Bilateral retinal vasculitis due to presumed sarcoidosis with rickettsial retinitis

OBJECTIVE

To describe a case of bilateral retinal vasculitis due to presumed sarcoidosis and rickettsial retinitis complicated with neovascularization with tear biomarker analysis.

METHODS

A retrospective case report.

RESULTS

A 16-year-old male presented with bilateral retinal vasculitis and retinitis in both eyes with inferotemporal quadrant neovascularization in the right eye. Multimodal imaging revealed the presence of active inflammation in both eyes. Weil Felix test was positive with raised ACE levels. This patient was treated with local and systemic steroids, doxycycline, and laser photocoagulation followed by oral methotrexate therapy which resulted in clinical resolution with recovery of visual acuity. Tear biomarker analysis showed raised sICAM-1 and MMP-9 levels in both eyes which significantly reduced following treatment.

CONCLUSION

Ocular sarcoidosis with rickettsial infection is a rare association. Tear biomarkers correlated well with clinical and imaging manifestations. High index of suspicion and aggressive anti-inflammatory therapy can help control inflammation and restore good vision.

Effects of intraocular treatments for Epstein-Barr virus (EBV) retinitis: A case report

RATIONALE

Intraocular infection of Epstein-Barr virus (EBV) may cause severe visual loss. However, it is relatively rare, and there is no consensus on its treatment.

PATIENT CONCERNS

A 44-year-old woman complained of a right-eye floater and exhibited a unilateral exudative change along the retinal veins at the Department of Ophthalmology, St. Luke's International Hospital.

DIAGNOSIS

EBV retinitis was diagnosed based on EBV-positive (9.09 × 103 copies/μl) and cytomegalovirus-negative results in the aqueous humor.

INTERVENTIONS

Oral prescription of valaciclovir hydrochloride, and an intravitreal injection of foscarnet sodium hydrate was administered. However, the retinal infiltration progressed, and vitreous opacity with cellular infiltration appeared. Intravitreal methotrexate (MTX) injection effectively suppressed retinal and vitreous infiltration. However, she developed optic-nerve papillitis, and central retinal vein occlusion related to the severe swelling of the optic-nerve, and began steroid pulse therapy. Considering the increase in intraocular EBV levels to 6.4 × 104 copies/ml, we restarted intravitreal foscarnet injections replacing MTX. This in turn rapidly reduced the EBV levels to 3.27 × 104 copies/ml, followed by papillitis alleviation.

OUTCOMES

The intraocular MTX administration reduced the inflammatory vitreous and retinal infiltration, but not the EBV load, while foscarnet reduced the EBV load and papillitis, but not vitreous infiltration.

LESSONS

The retinal infiltration may have involved EBV infection to the retinal neurons but also EBV-free reactive inflammatory cells. EBV infection to the neurons may have been, at least partially, treated by intravitreal foscarnet treatment, and the reactive inflammatory cells by intravitreal MTX. Further observations are warranted to reach a consensus on treating intraocular EBV infection.

Necrotizing retinitis in a patient with syphilis: A case report

RATIONALE

Ocular syphilis varies widely in presentation and should be considered in all patients with posterior uveitis. Necrotizing retinitis is a rare manifestation of ocular syphilis and mimics ARN.

PATIENT CONCERNS

We report a male patient who presented with bilateral dense vitritis obscuring fundus details similar to ARN, as a rare reported manifestation of syphilis, who was initially given intravitreal ganciclovir.

DIAGNOSIS

After the results for herpes viral PCR disclosed negative, the diagnosis of syphilitic necrotizing retinitis was made based on positive RPR.

INTERVENTION AND OUTCOMES

With the clinical diagnosis of ocular syphilis, treatment with intravenous penicillin was promptly initiated. His visual acuity improved to 20/100 in the right eye and still light perception in the left. Pars plana vitrectomy with silicon oil tamponade was performed in his left eye.

LESSONS

Ocular syphilis varies widely in presentation and should be considered in all patients with posterior uveitis. However, whenever ARN is clinically suspected, empiric treatment against herpetic viruses should be promptly administered while awaiting further infectious disease study results. Recognition of syphilitic retinitis and prompt initiation of intravenous penicillin is of critical important for clinicians.

Case Report: Endogenous Candida Endophthalmitis in Cornelia de Lange Syndrome: Atypical Stellate Neuroretinitis

SIGNIFICANCE

This study aimed to highlight the association of stellate neuroretinitis occurring secondary to endogenous candidemia.

