Parrino eye-glandular syndrome

Introduction Parinud's oculoglandular syndrome (POGS): In cat scratching, a small number of children (about 6%) develop this syndrome, which is caused by ocular granuloma or pre-auricular lymphadenopathy. Membrane inflammation. Carithers (1978) reported 14 cases of atypical cat scratch disease with this syndrome, and emphasized the characteristics of granulomatous lesions. Red to yellow nodules of 2 to 3 mm or even more than 1 cm were seen at the orbital membrane. . The appearance of ocular symptoms may be due to the direct or indirect entry of Hanseba into the eyelids. This syndrome is a self-limiting infection with a good prognosis. Palino eye-adenosed syndrome may also be caused by tuberculosis, rabbit fever, inguinal lymphogranuloma and syphilis, but recently the serine-specific DNA has been determined by serological detection and PCR techniques. This syndrome has been confirmed to be The most common form of atypical cat scratching.

Cause

(1) Causes of the disease

The pathogen of this disease was proved to be a polymorphic bacterium by Wear et al in 1983, and was negative for Gram stain. It was once called a caterpillar bacillus, and was named as Afipia felis by Brenner et al. (1991). . In the future, many studies could not prove that the pathogen of this disease was Effie, until Regenery et al. (1992) isolated two pathogens from the lymph nodes of typical cat scratch patients, which were identified as belonging to Rocalimae. One species, called the R. henselae. With the recommendation of Brenner et al. in 1993 to incorporate the Rokalima body into the Baton genus, the pathogen was officially known as Bartonella henselae. Among the biological traits of Hanseba, the morphology, culture, biochemical reaction and cell wall fatty acid composition are basically the same as those of the five-day thermobaine, and the alanine-tRNA (tRNAAla) gene sequence is also the same. The Hanseba citrate synthase gene (gltA) sequence is 65%, 63% and 66% identical to the rickettsia rickettsia, the Bayesian rickettsia and the E. coli gltA gene, respectively. Western blotting showed a clear serological cross-reaction between Hanseba and the five-day heat bar. One of the 48.5 kD dominant antigen proteins was shared by the five-day fever, Hansai, and Wansenba.

(two) pathogenesis

After the pathogen enters the human body, it can be spread through the lymphatic system or blood source, causing damage to multiple organs throughout the body. The pathogenesis is still unclear and may be related to the development of delayed allergic reactions in certain components of the Hanseba. When the body's immune function is normal, the pathological reaction is granuloma-like and suppurative; when the body's immune function is low, the pathological reaction is vascular proliferation. Early electron microscopy showed that there were pleomorphic Gram-negative pathogens in the vessel wall and macrophages, which were arranged in a single small body or in a chain or clustered, suggesting that the pathogen has affinity vascular endothelial cells. It has been reported that this pathogen can be found in cat red blood cells, suggesting that it also has affinity for red blood cells. Through the patient's lymph node biopsy, a stellate necrotizing granuloma appears in the paracortical area and between the follicles in the lymph nodes of the lesion. Later, a multi-focal small abscess was formed, and then merged into a larger abscess by suppuration. Epithelioid cells were seen at the edge of the abscess, and occasionally multinucleated giant cells. The lymph node is thickened. After several weeks to several months, fibroblasts proliferate in the lymph nodes and gradually form scars. Pathogens can be detected by using Warthin-Starry silver staining method in diseased tissues within 1 to 4 weeks.

an examination

1. Blood routine: the total number of white blood cells decreased in the early stage of the disease, the lymph nodes became mildly elevated, the neutrophils increased, and the erythrocyte sedimentation rate accelerated.

2. Pathogen culture and isolation: The Hanseba body can be isolated and cultured from the patient's blood, lymph node pus and primary skin lesions, and the diagnosis is positive. However, most of the pathogens are cell wall-deficient, and the culture conditions are relatively high. Only in the blood or chocolate medium, they can be cultured for 6 weeks in a 35 ° C carbon dioxide incubator, and then visible by Warthin-Starry silver staining method. Gram-negative bacilli. Therefore, it cannot be used as an early diagnosis method and is limited in clinical application.

