Active Ingredients: Doxycycline
We present a case of an adolescent suffering from unilateral neuroretinitis associated with Bartonella henselae infection characterized by abrupt loss of vision, optic disc swelling, and macular star exudates with optimal response to antibiotic treatment.
Figure 1 Left eye retinography at the time of admission: papilledema and macular star exudates. On initial findings neutrophilia and increase in acute-phase reactants antibiotic therapy with cefotaxime was started.
This treatment was maintained for 6 weeks after serological confirmation of Bartonella henselae infection. Discussion Bartonella henselae infection is usually a self-limited and oligosymptomatic disease in immunocompromised patients.
Atypical presentations are quite variable in patients likely to be immunocompromised, and neuroretinitis associated with cat-scratch disease is not frequently seen.
Neuroretinitis usually appears a few weeks after typical symptoms of this pathology manifest, which many times goes unnoticed. The main symptom is the abrupt unilateral loss of visual acuity although cases with bilateral affectation have been described.
The finding of disc swelling associated to macular star exudates, as it happened in this patient, is considered as a predictable sign of an ocular manifestation of cat-scratch disease. Other ophthalmologic findings related to Bartonella henselae infection have been described, such as massive subretinal exudates, multifocal retinochoroiditis, diffuse retinal hemorrhages, vascular occlusive episodes, and necrotizing retinitis.
Periodic ophthalmologic examination is mandatory in these cases. Diagnosis is mainly serological through enzyme immunoassays or indirect immunofluorescence with a high sensibility and specificity.
DNA sequencing from gland tissue samples and visceral granulomas require invasive and expensive procedures. In this case, diagnosis was accomplished through serological confirmation by indirect immunofluorescence of an increased IgM antibody titer to Bartonella henselae although a significant increase in IgG antibodies titer was observed, enough to consider an acute infection by Bartonella sp.
Nevertheless, antibiotic therapy is recommended in every patient with an atypical or disseminated presentation of neuroretinitis caused by Bartonella henselae despite its evolution is usually benign.
The possibility of ophthalmic irreversible structural lesions suggests prescription of combined antibiotic therapy: rifampicin and doxycycline in patients older than eight and rifampicin with azithromycin or co-trimoxazole for patients below that age of four to six weeks.
In this patient, antibiotic prescription was based upon clinical and epidemiological suspicion, and steroids were prescribed despite questionable usefulness after the visual evoked potential test findings.
Quick and complete recovery of ophthalmic symptoms experienced by this patient, in contrast to other cases referred to by the literature, could be in relation to the prompt beginning of treatment.