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Bartonella Neuroretinitis: A Case Report with New Insights from Fundus Autofluorescence Imaging | OMICS International
ISSN: 2155-9570
Journal of Clinical & Experimental Ophthalmology

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Bartonella Neuroretinitis: A Case Report with New Insights from Fundus Autofluorescence Imaging

Justin JY Yamanuha1,2* and Mihai Mititelu1
1Department of Ophthalmology and Visual Sciences, University of Wisconsin, Madison, Wisconsin 53705, USA
2Bascom Palmer Eye Institute at Palm Beach Gardens, 7101 Fairway Drive, Palm Beach Gardens, FL 33418, USA
Corresponding Author : Justin JY Yamanuha
Department of Ophthalmology and Visual Sciences
University of Wisconsin, 2870 University Avenue
Room 206, Madison, Wisconsin 53705, USA
Tel: 608-263-7290
Fax: 608-263-7694
E-mail: [email protected]
Received: February 15, 2015; Accepted: June 26, 2015; Published: June 30, 2015
Citation: Yamanuha JJY, Mititelu M (2015) Bartonella Neuroretinitis: A Case Report with New Insights from Fundus Autofluorescence Imaging. J Clin Exp Ophthalmol 6:445. doi:10.4172/2155-9570.1000445
Copyright: © 2015 Yamanuha JJY, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Abstract

Purpose: Fundus autofluorescence (FAF) is a modern functional imaging modality utilized to characterize abnormalities of the retinal pigment epithelium (RPE). There are no prior studies demonstrating FAF findings in both symptomatic and asymptomatic eyes of patients diagnosed with Bartonella neuroretinitis.
Methods: Case report and review of the literature.
Patients: Single patient case study. Results: In the symptomatic right eye, (FAF-Heidelberg Retina Angiograph; Heidelberg Engineering, Heidelberg, Germany) identified abnormality of the RPE which corresponded to pathology seen on fundus photography, fluorescein angiography (FA-Heidelberg Retina Angiograph; Heidelberg Engineering, Heidelberg, Germany) and spectral domain optical coherence tomography (SD-OCT-Spectralis®, Heidelberg Engineering, Heidelberg, Germany). Interestingly, FAF also demonstrated sub-clinical anatomic abnormalities not seen clinically nor detected as clearly by any other imaging modalities in the patient’s asymptomatic left eye. As the patient improved clinically, normalization of the FAF occurred in both eyes.
Discussion: This report is the first study to describe novel subclinical and clinical FAF findings as part of the evaluation of a patient with infectious neuroretinitis. Compared to FA, SD-OCT and clinical examination, FAF provided a more detailed functional understanding of this condition in its early stages and was also used to follow the clinical course of this patient. This functional imaging modality confirmed normalization of anatomic abnormalities also demonstrated by the other techniques.

