Acute multifocal retinitis: a retrospective review of 35 cases

Distribution of different Rickettsia species in countries of the WHO Eastern Mediterranean (WHO-EMRO) region: An overview

SUBJECT

Rickettsia is a zoonotic bacterial pathogen transmitted by vectors and has extensive reservoirs in animal and human populations. Rickettsiosis is a public health problem all over the world. However, comprehensive information on the geographical distribution of different Rickettsia species, infection status of reservoirs, vectors, and human cases is lacking in most parts of the world. Therefore, this study aimed to investigate the geographical distribution of different Rickettsia species and their vectors in countries of the WHO-EMRO region.

METHODS

In this review study, a search was conducted for reports and published studies on Rickettsia species from WHO-EMRO region countries in various databases from 1995 to 2022. Finally, the reported status of human cases, reservoirs, and vectors associated with each species in different countries was documented.

RESULTS

Reports of infections related to the detection of Rickettsia species were only available for 15 out of 22 WHO-EMRO member countries. A total of twenty-four Rickettsia species, including R. sibrica, R. lusitaniae, R. africae, R. prowazekii, R. felis, R. typhi, R. rickettsii, R. aeschlimannii, R. conorii, R. massiliae, R. helvetica, R. monacensis, R. rhipicephali, R. bellii, R. asembonensis, R. hoogstraalii, R. andeanae, R. raoultii, R. asiatica, R. slovaca, R. australis, R. barbariae, Candidatus R. amblyommii, and Candidatus R. goldwasserii, were reported from WHO-EMRO member countries. Furthermore, human cases infected with six different Rickettsia species, including R. sibrica, R. prowazekii, R. felis, R. typhi, R. rickettsii, R. aeschlimannii, R. conorii, R. massiliae, and R. helvetica, were reported from these countries.

CONCLUSION

The vast diversity of Rickettsia vectors has contributed to the ongoing discovery of new Rickettsia species. Therefore, further research on the reservoir hosts of Rickettsia infections in the understudied WHO-EMRO region is crucial. This research sheds light on Rickettsia disease's epidemiology and transmission dynamics in this region.

Human-biting ticks and zoonotic tick-borne pathogens in North Africa: diversity, distribution, and trans-Mediterranean public health challenges

North Africa is home to more than 200 million people living across five developing economies (Egypt, Libya, Tunisia, Algeria, and Morocco) and two Spanish exclaves (Ceuta and Melilla), many of whom are impacted by ticks and tick-borne zoonoses. Populations in Europe are also increasingly vulnerable to North African ticks and tick-borne zoonoses due to a combination of climate change and the movement of ticks across the Mediterranean on migratory birds, human travellers, and trafficked wildlife. The human-biting ticks and tick-borne zoonoses in North Africa are reviewed along with their distribution in the region. We also assess present and future challenges associated with ticks and tick-borne zoonoses in North African and highlight opportunities for collaboration and coordination between governments in Europe and North Africa to address public health challenges posed by North African ticks and tick-borne zoonoses.

Treatment Outcomes of Presumed Rickettsial Retinitis: Evidence from OCTA Based Quantitative Analysis

AIM

To quantify retinal ischemia following presumed rickettsial retinitis (RR). To compare outcomes between initial treatment with Doxycycline (Group 1) versus steroids (Group 2).

METHODS

Retrospective analysis of patients with presumed RR was done. ImageJ software was used to obtain %area of ischemia on swept-source optical coherence tomography angiography (SS-OCTA).

RESULTS

Eleven eyes of 8 patients belonged to Group1 and 6 eyes of 3 patients belonged to Group 2. The BCVA improved from logMAR 0.8 ∓ 0.7 to logMAR 0.06 ∓ 0.08 (p < 0.002) and central foveal thickness (CFT) changed from 479μ ∓ 341.3μ to 163.5μ ∓ 20.5μ (p < 0.005) after a median of 5 weeks in Group 1. In Group 2, BCVA improved from logMAR 1.03 ∓ 0.05 to logMAR 0.23 ∓ 0.23 (p < 0.004) and CFT changed from 286.5μ ∓ 158.8μ to 177.5μ ∓ 25.9μ (>0.05) following a mean of 11 weeks. Mean %area of ischemia was 4.6 ∓ 1.5 in Group 1 and 13.9 ∓ 4.1 in Group 2.

