Conservative management of documented neuroretinitis in cat scratch disease associated with Bartonella henselae infection

Clinical Manifestations Associated with Bartonella henselae Infection in a Tropical Region

Bartonella henselae is a zoonotic Gram-negative Bacillus associated with self-limited regional lymphadenopathy. In recent decades, an expanding spectrum of clinical manifestations has been described, in part, due to improved diagnostics. However, updated epidemiological data are sparse. We retrospectively reviewed the clinical features of 31 patients with B. henselae infection over 15 years from 2005 to 2019, in the tropical Top End of Australia. Our annual disease incidence of 1.3 cases per 100,000 population is lower than that in the national database surveillances in the United States, but the hospitalization incidence of 0.9 per 100,000 population in our region is higher than those reported in the literature, with an average length of stay of 9 days. Patients were more commonly male, aboriginal, and aged less than 14 years (median age: 7 years), living in a rural setting with presentation during our monsoon season. The disease spectrum included lymph node disease (74%), organ peliosis, endocarditis, cutaneous lesions, parapharyngeal abscess, parotitis, and neurologic and ocular syndromes. Lymph node disease was far commoner in children than the more serious systemic B. henselae infections associated with adults (P = 0.074). Although no deaths were reported, significant morbidities were observed. Two endocarditis cases presented with glomerulonephritis, and hematological and neurological features mimicking vasculitis, and consequently received immunosuppressants. One case was only diagnosed after representation with serial embolic strokes. Given the heterogeneity of disease manifestations with nonspecific symptoms and significant consequences, a timely and accurate diagnosis is needed to avoid unnecessary treatments or interventions.

Bartonella henselae encephalopathy in a paediatric patient: A case report and treatment review

WHAT IS KNOWN AND OBJECTIVES

Bartonella henselae is the etiologic agent of "cat scratch disease (CSD)". We describe a case of atypical CSD in a paediatric patient and include a review of the antibiotic treatment for this disease.

CASE DESCRIPTION

A 2-year-old child, with convulsive status and loss of consciousness, was admitted to hospital. Several antiepileptics and antibiotics were prescribed due to suspected central nervous system infection. When serology revealed Bartonella henselae antibodies, targeted antibiotic therapy was initiated and symptoms improved. However, seizures reappeared days after finishing the treatment so antiepileptics and antibiotics were reintroduced.

WHAT IS NEW AND CONCLUSION

A wide variety of antibiotic regimens have been used for the treatment of atypical CSD in paediatric patients. This report includes the case of a paediatric patient diagnosed with atypical CSD who presented neurological manifestations, and for which a regimen consisting of azithromycin and rifampin was employed to achieve recovery.

Treatment Strategies for Neuroretinitis: Current Options and Emerging Therapies

PURPOSE OF REVIEW

To explore and critically appraise the published data on the current and emerging treatment modalities for neuroretinitis.

RECENT FINDINGS

The optimum treatment strategy for neuroretinitis due to Bartonella henselae in immunocompetent individuals is not clear and a matter of debate. The role of systemic corticosteroids in infectious neuroretinitis and the optimum immunosuppressive regimen for use in recurrent idiopathic neuroretinitis also remains ill defined. There is no class 1 evidence to support a specific treatment strategy for neuroretinitis. For uncomplicated B. henselae-associated neuroretinitis in immunocompetent patients, initiation of antibiotic and corticosteroid therapy remains controversial. In patients with severe vision loss and/or moderate to severe systemic symptoms, a 4- to 6-week regimen of doxycycline or azithromycin with rifampin may provide some benefit. The routine use of systemic corticosteroids in infectious neuroretinitis is not recommended. Targeted antimicrobial agents should be instituted in cases of neuroretinitis due to specific infectious etiologies (e.g., syphilis, Lyme disease, tuberculosis). Azathioprine may be beneficial in cases of recurrent idiopathic neuroretinitis. There is a need for collaborative, multicenter prospective studies to provide definitive guidelines regarding the use of antibiotics and corticosteroids and to evaluate future therapies in infectious and recurrent idiopathic neuroretinitis.

Beyond cat scratch disease: widening spectrum of Bartonella henselae infection

Bartonella henselae was discovered a quarter of a century ago as the causative agent of cat scratch disease, a clinical entity described in the literature for more than half a century. As diagnostic techniques improve, our knowledge of the spectrum of clinical disease resulting from infection with Bartonella is expanding. This review summarizes current knowledge regarding the microbiology, clinical manifestations, diagnostic techniques, and treatment of B. henselae infection.