PURPOSE

We report an unusual presentation of endogenous Candida endophthalmitis as a stellate neuroretinitis in the setting of Cornelia de Lange syndrome.

CASE REPORT

A 34-month-old girl with severe Cornelia de Lange syndrome and a history of parenteral nutrition dependence requiring a chronic central venous catheter presented with bilateral endophthalmitis secondary to candidemia. In one eye, the endophthalmitis had the atypical presentation as a stellate neuroretinitis.

CONCLUSIONS

This case represents a unique association of stellate neuroretinitis secondary to Candida infection in a patient with Cornelia de Lange syndrome.

PRESUMED TUBERCULOUS MULTIFOCAL RETINITIS IN PATIENTS UNDER TREATMENT WITH BIOLOGIC AGENTS

PURPOSE

To report unique retinal fundus lesions and treatment outcomes of intraocular tuberculosis in patients under anti-tumor necrosis factor treatment.

METHODS

Retrospective review of two patients with laboratorial evidence of tuberculosis who had bilateral ocular signs and symptoms not attributable to other diseases. Multimodal imaging was analyzed at the time of presentation and after the treatment initiation. The study patients underwent standard treatment for tuberculosis.

RESULTS

Clinical and laboratory findings were consistent with the diagnosis of presumed tuberculosis. Color fundus photograph revealed the presence of multifocal yellowish retinal spots in the study eyes. On fluorescein angiography, the retinal lesions seen on color fundus photograph showed early hypofluorescence with progressive staining of its edges. Occlusive vasculitis with peripheral nonperfusion was also observed in both cases. Spectral domain optical coherence tomography demonstrated increased reflectivity and thickness on the topography of retinitis lesions. After specific antibiotic treatment for tuberculosis, there was complete disappearance of the retinal lesions in all study eyes.

CONCLUSION

We report two unique cases of bilateral presumed intraocular tuberculosis presenting as multifocal retinitis in patients under biologic agent treatment. Anti-tumor necrosis factor agents may be related to unusual fundus manifestations of tuberculosis.

Mycobiome changes in the vitreous of post fever retinitis patients

Fungi have been associated with various diseases of the eye like keratitis, uveitis and endophthalmitis. Despite this fact, fungal microbiome (mycobiome) studies compared to the bacterial microbiome studies have remained neglected. In the present study, using metagenomic sequencing, the mycobiomes of the vitreous of healthy control individuals (VC, n = 15) and individuals with post fever retinitis + non-PFR uveitis (PFR+, n = 9) were analysed and compared. The results indicated that Ascomycota was the most predominant phylum in both VC and PFR+ groups. Further, at the genera level it was observed that the abundance of 17 fungal genera were significantly different in post fever retinitis (PFR, n = 6) group compared to control group. Of these 17 genera, it was observed that 14 genera were relatively more abundant in PFR group and the remaining 3 genera in the VC group. Genus Saccharomyces, a commensal of the gut and skin, was predominantly present in the vitreous of both the cohorts, however it was significantly less abundant in PFR group. Further, significant increase in the genera that have a pathogenic interaction with the host were observed in PFR group. On the whole the mycobiome in both the groups differed significantly and formed two distinct clusters in the heatmap and Principal co-ordinate analysis. These results demonstrate significant changes in the mycobiome from the vitreous of post fever retinitis patients compared to healthy controls thus implying that dysbiotic changes in the fungal vitreous microbiome are associated with PFR.

[Bartonella endocarditis associated with glomerulonephritis and neuroretinitis]

Blood-culture negative endocarditis is a diagnostic challenge. Both Bartonella and Coxiella can cause it with similar clinical presentations mimicking a systemic vasculitis. The identification of the etiologic agent is essential because they differ in treatment type and duration. We present a case of blood-culture negative endocarditis caused by Bartonella henselae, associated with glomerulonephritis and neuroretinitis, with negative blood culture, positive anti-neutrophil cytoplasmic and antiproteinase 3 antibodies. The serology was positive for Bartonella with crossreactivity to Coxiella burnetti. The etiological diagnosis was achieved by polymerase chain reaction amplification and sequencing of a ribC gene fragment. The patient received antibiotic and immunosuppressive treatment followed by replacement of the aortic valve with favorable medium-term evolution.

