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C Oliveira Paulo1, Maria Luis Sacras1, C Figueiredo1, Flora Candeias1, Maria  João Brito1

1- Unidade de Infecciologia, Área de Pediatria Médica, Hospital Dona Estefânia, Centro Hospitalar Lisboa Central EPE, Lisboa

- 9th world congress of the world society for pediatric infectious diseases (wspid), Rio de Janeiro (Brasil), 18 a 21 de Novembro 2015 (Poster)

Introduction: Fever of unknown origin is a diagnostic challenge in daily practice. Although most underlying causes are common, with atypical manifestations, when the investigation doesn´t lead to an obvious diagnosis, infrequent causes should be considered.
Case report: Previously healthy 9 year old boy, presented with 8 week history of fever. His immunization program was updated; he lived in an urban region; didn´t consume unpasteurized dairy; had no recent travels. Physical examination revealed submandibular lymphadenopathy (1,2cm) with no inflammatory signs. Bloodwork: haemoglobin of 11,6g/dL, 12.000 leucocytes, 10% of monocytes, 10 mm/h sedimentation rate, reactive c protein 114,1mg/L. Cervical echography showed three solid hypoechoic heterogeneous nodules, largest with 15,3mm. Echocardiogram showed dilated left coronary artery (z-score 2,36), raising the hypothesis of atypical Kawasaki disease and immunoglobulin 2g/Kg was started. Subsequent re-evaluations showed no echographic or clinical improvement. Abdominal echography showed multiple hypoechoic nodules (5-13mm) in both hepatic lobes and spleen, and small mesenteric lymphadenopathies. Afterwards an angio-CT showed those nodules with contrast captation, suggesting hypervascularity. An excisional hepatic biopsy was performed through laparotomy and pathology reported fibrogranulomatous reaction with abscess, with no evidence of malignancy. Polymerase Chain Reaction was positive for Bartonella henselae. A 6 week treatment with rifampicin and ciprofloxacin resolved the fever, hepatosplenic and ganglionar nodules. Further enquiry revealed contact with an infected cat.
Conclusions: Hepatosplenic bartonellosis is an atypical and rare presentation of the cat-scratch disease (5-14%). In this clinical case, the echographic finding of dilated coronary arteries delayed the diagnosis, showing that the anamnesis is key to clinical investigation.

Palavras Chave: fever of unknown origin; Bartonella henselea;hepatosplenic