R4 陳怡杏May 12th, 2011

EBM Case discussion

+ Eye hit by silicone last week os, blurred vision now, eye pain c movement for 1wk, than blurred vision+ (ou)

+ recent common cold-, but throat pain++ past history: denied DM, HTN, CAD+ personal history: denied alcohol, smoke, drug

abuse history+ 2+ year-foreign worker from Tailand

+ 2011/05/02 PT OD:9mmHg OS:12mmHg + TVRM(sD) OD:+0.25/-0.75X83 OS:+4.0/-0.50X45 + VAcC(sD) OD:0.05(0.06X0/-0.75.X80) OS:CF>1M+ P: ortho+ pupil: isocoric, MG(-)+ EOM: f & f+ Conj: mild congestion, K: clear, AC : D/Cell+, Lens:

clear + color od 5/7 os 0/7

356 612

+ BP: 120/90mmhg+ arthritis (-), oral ulcer (-)+ Raised cat in Tailand (+), no cat scratch history

Diagnosis?

+ Cat scratch disease cat contact history?+ Syphillis VDRL, TPHA+ Harada’s disease+ Sarcoidosis ACE, CXR+ Toxoplasmosis Toxo IgG, IgM+ Idiopathic neuroretinitis+ Lyme disease+ Hypertensive retinopathy

+ Normal heart size+ Tortuosity of

thoracic aorta + Infiltration at bil.

lower lungs

+ First described by Leber in 1916+ characterized by (1) sudden onset of VA loss

(2) partial or complete macula star exudate (preceded by a peripapillary exudative neurosensory RD), and (3) optic nerve swelling with disc capillary leakage

+ Usually unilateral+ Cause: cat scratch disease 2/3

+ Gass: FAG-retinal leakage (-) and optic nerve swelling preceded or occurred in conjunction with the formation of a macular star

+ Pathophysiology: optic neuropathy with prelaminar permeability of disc capillaries producing the apparent retinal thickening and secondary macular exudates

+ Usually disc edema first+ Macular exudation often manifests within 2-4

wks after disease onset+ Often emerges as disc edema resolving (7 to 10

day from its initial appearance)+ May remain stable for several wks but gradually

resolve within 6 to 12 m/o+ Disc edema: begins to decrease in 2 weeks and

usually complete resolution in 8 to 12 wks

+ In the same/fellow/both eyes+ Accumulative visual loss after each episode+ Incomplete recovery of visual function: due to

permanent damage to the optic nerve, not the macula

+ Pathogenesis: patients without systemic disease may have immune disorder involving disc vasculature

Ach Ophthalmol. 2003; 121: 65-67J Neuro-Ophthalmol 2005;25: 286–288

+ 30 pt with recurrent NR, 7 pts had immunosuppresants (prednisone, azathioprine, or both)

+ Attack rate decreased 72% after initiation of immunosuppressive therapy (0.58-> 0.16 attacks/yr)

+ Other disease association: Toxoplasmosis, melanocytoma, sarcoidosis, multiple sclerosis

+ Most common :lymphadenitis+ Atypical forms: Parinaud oculoglandular

syndrome, stellate neuroretinitis (10%), persistent fever without localizing signs, hepatosplenic infection, encephalopathy, osteomyelitis, and endocarditis

+ First described by Parinaud in 1889

+ seroprevalence of Bartonella in patients with HIV infection: 16% to 40%, but seropositivity does not correlate directly with evidence of clinical infection

+ LN biopsy or conjunctiva biopsy+ Indirect fluorescent antibody (IFA) test: 88%

sensative, 94% specific+ Enzyme immunoassay (EIA) IgG sensitivity 86-

95%, specificity 96% compare to IFA+ PCR: amplify small fragment of bacterial 16S

rRNA gene of Bartonella DNA

+ Efficacy: Rifampin (87%), Ciprofloxacin (84%), gentamicin (73%) trimethoprim and sulfamethoxazole (58%)

+ Penicillins, cephalosporins, tetracycline, and erythromycin had minimal or no clinical efficacy

+ Immocompetants: rapidly responsive to many antibacterial agents, including those not felt to be effective

+ Immunocompromised pts: gentamicin, macrolides, quinolones, and rifampin

Current Opinion in Pediatrics 2001, 13:56–59

Cat-scratch disease has been confirmed as a cause of optic neuritis as well as neuroretinitis

+ CC: progressive blurred vision od for 3 months

+ 2011/03/01 VA OD:0.1+1 OS:L-S(-), RAPD (os)3+

+ PH:+ optic neuritis (od) s/p steroid pulse therapy

1/20-1/23 2008 (2008/10/6 VA od 0.4)+ optic neuritis(os) s/p steroid pulse therapy at

NTUH with optic atrophy

+ CT (-)+ CXR np+ LAB survey: WNL

+ Pre-tx (2011/3)

+ Post- tx + 3 day pulse therapy+ +doxycycline+ (2011/4/28)

#2001079941 y/o M, metamorphopsia (OD) since July 2010, grey color and then black

2010/7

2010/9 Since 2010/11

2010/11

2011/4

2010/7 2011/4