BARTONELLA QUINTANA-ASSOCIATED NEURORETINITIS: LONGITUDINAL SPECTRAL-DOMAIN OPTICAL COHERENCE TOMOGRAPHIC FINDINGS

PURPOSE

To report an unusual case of neuroretinitis caused by Bartonella quintana and its spectral-domain optical coherence tomographic (SD-OCT) features.

METHODS

A 12-year-old girl presented with unilateral neuroretinitis with stellate maculopathy. Bartonellosis was confirmed after serologic testing for antibodies to B. quintana.

RESULTS

Color photograph of the right eye revealed papillitis and stellate macular exudation. spectral-domain optical coherence tomography of the right eye revealed hyperreflective dots in the outer nuclear and outer plexiform layers, as well as disruption and loss of the external limiting membrane, ellipsoid zone, and interdigitation zone in the foveal area.

CONCLUSION

The authors report an unusual case of neuroretinitis by B. quintana and its spectral-domain optical coherence tomographic findings.

Optical Coherence Tomography Findings in Endogenous Fungal Chorioretinitis, Retinitis, and Endophthalmitis

BACKGROUND AND OBJECTIVE

To describe spectral-domain optical coherence tomography (SD-OCT) findings in eyes with endogenous fungal chorioretinitis and endophthalmitis.

PATIENTS AND METHODS

Retrospective, observational case series of subjects at Wills Eye Hospital and William Beaumont Hospital were identified by screening OCT billing data and cross-referencing with patient charts. Clinical and imaging data were collected for each patient and reviewed.

RESULTS

Twelve eyes of seven consecutive patients were identified, demonstrating two patterns of posterior ocular involvement: chorioretinal infiltration and superficial retinal/retinal vascular infiltration without choroidal involvement. Six of 12 eyes had follow-up imaging performed after antifungal treatment, which demonstrated decreased size of choroidal and/or retinal infiltrates.

CONCLUSIONS

All patients with follow-up imaging had anatomic improvement by OCT of the lesions with treatment. In the future, OCT imaging may provide a method to assess therapeutic response and prognosis for visual recovery in patients with endogenous fungal ocular disease. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:894-901.].

Neurorétinite unilatérale: une manifestation rare du syndrome post streptococcique

La streptocoque β hémolytique est responsable de plusieurs complications d'origine immunitaire, de localisation cardiaque, articulaire, dermatologique, rénale, cérébrale et oculaire. Nous rapportons le premier cas au Maroc d'une uvéite postérieure unilatérale post- streptococcique présentant une vascularite rétinienne avec œdème papillaire et des hémorragies rétiniennes en tache profondes et superficielles. Notre patient âgé de 56 ans, ayant comme antécédents pathologiques une notion d'angine et d’ érythème noueux à répétition d'origine streptococcique. Le bilan étiologique d'uvéite est revenu normal. En revanche, le titrage des anticorps antistreptococciques était significativement élevé: 430 IU /ml. Le patient a été mis sous amoxicilline protégée à une dose de 2 g par jour pendant 10 jours, associée à une corticothérapie à dose régressive sur un mois. L’évolution était favorable avec récupération totale de l'acuité visuelle (AV) et disparition des lésions neurorétiniennes

Candidal renal papillary necrosis conquered

Renal papillary necrosis due to Candida albicans is a rare but treatable cause of acute renal failure. We report this case of a middle aged male with history of type 2 diabetes mellitus who presented with infected right lower extremity and right lower lobe pneumonitis with hypotension. Though, he improved initially, during his stay in the hospital, he developed acute renal failure. Blood culture grew Candida albicans and the renal biopsy revealed candidal renal papillary necrosis. He also had candidal retinitis on ophthalmoscopy examination. He was treated with parenteral fluconazole for two weeks followed by oral fluconazole for a total of 4 weeks. Following treatment, the patient improved symptomatically and his renal parameters returned to normal. This case illustrates the need to consider candidal papillary necrosis as a differential in an immunocompromised patient with acute renal failure. It is potentially reversible, nonetheless a diagnostic and therapeutic challenge.

[Bilateral neuroretinitis as an ocular manifestation of cat scratch disease in 9-year-old boy. A case report]

PURPOSE

1. To highlight a less-known clinical entity neuroretinitis and the need for differentiation of this entity from the other retinal disease that can mimic. 2. To be familiar with ocular finding in Cat scratch disease.