CONCLUSION

Analysis of flow deficit on SS-OCTA confirms that treatment with Doxycycline in presumed RR results in less ischemia and quicker recovery than initial treatment with steroids.

Rickettsial disease: An underestimated cause of posterior uveitis

Rickettsioses are worldwide distributed infectious disease caused by intracellular small Gram-negative bacteria transmitted to humans by the bite of contaminated arthropods, such as ticks. Systemic disease typically consists of a triad of high fever, headache, and skin rash. It usually has a self-limited course, but severe, life-threatening complications can sometimes occur. It may be clinically difficult to differentiate rickettsial diseases from other febrile illnesses. Rickettsial infection has been largely underestimated as a cause of infectious uveitis for long decades in the past. Conversely, recent data show that ocular involvement is much more common than previously thought, with retinitis, retinal vasculitis, and neuroretinitis being the most typical and frequent findings. Early clinical diagnosis of rickettsial disease, while awaiting laboratory test results, is essential for prompt initiation of appropriate antibiotic treatment to prevent systemic and ocular morbidity. The prevention remains the mainstay of rickettsial infection control.

Acute multifocal retinitis in a patient with Q fever (Coxiella Burnetii infection) with endocarditis

Objective

To report acute multifocal retinitis in association with serologically-proven Coxiella (C) Burnetii infection (Q fever) with endocarditis.

Material and methods

A single case report documented with multimodal imaging.

Results

A 67-year-old cattle breeder presented with a 2-week history of persistent fever, headache, and floaters in both eyes. On examination, his best-corrected visual acuity was 20/20, and there was 1+ vitreous cells in both eyes. Bilateral fundus examination showed multiple small superficial white retinal lesions scattered in the posterior pole and midperiphery associated with a few retinal hemorrhages. These retinal lesions did not stain on fluorescein angiography (FA) and showed focal hyperreflectivity and thickening primarily involving the inner retinal layers on optical coherence tomography (OCT). There also was a band-like hyper-reflective area in the middle retina consistent with paramacular acute middle maculopathy. Transthoracic echocardiogram (TTE) showed a mobile echodensity on the anterior aortic leaflet consistent with a diagnosis of endocarditis. Elisa assays performed on paired serum samples collected 2 weeks apart showed increase in antibodies against C burnetii from 60 IU/ml to 255 IU/ml. The patient was treated with doxycycline 100 mg twice a day for 18 months, with subsequent resolution of the endocarditis. Sequential ocular examinations showed gradual resolution of all acute retinal findings without visible scars.

Conclusion

Acute Q fever, caused by C burnetii infection, should be considered in the differential diagnosis of acute multifocal retinitis. A systematic cardiac assessment with echocardiography is essential for early diagnosis of associated endocarditis and for prompt administration of appropriate antibiotic treatment to improve clinical outcomes.

Posterior Segment Manifestations of Cat-scratch Disease: A Mini-review of the Clinical and Multi-modal Imaging Features

Bartonella henselae, an intracellular gram-negative bacillus, is usually transmitted from infected cats to humans by direct or indirect contact. The bacterium mainly infects erythrocytes and endothelial cells thereby leading to so called cat-scratch disease (CSD) and may present with various localised and/or systemic manifestations. The eye is the most commonly affected organ in disseminated CSD and ocular bartonellosis has been reported in 5-10% of CSD patients. The most well-known clinical feature of ocular bartonellosis is neuroretinitis but various sight-threatening posterior segment lesions involving the optic nerve, retinal vasculature, retinal and choroidal tissues may occur during the disease course. This mini-review aims to overview both the clinical and multi-modal imaging characteristics of posterior ocular segment manifestations of CSD.

