A case of cat scratch disease neuroretinitis confirmed by polymerase chain reaction

BACKGROUND: Cat scratch disease neuroretinitis is caused by infection by Bartonella henselae. To demonstrate B. henselae infection, serologic examination is commonly used, but sometimes serologic examination is not adequate for correct diagnosis. Here we present a case of cat scratch disease neuroretinitis confirmed by polymerase chain reaction in addition to serologic examination. CASE: A 55-year-old woman, presenting with headache and high fever, had noticed visual disturbance. The best-corrected visual acuity in her right eye was 0.01. Meningitis, optic neuritis and retinitis were observed and she was treated with oral prednisolone. After repeated questioning, the patient remembered being scratched by a cat. Systemic examination focusing on B. henselae infection was conducted and B. henselae-specific immunoglobulin (Ig) G, but not IgM, was detected in both serum and cerebrospinal fluid. To confirm B. henselae infection, polymerase chain reaction (PCR) analysis using cerebrospinal fluid was performed and the presence of B. henselae-specific DNA was demonstrated. From these results, we diagnosed cat scratch disease neuroretinitis and treated the patient with minocycline hydrochloride together with prednisolone. Following this treatment regimen, the patient's condition improved, and the best-corrected visual acuity in her right eye increased to 0.6 five months after the onset.CONCLUSION: The PCR technique is useful to correctly diagnose cat scratch disease neuroretinitis, if patients exhibit marginal data on B. henselae-specific antibody titer.     

Pattern Visual Evoked Potentials in Eyes with Disc Swelling due to Cat Scratch Disease-associated Neuroretinitis

Purpose: To evaluate optic nerve function by pattern visual evoked potentials (VEPs) in eyes with optic disc swelling due to neuroretinitis associated with cat scratch disease (CSD). Methods: Four eyes of four patients with marked optic disc swelling resembling optic neuritis but diagnosed serologically as CSD received systemic steroid treatment. VEPs elicited by black and white checkerboard stimuli created on a TV monitor were recorded before the treatment. Results: The visual acuity (VA) in the affected eyes was decreased to 20/50 in two eyes and finger counting in two eyes at their initial visits. Ophthalmoscopic examination revealed neuroretinitis characterized by severe optic disc swelling, chorioretinal exudates, and macular edema in all eyes. Anti-Bartonella henselae serum antibody was markedly elevated in all patients confirming the diagnosis of CSD. The P100 of the transient VEPs was only mildly reduced without a delay in the implicit times in three eyes and only slightly delayed in the other eye. The steady-state VEPs were mildly reduced in two eyes and phase-reversed in other two eyes. The VA fully recovered after systemic steroid treatment in all patients. Conclusions: Although all examined patients showed marked swelling of the optic disc and visual decrease, the pattern VEPs were not affected as severely as in idiopathic optic neuritis. However, the degree of change of the pattern VEPs varied among patients.     

Cat-scratch disease neuroretinitis

We report a case of cat-scratch disease neuroretinitis for which systemic and ocular investigations proved the responsibility of Bartonella henselae. An 11-year-old boy was referred to the hospital in November 2002 for severe visual loss in the left eye over the preceding 2 weeks. At the same time, he also developed a flu-like illness. The best corrected acuity in the left eye was counting fingers at 30 cm. Posterior segment examination on the left eye showed an optic disk edema with papillary and peripapillary hemorrhages and serous retinal detachment, mild vitreous inflammation, and two little perivascular white spots. The medical history was unremarkable except for a cat scratch on his left forearm 2 months before. Four weeks of antibiotic therapy including oral rifampin and doxycycline was used. Bartonella henselae immunoglobulin M were first detected with Bartonella henselae immunoglobulin G testing negative at this time. A 3-week serum showed immunoglobulin M seroreversion, while Bartonella henselae immunoglobulin G appeared. Other causes of optic disk edema with macular star were excluded by biological data. Bartonella antibodies to both Bartonella henselae and Bartonella clarridgeiae were detected in the cat. Ophthalmic follow-up showed progressive resorption of the neuroretinitis and the visual acuity increased to 5/10. The significance of this case report lies in the reminder that this pathology can be the cause of neuroretinitis; the prognosis can be improved by earlier treatment.     