CASE REPORT

Authors describe a clinical course of bilateral neuroretinitis in a 9-year-old boy who was referred to our clinic with painless decreased corrected visual aquity in the right eye (6/18) and in the left eye (6/9). Fundus examination disclosed bilateral stellate maculopathy. Patient had a history of close contact with a cat. Serologic tests for infective disease confirmed the presence of IgG antibody against Bartonella henselae (1:64). Specific antibiotic treatment with bacteriostatical activity against Bartonella henselae restored functional and anatomical changes in both of eyes within two month.

RESULTS

Noninfective etiology of bilateral neuroretinitis was essential to exclude in differential diagnosis. Diagnosis of Cat scratch disease was based on positive epidemiological diagnosis, bilateral manifestation of neuroretinitis, high IgG antibody titre against Bartonella henselae and successful treatment of this disease after specific antibiotic therapy.

CONCLUSION

Neuroretinitis is the most common ocular manifestation of cat scratch disease. Familiarity with differential diagnosis of neuroretinitis is essential for prompt causal treatment initialisation.

Neuroretinitis caused by Bartonella quintana

A 57-year-old woman presented to the eye clinic for impaired vision on the left eye persisting for three months. Clinical examination revealed massive peripapillary exudate and stellate macular exudate, raising suspicion of a cat-scratch disease. Tetracycline therapy was introduced, followed by azithromycin and topical corticosteroids. Serologic testing for Bartonella henselae and Bartonella quintana was performed. In the first sample, Bartonella quintana IgG titer was 128, and IgM titer 20, whereas in repeat sample the respective findings were 64 and negative. Such a titer dynamics pointed to Bartonella quintana infection. The prescribed therapy resulted in vision improvement and normalization of the clinical picture. After nine months of therapy initiation, macular exudate had almost completely disappeared. Based on the patient's history, symptoms, therapeutic response and IgM pattern, the neuroretinitis must have developed secondary to Bartonella quintana infection.

Bilateral Bartonella henselae neuroretinitis with stellate maculopathy in a 6-year-old boy

PURPOSE

Bartonella henselae, the cause of cat-scratch disease in humans, may lead to characteristic vision-threatening ocular findings, which importantly indicate diagnosis.

METHODS

This is an observational case report of a 6-year-old boy who presented with bilateral stellate maculopathy and lymphadenopathy.

RESULTS

After serologic verification of B. henselae infection, systemic azithromycin therapy initiated the full recovery of visual acuity and bilateral complete resolution of stellate exudates during the following months.

CONCLUSION

Stellate maculopathy should always include the differential diagnosis of B. henselae infection. In this rare case of bilateral stellate maculopathy, we observed full recovery of function following systemic macrolide therapy.

A serologically proven case of cat-scratch disease presenting with neuroretinitis

Cat-scratch disease is a clinical syndrome that usually presents as a self-limiting illness featuring regional lymphadenopathy, fever, and small skin lesions in association with a cat scratch or bite. It is caused by the Gram-negative bacillus Bartonella henselae, which commonly affects children and young adults. Ocular bartonellosis is the most common atypical manifestation of cat-scratch disease. It can present with a wide spectrum of ocular diseases including neuroretinitis, Parinaud's oculoglandular syndrome, and other forms of intra-ocular inflammation. This case report describes cat-scratch disease neuroretinitis in a 10-year-old girl who presented with typical signs, including optic disc swelling and a macular star, preceded by pyrexia of unknown origin and cervical lymphadenopathy.

[Neuroretinitis. Clinical cases]

OBJECTIVE

Evaluate the etiology and the most frequent funduscopic alterations of the neuroretinitis.

METHODS

We present the case of a woman 24 years old with a bilateral decrease of visual sharpness (AV), painless and progressive, the funduscopic examination of which reveals a bilateral optical disc edema, with no hemorrhages or exudates, retina edema of the posterior pole and phlebitic areas. The systematic study was normal except for the hemogram (18,000/mm(3) leucocytes with 79% neutrophils) and the positive serology next to a Chlamydia. We also present the case of a 64 years old woman with a decrease of AV at the right eye of one week duration. At the back of the eye a macular star can be seen, and papilla edema. A systematic study gave normal results and positive serology at Bartonella henselae.

