Case Report: Treatment of Severe Neuroretinitis and other Sequelae Associated with Cat Scratch Disease

Abstract

SIGNIFICANCE:Severe vision loss from Bartonella neuroretinitis can be best treated to improve visual outcomes with a combination of systemic corticosteroids and antibiotics. Topical ketorolac 0.5% and difluprednate 0.05% are presented as a new adjunct therapy to potentially improve visual outcomes. PURPOSE: This case illustrates severe posterior pole complications that can occur with cat scratch disease disseminated to the eye. Combination therapy with antibiotics and corticosteroids results in better visual outcomes. Topical treatment might further enhance visual outcome by preventing inflammatory damage without significant immunosuppression.CASE REPORT: A 17-year-old male teenager presented with right eye vision loss. He had been hospitalized 2 weeks prior for optic neuritis and treated with intravenous methylprednisolone. After 3 days, vision had improved from 20/200 to 20/40. After positive serology for Bartonella henselae was obtained, he was released and treated with oral rifampin, doxycycline, and prednisone. Sixteen days later, he regressed to 20/200, and many more ophthalmic complications were observed. After discontinuation of rifampin, oral prednisone was continued for an additional 2 weeks, and doxycycline was continued for approximately 3 weeks. Topical drops ketorolac 0.5% twice a day and difluprednate 0.05% four times a day were used for more than 6 weeks before tapering after vision returned to normal.CONCLUSIONS: Bartonella neuroretinitis associated with pre-retinal hemorrhage, vitritis, and subretinal hemorrhage can be successfully treated with a combination of systemic medications and topical drops. Monotherapy with doxycycline is effective and well tolerated. Rifampin can cause rapid metabolization and reduction in plasma levels of both prednisone and doxycycline and should be avoided with combined therapy. Oral prednisone and topical difluprednate are recommended to quell initial inflammation during the first few weeks. The anti-inflammatory effects of doxycycline and topical ketorolac used for longer duration may be beneficial in preventing tissue damage without systemic immunosuppression and result in better visual outcomes.