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Cat scratch disease of the eye: a case report and literature review.

Introduction

Bartonellosis is a disease that has been described for decades and typically presents as "cat-scratch fever." It is a Gram negative rod and is often transmitted from cats (or kittens) to humans. The cutaneous disease of a papular rash and lymphadenopathy occurs in approximately 22,000 cases per year in the U.S. Of these, 5-10% will develop neuroretinal involvement. (1) In an older population, it may be missed if there are confounding comorbidities. Literature review shows that the ocular manifestations of Bartonella henselae are broad, leading to many missed diagnoses. In many of these cases, it was only upon detailed review of the patients' history that the diagnosis was prompted. In January 2012, a U.S. multicenter retrospective review of 53 cases of ocular cat scratch disease outlined the following clinical characteristics; 1) a mean age of 27.8 yrs. (range: 8-65 yrs.) (2), 2) an encounter with a cat in 67% of patients, 3) the typical ophthalmologic finding of a "macular star" in 45%. (2) While systemic corticosteroids are used often to decrease the risk of permanent vision loss, they are always used in conjunction with antimicrobials. Once the diagnosis is made and correct therapy is initiated, the prognosis for visual recovery is good.

Case History

A 62 year-old Caucasian male with no prior medical history presented to the emergency department for sudden, painless blurriness of his left eye. He was afebrile and hemodynamically stable. He had no neurological deficits. His leukocyte count was 7.5 x 103 with a normal differential. A MRI of the brain was done. This was negative for acute abnormalities. He had mildly elevated inflammatory markers; his C-reactive protein was 1.8 and his estimated sedimentation rate was 36. Ophthalmology performed a retinal exam and found 3+ edema of the left optic nerve head. His visual acuity was 20/200 in the left eye. Initially, there was concern for giant cell arteritis or autoimmune process and he was started on 40 mg of prednisone to be tapered. Additionally, Bartonella serology, FTA-AB and tick borne serology was performed. He was sent home from the emergency department to follow up with an ophthalmologist as an outpatient.

He returned to his ophthalmologist 8 days later. During that visit, he reported feeling "fine." He had no fever and was hemodynamically stable. His vision, however, was still blurry and unchanged. A repeat ophthalmologic exam revealed retinal infiltrate and increased macular edema (Figure 1). He was directly admitted for these changes out of concern of vasculitis. He was continued on oral prednisone and started on oral Azithromycin 250 mg every 24 hours. A temporal artery biopsy was performed the same day. Pathology returned negative for temporal arteritis. Serum ANA, ANCA and rheumatoid factor were negative. Human immunodeficiency virus screening, serum syphilis, Mycobacterium TB quantiferon were all negative. The day after admission, his initial Bartonella serology returned abnormal. It showed elevated Bartonella henselae IgM and IgG (1:100 and 1:320 respectively). He was evaluated by infectious disease service. Upon further interview, he recalled his daughter visiting him and his wife with her cat one month prior to this episode. He stated that the cat had slept on his bed a few times. He cannot recall any scratches. He was started on Doxycycline 100 mg twice daily and Rifampin 300 mg twice daily for ocular Bartonellosis. On this regimen, he experienced slow but noticeable improvement in his vision. His repeat Bartonella henselae titers 22 days later showed undetectable IgM and IgG >1:2560, confirming acute infection. He completed 42 days of Doxycycline and Rifampin. On day 52 of his illness, his visual acuity was 20/50 on the left with macular edema resolved.

Discussion

The presentation of sudden, painless, unilateral loss of vision has a broad list of possible causes. In this patient, with a vague cat exposure and indeterminate initial findings, Bartonella henselae was not high on the list of etiologic suspects. This case further supports the need to quickly differentiate between infectious and noninfectious causes when triaging an outpatient complaining of the above symptoms. Unfortunately, as described in the abovementioned review, even though there are clinical aspects that are characteristic of Bartonella ocular infection, a significant number of cases present outside the "typical" presentation. For example, a published report in 2013 depicted a 7 year-old girl who presented with rash, biquotidian fever, night sweats, and arthralgias and no antecedent history of cat contact. Investigations showed increased inflammatory markers, leukocytosis, thrombocytosis, hypercalcemia, and raised angiotensin-converting enzyme. (3) Abdominal imaging demonstrated multifocal lesions of the liver and spleen, chest X-ray showed enlarged hilar lymph nodes, and ophthalmology review revealed uveitis. She was diagnosed and treated for sarcoidosis. It was only until serological testing was performed did it reveal Bartonella henselae. Complete resolution was achieved with systemic gentamycin. Similar cases of misdiagnosed ocular Bartonellosis show there is often a delay in therapy due to low index of suspicion. This may be due to multiple factors. Patients with confirmed ocular Bartonellosis may not have any recollection of any contact with felines. Furthermore, the typical stellate macular exudates are not frequently found. To that point, they may not present with maculopathy. Another case review in Greece reported the most common finding was intermediate uveitis rather than macular exudates. (4) The actual incidence of Bartonella ocular infection may be underreported. Serology may be performed too early in acute infection; the patient may not have seroconverted. Thus serology would be negative. Another possibility is that the abnormal serological tests may not be followed up on or may not be repeated to check convalescent titers. This case and a review of the literature support the idea of Bartonella species being considered one of the usual suspects in neuroretinitis. Corticosteroids without concomitant antimicrobials should, perhaps, only be considered if there is high confidence in a noninfectious cause. A thorough interview regarding zoonotic exposure should be taken. Considering Bartonella ocular infection early in the course would have changed the course of this patient's treatment. In his case it meant the difference of being placed on an immunosuppressive therapy for 10 days during active infection without the presence of antimicrobials.

Conclusion

In summary, our patient presented to the emergency department with painless, unilateral visual disturbances. What can be derived from this scenario is that the index of suspicion must be raised when triaging similar cases. It is important to recall that "typical findings" are not common and a thorough history is invaluable.

References

(1.) Jackson LA, Perkins BA, Wenger JD. Cat scratch disease in the United States: an analysis of three national databases. Am J Public Health. 1993;83(12):1707.

(2.) Sulene L. Chi, MD, PhD, Sandra Stinnett, DrPh, Eric Eggenberger, DO, et. al. Clinical Characteristics in 53 patients with Cat Scratch Optic Neuropathy. Ophthalmology 2012; 119:183-187.

(3.) Maritsi DN, Zarganis D, Metaxa Z, et al. Bartonella henselae Infection: An Uncommon Mimicker of Autoimmune Disease. Case Rep Pediatr. 2013;2013:726826.

(4.) Kalogeropoulos C, Koumpoulis I, Mentis A, et al. Bartonella and intraocularinflammation: a series of cases and review of literature. Clinical Ophthalmology. 2011;5:817-29.

Kristina Alaan, MD

Section of Infectious Disease, WV University, Morgantown, WV

Melanie Fisher, MD, FACP, MSC

Section of Infectious Disease, WV University, Morgantown, WV

Brian Ellis, MD

Section of Infectious Disease, WV University, Morgantown, WV

Corresponding Author: Kristina Alaan, MD, Section of

Infectious Disease, Robert C. Byrd Health Sciences Center, 2181

HSC North, PO Box 9163, Morgantown, WV 26506-9163. Email:

kcalaan@hsc.wvu.edu
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Title Annotation:Case Report
Author:Alaan, Kristina; Fisher, Melanie; Ellis, Brian
Publication:West Virginia Medical Journal
Article Type:Clinical report
Date:Sep 1, 2014
Words:1244
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