RESULTS

The illness produced by a cat scratch is the most common cause of neuroretinitis. The customary findings are a loss of AV, discromatopsia, afferent papillary defects and abnormality on the visual field. Other frequent findings at the back of the eye are hemorrhagic nerve fibers, cotton-like exudates, papilla edema, macular star and glassy inflammation. The roll of antibiotic therapy is questionable. Oral ciprofloxacine seems to give good results.

Treatment of cytomegalovirus (CMV) retinitis with intravitreous ganciclovir in HIV-infected children

OBJECTIVES

To evaluate the efficacy, visual outcomes, and complications of intravitreous ganciclovir treatment in cytomegalovirus (CMV) retinitis in HIV-infected children.

MATERIAL AND METHOD

The medical records of HIV-infected children who were screened for CMV retinitis from February 2002 to February 2005 were reviewed. The children with CD4+ < 15%, or with clinical category C would have complete ophthalmic examination every 3 months. Ganciclovir (4 mg/0.04 ml) was administered intravitreously to the eye with CMV retinitis every 2 weeks under general anaesthesia. After injection, fundi were examined immediately, 1 day, 14 days and every 2 weeks until the lesions were stable.

RESULTS

Six (9 eyes) out of 45 children (13%) aged 2-12 years were found to have CMV retinitis. All CMV retinitis lesions were "cheese and ketchup like" (retinal hemorrhage and exudate) lesions and presented in the posterior pole. Bilateral CMV retinitis were found in 3 children. Intravitreous ganciclovir was injected in 4 children (5 eyes). The average number of intravitreous injections for each patient was 5.6 (3-7) times. All of the children received antiretroviral therapy and 3 children also received intravenous ganciclovir CMV retinitis lesions were improved in every eye. The visual acuity (VA) remained stable in 4 eyes, but endophthalmitis developed in one eye a few days after injection. The average duration of follow-up was 13.5 months (3-23 months).

CONCLUSION

CMV retinitis was not uncommon. The authors found that intravitreous ganciclovir was effective but may cause complications. This treatment should be considered in a resource-limited setting.

Utility of MR imaging in cat-scratch neuroretinitis

About 80% of cat-scratch disease (CSD) infections occur in children, and CSD neuroretinitis (optic neuropathy with retinal exudates in a "macular star" pattern) mostly occurs in children and young adults. A recent study suggested that CSD optic neuropathy has specific features on MR imaging. However, MR imaging findings in CSD neuroretinitis are not well described in the pediatric literature. We present a patient with CSD neuroretinitis in whom these specific MR imaging features preceded the macular star, a funduscopic finding strongly suggestive of neuroretinitis. This case demonstrates how knowledge of these features is important in the appropriate diagnostic work-up of optic neuropathy. MR imaging also incidentally revealed neuritis of another cranial nerve in the auditory canal-a rare manifestation of CSD.

[Neuroretinitis in children--independent observations]

INTRODUCTION

Neuroretinitis in children is a rarely occurring entity that is characterized by optic disk edema, macular hard exudates, peripapillary subretinal exudates and the presence of posterior vitreous cells. Neuroretinitis' etiology can be infectious or non-infectious. The non-infectious causes include: systemic diseases, vascular diseases, diabetes, cancer. Most cases of neuroretinitis are idiopathic. Other forms can have an infectious cause: from animal, bacterial, viral, fungal. It occurs usually as a benign complication of pediatric infectious diseases, cat scratch disease (bartonellosis), tuberculosis. Relaminar vasculitis is responsible for the clinical picture of neuroretinitis as opposed to the primary demyelination seen in optic neuritis. Exudate from the optic nerve head resulted from leakage of the disc capillaries that had extended into the macular area along the plane of the outer plexiform layer.

MATERIAL AND METHODS

The examination of 5 girls aged 8-12, hospitalized in the Ophthalmology Clinic of The Children's Memorial Health Institute in Warsaw in 2006-2007 revealed the intrabulbar neuroretinitis-type changes. Each patient was interviewed in detail and underwent full ophthalmologic examination.

RESULTS

All patients suffered from the loss of vision, 2 of them had ocular pain when looking at the sides. There was a marked afferent pupillary defect and the changes in the visual field were also reported. Fluorescein angiogram showed leakage of disk vessels; there was no leakage of other retinal vessels. In case of each girl, a vast differential diagnostics of infectious and systemic diseases was applied.