Keywords
Bartonella; Neuroretinitis; Autofluorescence
Introduction
Bartonella species are facultative intracellular Gram negative bacilli that target erythrocytes or endothelial cells producing bartonellosis [1]. Upwards of 10-15% of affected patients can develop ocular manifestations which can include Parinaud oculoglandular syndrome as well as neuroretintis, a condition comprised of optic nerve and macular edema and retinal exudates [2].
We present a case of a 26 year-old male who presented with neuroretinitis. FA, SD-OCT, and FAF were used to characterize the clinical course of this patient. FAF was used to localize the focus of pathology and highlighted previously uncharacterized anatomic changes in this condition.
Case Report
A 26 year old myopic male developed flu like symptoms and a blurry spot in the right eye. Medical history was significant for psoriasis and asthma, for which he used topical and inhaled steroids, respectively. The patient worked as a window washer and owned cats. He denied chills, weight loss, recent travel, or new sexual partners.
Examination showed acuity of 20/200 in the right eye and 20/20 in the left eye. Pupillary responses were normal without afferent pupillary defects and intraocular pressure measured 12 mmHg in each eye. Anterior segment examinations were normal without conjunctival injection or anterior chamber inflammation. Dilated fundus examinations revealed clear vitreous with disc edema in both eyes. There was a radial pattern of exudates in the symptomatic right eye (Figure 1) and no exudates in the asymptomatic left eye (Figure 2).
Ancillary testing revealed significant optic disc hyperfluorescence without macular leakage on FA of the right eye (Figure 3) and less extensive optic disc hyperfluorescence without macular leakage in the left eye (Figure 4). SD-OCT demonstrated hyper-reflective deposits in the outer retina with hypo-reflective subretinal fluid in the right eye (Figure 5). There was subtle thickening of the outer nuclear layer in the nasal macula in the right eye. SD-OCT of the left eye identified minimal punctuate intraretinal hyper-reflective deposits in the nasal macula overlying an area of focal irregularity of the retinal outer segments. There was no retinal thickening or fluid on the SD-OCT of the left eye (Figure 6). Serologies revealed elevated Bartonella titers and Infectious Disease consultation recommended oral doxycycline and rifampin because of the patient’s fulminant presentation with severe visual loss in the right eye.
At one week follow-up, the patient’s scotoma improved along with visual acuity from 20/200 to 20/70 in the right eye. The left eye remained asymptomatic with visual acuity of 20/20. SD-OCT of the right eye at one week demonstrated improved hyper-reflective intraretinal deposits and hypo-reflective subretinal fluid (Figure 7). FAF showed a welldefined central circular pattern of hyper-autofluorescence in the right eye and a subtle wedge shaped pattern of temporal peripapillary hyperautofluorescence extending into the macula in the asymptomatic left eye (Figure 8). Of all the imaging modalities, FAF was able to detect pathology not well delineated by other techniques.
At the three month follow up visit, the patient experienced resolution of the scotoma in the right eye with good visual recovery (improvement to 20/40). The left eye remained asymptomatic, maintained 20/20 visual acuity, and was free of fluid. The exudates had nearly completely resolved in the right eye (Figure 9) and SD-OCT demonstrated resolution of the intraretinal hyper-reflective deposits and subretinal hypo-reflective fluid (Figure 10). FAF revealed normalization of the hyper-autofluorescence pattern in both eyes without progression to hypo-autofluorescence in either eye (Figure 11).
Discussion
Infectious neuroretinitis typically presents with optic nerve and retinal edema as well intraretinal exudates in a stellate pattern, typically within the outer plexiform layer [3-5]. Other previously described clinical manifestations have included retinal vascular occlusions and even full thickness macular holes [6]. This clinical entity has been characterized previously by fundus photography, SD-OCT, and FA, but this is the first study to classify FAF findings in the symptomatic and contralateral asymptomatic eye of a patient with serologically confirmed Bartonella neuroretinitis.
FAF is an imaging modality used to assess the integrity of the RPE by non-invasive excitation of the A2E lipofuscin, the main fluorophore contained within the RPE [7], but other fluorophores such as DHP-A2- PE, A2E-DHP-PE, A2 GPE, monofuran-A2E and monoperoxy-A2E also contribute to the FAF signal [8].
Abnormal patterns of FAF have been documented in several chorioretinal conditions ranging from Stargardt’s Disease to Age-Related Macular Degeneration [9]. For example, in hydroxychloroquine toxicity, progression from hyper-autofluorescence to hypo-autofluorescence is believed to occur after permanent, irreversible injury to RPE [10]. In our patient, the return to a near normal appearance of the FAF pattern, rather than progression to hypo-autofluorescence, suggested that the RPE did not sustain a longstanding insult. The maintenance of the IS/ OS line on SD-OCT in the fovea of the right eye also supported the ultimate recovery of vision in this patient.
FAF demonstrated a radial pattern of hyper-autofluorescence in this patient’s symptomatic right eye, signaling localized RPE disturbance in the macula secondary to accumulation of subretinal fluid [11]. Interestingly, FAF also revealed a subtle pattern of hyperautofluorescence in the patient’s asymptomatic left eye. The extent of this RPE disturbance could not be detected by clinical examination or as effectively by SD-OCT or FA of the left eye. We have demonstrated that in Bartonella neuroretinitis, FAF best demonstrated localized RPE dysfunction despite the lack of exudative signs on examination, SD-OCT and FA; such findings have only been noted previously in non-infectious etiologies, such as Retinitis pigmentosa and cone dystrophy [9].
We hypothesize that the initial leakage from the inflamed optic nerve in both eyes caused a transient diffuse injury to the RPE, which gradually resolved as the optic nerve inflammation subsided. It is likely the optic nerve rather than the retina represented the primary source of inflammation in infectious neuroretinitis; in the early stages, such inflammation can be visually insignificant, as was the case of this patient’s left asymptomatic left eye.
The natural history of Bartonella neuroretinitis is typically spontaneous resolution. Although management with systemic steroid and antibiotics has been described [12], such treatment is not universally advocated [13]. The decision to treat our patient with systemic oral antibiotics was influenced by his initial severe vision loss in the right eye. In summary, we recommend the use of FAF in patients with infectious Bartonella neuroretinitis as a fast and readily available tool for the detection of asymptomatic pathology and the monitoring of clinical course over time.
Summary Statement
We present a case report of a 26-year old male who developed infectious neuroretintis, confirmed to be caused by Bartonella hensellae on serologic testing. Fundus autofluorescence (FAF) as well as other imaging modalities—including spectral-domain optical coherence tomography (SD-OCT) and fluorescein angiography (FA)—were used to identify and follow subtle anatomic abnormalities throughout the disease course, highlighting pathology in both the symptomatic right eye and asymptomatic left eye. FAF provided novel imaging features and proved to be a valuable imaging modality in this rare clinical entity.
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