/dl; aspartate aminotransferase 18 IU/l; alanine aminotransferase 14 IU/l; lactic dehydrogenase 292 IU/l; and alpha-fetoprotein 1.7 ng/ml. An abdominal computerized tomography (CT) scan showed a single 3.3- by 5.1-cm hypodense lesion in the left hepatic lobe (Fig. 1, left). The mass slightly decreased in size without therapy thereafter. On the 30th day she underwent a partial left hepatic lobectomy. A single 1.8- by 2.2-cm nodule and a few small nodules were seen in a cut section of the hepatic resection specimen (Fig. 1, right). Histopathologic diagnosis was multiple epithelioid granuloma. Polymerase chain reaction detected B. henselae DNA in tissue specimens, and the sequence of the amplicons was identical with that previously reported for B. henselae. 6 On the 35 day IgM antibody to B. henselae was negative, and IgG titer was 1/512 by an indirect fluorescence antibody method.
The hepatic and splenic lesions in patients with B. henselae infection are often multiple, small and can appear as hypoechoic or low attenuation lesions scattered throughout the hepatic or splenic parenchyma on ultrasonography or CT scans. 3 Most of these lesions ranged in size up to 10 mm. 1–3 The giant granuloma seen in this case is presumed to be rare. This case suggests that B. henselae infection must be considered in the differential diagnosis of a large hepatic mass.
1. Malatack JJ, Jaffe R. Granulomatous hepatitis in three children due to cat-scratch disease without peripheral adenopathy: an unrecognized cause of fever of unknown origin. Am J Dis Child 1993; 147: 949–53.
2. Dangman BC, Albanese BA, Kacica MA, Wallach MT. Cat scratch disease in two children presenting with fever of unknown origin: imaging features and association with a new causative agent, Rochalimaea henselae
. Pediatrics 1995; 95: 767–71.
3. Liston TE, Koehler JE. Granulomatous hepatitis and necrotizing splenitis due to Bartonella henselae
in a patient with cancer: case report and review of hepatosplenic manifestations of Bartonella
infection. Clin Infect Dis 1996; 22: 951–7.
4. Dunn MW, Berkowitz FE, Miller JJ, Snitzer JA. Hepatosplenic cat-scratch disease and abdominal pain. Pediatr Infect Dis J 1997; 16: 269–72.
5. Ventura A, Massei F, Not T, Massimetti M, Bussani R, Maggiore G. Systemic Bartonella henselae
infection with hepatosplenic involvement. J Pediatr Gastroenterol Nutr 1999; 29: 52–6.
6. Tsukahara M, Tsuneoka H, Iino H, Ohno K, Murano I. Bartonella henselae
infection from a dog. Lancet 1998; 352: 1682.