CONCLUSION

Despite significant diagnostic difficulties in this age group, 2 girls were recognized with non-pulmonary tuberculosis as the cause of neuroretinitis. The application of tuberculosis treatment significantly improved recovery.

Poststreptococcal syndrome uveitis: a descriptive case series and literature review

PURPOSE

To describe the clinical features in a series of patients with poststreptococcal uveitis and to review literature on the pathophysiology and management.

DESIGN

Retrospective and descriptive case series.

PARTICIPANTS

Ten consecutive cases of poststreptococcal syndrome uveitis diagnosed between 1996 and 2003.

METHODS

Review of patient case notes.

MAIN OUTCOME MEASURES

Age, laterality, clinical features, and anti-streptococcal lysin O titers.

RESULTS

Ten consecutive cases of poststreptococcal syndrome uveitis were identified. All our cases had bilateral nongranulomatous inflammation and raised anti-streptococcal lysin O titers. Collating data from previous reports and this series showed that 96% of the patients were below 40 years of age, and 87.5% had evidence of previous streptococcal infection. One third of the patients had posterior segment involvement. In our patients, this was in the form of vitritis, focal retinitis, optic disc swelling, and multifocal choroiditis.

CONCLUSIONS

Poststreptococcal syndrome uveitis should be considered in the etiology of acute bilateral nongranulomatous uveitis in children and young patients.

Toll-like receptors in ocular immunity and the immunopathogenesis of inflammatory eye disease

Microbial agents have an important role in the pathogenesis of various inflammatory eye diseases, such as uveitis and keratitis. Microbial infections of the eye such as microbial keratitis, ocular onchocerciasis, bacterial endophthalmitis, viral retinitis, and other infectious uveitis are unfortunately common. In addition, microbial agents have been implicated in the pathogenesis of "non-infectious" immune mediated diseases such as HLA-B27 associated acute anterior uveitis. Toll-like receptors (TLR) are a family of pattern recognition receptors that initiates rapid host innate immune response to microbial components known as pathogen associated molecular patterns, which are unique to a given class of microbes, such as lipopolysaccharide of Gram negative bacteria. Recent in vitro and in vivo studies have demonstrated the expression and function of TLRs in the eye, with significant implications for better understanding of ocular immunity and the pathogenesis of inflammatory eye diseases affecting the cornea, uvea, and retina.

Syphilitic Retinitis With Focal Inflammatory Accumulations

A 42-year-old man with a history of human immunodeficiency virus and previous immune reconstitution after initiating a highly active antiretroviral therapy regimen was referred to rule out cytomegalo-virus retinitis. He had an unusual juxtapapillary collection of white superficial material and multiple preretinal collections resting on a peripheral ground glass opacification of the retina. These lesions quickly resolved after initiating treatment for syphilitic retinitis. The patient appeared to have developed an exaggerated response to the ocular syphilitic infection that may be related to the augmentation of his impaired immune system by highly active antiretroviral therapy.

[Posterior retinal hole secondary to a candida retinitis]

CASE REPORT

We describe the case of a 36-year-old man with a history of intravenous heroin use, who was HIV negative. Left ocular examination disclosed a focal candida retinitis in the posterior pole associated with vitritis and moderate iritis. Treatment with fluconazole inactived the chorio-retinal lesion and resolved the vitritis, but developed an inner limiting membrane contraction over the macula. Two years later, vitreous traction produced a retinal hole that needed argon laser photocoagulation.

DISCUSSION

Candida retinitis which penetrates into the vitreous cavity can produce retinal holes by vitreous traction over the lesion.

Ocular syphilis: the new epidemic

AIM

To present the clinical presentation, diagnosis, and management of syphilitic uveitis in the context of an epidemic of syphilis in the UK.

METHOD

Retrospective clinical case series.

RESULTS

Six new cases of syphilitic uveitis presented to the Manchester Uveitis Clinic in 2004, after a 15-fold increase in the incidence of syphilis in the UK, including 615 cases in Greater Manchester in the 5 years to 2004. Four cases had secondary syphilis, two had latent disease, two had no rash, and two were HIV positive. Ocular involvement included anterior or panuveitis, retinitis, retinal vasculitis, and papillitis. All resolved on treatment including intramuscular procaine penicillin G with oral probenecid.

CONCLUSIONS

Syphilis is much more common recently and syphilitic uveitis should be considered in all patients with rash and/or headache, where there is retinitis and/or retinal vasculitis, or in any uveitis of uncertain origin. Treatment is that of neurosyphilis.

