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Editor,—Cat scratch disease (CSD) is a relatively common and self limited infection causing fever and lymphadenopathy mainly in children and adolescents.1Previously reported ocular complications of CSD include Parinaud’s oculoglandular conjunctivitis,2 papillitis,3neuroretinitis,4 peripapillary angiomatosis,5and serous neurosensory retinal detachment.6 We present a case of CSD associated with anterior uveitis, a scenario previously unreported.
A 51 year old man presented to us with a 2 week history of a painful, red left eye associated with a reduction in vision. He gave a clear account of being scratched by his kitten, over the left eyebrow 3 weeks earlier. The ensuing fever, rigors, and submandibular lymphadenopathy had led his general practitioners to prescribe a course of oral clarithromycin for presumed CSD. Our patient developed pain and redness of a moderate degree in his left eye during a conference in Denmark 1 week after the scratch. He was seen by a local ophthalmologist who made a diagnosis of Parinaud’s oculoglandular conjunctivitis and prescribed tetracycline four times daily to the affected left eye. His symptoms, however, failed to improve on this treatment.
When seen by us he had a 4 cm by 1 cm ulcerating papular skin lesion just above the medial aspect of the left eyebrow, extending onto the lateral aspect of the upper nose (Fig 1). There was a solitary non-tender submandibular lymph node on the left side.
Best corrected visual acuity was right eye 6/4-1, left eye 6/9. Slit lamp examination revealed mild circumcorneal injection, large non-pigmented keratic precipitates (Fig 2), and anterior chamber cells +2 and flare +2. The intraocular pressure was normal and the vitreous showed no inflammatory activity. There were no fundal abnormalities. The fellow eye was normal. He was treated with betamethasone 0.1% 2 hourly and cyclopentolate 1% twice daily. Over the following 3 weeks his anterior uveitis resolved, visual acuity improved to left eye 6/5-1, and the ulcerated skin lesion healed.
Immunofluorescent antibody studies at 3 weeks from the cat scratch demonstrated a positive (1/16) titre for Bartonella henselae confirming the clinical diagnosis of cat scratch disease. For this test, antigen was derived from Bartonella henselae grown in Vero cells, and a whole antibody test was used. We felt it unnecessary to obtain a tissue diagnosis by histopathology. He was HLA B27 positive with a sacroiliac radiograph reported as normal. Further investigations revealed no deviation from normal in blood count, angiotensin converting enzyme level, and chest radiograph. The autoantibody screen proved negative.
To our knowledge this is the first case of anterior uveitis occurring in association with CSD. Our patient had completed a 2 week course of oral clarithromycin. Although this drug is not widely reported to be the first line treatment for CSD, our patient did not exhibit signs of systemic infection on presentation to us and the uveitis was successfully treated with topical steroids and mydriatic. This case is unusual with respect to the location of the inoculation site. Previously reported cases of ocular involvement in cat scratch disease have had an inoculation site either on the conjunctiva or the eyelids2 whereas in this case the inoculation site was not directly on ocular structures. The anterior uveitis could be coincidental but the short time interval between the cat scratch and development of the anterior uveitis tend to support a causal relation between CSD and anterior uveitis in this case. Another possibility is that the uveitis occurred as a side effect of clarithromycin or tetracycline; however, uveitis is not a reported side effect of either of these two drugs. A number of Gram negative bacteria have been implicated in the pathogenesis of HLA B27 related anterior uveitis including Klebsiella sp, Salmonella sp, and Yersinia enterocolitica.7 Bartonella henselae is a Gram negative pleomorphic bacillus which may have the ability to cause such a reaction in patients with the HLA B27 antigen and is thus deserving of further attention.