Cat-scratch neuroretinitis.

BACKGROUND: Cat-scratch disease is a subacute regional lymphadenitis, usually preceded by a history of a cat scratch or exposure to kittens. The disease is caused by Bartonella henselae, and possibly Bartonella quintana, pleomorphic gram-negative rods formerly known as Rochalimaea henselae and Rochalimaea quintana. Ocular involvement is rare and typically manifests as either Parinaud's oculoglandular syndrome or neuroretinitis. Patients with neuroretinitis resulting from cat-scratch disease may be asymptomatic or experience mild-to-severe vision loss. The clinical features, angiographic appearance, differential diagnosis, and management of cat-scratch neuroretinitis are discussed. CASE REPORT: A 30-year-old white woman reported to the eye clinic with painless, decreased vision in the right eye. A diagnosis of cat scratch neuroretinitis was made on the basis of the history of cat scratch, clinical appearance, and angiographic findings. Treatment with oral ciprofloxacin restored vision to normal in 4 weeks. CONCLUSION: Painless vision loss associated with optic nerve swelling and macular star exudate should alert suspicion of systemic disease. Additional findings--including positive history of a cat scratch, lymphadenopathy, and flu-like symptoms--may indicate Bartonella henselae or Bartonella quintana infection. While treatment remains controversial, appropriate serology testing may aid in the diagnosis and management of the underlying infection.     

Bilateral Neuroretinitis in Cat Scratch Disease with Exudative,Obliterative Vasculitis in the Optic Disc

Abstract

A 29-year-old fisherman exhibited optic disc oedema and peripapillary retinal detachment in the right eye, whereas in the left eye, optic atrophy and intraretinal exudates were already observed on first examination. About 6 months earlier, he noticed blurred vision of the left eye but took no medication. Visual acuity was 0.4 OD and 0.01 OS. Perimetry showed a large lower-half field defect with sparing 10° central field in the right eye and a large central scotoma in the left eye. Fluorescein angiography showed existence of arteriole or capillary nonperfusion and hyperpermeability of surrounding capillaries. Since serological examinations showed positive Bartonella immunoglobulin G (IgG) and other causes of neuroretinitis (NR) were excluded, NR in the present case was caused by cat scratch disease (CSD). Optic atrophy appeared 2 weeks after onset. Optical coherence tomography 13 weeks after onset revealed severe loss of retinal nerve fibre layer (RNFL) superior and nasal to the optic disc in both eyes and temporal in the left eye. Visual acuity of the right eye improved to 1.2 by the treatment, whereas visual field defects were persistent. CSD-NR in the present case developed abrupt appearance of optic atrophy with severe RNFL loss in the right eye, which was elicited by exudative, obliterative vasculitis in the superficial layer of the optic disc.     

Bilateral Neuroretinitis in Cat Scratch Disease with Exudative,Obliterative Vasculitis in the Optic Disc

A 29-year-old fisherman exhibited optic disc oedema and peripapillary retinal detachment in the right eye, whereas in the left eye, optic atrophy and intraretinal exudates were already observed on first examination. About 6 months earlier, he noticed blurred vision of the left eye but took no medication. Visual acuity was 0.4 OD and 0.01 OS. Perimetry showed a large lower-half field defect with sparing 10° central field in the right eye and a large central scotoma in the left eye. Fluorescein angiography showed existence of arteriole or capillary nonperfusion and hyperpermeability of surrounding capillaries. Since serological examinations showed positive Bartonella immunoglobulin G (IgG) and other causes of neuroretinitis (NR) were excluded, NR in the present case was caused by cat scratch disease (CSD). Optic atrophy appeared 2 weeks after onset. Optical coherence tomography 13 weeks after onset revealed severe loss of retinal nerve fibre layer (RNFL) superior and nasal to the optic disc in both eyes and temporal in the left eye. Visual acuity of the right eye improved to 1.2 by the treatment, whereas visual field defects were persistent. CSD-NR in the present case developed abrupt appearance of optic atrophy with severe RNFL loss in the right eye, which was elicited by exudative, obliterative vasculitis in the superficial layer of the optic disc.     