Neurorétinite à Bartonella henselae : maladie des griffes du chat

We report a case of cat-scratch disease neuroretinitis for which systemic and ocular investigations proved the responsibility of Bartonella henselae. An 11-year-old boy was referred to the hospital in November 2002 for severe visual loss in the left eye over the preceding 2 weeks. At the same time, he also developed a flu-like illness. The best corrected acuity in the left eye was counting fingers at 30 cm. Posterior segment examination on the left eye showed an optic disk edema with papillary and peripapillary hemorrhages and serous retinal detachment, mild vitreous inflammation, and two little perivascular white spots. The medical history was unremarkable except for a cat scratch on his left forearm 2 months before. Four weeks of antibiotic therapy including oral rifampin and doxycycline was used. Bartonella henselae immunoglobulin M were first detected with Bartonella henselae immunoglobulin G testing negative at this time. A 3-week serum showed immunoglobulin M seroreversion, while Bartonella henselae immunoglobulin G appeared. Other causes of optic disk edema with macular star were excluded by biological data. Bartonella antibodies to both Bartonella henselae and Bartonella clarridgeiae were detected in the cat. Ophthalmic follow-up showed progressive resorption of the neuroretinitis and the visual acuity increased to 5/10. The significance of this case report lies in the reminder that this pathology can be the cause of neuroretinitis; the prognosis can be improved by earlier treatment.

Bartonella henselae infection associated with neuroretinitis, central retinal artery and vein occlusion, neovascular glaucoma, and severe vision loss

PURPOSE

To report a case of Bartonella henselae infection.

DESIGN

Observational case report.

METHODS

Review of the clinical, laboratory, photographic, and angiographic records of a patient with cat scratch disease associated with central retinal artery and vein occlusion, neovascular glaucoma, and severe vision loss.

RESULTS

A 21-year-old man had no light perception in the left eye secondary to concurrent central retinal artery and vein occlusion believed to have resulted from infection with Bartonella henselae. Forty days later, he developed neovascular glaucoma in the left eye.

CONCLUSION

Ocular complications associated with Bartonella henselae infection may include central retinal artery and vein occlusion, neovascular glaucoma, and severe vision loss.

Rocky Mountain Spotted Fever as a Cause of Macular Star Figure

An 86-year-old woman with a history of tick bites in the previous months developed subnormal visual acuity in both eyes, keratic precipitates, anterior chamber and vitreous cells, optic disc edema, retinal hemorrhages, and retinal arteriolar sheathing. She had no fever or skin rash. Three weeks later, binocular macular star figures appeared. Brain imaging was negative; cerebrospinal fluid disclosed a lymphocytic pleocytosis and elevated protein. The serum Rickettsia rickettsii antibody test was markedly positive, establishing a diagnosis of Rocky Mountain Spotted Fever (RMSF) as the cause of the ophthalmic findings. Despite treatment with oral doxycycline, these findings improved only modestly. Although neuroretinitis has been previously described in RMSF, macular star has not been documented.

Neuroretinitis associated with cat-scratch disease in Japanese patients

PURPOSE

To clarify the prevalence and clinical profile of neuroretinitis associated with cat-scratch disease (CSD) in Japan.

METHODS

Japanese patients were searched using a computer web site, Japana Centra Revuo Medicina. Location of patients, medical history, systemic and intraocular findings, treatments and visual outcome were examined.

RESULTS

We reviewed 15 eyes of 14 patients, including our own case. Incidences of the disease were more common in summer than in winter and presented in the warmer parts of Japan. All patients had been previously healthy and had been exposed to cats or flea bites. Of the 14 patients, 13 (93%) had febrile illness and seven of these (54%) had lymphadenopathy. Uveitis and macular stars were observed in 11 of 15 eyes (73%). Most patients were treated with antibiotics and systemic steroids and visual prognoses were good.

CONCLUSIONS

The clinical features of CSD-associated neuroretinitis in Japan are similar to those in other countries. Its distribution may correlate with the prevalence of Bartonella henselae-seropositive cats in Japan.

A case of cat scratch disease neuroretinitis confirmed by polymerase chain reaction

BACKGROUND

Cat scratch disease neuroretinitis is caused by infection by Bartonella henselae. To demonstrate B. henselae infection, serologic examination is commonly used, but sometimes serologic examination is not adequate for correct diagnosis. Here we present a case of cat scratch disease neuroretinitis confirmed by polymerase chain reaction in addition to serologic examination.

