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Cat-scratch disease: Author’s reply
Letters to the Editor
Cat-scratch Disease Dear Editor: Ormerod et al reported two patients with retinal and choroidal manifestations of cat-scratch disease (Ophthalmology 1998; 105:1024 –31). Both patients underwent extensive serologic testing for infectious and inflammatory etiologies, and case one underwent cerebrospinal fluid evaluation and a magnetic resonance imaging study of the brain and orbit. The authors presented a nice discussion and summary of the posterior segment manifestations and treatment of catscratch disease. What should be the evaluation for patients with optic disc edema and other vitreous, retinal, or choroidal inflammatory signs? It has been our practice to perform limited testing in such patients, focusing on underlying inflammatory or infectious etiologies such as syphilis serology, Lyme serology in high-risk patients, Bartonella henselae titers, complete blood count, antinuclear antibody, angiotensin-converting enzyme, erythrocyte sedimentation rate, and chest radiograph. We have reserved lumbar puncture and magnetic resonance imaging of the head for patients with atypical features (e.g., bilateral optic disc edema, lack of inflammatory posterior segment signs, lack of visual improvement). We also start empiric ciprofloxacin in patients with suspected cat-scratch disease prior to the confirmation of the diagnosis with Bartonella henselae titers. Would the authors agree with this approach based on their experience and review of the literature? ANDREW G. LEE, MD Houston, Texas Author’s reply Dear Editor: Dr. Lee proposes a sensible and cost-effective approach to the investigation of cases presenting with the combination of optic nerve swelling and other posterior segment inflammatory signs. A detailed history and examination will often be revealing and suggest an even more focused approach to diagnosis. The clinical picture can be complex, and consideration should be given to a number of other diagnoses, including panuveitis from any cause, herpetic and other viral retinitis, multiple sclerosis, Vogt-Koyanaga-Harada disease, sympathetic ophthalmia, a systemic or severe retinal vasculitis, birdshot chorioretinopathy, toxoplasmosis, tuberculosis, and a number of other systemic infections, including several that are AIDS-related. Lumbar puncture and neuroimaging techniques should be used selectively, but potential central nervous system involvement of newly described syndromes needs to be evaluated. Cat-scratch disease (CSD) is usually a disease of children and young adults exposed to kittens; regional lymphadenopathy should be sought. As we discussed in our recent paper (Ophthalmology 1998;105:1024 –31), there are many anecdotal reports of successful CSD treatment with numerous antibiotics, but
there are no controlled studies of antibiotic use in CSD neuroretinitis or CSD retinitis choroiditis. Margileth1 evaluated 268 patients with (principally) localized lymphoidal CSD in a retrospective study of immunocompetent individuals and deduced evidence of satisfactory effectivity in only 4 of 18 antibiotics tested: rifampin, ciprofloxacin, intramuscular gentamicin, and trimethoprim–sulfamethoxazole. CSD is now known to be a common cause of Leber neuroretinitis, previously believed idiopathic, that usually resolves spontaneously without treatment. It remains to be determined by controlled trials whether there is or is not a role for ciprofloxacin therapy in disseminated intraocular CSD infections. There is some evidence that early antibiotic treatment may inhibit the bacteremic phase of CSD infection and reduce the occasional recurrence.2 L. DAVID ORMEROD, MD Columbia, Missouri References 1. Margileth AM. Antibiotic therapy for cat-scratch disease: clinical study of therapeutic outcome in 268 patients and a review of the literature. Pediatr Infect Dis J 1992;11:474 – 8. 2. Wong MT, Dolan MJ, Lattuada CP Jr., et al. Neuroretinitis, aseptic meningitis, and lymphadenitis associated with Bartonella (Rochalimaea) henselae infection in immunocompetent patients and patients infected with human immunodeficiency virus type 1. Clin Infect Dis 1995;21:352– 60.