Bilaterale Panuveitis mit seröser Amotio retinae

History

A 45-year-old patient with cat scratch disease presented with bilateral panuveitis as well as bilateral serous detachment of the retina. The patient had suffered from influenza with swollen lymph nodes 2 weeks previously.

Diagnosis

The diagnosis could be made serologically: IgG and IgM antibodies against Bartonella henselae were highly positive in the immunofluorescence test and the values for inflammation were also strongly increased.

Therapy

A macular star developed during the course, more in the left eye than in the right eye. The patient was treated with a sulfonamide (Bactrim forte) and prednisolonacetate (Urbason), which was changed to doxyzycline (Doxybene) after an allergic reaction developed. Clinical findings were reduced significantly and visual acuity improved.

Conclusions

Bartonella henselae should be excluded when panuveitis occurs with serous retinal detachment. A uveitis anterior could precede this occurrence.     

The Clinical Profile of Idiopathic and Cat Scratch Neuroretinitis: Who is at Risk for Recurrence?

Background: Most cases of neuroretinitis (NR) are idiopathic or due to cat scratch disease and occur as a single episode but a subgroup of patients experience recurrent attacks with cumulative visual loss. We reviewed our cases of NR to better characterize the clinical features of these subgroups in an effort to predict the risk of recurrence.

Methods: Retrospective study of NR patients from a single institution. Sixty-seven patients were divided into three groups: 22 cases due to cat scratch disease (CSD-NR), 24 with idiopathic neuroretinitis (I-NR) and 21 (23 eyes) with recurrent neuroretinitis (R-NR).

Results: Preceding systemic symptoms, predominantly central visual field (VF) loss and the combination of poor acuity with small relative afferent pupillary defect at presentation were common features of CSD-NR. There were no cases of recurrent CSD-NR. In the first attack of R-NR, the magnitude of VF loss at presentation was greater compared to the other two groups. While 39% of R-NR had a pattern of VF loss other than a central or cecocentral scotoma, only 13.6% of CSD-NR and 17% of I-NR showed this pattern. Visual recovery was least substantial for the R-NR group (average gain of 3.7 lines of Snellen acuity vs. 5 and 6.4 lines for CSD-NR and I-NR, respectively, and an average gain in VF score of 5.1 in the R-NR group compared to 8.2 and 11.5 for the other two groups).

Conclusion: The main predictive factors for recurrence are absence of systemic symptoms, significant VF loss at presentation, particularly loss outside the central 30°, and less substantial visual recovery.     

Cat scratch disease with posterior segment involvement

PURPOSE: To describe the clinical characteristics of patients with cat scratch disease during the last 2 years. METHODS: Clinical characteristics and anterior and posterior segment manifestations were reviewed in five patients who were serologically diagnosed as having cat scratch disease. RESULTS: Four women and one man were examined. Their ages ranged from 7 to 60 years. Each patient had a markedly elevated serum anti-Bartonella henselae antibody titer. Visual symptoms developed 2 weeks or less after the onset of systemic symptoms. Lymphadenopathy was detected in one of five patients. Neuroretinitis was found in 4 patients, and papillitis in 1 patient. Seven eyes showed retinochoroidal exudates. Anterior uveitis was observed in three eyes. Four patients received systemic corticosteroids. CONCLUSION: The ocular manifestations of cat scratch disease include neuroretinitis, papillitis, retinochoroidal exudates, and anterior uveitis.     

