Bartonella henselae neuroretinitis: A case report

Alonso Montejo, María del Mar; Muñoz Vilches, María José

doi:10.1016/j.medcle.2020.07.026

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Patients usually report a history of cat bites or scratches and, clinically, present with lesions at the site of inoculation and regional enlarged nodes, with the process self-limiting over a period of weeks. In rare cases, these symptoms may occur as neuroretinitis or endocarditis, especially in immunocompromised patients<a class="elsevierStyleCrossRef" href="#bib0005">1</a>. Diagnosis is usually made by serology, since direct microbiological media in blood (culture or polymerase chain reaction-PCR) have low yield. In cases of neuroretinitis, empirical treatment is usually started early on clinical suspicion and a history of contact with cats<a class="elsevierStyleCrossRef" href="#bib0010">2</a>.Given the scarcity of literature references in paediatric patients, we consider this case report to be of interest.11-year-old female patient referred for "central black spot" vision and deterioration of visual acuity in the left eye in the last 24 h. She reported having a mild headache for several days towards the end of the day. Physical examination revealed multiple cat scratch wounds on the upper and lower limbs, no palpable enlarged nodes and the rest of the examination was normal. She reported daily contact with two cats in her rural residence. She had no personal or family history of interest and was an immunocompetent patient.Ophthalmological examination revealed a visual acuity of the left eye of 0.2 with papillary oedema, confirmed by optical coherence tomography (OCT). A central scotoma was also detected by campimetry. The examination of the right eye was perfectly normal. The eye movements of both eyes were preserved and painless and there was no dyschromatopsia.After the ophthalmological examination, a complete blood count, biochemistry, immunological study, gamma interferon and tuberculin test were requested with normal results (ESR 11 mm/h). IFA serology was performed for Bartonella quintana, Bartonella henselae, Borrelia burgdorferi, Brucella spp, Treponema pallidum, Toxocara canis, Toxoplasma gondii, herpes simplex viruses 1 and 2 and Rickettsia conorii; IFA serology and PCR for cytomegalovirus and ELISA serology and PCR for human immunodeficiency virus, all negative.After one week, worsening was observed with increased papillary oedema, star-shaped macular exudates, and moderate afferent pupillary reflex involvement in the left eye. Given the high clinical and epidemiological suspicion of neuroretinitis due to Bartonella, antibiotic therapy was started with doxycycline 100 mg twice a day and rifampicin 300 mg twice a day, in combination with oral corticotherapy 2 mg/kg/day.The clinical course was progressively favourable, with seroconversion confirming Bartonella henselae infection (1/64 titre) after three weeks. A PCR for Bartonella henselae in blood was reported negative.She completed six weeks of treatment, with progressive tapering of corticosteroid therapy, with no side effects. Recovery was complete with restored visual acuity and normal OCT.Ocular involvement by Bartonella henselae occurs in 5–10% of cases of CSD and may occur in the absence of general symptoms as in our patient, making diagnosis difficult<a class="elsevierStyleCrossRef" href="#bib0015">3</a>.In our case, diagnostic confirmation was performed using serological techniques (IFA) with a high titre of anti-Ig G Bartonella henselae antibodies three weeks after the onset of symptoms. Initial serology with anti-Bartonella henselae Ig M was negative, probably due to the described variability in the sensitivity of the technique<a class="elsevierStyleCrossRef" href="#bib0005">1</a>. However, the ophthalmological findings, the macular exudate in the fundus, characteristic of CSD, the epidemiological history and the favourable course after initiation of dual antibiotic therapy led to this aetiology even before seroconversion was confirmed.Blood PCR yield is low, so a negative result does not invalidate the diagnosis<a class="elsevierStyleCrossRef" href="#bib0020">4</a>.Our experience with dual antibiotic therapy was excellent, but some authors recommend quinolone monotherapy<a class="elsevierStyleCrossRef" href="#bib0025">5</a>.In summary, we consider it essential to suspect this entity in a paediatric patient with neuroretinitis and papilledema, as well as the early empirical initiation of treatment with dual antibiotic therapy and corticosteroids, given the risk of visual loss and its sequelae.FundingThis article has not received any type of funding.Conflict of interestsThe authors declare no conflict of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflict of interests" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Alonso Montejo Md M, Muñoz Vilches MJ. Neurorretinitis por Bartonella henselae: a propósito de un caso. Med Clin (Barc). 2020. https://doi.org/10.1016/j.medcli.2020.07.020" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Update on Bartonella neuroretinitis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "I. Ksiaa" 1 => "N. Abroug" 2 => "A. Mahmoud" 3 => "S. Zina" 4 => "A. Hedayatfar" 5 => "S. Attia" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.joco.2019.03.005" "Revista" => array:6 [ "tituloSerie" => "J Curr Ophthalmol." 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Vol. 157. Issue 4.

Pages 199-200 (August 2021)

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