Management of B. henselae Neuroretinitis in Cat-scratch Disease Dear Editor: The recent article “Bartonella henselae Neuroretinitis in Cat-scratch Disease” by Reed and associates1 reviews the course of seven patients with confirmed CSD neuroretinitis treated with doxycycline and rifampin. All patients showed excellent resolution of disease. The authors concluded that the suggested regimen “appeared to promote resolution of neuroretinitis and truncate systemic infection.” While possible that their conclusion is accurate, its grounds are weak. Recently B. henselae has been documented as an infectious agent associated with the neuroretinitis of CSD. The pathogenesis of the neuroretinitis remains obscure. The frequency of long-term sequelae in confirmed B. henselae neuroretinitis remains inadequately quantified. It is generally believed that in otherwise healthy hosts the neuroretinitis is self limited, and significant long-term sequelae are not very common. We do not know accurately what proportion of patients with neuroretinitis suffer, for example, recurrent febrile illness, permanent loss of acuity, or other untoward outcomes. The authors only address the issue of quantitative comparison by stating “some individuals . . . may experience recurrent febrile illness . . . and others may fail to regain baseline acuity,” and contrast this to their seven antibiotic-treated patients where “the febrile illness . . . im-
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Cat-scratch Disease Dear Editor: Ormerod et al reported two patients with retinal and choroidal manifestations of cat-scratch disease (Ophthalmology 1998; 105:1024 –31). Both patients underwent extensive serologic testing for infectious and inflammatory etiologies, and case one underwent cerebrospinal fluid evaluation and a magnetic resonance imaging study of the brain and orbit. The authors presented a nice discussion and summary of the posterior segment manifestations and treatment of catscratch disease. What should be the evaluation for patients with optic disc edema and other vitreous, retinal, or choroidal inflammatory signs? It has been our practice to perform limited testing in such patients, focusing on underlying inflammatory or infectious etiologies such as syphilis serology, Lyme serology in high-risk patients, Bartonella henselae titers, complete blood count, antinuclear antibody, angiotensin-converting enzyme, erythrocyte sedimentation rate, and chest radiograph. We have reserved lumbar puncture and magnetic resonance imaging of the head for patients with atypical features (e.g., bilateral optic disc edema, lack of inflammatory posterior segment signs, lack of visual improvement). We also start empiric ciprofloxacin in patients with suspected cat-scratch disease prior to the confirmation of the diagnosis with Bartonella henselae titers. Would the authors agree with this approach based on their experience and review of the literature? ANDREW G. LEE, MD Houston, Texas Author’s reply Dear Editor: Dr. Lee proposes a sensible and cost-effective approach to the investigation of cases presenting with the combination of optic nerve swelling and other posterior segment inflammatory signs. A detailed history and examination will often be revealing and suggest an even more focused approach to diagnosis. The clinical picture can be complex, and consideration should be given to a number of other diagnoses, including panuveitis from any cause, herpetic and other viral retinitis, multiple sclerosis, Vogt-Koyanaga-Harada disease, sympathetic ophthalmia, a systemic or severe retinal vasculitis, birdshot chorioretinopathy, toxoplasmosis, tuberculosis, and a number of other systemic infections, including several that are AIDS-related. Lumbar puncture and neuroimaging techniques should be used selectively, but potential central nervous system involvement of newly described syndromes needs to be evaluated. Cat-scratch disease (CSD) is usually a disease of children and young adults exposed to kittens; regional lymphadenopathy should be sought. As we discussed in our recent paper (Ophthalmology 1998;105:1024 –31), there are many anecdotal reports of successful CSD treatment with numerous antibiotics, but
there are no controlled studies of antibiotic use in CSD neuroretinitis or CSD retinitis choroiditis. Margileth1 evaluated 268 patients with (principally) localized lymphoidal CSD in a retrospective study of immunocompetent individuals and deduced evidence of satisfactory effectivity in only 4 of 18 antibiotics tested: rifampin, ciprofloxacin, intramuscular gentamicin, and trimethoprim–sulfamethoxazole. CSD is now known to be a common cause of Leber neuroretinitis, previously believed idiopathic, that usually resolves spontaneously without treatment. It remains to be determined by controlled trials whether there is or is not a role for ciprofloxacin therapy in disseminated intraocular CSD infections. There is some evidence that early antibiotic treatment may inhibit the bacteremic phase of CSD infection and reduce the occasional recurrence.2 L. DAVID ORMEROD, MD Columbia, Missouri References 1. Margileth AM. Antibiotic therapy for cat-scratch disease: clinical study of therapeutic outcome in 268 patients and a review of the literature. Pediatr Infect Dis J 1992;11:474 – 8. 2. Wong MT, Dolan MJ, Lattuada CP Jr., et al. Neuroretinitis, aseptic meningitis, and lymphadenitis associated with Bartonella (Rochalimaea) henselae infection in immunocompetent patients and patients infected with human immunodeficiency virus type 1. Clin Infect Dis 1995;21:352– 60.
Management of B. henselae Neuroretinitis in Cat-scratch Disease Dear Editor: The recent article “Bartonella henselae Neuroretinitis in Cat-scratch Disease” by Reed and associates1 reviews the course of seven patients with confirmed CSD neuroretinitis treated with doxycycline and rifampin. All patients showed excellent resolution of disease. The authors concluded that the suggested regimen “appeared to promote resolution of neuroretinitis and truncate systemic infection.” While possible that their conclusion is accurate, its grounds are weak. Recently B. henselae has been documented as an infectious agent associated with the neuroretinitis of CSD. The pathogenesis of the neuroretinitis remains obscure. The frequency of long-term sequelae in confirmed B. henselae neuroretinitis remains inadequately quantified. It is generally believed that in otherwise healthy hosts the neuroretinitis is self limited, and significant long-term sequelae are not very common. We do not know accurately what proportion of patients with neuroretinitis suffer, for example, recurrent febrile illness, permanent loss of acuity, or other untoward outcomes. The authors only address the issue of quantitative comparison by stating “some individuals . . . may experience recurrent febrile illness . . . and others may fail to regain baseline acuity,” and contrast this to their seven antibiotic-treated patients where “the febrile illness . . . im-
1