Diverse Clinical Signs of Ocular Involvement in Cat Scratch Disease

Abstract

Objectives: To describe ocular manifestations, diagnosis, and treatment of cat scratch disease.

Materials and methods: Clinical records of patients with ocular cat scratch disease were reviewed.

Results: Thirteen eyes of 10 patients (7 female, 3 male) with a mean age of 26.9±18.5 years were included. Nine patients had a history of cat contact and had systemic symptoms associated with cat scratch disease 2-90 days prior to the ocular symptoms. Ocular signs were: neuroretinitis in 4 eyes (associated with serous retinal detachment in the inferior quadrant in 1 eye), optic neuropathy in 2 eyes (1 papillitis and optic disc infiltration, 1 optic neuritis), retinal infiltrates in 6 eyes, retinochoroiditis in 1 eye, branch retinal arteriolar occlusion in 3 eyes, and endophthalmitis in 1 eye. Visual acuities at presentation were 1.0 in 7 eyes, 0.3 in 1 eye, ≤0.1 in 4 eyes, and light perception in 1 eye. Bartonella henselae immunoglobulin (Ig) M and/or IgG were positive in all patients. Systemic antibiotic therapy was administered in all patients. Systemic corticosteroid treatment (15-40 mg/day) was added to the therapy in 4 patients, following 5 days of intravenous pulse methylprednisolone in 2 patients. Treatment was ongoing for 1 patient and the mean treatment duration of the other 9 patients was 47±14.5 days. Visual acuities at final visit were 1.0 in 9 eyes, 0.8 in 1 eye, 0.4 in 1 eye, and no light perception in 1 eye.

Conclusion: Cat scratch disease may present with different ocular signs and should be considered in the differential diagnosis in patients with such presentations.

Keywords: Cat scratch disease; endophthalmitis; neuroretinitis; optic neuropathy; retinal infiltrate.

Figure 1. Imaging of patient 4 performed at time of presentation: right eye color fundus photographs (A and D), right eye fluorescein angiography (B and E), optical coherence tomography cross-section including retinal infiltrates in the superotemporal quadrant of the right eye (C), color photography of left eye (F), and fluorescein angiography image (G). Color fundus photography of the right eye shows multiple retinal infiltrates in the posterior pole and superonasal quadrant, and a superonasal area of retinal edema adjacent to the optic disc (A and D). Fluorescein angiography of the right eye shows partial staining of the optic disc, posterior pole retinal infiltrates with central hypofluorescence surrounded by hyperfluorescence, an area of retinal ischemia adjacent to the optic disc and arteriole filling defect (arrow) in the superonasal quadrant (B and E). Optical coherence tomography corresponding to the retinal infiltrates in the superotemporal quadrant of the right eye (indicated by arrows in A, B and C) shows focal hyperreflective retinal thickening (C). Color fundus photography of the left eye revealed multiple retinal infiltrates at the posterior pole (F). Fluorescein angiography of the left eye shows partial staining of the optic disc and posterior pole retinal infiltrates with central hypofluorescence surrounded by hyperfluorescence (G)

Figure 2. Left eye color fundus photograph of patient 6 taken at presentation shows papillitis and infiltrates in the nasal aspect of the optic disc

Figure 3. Right eye color fundus photographs from patient 7 taken at presentation (A and B), in the 4th week of treatment (C and D) and at final examination (E). Neuroretinitis, posterior pole hemorrhages, and posterior pole and inferior peripheral serous detachment are evident at presentation (A and B). Reduced optic disc edema, regression and slight pallor of the infiltrates, and multiple hard exudates in the posterior pole and inferior periphery are apparent after 4 weeks of treatment (C and D). At final examination, optic disc pallor and surrounding gliotic membrane as well as a large nerve fiber layer defect in the posterior pole are visible (E)