Paradoxical response in ocular bartonellosis

Abstract

IntroductionCat scratch disease is an infectious disease caused by thebacteria Bartonella henselae [1] and is transmitted by catscratches or exposure to cat saliva. The spectrum of itsocular manifestations includes Parinaud's oculoglandularsyndrome, iritis, vitritis, neuroretinitis, panuveitis, retinitisappearing as small white intraretinal infiltrates, and choroi-dal white lesions [1, 2]. B. henselae is reported to be themost common cause of neuroretinitis; typically character-ized by optic disk edema in association with a partial orcomplete macular star. The majority of infected patientspresenting with neuroretinitis reported in the literature aretreated with antibiotics. In some cases steroids were added.However several reports showed that even patients who didnot receive treatment had an excellent visual outcome [1].We describe here a paradoxical response to treatment in ayoung female presenting with bilateral neuroretinitis andinflammatory optic disk lesions.Case reportA 19-year-old healthy female presented with an abruptdeterioration of left eye vision of 1-day duration. For10 days prior to presentation, she was suffering from drycough; 5 days later she had intermittent fever up to 41°Cwith shaking chills. There was a history of contact with acat, but she denied being scratched. On admission, physicaland neurologic examinations were unremarkable. Ophthal-mologic assessment disclosed visual acuity of 4/4 in theright eye and 4/60 in the left eye. She had normal anteriorsegments and intraocular pressures. A left afferent pupillarydefect was noted. Funduscopy of the right eye showed asmall white optic disk lesion in its temporal aspect with adeep retinal white lesion along the superonasal arcade(Fig. 1). The left optic disk had blurred margins with biggerwhite lesions in its nasal and temporal aspects with anassociated localized vitreous opacity on its surface (Fig. 1).There was marked macular edema and two deep retinalwhite lesions along the superotemporal arcade and infer-onasal to the optic disk. Optical coherence tomography(OCT) revealed intraretinal fluid in the right papillomacularbundle and left exudative macular detachment (Fig. 2).Visual field examination showed right nasal step andsuperonasal arcuate defect while there was enlargement ofthe left blind spot with nasal step (Fig. 3). Work-uprevealed mild anemia with hemoglobin of 11.7 g% andleukocytosis of 14,800 (lymphocytes, 31%). Kidney andliver functions were within normal limits except for aslightly elevated lactate dehydrogenase at 768 (normalrange, 300–620 u/l). She had elevated erythrocyte sedi-mentation rate (ESR) (90 mm/h) and C-reactive protein(5.3 mg%; normal range, less than 1). Chest X-ray did notreveal any pathological findings, and CT scan and MRI ofthe head and brain showed mild thickening of the opticnerves bilaterally and hyperintense foci in the flairsequences in the intraocular aspects of the optic nerves,respectively. Cerebrospinal fluid cytology was normal.Serological tests were negative for HIV, syphilis, Brucella,Coxiella burnetti, toxoplasma, and toxocara. Serologicaltests for B. henselae revealed positive IgM titer at 75 units