Cat Scratch Disease (Grand Rounds)
Cat Scratch Disease (Grand Rounds)
- 1 Financial Disclosure
- 2 Chief Complaint
- 3 History of Present Illness:
- 4 History
- 5 Examination
- 6 Differential Diagnosis
- 7 Laboratory Testing
- 8 Final Diagnosis
- 9 Other Findings
- 10 Management
- 11 Summary
- 12 Follow Up
- 13 Discussion
- 14 References
Resident Grand Rounds Case
Sally Chang, M.D.
California Pacific Medical Center
- Financial disclosures: none
- "Seeing blurry spot in the right eye"
History of Present Illness:
- JT is a 22 year old, Caucasian man who was healthy until 3 months ago when he started having flu-like symptoms including headache, high fever, and cough. He was diagnosed with mononucleosis and was not treated. Symptoms resolved after 2 months.
- A week later, the patient started seeing a blurry spot temporal to his central vision in the right eye, which was stable for the past 3 weeks. He denied any eye pain.
Review of Systems:
- Headache, high fever, and cough, which resolved 1 month ago. Never had lymphadenopathy.
- No joint pain, no shortness of breath, no sexually transmitted disease
- Past Medical History: none
- Allergies: NKDA
- Medications: none
- Social History: No smoking, alcohol, or illicit drug use. Lives in the San Francisco Bay Area, with recent camping trips around the Sierra mountains with no known tick bites
- Vision: OD 20/25, OS 20/20
- Pupils: reactive to light OU, no RAPD
- Tonometry: OD 11, OS 13
- Extraocular Motility: full OU
- Visual Fields: full OU
- External Exam: within normal limit OU
- Slit Lamp Findings: Anterior segment normal OU
- Dilated Fundus Exam Findings: see pictures
- Bilateral optic disc edema with disc hyperemia, worse in the right eye
- Macular Edema extending from the optic nerve
- Multiple punctate chorioretinitis throughout both fundi
- Staining of multiple punctate lesions and optic disc in both eyes
Optical Coherence Tomography
- What is the differential diagnosis for multifocal punctate chorioretinitis with disc involvement?
- Diffuse unilateral subacute neuroretinitis
- White dot syndrome
- Punctate Inner Choroidopathy
- Diabetic retinopathy
- Hypertensive retinopathy
- Malignancy / Metastases
- Toxoplasmosis IgM and IgG titers
All these tests were negative
- B. Henselae IgM titer 1:80 (normal <1:20)
- B. Henselae IgG titer >1:1024 (normal <1:64)
- Patient got a kitten in 6/11
- Flu-like symptoms started in 7/11-9/11
- Eye symptoms started 10/11
- Multiple cat scratches
Cat scratch disease
- Worldwide zoonotic infection
- Reservoir: asymptomatic bacteremia in domestic cats
- Transmission to human: cat scratches, contamination of wounds
- Mainly involve children and adolescents
- Immunosuppressed people are at a higher risk
- 24,000 cases in US annually
- 2,000 hospital admissions in US annually
- Higher incidence in the southern US, lower in the western US
- Inoculation site: macule, papule, vesicle
- Febrile prodrome
- Regional lymphadenopathy
- Disseminated disease
- Intraretinal white spots
- Branch retinal artery occlusions
- Branch retinal vein occlusions
- Vitritis, pars planitis
- Peripapillary angiomatosis
At least 3 of the 4 following:
- History of cat exposure
- Positive skin test to cat scratch disease antigen
- Negative laboratory tests for other diseases
- No clear benefit with antibiotics, but may shorten duration
- Adults: doxycycline, erythromycin, rifampin, azithromycin, or ciprofloxacin x 1 month
- Children: azithromycin, bactrim
- Antibiotics treatment is beneficial for 4 months
- Erythromycin, doxycycline
- Ocular complications of cat-scratch disease include Parinaud's oculoglandular syndrome, Leber's neuroretinitis, and focal chorioretinitis
- Serologic testing is the best way to confirm diagnosis
- Consider antibiotics treatment in all patients
- After starting doxycycline 100mg BID, the patient's vision improved to 20/20 OU after 3 days.
- He also developed macular star in the right eye after 2 weeks.
- Multiple chorioretinitis became more pale and inactive.
Please use the discussion tab at the top of this page to talk about this case.
- Ormerod LD, Dailey JP. Ocular manifestations of cat-scratch disease. Curr opin Ophthalmol 1999,10:209-216.
- Cunningham ET, Koehler JE. Ocular bartonellosis. AJO 2000;130:340-349.
- Purvin V, Sundarem S, Kawasaki A. Neuroretinitis: review of the literature and new observations. J Neuro-Ophthalmol 2011;31:58-68.
- Chi SL, Stinnett S, Eggenberger E, et al. Clinical characteristics in 53 patients with cat scratch optic neuropathy. Ophthalmology 2011
- Habot-Wilner Z, Zur D, Goldstein M, et al. Macular findings on optical coherence tomography in cat-scratch disease neuroretinitis. Eye 2011,25,1064-68.