Cat scratch disease neuroretinitis: A case report

Introduction

Cat scratch disease (CSD) is a ubiquitous infectious disease caused by a Gram-negative intracellular bacillus, Bartonella henselae. Neuroretinitis is a classical but rare manifestation of CSD.

Case presentation

A 20-year-old woman presented with a 5-day-history of reduced vision in the left eye (LE). Two weeks before eye symptoms, she complained from fever, fatigue and arthromyalgia which resolved spontaneously. In the LE, visual acuity (VA) was 7/10, fundus photography showed optic disc edema with macular exudates arranged in incomplete macular star. Serologic test for Bartonella henselae using indirect immunofluorescent assay (IFA) was highly positive (1:2560 UI/L) for immunoglobulin G (Ig G). The diagnosis of CSD associated neuroretinitis has been made and the patient was treated with doxycycline, rifampicin and oral prednisolone. Twelve months after the end of therapy, VA was 10/10, fundus photography and Macular OCT were normal.

Discussion

In CSD, neuroretinitis occurs 2–3 weeks after systemic symptoms. The clinical features of CSD are not specific hence the need for bacteriological diagnosis which is based mainly on serologic testing by the detection of Ig G and Ig M by IFA or ELISA. The treatment of CSD-associated neuroretinitis is not standardized. Antibiotics active against intracellular bacteria, with or without systemic corticosteroids, should be prescribed especially in severe cases. The outcome of Bartonella henslae neuroretinitis is usually favourable.

Conclusion

Despite rarely reported in Tunisia, CSD should be considered in patients with presence of typical neuroretinitis with macular star and of a history of contact with cats.

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Cat scratch disease is usually a self-limited lymphadenitis.

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Neuroretinitis is a rare but classic manifestation of cat scratch disease.

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Neuroretinitis occurs in 1–2% of patients with cat scratch disease.

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Diagnosis confirmation is based on serologic testing.

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The prognosis is usually good.

Clinical profile and response to steroids in post-fever retinitis: a nine-year experience from a referral institute in the rural hinterland of Central India

PURPOSE

To describe the demographics, clinical features, and treatment outcomes with systemic steroids in eyes presenting with post-fever retinitis (PFR) from Central India.

METHODS

Single-center, retrospective analysis of 147 eyes of 98 PFR cases between 2011 and 2019.

RESULTS

Mean age of the study cohort was 33.46 ± 12.76 years, with 72 males and 26 females. The mean interval between the onset of fever and the diminution of vision was 21.10 ± 13.54 days (range 0-60 days). The number of PFR cases increased over the nine years with 89 cases (90.1%) presenting during winters. Unilateral involvement was seen in 49 cases, while 49 had bilateral involvement. Clinical characteristics included: multifocal retinitis (n = 122; 61.2%), hemorrhages (n = 132; 89.8%), disc edema (n = 57; 38.8%), anterior chamber reaction (n = 28; 19%), and vitritis (n = 103; 70.1%). Treatment included intravenous followed by oral steroids in 70 patients and oral steroids exclusively in 23; five patients denied treatment. The visual acuity improved from 1.09 ± 0.52 LogMAR to 0.29 ± 0.42 LogMAR (p < 0.05).

CONCLUSION

There has been an increase in the prevalence of PFR cases over the last decade with clustering during the winters. Multifocal retinitis, retinal hemorrhages, and vitritis were the most common clinical findings in our series. The retinitis resolved with improvement in vision following steroid therapy in all eyes.

Role of multicolour imaging in post-fever retinitis involving posterior pole

PURPOSE

To describe composite multicolour (MC) imaging features along with the monocoloured fundus reflectance images in active and resolving stages of post-fever retinitis (PFR).

METHODS

Retrospective image analysis of cases of PFR who underwent dilated retinal clinical examination followed by optical coherence tomography and MC imaging.