3. Immunological examination

(1) Skin test: The cat scratching antigen has not yet been commercialized, so it is more valuable to use the antigen from the lymph node puncture liquid for sterilization. Skin test method: Take 0.1ml of the forearm and intradermal injection of the forearm. For 48h, the induration with diameter 5mm is positive, surrounded by 30~40mm edema flush, the blush generally exists for 48h, and the induration can last for 5-6 days or 4 weeks. . The skin test is a delayed type of allergic reaction, which is more sensitive and specific, and its false positive is about 5%. The diagnosis of cat scratching can be excluded by repeating 2 times at 4 weeks intervals. The positive skin test after infection can be maintained for more than 10 years.

(2) Indirect immunofluorescent antibody test (IFA): The serotonin-labeled antigen was used to measure the specific antibody against Hansaiba in the serum of the patient, and the titer was 1:64. The positive rate was reported to be 88%, and the control group was only 3%. In the early stage of the disease and 4 to 6 weeks, the serum titers increased by more than 4 times, which is also meaningful for diagnosis. This test is a simple, rapid, sensitive and specific method for the diagnosis and treatment of this disease.

(3) Enzyme-linked immunosorbent assay: detection of anti-Hansaiba T-body IgM antibody, sensitive, specific, and clinical diagnostic value. ELISA ~ IgG antibodies are less sensitive and cannot be used as a laboratory diagnostic criteria.

The above IFA and ELISA-IgM antibodies were used as serological diagnostic criteria for cat scratching, and the two were rarely different in serotype and cross-reacted with the five-day heat barton. If the type is to be classified, it should be cultured for further clarification.

4. Molecular biological detection: In recent years, PCR, nested PCR or PCR in situ hybridization technology was used to detect the DNA of Hansaiba DNA from lymph node biopsy specimens and pus, with a positive rate of 96%. However, this method with high specificity and sensitivity requires high experimental conditions and is difficult to be used as a routine clinical examination. PCR detection of Hansai and R. chinensis DNA, a pair of specific primers for CAT1 and CAT2, the nucleotide sequence (5'3') is GATTCAATTGGTTTGAA (G and A) GAGGCT and TCACAATCACCAGG (A and G) CGTATTC, a 414 bp fragment product can be amplified.

5. Histopathological examination: For the biopsy tissue for Warthin-Starry and Brown-Hopps tissue staining or tissue electron microscopy, it is helpful for diagnosis. However, tissue staining does not distinguish between different bacterial types or other pathogens of the baton.

Early electron microscopy showed that there were pleomorphic Gram-negative pathogens in the vessel wall and macrophages, which were arranged in a single small body or in a chain or clustered, suggesting that the pathogen has affinity vascular endothelial cells. It has been reported that this pathogen can be found in cat red blood cells, suggesting that it also has affinity for red blood cells. Through the patient's lymph node biopsy, a stellate necrotizing granuloma appears in the paracortical area and between the follicles in the lymph nodes of the lesion. Later, a multi-focal small abscess was formed, and then merged into a larger abscess by suppuration. Epithelioid cells were seen at the edge of the abscess, and occasionally multinucleated giant cells. The lymph node is thickened. After several weeks to several months, fibroblasts proliferate in the lymph nodes and gradually form scars. Pathogens can be detected by using Warthin-Starry silver staining method in diseased tissues within 1 to 4 weeks.

Differential diagnosis

The disease should be differentiated from lymphoma, tuberculosis, rabbit fever, sexually transmitted lymphogranuloma and AIDS.

1. Blood routine: the total number of white blood cells decreased in the early stage of the disease, the lymph nodes became mildly elevated, the neutrophils increased, and the erythrocyte sedimentation rate accelerated.

