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A young woman with fever and low visual acuity

      1. Case description

      A 38-year-old woman with no particular medical history was referred to our hospital for low-grade fever and polyarthralgias since 15–20 days ago. She revealed a history of contact with cats at home without recent bite or cat scratches although she admitted flea bites. Physical examination was normal without evidence of palpable lymphadenopathies or signs of joint inflammation. Laboratory evaluation showed normal white blood count, an increase in aspartate aminotransferase at 74 U/l and alanine aminotransferase at 138 U/l; the antinuclear antibodies (ANA) and rheumatoid factor were normal. The screening for the commonest viral, bacterial, parasitic and fungal infections of our country resulted negative except a serology for Bartonella henselae (IgM 1:80). Chest images, abdominal ultrasonography and body CT scan showed no important abnormalities.
      During the second week of hospital admission she noticed blurred vision in her right eye. Ophthalmic examination disclosed cottony retinal exudates and retinal haemorrhages in the right eye (Fig. 1A ) with minimal exudates and intraretinal haemorrhages in the left eye. A week later, fundus examination revealed the image we showed (Fig. 1B).
      Fig. 1
      Fig. 1A) Findings of initial ophthalmoscopy: cottony retinal exudates (*) and intraretinal haemorrhages (>). B) Posterior ophthalmoscopy: macular edema with macular star ().
      What is the diagnosis?

      2. Diagnosis

      Answer: Bartonella henselae Neuroretinitis in Cat scratch disease.
      Neuroretinitis is characterized by optic nerve edema in association with a partial or complete macular star. The patients usually present with fever, general discomfort and unilateral blurred vision. Bartonella henselae is considered to be one of the most common causes and the presence of retinochoroiditis foci provides strong support for this etiological diagnosis [
      • Golnik K.C.
      • Marotto M.E.
      • Fanous M.M.
      • et al.
      Ophthalmic manifestations of Rochalimaea species.
      ,
      • Reed J.B.
      • Scales D.K.
      • Wong M.T.
      • et al.
      Bartonella henselae neuroretinitis in cat scratch disease. Diagnosis, management, and sequelae.
      ]. Macular star can be seen without papilledema presumably because the edema is resolved early in the course of the disease.
      Cat scratch disease is usually benign and self-limited, but the visual recovery in ocular bartonellosis with neuroretinitis could be delayed several months. Although there are not controlled studies that evaluate the efficacy of antimicrobial therapy, it is believed that may shorten the course of the disease and accelerate the recovery of visual acuity. The antibiotic therapy used are tetracyclines, macrolides, quinolones and rifampicin [
      • Reed J.B.
      • Scales D.K.
      • Wong M.T.
      • et al.
      Bartonella henselae neuroretinitis in cat scratch disease. Diagnosis, management, and sequelae.
      ]. In our patient the association of rifampicin and tetracycline was useful with disappearance of fever, normalization of liver tests and recovery of visual acuity in eight weeks.
      Ocular complications of Bartonella henselae infection affect nearly 10% of patients with disseminated disease. Parinaud's oculoglandular syndrome is the most common (2–8%). Other atypical or disseminated ocular manifestations include neuroretinitis, focal o multifocal choroidoretinitis, artery and vein occlusions, and serous retinal detachment [
      • Cunningham E.T.
      • Koehler J.E.
      Ocular bartonellosis.
      ].

      Conflicts of interest

      The authors declare no conflicts of interest.

      References

        • Golnik K.C.
        • Marotto M.E.
        • Fanous M.M.
        • et al.
        Ophthalmic manifestations of Rochalimaea species.
        Am J Ophthalmol. 1994; 118: 145-151
        • Reed J.B.
        • Scales D.K.
        • Wong M.T.
        • et al.
        Bartonella henselae neuroretinitis in cat scratch disease. Diagnosis, management, and sequelae.
        Ophthalmology. 1998; 105: 459-466
        • Cunningham E.T.
        • Koehler J.E.
        Ocular bartonellosis.
        Am J Ophthalmol. 2000 Sept; 130: 340-349