Clinical implication of prolonged fever in children with cat scratch disease

Cat scratch disease, caused by Bartonella henselae, typically presents with a localized lymphadenopathy with a brief period of fever and general symptoms. However, there are atypical cases with a wide spectrum of clinical manifestations including prolonged fever (> or =37.5 degrees C, for more than 7 days), or with systemic complication, or without lymphadenopathy. We analyzed relationships among those manifestations in children with cat scratch disease. A total of 127 patients were serologically diagnosed as having Bartonella infection between 1997 and 2003. Relationships among clinical manifestations were analyzed by use of multiple regression and multiple logistic regression analyses. Of the 127 seropositive cases, 75 (59.1%) had typical cat scratch disease and 52 (40.9%) had an atypical one. As atypical manifestations, 46 (36.2%) had prolonged fever, 23 (18.1%) had no lymphadenopathy, and 21 (16.5%) had complications: hepatic/splenic abscesses or low-echoic lesions, hepatic granuloma, and central nervous system involvements. Prolonged fever was observed in 20 (87%) of the 23 cases without lymphadenopathy and 16 (76.2%) of the 21 cases with complications. By multiple regression analysis, the duration of fever was significantly associated with both the absence of lymphadenopathy and the presence of complications. The child suffering from cat scratch disease without lymphadenopathy or with complication tends to have prolonged fever. Conversely, when a child has a prolonged fever of unknown origin, possibility of cat scratch disease should be considered, and a search for underlying systemic complications is recommended for prompt diagnosis and appropriate treatment.

Treatment of cat-scratch disease

Cat-scratch disease is an infection caused by Bartonella henselae, a fastidious gram-negative bacillus acquired from exposure to an infected kitten or cat. The most common manifestation of human disease is lymphadenitis. Atypical forms of infection include Parinaud oculoglandular syndrome, stellate neuroretinitis, persistent fever without localizing signs, hepatosplenic infection, encephalopathy, osteomyelitis, and endocarditis. Immunocompromised individuals with B. hensalae infection may develop bacillary angiomatosis, bacillary peliosis, and relapsing bacteremia with fever syndrome. The bacillus is susceptible to several antibacterial agents in vitro, including penicillins, cephalosporins, aminoglycosides, tetracyclines, macrolides, quinolones, trimethoprim and sulfamethoxazole, and rifampin. Greatest clinical efficacy has been observed following treatment with rifampin, ciprofloxacin, gentamicin, trimethoprim and sulfamethoxazole, clarithromycin, and azithromycin. In one placebo-controlled study, azithromycin therapy was associated with more rapid diminution in size of infected lymph nodes. The majority of cases of cat-scratch disease occurring in normal hosts do not require anti-infective therapy for resolution of infection.

Optic disk edema associated with peripapillary serous retinal detachment: an early sign of systemic Bartonella henselae infection

PURPOSE

To describe optic disk edema associated with peripapillary serous retinal detachment as an early sign of systemic Bartonella henselae infection.

METHODS

Multicentered, retrospective case series.

RESULTS

Five women and two men presented with optic disk edema producing peripapillary serous retinal detachment. Each patient had a markedly elevated serum anti-B. henselae antibody titer. Patient age ranged from 11 to 44 years, with a mean and median of 26.6 and 28 years, respectively. The time from the onset of systemic symptoms to the onset of visual symptoms varied from 3 days to 1 month. The peripapillary serous retinal detachment resolved within 1 to 3 weeks in each case, producing a macular star in four of seven patients. Initial vision was 20/200 or worse in five of seven patients and improved in four of these five patients to 20/30 or better.

CONCLUSIONS

Systemic B. henselae infection should be considered in patients who develop optic disk edema associated with a peripapillary serous retinal detachment, even in the absence of classic neuroretinitis with a macular star.

Ocular bartonellosis

PURPOSE

To review recent advances in the basic and clinical biology of Bartonella-related eye disease.

METHOD

A review of the pertinent medical literature was performed.

RESULTS

A number of novel Bartonella species have been identified over the past decade. Of these, Bartonella henselae, the etiologic agent in cat scratch disease, is most often associated with ocular complications, which may include Parinaud oculoglandular syndrome, neuroretinitis, and focal retinochoroiditis. Although cat and flea exposure appear to be the main risk factors for contracting cat scratch disease, the diagnosis of ocular bartonellosis relies primarily on the recognition of suggestive clinical signs in conjunction with positive serologic testing. B. henselae-associated ocular complications are usually self-limited but may be treated with doxycycline or erythromycin, with or without rifampin, when the infections are severe or sight-threatening.

CONCLUSIONS

B. henselae infection is common and should be considered in patients with Parinaud oculoglandular syndrome, neuroretinitis, or focal retinochoroiditis, particularly when there is a history of cat or flea exposure.