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Ocular Bartonellosis

  • Saira Farid
    Correspondence
    Correspondence: Address to Saira Farid, MD, Division of Infectious diseases, Department of Medicine, Mayo Clinic College of Medicine and Science, 200 First Street SW, Rochester, MN 55905.
    Affiliations
    Division of Infectious Diseases, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
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  • M. Rizwan Sohail
    Affiliations
    Division of Infectious Diseases, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
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      A 23-year-old woman presented with a 2-week history of progressive blurring of vision in her left eye, associated with fever, fatigue, and myalgia. The patient had a pet cat and reported incidents of being scratched. Her fundus examination revealed optic disc edema and macular satellite exudates/star bilaterally (Figure). Laboratory test results revealed a normal complete blood count and liver enzymes. Screening results for human immunodeficiency virus, Lyme disease, syphilis, and tuberculosis were negative. Head magnetic resonance imaging and cerebrospinal fluid test results were unremarkable. A Bartonella henselae IgG titer test result was more than 1:1024. Ocular bartonellosis was diagnosed on the basis of funduscopic findings and strongly positive serology.
      Figure thumbnail gr1
      FigureColor fundus photos of the left eye and right eye, which demonstrate substantial subretinal fluid with macular star pattern exudates (black arrows). Both eyes exhibit multiple, small, elevated circular white lesions (white arrows) with slightly tortuous venules. The exudates are more substantial in the left eye. Both eyes have massive disc edema, which is more predominant in the left eye. No snowballs or snowbanks are present in either eye.
      Approximately 5%-10% of patients with cat-scratch disease have ocular involvement, most commonly Parinaud's oculoglandular syndrome, followed by neuroretinitis in 1%-2%.
      • Solley W.A.
      • Martin D.F.
      • Newman N.J.
      • et al.
      Cat scratch disease: posterior segment manifestations.
      • Chi S.L.
      • Stinnett S.
      • Eggenberger E.
      • et al.
      Clinical characteristics in 53 patients with cat scratch optic neuropathy.
      Optic disc edema and unilateral vision loss are typical early findings. Subsequently, exudative optic neuritis transudes into the macula and forms a macular star in 2-4 weeks. Patients may develop retinal detachment, multifocal retinitis or choroiditis, and vasculitis. Serology is the most common method of diagnosis. Immunofluorescent antibody IgG titer of more than 1:64 for B. quintana or B. henselae indicates possible infection, and a titer of more than 1:256 strongly suggests recent or acute infection. Polymerase chain reaction testing of ocular fluid can help to confirm the diagnosis. The role of antimicrobial therapy is debatable, with some data suggesting no difference in outcome, especially in mild cases with visual acuity of 20/25 or better.
      • Chi S.L.
      • Stinnett S.
      • Eggenberger E.
      • et al.
      Clinical characteristics in 53 patients with cat scratch optic neuropathy.
      • Bhatti M.T.
      • Lee M.S.
      Should patients with bartonella neuroretinitis receive treatment?.
      However, 4-6 weeks of combination therapy with doxycycline and rifampin (as in our case) may shorten the duration of illness.
      Learning points from this case are as follows. Cat-scratch disease will have ocular involvement for 5%-10% of patients, and young patients tend to be affected more. Bilateral neuroretinitis is rare. Optic disc edema and macular satellite exudates or star are characteristic findings in cat scratch disease–related neuroretinitis. In patients who have visual acuity of 20/25 or better at presentation, outcomes do not differ between treated and untreated patients, but a 4-6 week course of doxycycline/rifampin may enhance recovery and shorten the duration of illness. Visual acuity on presentation and presence of systemic symptoms determine the outcome and prognosis.

      References

        • Solley W.A.
        • Martin D.F.
        • Newman N.J.
        • et al.
        Cat scratch disease: posterior segment manifestations.
        Ophthalmology. 1999; 106: 1546-1553
        • Chi S.L.
        • Stinnett S.
        • Eggenberger E.
        • et al.
        Clinical characteristics in 53 patients with cat scratch optic neuropathy.
        Ophthalmology. 2012; 119: 183-187
        • Bhatti M.T.
        • Lee M.S.
        Should patients with bartonella neuroretinitis receive treatment?.
        J Neuroophthalmol. 2014; 34: 412-416