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Grand Rounds Conference

Grand Rounds Conference. Janelle Fassbender , MD, PhD University of Louisville Department of Ophthalmology and Visual Sciences January 3, 2014. Subjective. CC: Blurred vision right eye

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Grand Rounds Conference

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  1. Grand Rounds Conference Janelle Fassbender, MD, PhD University of Louisville Department of Ophthalmology and Visual Sciences January 3, 2014

  2. Subjective CC: Blurred vision right eye HPI: 42 yo WM awoke 2 days ago with decreased vision in the superior half of his right eye. Mild pain with eye movement. *Multiple feral cats at home of various ages.

  3. History POH: None PMH: HIV+ (CD4 count 336), migraine Eye Meds: Artificial tears Meds: Stribild (HAART), Neurontin, Celexa Allergies: Penicillin, sulfa, phenergan ROS: Positive: headaches, eye pressure, neck stiffness Negative: fever, chills, recent illness

  4. Objective OD OS BCVA: 20/80 20/20 Pupils: 4 to 2 mm OU, +/- RAPD OD IOP: 17 18 EOM: Full Full CVF : Inferior altitudinal defect OD

  5. Objective SLE: External/Lids Normal OU Conjunctiva/Sclera Normal OU Cornea Clear OU Anterior Chamber Deep, quiet OU Iris Normal OU Lens Clear OU VitreousNormal OU

  6. Dilated Fundus Exam OD: Optic disc edema, Disc hemorrhages OS: Normal

  7. Visual Fields (30-2) OD: inferior altitudinal defect OS: full

  8. OCT OD Patient referred to retina clinic for further work up. OCT of right eye demonstrated intact fovealarchitecture with no evidence of fluid or exudate.

  9. Fluorescein angiography FA of right eye showing optic disc hyperemia with leakage as well as patchy hypofluorescence just temporal to the disc corresponding to intra-retinal heme.

  10. Differential Diagnosis of Optic Neuritis • Non-infectious: • Multiple sclerosis • Sarcoidosis • Anterior ischemic optic neuropathy • Systemic lupus erythematosus • Neuromyelitisoptica • Infectious: • Bartonellahenselae(Cat Scratch Disease) • Syphilis • Lyme disease • Toxoplasmosis • Herpes simplex; Herpes zoster • Tuberculosis

  11. Workup • Labs: • CBC, CMP, UA: Normal • CSF: • Glucose: Normal; Protein: High • VDRL, HSV, cryptoccal antigen: Negative • Cultures: Negative • Serology: • RPR, FTA-ABS, Toxoplasma, HSV/VZV, Quantiferon, Lyme titers: Negative • BartonellahenselaeIgGantibodies: Positive (1:512)

  12. Imaging CT Head (11/3/13) – Negative MRI Brain with contrast (11/06/13) – Negative

  13. Diagnosis Atypical optic neuritis secondary to Bartonellahenselae infection (Cat Scratch Disease).

  14. Treatment plan • Doxycycline, 100 mg twice daily for 4 weeks. • Neurophthalmology referral

  15. Follow-up • Week 1-3: • VA improved to 20/60 • Persistent CVF defect inferiorly • Persistent optic disc edema • Week 7: • VA 20/70 • Resolution of disc edema, doxycycline discontinued

  16. Ocular Bartonellosis Bartonellahenselaeis the principal etiologic agent of cat-scratch disease. Feline-associated bacterial zoonotic disease found world-wide. Incidence is 9.3 cases per 100,000 persons in the U.S.A. Seasonal pattern: Fall and winter. Most prevalent in southern states, California and Hawaii.

  17. Transmission • Cats (90% are < 1 yr old) are the primary mammalian reservoir with the cat flea as the vector for transmission among cats. • Transmission to humans occurs by the scratches, licks and bites of domestic cats (especially kittens). • Facultative intracellular gram negative rod that infects endothelial cells or erythrocytes (Bincardi and Curi, 2013). • Immunocompetent: granulomatous disease • Immunocompromised: vasoproliferative lesions

  18. Pathogenesis • An erythematous papule may form at site of cutaneous injury3-10 days after initial injury. • 1-2 weeks before systemic manifestations. • Evades the innate immune system because its LPS structure is a TLR-4 antagonist (Popa et al, 2007). • Ocular involvement occurs in 5-10% of patients (Bincardi and Curi, 2013). • 2-5% Manifest Parinaud’sOculoglandular syndrome

  19. Posterior segment findings • Neuroretinitis: • Abrupt visual loss (20/25 to 20/200) • Unilateral optic disc swelling • Macular star formation • 1-2% of patients with Cat-Scratch disease • Optic disc edema observed 2-4 weeks prior to appearance of macular star.

  20. Diagnosis and Treatment • Two types of serologic tests • Indirect fluorescence assay • Enzyme immunoassay • May obtain convalescent titer 2 weeks following initial negative result (Gulati et al, 2012). • Immuno-competent vs –compromised: 4 weeks vs 4 months • Doxycycline • Rifampin • Ciprofloxacin • Trimethoprim-sulfamethoxazole

  21. Ocular Manifestation of Cat-ScratchDisease in HIV-Positive PatientsCuri AL, et al. 2006. Am J Ophthalmol, 141:400-1 • Retrospective case series of 3 HIV+ patients with diagnosed ocular cat-scratch disease. • Men, 27 to 53 yrs old • Presented with yellowish, subretinal lesions confirmed by FA to be abnormal vascular network. • Angiomatous lesions resolved with 1 month treatment. • 1 patient required additional course due to recurrence.

  22. Fluorescein angiogram OD demonstrating multiple angiomatous lesions.

  23. Cat-Scratch disease in HIV • Anti-apoptotic bacterial effector protein BepAinhibits endothelial cell (EC) apoptosis. • Facilitates intra-cellular bacterial replication. • BepAtranslocates then localizes to the EC membrane, triggering production cAMP in quantities effective for blocking apoptosis (Schmidet al, 2006).

  24. References • Roe, RH, et al. 2008. Ocular Bartonella Infections. IntOphth Clinics, 48(3):93-105. • 2013. BCSC: Uveitis. • Gulati, A, et al. 2012. Cat scratch neuroretinitis. J Neuroophthalmol. 32:243-5. • Toosy AT, Mason DF, Miller DH. 2012. Optic neuritis. Lancet Neurol, 13:83-99. • Curi AL, et al. 2006. Ocular manifestation of cat-scratch disease in HIV patients. Am J Ophthalmol, 141:400-1. • Popa, et al. 2007. BartonellaquintanaLipopolysaccharide is a natural antagonist of Toll-like receptor 4. Infect Immun, 75(10): 4831–4837. • Schmid, et al. 2006. Translocated bacterial protein protects vascular endothelial cells from apoptosis. PLoSPathog, 2(11):e115. • Bincardi and Curi. 2013. Cat-Scratch Disease. OculImmunolInflamm, ePub ahead of print. • Mosepele et al. 2012. Bartonella Infection in Immunocompromised Hosts: • Immunology of Vascular Infection and Vasoproliferation. Clinical and Developmental Immunology, 2012.

  25. Timeline • 1889: First report of Parinaud’soculoglandular syndrome (POGS) • 1950: Debre first described Cat scratch disease (CSD) • 1953: CSD associated with POGS • 1970: CSD associated with neuroretinitis • 1980s: Microbial agent isolated from lymph nodes of CSD patients • Similar to causative agent for bacillary angiomatosis (Rochalimaeahenselae) • 1994: First serologic link with a Bartonella species • Eight of 21 Bartonellaspecies identified as causing human disease • Four of these eight associated with ocular complications

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