Bartonella and intraocular inflammation: a series of cases and review of literature

Abstract

Purpose: To present various forms of uveitis and/or retinal vasculitis attributed to Bartonella infection and review the impact of this microorganism in patients with uveitis.

Methods: Retrospective case series study. Review of clinical records of patients diagnosed with Bartonella henselae and Bartonella quintana intraocular inflammation from 2001 to 2010 in the Ocular Inflammation Department of the University Eye Clinic, Ioannina, Greece. Presentation of epidemiological and clinical data concerning Bartonella infection was provided by the international literature.

Results: Eight patients with the diagnosis of Bartonella henselae and two patients with B. quintana intraocular inflammation were identified. Since four patients experienced bilateral involvement, the affected eyes totaled 14. The mean age was 36.6 years (range 12-62). Uveitic clinical entities that we found included intermediate uveitis in seven eyes (50%), vitritis in two eyes (14.2%), neuroretinitis in one eye (7.1%), focal retinochoroiditis in one eye (7.1%), branch retinal vein occlusion (BRVO) due to vasculitis in one eye (7.1%), disc edema with peripapillary serous retinal detachment in one eye (7.1%), and iridocyclitis in one eye (7.1%). Most of the patients (70%) did not experience systemic symptoms preceding the intraocular inflammation. Antimicrobial treatment was efficient in all cases with the exception of the case with neuroretinitis complicated by anterior ischemic optic neuropathy and tubulointerstitial nephritis.

Conclusion: Intraocular involvement caused not only by B. henselae but also by B. quintana is being diagnosed with increasing frequency. A high index of suspicion is needed because the spectrum of Bartonella intraocular inflammation is very large. In our study the most common clinical entity was intermediate uveitis.

Keywords: Bartonella; intermediate uveitis; neuroretinitis; retinal vascular occlusion.

Figure 1

Patient 1 (Tables 2 and 3) with neuroretinitis: optic disc edema and macular star (A) and AION (B) with characteristic visual fields defect and positive serology for Bartonella henselae and history of cat scratch. Abbreviation: AION, anterior ischemic optic neuropathy.

Figure 2

Patient 4 (Tables 2 and 3). A, B, C, D: BRVO along with cystoid macular edema (CME) in OCT and signs of vasculitis (FA arrows) treated previously with laser and intravitreal bevacizumab (positive serology for Bartonella henselae and history of cat scratch). E, F, G, H: After 4 weeks’ treatment with azithromycin and rifampicin, there is a significant improvement of fundus findings along with FA findings and total regression of CME (OCT). Abbreviations: BRVO, branch retinal vein occlusion; FA, fluorescein angiography; OCT, optical coherence tomography; CME, cystoid macular edema.

Figure 3

Patient 5 (Tables 2 and 3) with positive serology for Bartonella henselae and history of cat scratch, presenting with unilateral intermediate uveitis. A) before treatment and B) after 4 weeks treatment with ciprofloxacin: regression of uveitis (the absence of snowballs is notable).

Figure 4

Patient with bilateral intermediate uveitis and peripheral vasculitis (increased IgG titers against B. quintana; patient 8 in Tables 2 and 3). (A) and (B) right eye with snowballs masking the vessels with mild vasculitis in fluorescein angiography (FA), (C) and (D) the vasculitis is more prominent in left eye; in FA segmental periphlebitis is present.

Figure 5

Recurrent nongranulomatous iridocyclitis with posterior synechiae in the left eye of a patient working in a furs elaboration industry, with positive serology for B. quintana (patient 9 in Tables 2 and 3).