Cat scratch disease (CSD) in patients with stellate neuroretinitis: 3 cases

This case series describes three patients with a similar clinical picture: unilateral abrupt visual loss, optic nerve edema, and a macular star exudate. In all cases we found significant antibody titers to Bartonella henselae, the causative agent of cat scratch disease. Cat scratch disease seems to be the most common cause of stellate neuroretinitis, formerly known as Leber's idiopathic stellate retinopathy. A review of the pertinent literature shows that serologic evidence of B. henselae is sufficient to confirm the diagnosis given the low incidence of significant titers in the general population. Cat scratch disease is usually a self limiting disorder in immunocompetent patients, but treatment with doxycycline is recommended.     

Final Diagnosis in Patients Referred with a Diagnosis of Neuroretinitis

The purpose of this study was to determine final diagnosis of patients referred with a diagnosis of neuroretinitis. A retrospective study of 40 patients with optic disc oedema with macular star (ODOMS) referred with a diagnosis of neuroretinitis was conducted. The final diagnosis was neuroretinitis in 26 patients (65%), with most of these patients (96.1%) having unilateral involvement. Main underlying aetiologies included cat scratch disease (30.8%), rickettsiosis (19.2%), and idiopathic neuroretinitis (23.1%). The remaining 14 patients (35%) had ODOMS that had been mistaken for neuroretinitis. Of these patients, 42.8% were found to have a previously unknown malignant systemic hypertension in association with bilateral ODOMS. Neuroretinitis, usually unilateral, should be differentiated from other causes of unilateral or most often bilateral ODOMS that may masquerade as neuroretinitis, mainly malignant systemic hypertension. This is essential to avoid inappropriate work-up and management and subsequent potential visual or systemic morbidity.     

Final Diagnosis in Patients Referred with a Diagnosis of Neuroretinitis

Abstract

The purpose of this study was to determine final diagnosis of patients referred with a diagnosis of neuroretinitis. A retrospective study of 40 patients with optic disc oedema with macular star (ODOMS) referred with a diagnosis of neuroretinitis was conducted. The final diagnosis was neuroretinitis in 26 patients (65%), with most of these patients (96.1%) having unilateral involvement. Main underlying aetiologies included cat scratch disease (30.8%), rickettsiosis (19.2%), and idiopathic neuroretinitis (23.1%). The remaining 14 patients (35%) had ODOMS that had been mistaken for neuroretinitis. Of these patients, 42.8% were found to have a previously unknown malignant systemic hypertension in association with bilateral ODOMS. Neuroretinitis, usually unilateral, should be differentiated from other causes of unilateral or most often bilateral ODOMS that may masquerade as neuroretinitis, mainly malignant systemic hypertension. This is essential to avoid inappropriate work-up and management and subsequent potential visual or systemic morbidity.     

Cat-scratch disease neuroretinitis diagnosed by a polymerase chain reaction approach

PURPOSE: To assess the value of polymerase chain reaction in the diagnosis of cat-scratch disease neuroretinitis without conclusive serology. METHODS: Interventional case report. A 13-year-old girl developed a right neuroretinitis 2 months after a cat scratch. Despite the lack of accompanying features, an infection by Bartonella henselae was suspected and a systemic check-up was performed. RESULTS: Serologic results excluded other proposed origins but were insufficient in making the diagnosis because of low B. henselae specific IgG level in serum. A polymerase chain reaction analysis for B. henselae DNA in a small axillary lymphadenopathy aspirate enabled us to achieve a definitive diagnosis of cat-scratch disease. CONCLUSION: Polymerase chain reaction is a valuable method of diagnosing cat-scratch disease when serology is considered negative or borderline.     