2. Pathogen culture and isolation: The Hanseba body can be isolated and cultured from the patient's blood, lymph node pus and primary skin lesions, and the diagnosis is positive. However, most of the pathogens are cell wall-deficient, and the culture conditions are relatively high. Only in the blood or chocolate medium, they can be cultured for 6 weeks in a 35 ° C carbon dioxide incubator, and then visible by Warthin-Starry silver staining method. Gram-negative bacilli. Therefore, it cannot be used as an early diagnosis method and is limited in clinical application.

3. Immunological examination

(1) Skin test: The cat scratching antigen has not yet been commercialized, so it is more valuable to use the antigen from the lymph node puncture liquid for sterilization. Skin test method: Take 0.1ml of the forearm and intradermal injection of the forearm. For 48h, the induration with diameter 5mm is positive, surrounded by 30~40mm edema flush, the blush generally exists for 48h, and the induration can last for 5-6 days or 4 weeks. . The skin test is a delayed type of allergic reaction, which is more sensitive and specific, and its false positive is about 5%. The diagnosis of cat scratching can be excluded by repeating 2 times at 4 weeks intervals. The positive skin test after infection can be maintained for more than 10 years.

(2) Indirect immunofluorescent antibody test (IFA): The serotonin-labeled antigen was used to measure the specific antibody against Hansaiba in the serum of the patient, and the titer was 1:64. The positive rate was reported to be 88%, and the control group was only 3%. In the early stage of the disease and 4 to 6 weeks, the serum titers increased by more than 4 times, which is also meaningful for diagnosis. This test is a simple, rapid, sensitive and specific method for the diagnosis and treatment of this disease.

(3) Enzyme-linked immunosorbent assay: detection of anti-Hansaiba T-body IgM antibody, sensitive, specific, and clinical diagnostic value. ELISA ~ IgG antibodies are less sensitive and cannot be used as a laboratory diagnostic criteria.

The above IFA and ELISA-IgM antibodies were used as serological diagnostic criteria for cat scratching, and the two were rarely different in serotype and cross-reacted with the five-day heat barton. If the type is to be classified, it should be cultured for further clarification.

4. Molecular biological detection: In recent years, PCR, nested PCR or PCR in situ hybridization technology was used to detect the DNA of Hansaiba DNA from lymph node biopsy specimens and pus, with a positive rate of 96%. However, this method with high specificity and sensitivity requires high experimental conditions and is difficult to be used as a routine clinical examination. PCR detection of Hansai and R. chinensis DNA, a pair of specific primers for CAT1 and CAT2, the nucleotide sequence (5'3') is GATTCAATTGGTTTGAA (G and A) GAGGCT and TCACAATCACCAGG (A and G) CGTATTC, a 414 bp fragment product can be amplified.

5. Histopathological examination: For the biopsy tissue for Warthin-Starry and Brown-Hopps tissue staining or tissue electron microscopy, it is helpful for diagnosis. However, tissue staining does not distinguish between different bacterial types or other pathogens of the baton.

6. Early electron microscopy of infection showed that there were pleomorphic Gram-negative pathogens in the blood vessel wall and macrophages, which were arranged in a single small body or in a chain or clustered, suggesting that the pathogen has affinity vascular endothelial cells. It has been reported that this pathogen can be found in cat red blood cells, suggesting that it also has affinity for red blood cells. Through the patient's lymph node biopsy, a stellate necrotizing granuloma appears in the paracortical area and between the follicles in the lymph nodes of the lesion. Later, a multi-focal small abscess was formed, and then merged into a larger abscess by suppuration. Epithelioid cells were seen at the edge of the abscess, and occasionally multinucleated giant cells. The lymph node is thickened. After several weeks to several months, fibroblasts proliferate in the lymph nodes and gradually form scars. Pathogens can be detected by using Warthin-Starry silver staining method in diseased tissues within 1 to 4 weeks.

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