RESULTS

Twenty-five eyes of 18 patients diagnosed with PFR were included. There were 11 males and 7 females. Mean age of patients was 30.63 years. The retinitis lesion appeared bright white on MC image and white mainly on blue and green reflectance images during the active stages of PFR. The lesion appeared dull-grey to greyish white during the resolving stages and as dull-green in resolved cases. The active stages showed the presence of intraretinal/subretinal fluid which appeared as green colour on MC images and less green to normal during resolving stages. Hard exudates were seen as bright yellow- or orange-coloured spots on MC image during the resolving stages of the disease.

CONCLUSION

The different stages of PFR show different colour on multicolour image and different reflectance patterns on individual colour reflectance channels. Hence, multimodal fundus imaging with different wavelength can be helpful for differentiation of activity in PFR.

Clinical profile and visual outcome of intraocular inflammation associated with cat-scratch disease in Japanese patients

PURPOSE

To evaluate intraocular inflammation in Japanese patients with cat-scratch disease (CSD).

STUDY DESIGN

Retrospective clinical chart review.

PATIENTS AND METHODS

The cases of 15 consecutive patients (19 affected eyes) in Kochi Prefecture, Japan who were serologically positive for Bartonella henselae or Bartonella quintana infection in association with intraocular inflammation were reviewed. The clinical manifestations, ocular complications, and treatment modalities were recorded. The clinical charts and photographic records were also reviewed for evidence of optic disc lesions, macular star, foci of chorioretinitis, and other findings.

RESULTS

Thirteen patients reported fever before or at the time of the initial presentation. Ten of 11 patients with decreased visual acuity manifested neuroretinitis, and the remaining patient showed retinochoroiditis with macular involvement. One patient with a visual field defect manifested branch retinal artery occlusion. Three patients without visual disturbance presented with fever of unknown cause. Discrete white retinal or retinochoroidal lesions were the most common findings (84% of eyes, 87% of patients), followed by retinal hemorrhage (63% of eyes, 80% of patients), optic disc lesions (63% of eyes, 73% of patients), serous retinal detachment (53% of eyes, 67% of patients), and macular star (47% of eyes, 60% of patients).

CONCLUSION

White retinal or retinochoroidal foci were the most common ocular posterior segment manifestations of CSD in this patient population. A diagnosis of CSD should be suspected in patients with fever and chorioretinal white spots, and the absence of neuroretinitis or macular star does not exclude the possibility of intraocular inflammation in CSD.

Rickettsia conorii retinitis: an emerging infection in the southeast of the Iberian Peninsula

CASE REPORT

A case is presented of a 60-year-old patient with loss of visual acuity in both eyes after fever and skin rash with palmoplantar involvement. After a complete examination and relevant complementary tests, the diagnosis of retinitis was made in the context of Rickettsia conorii infection. The evolution after treatment with doxycycline and prednisone at six weeks with significant anatomical and functional improvement is presented. Rickettsiosis is an emerging zoonosis that can present with ocular involvement. This is usually a multifocal retinitis affecting posterior pole with macular serous detachment and vitritis. Clinical suspicion will require serological confirmation for a definitive diagnosis. Treatment with antibiotics and corticosteroids has been shown to be effective. It should be taken into account in Mediterranean endemic areas, and in in the summer period, where the risk is much higher.

Ocular complications of cat scratch disease

Cat scratch disease (CSD) in humans is caused by infection with Bartonella henselae or other Bartonella spp. The name of the disease reflects the fact that patients frequently have a history of contact (often involving bites or scratches) with infected cats. Patients with CSD typically develop lesions at the site where the skin is broken together with regional lymphadenopathy but may go on to exhibit systemic symptoms and with deep-seated infections at a range of sites including the eye. Patients with CSD may present with a range of inflammatory eye conditions, including Parinaud's oculoglandular syndrome, neuroretinitis, multifocal retinitis, uveitis and retinal artery occlusion. Bartonella spp. are fastidious bacteria that are difficult to culture from clinical specimens so microbiological diagnosis is frequently made on the basis of positive serology for anti-Bartonella antibodies or detection of bacterial DNA by PCR. Due to the lack of clinical trials, the evidence base for optimal management of patients with CSD-associated eye infections (including the role of antibiotics) is weak, being derived from single reports or small, uncontrolled case series.