Bartonella henselae infection presenting as a unilateral panuveitis simulating Vogt-Koyanagi-Harada syndrome

PURPOSE: To report an unusual ocular manifestation of cat scratch disease. DESIGN: Observational case report. METHODS: Review of the clinical, laboratory, photographic, and angiographic records of a patient with cat scratch disease. RESULTS: A 54-year-old woman presented with counting fingers visual acuity in the right eye associated with optic disk edema, diffuse choroidal thickening, and panuveitis. Fluorescein angiography showed disk leakage and hyperfluorescent spots with late leakage suggestive of Vogt-Koyanagi-Harada disease. She was diagnosed with cat scratch disease by serum antibody titers and clinical course. CONCLUSIONS: Ocular manifestations of cat scratch disease can include diffuse thickening of the choroid. Cat scratch disease may manifest with angiographic features suggestive of Vogt-Koyanagi-Harada disease.     

Optic neuropathy secondary to cat scratch disease: case report

Optic neuropathy due to cat scratch disease is a relatively infrequent occurrence associated with macular star formation and is characterized by sudden painless loss of vision mostly unilateral. Bartonella henselae is well recognized as the etiologic agent in cat scratch disease. Ocular complications of the disease occur in up to 10% of patients and include neuroretinitis. Ocular bartonelosis is usually self-limited with complete or near-complete recovery of vision in otherwise healthy patients. A case of a boy with neuroretinitis caused by B. henselae is reported.     

Cat scratch disease: posterior segment manifestations.

OBJECTIVE: To evaluate the posterior segment findings seen in ocular cat scratch disease. DESIGN: Retrospective case series. PARTICIPANTS: There were 24 patients (35 eyes) with choroidal, retinal, or optic disc manifestations of Bartonella infection evaluated at the authors' institutions over a 6-year period. MAIN OUTCOME MEASURES: Clinical and photographic records were reviewed for evidence of disc edema, macular star, foci of retinitis or choroiditis, choroidal masses, optic nerve masses, vascular-occlusive events, or other findings. RESULTS: Discrete white retinal or choroidal lesions, 50 to 3000 microm in diameter, were the most common posterior segment findings in this series of patients (83% of eyes, 83% of patients). Optic disc swelling was the second most common finding (46% of eyes, 63% of patients) followed by a macular star (43% of eyes, 63% of patients). Vascular-occlusive events were also seen (14% of eyes, 21% of patients), and the site of occlusion was found to be intimately associated with the aforementioned retinal lesions. Final visual acuity was 20/25 or better in 26 (74%) of 35 eyes and was similar in both treated and untreated patients. CONCLUSION: Isolated foci of retinitis or choroiditis were the most common ocular manifestation of cat scratch disease in the authors' patient population, but an array of posterior segment findings may occur.     

Ocular bartonellosis

PURPOSE: To review recent advances in the basic and clinical biology of Bartonella-related eye disease. METHOD: A review of the pertinent medical literature was performed. RESULTS: A number of novel Bartonella species have been identified over the past decade. Of these, Bartonella henselae, the etiologic agent in cat scratch disease, is most often associated with ocular complications, which may include Parinaud oculoglandular syndrome, neuroretinitis, and focal retinochoroiditis. Although cat and flea exposure appear to be the main risk factors for contracting cat scratch disease, the diagnosis of ocular bartonellosis relies primarily on the recognition of suggestive clinical signs in conjunction with positive serologic testing. B. henselae-associated ocular complications are usually self-limited but may be treated with doxycycline or erythromycin, with or without rifampin, when the infections are severe or sight-threatening. CONCLUSIONS: B. henselae infection is common and should be considered in patients with Parinaud oculoglandular syndrome, neuroretinitis, or focal retinochoroiditis, particularly when there is a history of cat or flea exposure.     

