Atypical case of neuroretinitis Arnaldo Belzunce Manterola Complejo

Atypical case of neuroretinitis Arnaldo Belzunce Manterola Complejo hospitalario de Navarra

Clinical case Female of 11 years and 11 months of age who consults for loss of light and chromatic sensitivity of 3 weeks of evolution and headache. No vaccune or viral infection the day or weeks before. No toxics. Tick bite months before.

Examination • Visual acuity: • RE: 0, 50. Best corrected visual acuity (BCVA) -1 sph. 0, 50 • LE: 0, 70 BCVA: -0, 75 -0, 50 a 50º: 1 • Pupils constricts normally. • Slit lamp. Anterior chamber clear. • Fundoscopy: RE. Optic nerve head swelling in nasal border. LE: Optic nerve head swelling. Vascular sheathing in wax drop. Snow balls in vitreous body.

Workup OCT. Retinal nerve fiber layer. LE: increase in thickness.

Workup OCT. Macula LE : peripapilar intra retinal fluid and subfoveal neurosensorial detachment.

Workup OCT. Retinal nerve fiber layer. RE: minimal optic disc swelling.

Workup. Bilateral papilitis • Blood pressure: 110/60 • Hospitalization. • Cerebroespinal fluid clear. PCR herpes negative. No oligoclonal bands • I. V. Corticosteroids. Solumoderin 600 mg once a day , five doses.

• Workup Magnetic resonance imaging. without pathological findings. T 2

Workup • Fluorescein angiography: leakage of dye from vessel of the disc and retinal vessels: Choroidal perfusion is normal and macula don´t shows any anomalies in vascularization or dye leakage. • VEP. LE optic nerve dysfunction • Blood analysis. Blood count normal. Biochemistry normal. Igs normal. Serology ASLO, EBV, CMV, Toxoplasmosis, RPR , FTA abs, Borrelia negative Bartonella positive.

• Two weeks later: Follow up • BCVA LE 0, 90 • Macular star. Lipid exudates in outer retinal layer in LE. There is sheating vascular (phlebitis) yet with ecuatorial intrarretinals hemorrhages. • OCT Reduction of subretinal fluid. Bartonella serology

Follow up • 2 months later: Positive serology for Bartonella hensalae Ig G 1/256 Ig M 1/80 Bartonella quintana Ig G 1/128 ->Leber´s stellate neuroretinitis: • Doxycycline 100 mg twice and rifampin 100 mg/5 ml 15 ml (300 mg/12 hours) six weeks.

Follow up

One year later: BCVA: 1 BE FO: Follow up

One year later: BCVA: 1 BE FO: IV and Oral corticosteroids. Doxycycline 100 bid and rifampin 300 bid six weeks more. Follow up Frost periphlebitis and vitreous snow balls

CONCLUSION • Cat-Scratch disease is produced by Bartonella henselae. CSD is feline-associated zoonosis found worldwide. It is transmited by scratches, licks and bites of domestic cats, particularly kittens. • Neurorretinitis (optic disc swelling and macular star formation) 1 -2 % of the CSD. Unilateral more frecuent. Bilateral and asymetric like our case has been previous reported. Optic disc edema with peripapillary serous retinal detachment visible in OCT 2 weeks before than macular star. Macular star resolve in 8 -12 weeks. Multifocal retinal or choroidal lesions support diagnosis of B hensalae infection • NO vascular sheating has been described in neurorretinits Moorthy RS, Davis J, Foster CS et al. Infectious uveitis in intraocular inflammation and uveitis. Basic and clinical Science Course. American Academy of ophthalmology. 2009