Elsevier

Ophthalmology

Volume 105, Issue 3, 1 March 1998, Pages 459-466
Ophthalmology

Bartonella henselae neuroretinitis in cat scratch disease: Diagnosis, management, and sequelae1, 2,

Presented in part at the 94th General Meeting of the American Society of Microbiology, Las Vegas, Nevada, 1994; the Association for Research in Vision and Ophthalmology (ARVO), May 1995; the American Uveitis Society, May 1995; the Association of Ophthalmic Pathology, October 1995; ARVO, May 1996; and the American Academy of Ophthalmology, October 1996.
https://doi.org/10.1016/S0161-6420(98)93028-7Get rights and content

Abstract

Objective

This study aimed to report the long-term outcomes of patients treated with an antibiotic drug combination for Bartonella henselae neuroretinitis.

Design

The study design was a retrospective case series.

Participants

Seven consecutive patients with neuroretinitis and cat scratch disease participated.

Interventions

Patients underwent medical and ophthalmic evaluations. Blood cultures were obtained, and B. henselae antibody titers were measured. Tuberculosis, Lyme, toxoplasmosis, syphilis, and sarcoidosis were excluded. Patients received oral doxycycline 100 mg and rifampin 300 mg twice daily for 4 to 6 weeks and were observed for an average of 16 months (range, 10–24 months). Formal electrophysiologic testing was performed in three patients after resolution of neuroretinitis.

Main outcome measures

The changes in ocular inflammation and visual function associated with treatment were recorded. Follow-up examinations and electrophysiologic testing documented sequelae.

Results

Patients presented following cat exposure with fever, malaise, and blurred vision. Decreased visual acuity (ranging from 20/40 to counting fingers) frequently was associated with dyschromatopsia and afferent pupillary defects. Ophthalmoscopic analysis showed signs of neuroretinitis, including nerve fiber layer hemorrhages, cottonwool spots, multiple discrete lesions in the deep retina, and stellate macular exudates. B. henselae infection was confirmed with positive blood cultures or elevated immunofluorescent antibody titers or both. Therapy appeared to promote resolution of neuroretinitis, restoration of visual acuity, and clearance of bacteremia. After 1 to 2 years, two eyes had residual disc pallor, afferent pupillary defects, retinal pigmentary changes, and mildly decreased visual acuity. Electrophysiologic studies showed that when compared to the fellow eye, affected eyes had subnormal contrast sensitivity, abnormal color vision, and abnormal visually evoked potentials. Conversely, electroretinograms were normal in all subjects.

Conclusions

B. henselae is a cause of neuroretinitis in cat scratch disease. Compared to historic cases, doxycycline and rifampin appeared to shorten the course of disease and hasten visual recovery. Long-term prognosis is good, but some individuals may acquire a mild postinfectious optic neuropathy.

Section snippets

Materials and methods

Staff physicians in the Departments of Ophthalmology (Retina/ Uveitis service) and Infectious Diseases evaluated all seven previously healthy patients. A detailed ophthalmologic workup was conducted that included best-corrected Snellen visual acuity, dilated ophthalmoscopic analysis, and Humphrey visual field analysis. Defects in color discrimination were recorded on the day of presentation with D-15 studies or Ishihara color plates and redcap testing. Relative afferent pupillary defects

Results

Table 1 presents demographic data, month of presentation, predominant systemic findings, nature of cat exposure, and supportive laboratory results. Ages ranged from 19 to 31 years, and most recalled a scratch or bite that was an antecedent to clinical infection. Cases occurred most frequently in late fall and early winter months. Reported problems of fever, chills, night sweats, headache, and malaise were common, but none of the patients had focal neurologic signs or pain with eye movement. Two

Discussion

This case series illustrates three points that deserve special emphasis:

  • 1.

    B. henselae causes neuroretinitis in CSD.

  • 2.

    A mild optic neuropathy may result.

  • 3.

    Early antibiotic therapy appeared to shorten the course of infection and hasten visual recovery.

Previously, B. henselae was associated heavily with neuroretinitis based on indirect tests such as the IFA,5, 7, 8 enzyme-linked immunofluorescent antibodies,6 positive CSD skin test results,9 and suggestive bacillary forms on Warthin-Starry preparations.

References (34)

  • R.W. Newsom et al.

    Cat-scratch disease diagnosed serologically using an enzyme immunoassay in a patient with neuroretinitis

    Arch Ophthalmol

    (1996)
  • G.A. Chrousos et al.

    Neuroretinitis in cat scratch disease

    J Clin Neuroophthalmol

    (1990)
  • D.J. Brenner et al.

    Proposals to unify the genera Bartonella and Rochalimaea, with descriptions of Bartonella quintana Comb. nov., Bartonella vinsonii Comb. nov., Bartonella henselae Comb. nov., and Bartonella elizabethae Comb. nov., and to remove the family Bartonellaceae from the order Rickettsiales

    Int J Syst Bacteriol

    (1993)
  • L.N. Slater et al.

    A newly recognized fastidious gram-negative pathogen as a cause of fever and bacteremia

    N Engl J Med

    (1990)
  • K.A. Adal et al.

    Cat scratch disease, bacillary angiomatosis, and other infections due to Rochalimaea

    N Engl J Med

    (1994)
  • B. Anderson et al.

    Detection of Rochalimaea henselae in cat-scratch disease skin test antigens

    J Infect Dis

    (1993)
  • M.J. Dolan et al.

    Syndrome of Rochalimaea henselae adenitis suggesting cat scratch disease

    Ann Intern Med

    (1993)
  • Cited by (219)

    • Pediatric Bartonella henselae neuroretinitis masking co-infections

      2022, American Journal of Ophthalmology Case Reports
    • The development and spontaneous resolution of a full-thickness macular hole in bartonella henselae neuroretinitis in a 12-year-old boy

      2019, American Journal of Ophthalmology Case Reports
      Citation Excerpt :

      The majority of studies on this subject are small and retrospective. Some small studies suggest a benefit of doxycycline, ciprofloxacin, rifampin, gentamycin, or TMP/SMX with regards to shorter duration of ocular disease and improved visual outcomes in CSD.30–34 Because of contradictory reports regarding the benefit of antibiotics and a paucity of data, there is no established standard of care for the management of CSD.

    • Update on Bartonella neuroretinitis

      2019, Journal of Current Ophthalmology
      Citation Excerpt :

      Visual field testing often demonstrates a cecocentral, central, or paracentral scotoma, or an enlarged blind spot.29 Other functional alterations include color vision abnormalities and reduction in average visually evoked potential (VEP) with normal electroretinogram.19 The diagnosis of CSD-associated neuroretinitis is based on clinical findings including young age, history of contact with a cat, typical neuroretinitis, systemic symptoms, and positive serology.

    View all citing articles on Scopus

    Supported by the Research to Prevent Blindness Foundation, New York, New York.

    1

    None of the authors has a proprietary interest in the development or marketing of any drug mentioned in this article. The use of trade names or commercial products is for identification only and does not imply endorsement by any agency of the U.S. Government.

    2

    The views expressed in this article are those of the authors and do not reflect the official policy of the United States Air Force, Department of Defense, or other agencies of the U.S. Government.

    3

    Dr. Reed is assigned to the Air Force Institute of Technology.

    View full text