Prevalence of serologic evidence of cat scratch disease in patients with neuroretinitis

OBJECTIVE: To determine the prevalence of Bartonella henselae seropositivity in patients with a clinical diagnosis of neuroretinitis. DESIGN: Retrospective, clinic-based, cross-sectional study. PARTICIPANTS: Eighteen consecutive patients seeking treatment at the Casey Eye Institute from November 1993 through November 1998 who had neuroretinitis. METHODS: The billing and photographic records of the Casey Eye Institute were searched for patients with a primary or secondary diagnosis of neuroretinitis or Leber's idiopathic stellate neuroretinitis. Charts were then reviewed to determine the results of B. henselae antibody titers and other pertinent clinical information. MAIN OUTCOME MEASURES: Results of B. henselae serologic testing. RESULTS: Fourteen of 18 patients with neuroretinitis had serologic studies. Nine of the 14 tested patients (64.3%) were found to have elevated IgM or IgG for B. henselae, suggesting current or past infection. Patients with positive serologic analysis results tended to have worse vision at presentation. There were no other obvious differences between seropositive and seronegative groups in this study, including duration or quality of recovery. CONCLUSIONS: At our tertiary care ophthalmology institution, most tested patients with neuroretinitis had evidence of past or present cat-scratch disease based on positive serologic analysis for B. henselae, a much greater prevalence than is expected to be found in the general population or in patients with idiopathic uveitis. Further study is indicated to clarify the prevalence of cat-scratch disease in neuroretinitis and the role and efficacy of antibiotics in treatment.     

Suspected Simultaneous Bilateral Anterior Ischemic Optic Neuropathy in a Patient with Behçet's Disease

Aim: To report a 47-year-old Japanese woman with a one-year history of Behçet's disease who complained of sudden bilateral visual loss with concurrent anterior ischemic optic neuropathy (AION). Case Report: The patient's Snellen visual acuity was 0.1 (OD) and 0.3 (OS) of onset. There was bilateral mild anterior chamber inflammation. Bilateral optic disc pale swelling was observed without retinal exudates and edema. Fluorescein angiography demonstrated bilateral hypofluorescence of the optic disc in early frames but with no distinct retinal vasculitis. Visual field showed bilateral relative central scotoma and right altitudinal hemianopsia. Laboratory examination revealed an ESR of 26 mm in the first hour with a C-reactive protein level of < 0.3 mg/dl. Periocular injection of triamcinolone acetonide in both eyes without systemic corticosteroid administration improved her visual acuity to 0.7 (OD) and 1.2 (OS) within 45 days of onset. Bilateral optic disc swelling gradually resolved. In the early stages, fluorescein angiography demonstrated normal optic disc filling in both eyes. There was a residual right central scotoma on visual field. Conclusion: We observed an extremely rare case of simultaneous bilateral AION with Behçet's disease with marked visual recovery within 45days of onset.     

Leber's idiopathic stellate neuroretinitis: about two cases

BACKGROUND: Described by Theodore Leber in 1916, this syndrome is characterized by unilateral visual loss, optic disc swelling and a stellate pattern of exudative deposits in the macula. MATERIAL AND METHODS: Two young adults were examined for sudden unilateral visual loss preceded by a flu-like syndrome. Fundus examination revealed a swollen optic disc and a macular star, visualized on fluorescein angiography. Visual field, laboratory tests and cranial and orbital tomodensitometry were performed. RESULTS: Visual field examination showed a centrocecal scotoma. Laboratory tests showed inflammatory syndrome in one case. Serology testing (leptospirosis, cat scratch disease, toxoplasmosis and syphilis, etc.) were negative. Tomodensitometry of the brain and orbits gave normal results. One of the patients was treated with intravenous steroid boluses; the other received no treatment. A few weeks after the beginning of symptoms, the swelling of the optic disc seemed to have declined, leaving the macular star unchanged. CONCLUSION: These two cases typically describe Leber's idiopathic stellate neuroretinitis. The prognosis for visual recovery is usually reported to be excellent, but visual sequelae have been described.