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Intraocular cat scratch disease may present with different clinical features including neuroretinitis, retinitis, retinal infiltrates, arterial and vein occlusions. Most of the cases show spontaneous recovery without therapy.1
There are only few reports of intraocular cat scratch disease in HIV+ patients. We report an unusual case of cat scratch disease presenting as helioid unifocal choroiditis in an HIV+ patient that showed good response to systemic therapy.
Case report
A 30 year old homosexual HIV+ man was referred to the uveitis department complaining of blurred vision in the left eye. He was taking zidovudine, lamivudine, ritonavir, and saquinavir. His last CD4+ count was 128 cells ×106/l and viral load 1 300 000.
His visual acuities were 6/6 in the right eye and counting fingers in the left. There was no inflammation in the anterior chambers or in the vitreous. Ophthalmoscopy revealed a yellowish choroidal lesion surrounded by fluid and haemorrhages in the macula of the left eye (Fig 1). Fluorescein angiography showed an angiomatous lesion corresponding to those seen clinically. Blood tests were ordered including VDRL, toxoplasmosis serology, Lyme disease serology, ELISA for toxocariasis and were all negative. Computed tomography (CT) scan and serum studies were unremarkable. Blood sample was sent to CDC Atlanta for Bartonella serology. Since clinical diagnosis was cat scratch disease and most patients show good recovery without treatment we decided not to treat before results of blood tests. We kept examining the patient every week with ophthalmoscopy and fluorescein angiography (Fig 2A, B). The lesion progressively increased in size but he did not show visual acuity deterioration.
Fundus photograph of yellowish chorioretinal lesion surrounded by fluid and haemorrhages.
(A) Fundus photograph at second visit, yellowish lesion increased. (B) Arteriovenous phase fluorescein angiogram showing an angiomatous-like lesion.
A month after presentation the lesion had increased and four small lesions appeared in the right eye. His visual acuity dropped to hand movements. Although we did not have the results of Bartonella serology, we decided to give him ciprofloxacin. Bartonella henselae serology was positive for IgG, 1:256, and IgM negative.
Fifteen days after treatment was started the lesions in the right eye disappeared and the macular lesion in the left eye resolved completely.
Comment
There is a well established association between neuroretinitis and cat scratch disease although many different clinical presentations have been described.1 Ormerod et al1 described two patients with small areas of retinitis and arteriolar occlusions. Pollock and Kristinsson2 described one patient with cat scratch disease and helioid unifocal choroiditis. Hong et al3 first described this syndrome when they reported six young patients with a solitary round yellow chorioretinal lesion associated with subretinal fluid. There was no association with inflammatory or infectious diseases. Fish et al4 reported a case of peripapillary angiomatosis associated with neuroretinitis. Our patient presented with clinical features of helioid unifocal choroiditis but after angiogram we could see an angiomatous-like lesion.
The treatment of ocular cat scratch disease remains controversial. Pollock and Kristinsson2 reported a case that improvement in visual acuity from 6/12 to 6/6 occurred after 3 weeks without treatment. One of the cases described by Ormerod showed some benefit after treatment although his recovery was very slow. The second patient showed improvement without treatment. Warren et al5 reported an HIV+ patient with cat scratch disease whose lesion enlarged without treatment. Once the diagnosis of Bartonella was confirmed by polymerase chain reaction of the retina sample, the patient was started on systemic antibiotics with good results. Considering that spontaneous recovery could occur we decided not to treat until our patient showed deterioration in the left eye and involvement in the fellow eye.
Ophthalmologists should be aware of this unusual presentation of cat scratch disease with helioid unifocal choroiditis and angiomatous-like lesions. Although larger series and control studies are needed, HIV+ patients with intraocular manifestations of cat scratch disease may benefit from systemic treatment with antibiotics.