CASE

A 55-year-old woman, presenting with headache and high fever, had noticed visual disturbance. The best-corrected visual acuity in her right eye was 0.01. Meningitis, optic neuritis and retinitis were observed and she was treated with oral prednisolone. After repeated questioning, the patient remembered being scratched by a cat. Systemic examination focusing on B. henselae infection was conducted and B. henselae-specific immunoglobulin (Ig) G, but not IgM, was detected in both serum and cerebrospinal fluid. To confirm B. henselae infection, polymerase chain reaction (PCR) analysis using cerebrospinal fluid was performed and the presence of B. henselae-specific DNA was demonstrated. From these results, we diagnosed cat scratch disease neuroretinitis and treated the patient with minocycline hydrochloride together with prednisolone. Following this treatment regimen, the patient's condition improved, and the best-corrected visual acuity in her right eye increased to 0.6 five months after the onset.

CONCLUSION

The PCR technique is useful to correctly diagnose cat scratch disease neuroretinitis, if patients exhibit marginal data on B. henselae-specific antibody titer.

[Severe retinal phlebitis in ocular bartonellosis]

PURPOSE/METHODS

To report the clinical case of a 34-year-old male with atypical ophthalmic manifestations of cat-scratch disease (ocular bartonellosis), including an extensive retinal phlebitis, as well as the evolution of the clinical picture with treatment.

RESULTS/CONCLUSIONS

The clinical diagnosis of ocular bartonellosis was serologically confirmed. Oral treatment with ciprofloxacine healed the phlebitis and the neuroretinitis, with a residual optic disk pallor. This case exemplifies the diversitiy of ocular manifestations of this disease. The authors recommend considering this condition in the differential diagnosis of posterior uveitis in young patients.

Cat-scratch disease neuroretinitis diagnosed by a polymerase chain reaction approach

PURPOSE

To assess the value of polymerase chain reaction in the diagnosis of cat-scratch disease neuroretinitis without conclusive serology.

METHODS

Interventional case report. A 13-year-old girl developed a right neuroretinitis 2 months after a cat scratch. Despite the lack of accompanying features, an infection by Bartonella henselae was suspected and a systemic check-up was performed.

RESULTS

Serologic results excluded other proposed origins but were insufficient in making the diagnosis because of low B. henselae specific IgG level in serum. A polymerase chain reaction analysis for B. henselae DNA in a small axillary lymphadenopathy aspirate enabled us to achieve a definitive diagnosis of cat-scratch disease.

CONCLUSION

Polymerase chain reaction is a valuable method of diagnosing cat-scratch disease when serology is considered negative or borderline.

[Optic nerve involvement in syphilis in 4 patients]

BACKGROUND

Due to increasing numbers of cases syphilis again becomes more important in ophthalmology. Syphilitic ocular manifestations do not show any typical characteristics and therefore are often not diagnosed although a correct and early diagnosis with adequate therapy is very important for the visual outcome.

PATIENTS

We report on four patients with luetic ocular fundus manifestations, who were referred to our clinic with unspecific ocular complaints. Funduscopic examination revealed in all patients a papilledema, which was bilateral in three patients and unilateral in one patient. Additional findings were a non-granulomatous uveitis anterior and a chorioretinitis in both eyes of a 61-year-old HIV positive patient with retinal scars from a bilateral acute retinal necrosis syndrome (ARN), a mild non granulomatous iridocyclitis in a 53-year-old patient and a bilateral chorioretinitis and a cystoid macular edema in a 37-year-old patient. A 54-year-old patient showed a vein branch occlusion. Serological analysis demonstrated active syphilis in all cases and an EBV-infection in two patients. After penicillin therapy the ocular findings resolved.

CONCLUSION

In all cases of inflammatory fundus manifestations syphilis should be taken into consideration and serological lues tests should be performed routinely.

[Neuroretinitis in an HIV-infected patient]

CASE REPORT

We present a 35 year-old man, suffering from HIV infection with a left neuroretinitis and bilateral multifocal inner retinitis. A systematic approach supported the presumed diagnosis of cat-scratch disease. The patient was treated with oral azytromicine following a full-clinical recovery.

DISCUSSION

We discuss the differential diagnosis of this clinical entity, treatment and clinical evolution.