Ocular Bartonellosis

J Trop Med. 2017; 2017: 7946123.
Published online 2017 Feb 7. doi:  10.1155/2017/7946123
PMCID: PMC5318637

Clinical Profile and Visual Outcome of Ocular Bartonellosis in Malaysia
Chai Lee Tan, Lai Chan Fhun,  Evelyn Li Min Tai, Nor Hasnida Abdul Gani, Julieana Muhammed, Tengku Norina Tuan Jaafar, Liza Sharmini Ahmad Tajudin, and Wan-Hazabbah Wan Hitam 


Background. Ocular bartonellosis can present in various ways, with variable visual outcome. There is limited data on ocular bartonellosis in Malaysia. Objective. We aim to describe the clinical presentation and visual outcome of ocular bartonellosis in Malaysia. Materials and Methods. This was a retrospective review of patients treated for ocular bartonellosis in two ophthalmology centers in Malaysia between January 2013 and December 2015. The diagnosis was based on clinical features, supported by a positive Bartonella spp. serology. Results. Of the 19 patients in our series, females were predominant (63.2%). The mean age was 29.3 years. The majority (63.2%) had unilateral involvement. Five patients (26.3%) had a history of contact with cats. Neuroretinitis was the most common presentation (62.5%). Azithromycin was the antibiotic of choice (42.1%). Concurrent systemic corticosteroids were used in approximately 60% of cases. The presenting visual acuity was worse than 6/18 in approximately 60% of eyes; on final review, 76.9% of eyes had a visual acuity better than 6/18. Conclusion. Ocular bartonellosis tends to present with neuroretinitis. Azithromycin is a viable option for treatment. Systemic corticosteroids may be considered in those with poor visual acuity on presentation.

In the results section we learn that 19 patients with ocular bartonellosis were followed from 3-68 weeks. Neuroretinitis is an inflammation of the neural retina and optic nerve which can be caused by viruses, autoimmune disease, or bacteria including: syphilis, Rocky Mountain Spotted Fever, toxoplasmosis, toxocariasis, histoplasmosis, leptospirosis, and Lyme Disease. Tuberculosis and Tularemia can also present similarly. The most common ocular complaint was blurred vision with around 60% reporting headaches as their initial symptom.

We also learn that the treatment of choice was Azithromycin followed by Doxycyline, ciprofloxacin, ceftazidime, and cotrimoxazole, with 60% receiving systemic corticosteroid therapy. The discussion section states that the treatment of Bartonellosis is still controversial and that they had to resort of isolated case reports for information.

http://webeye.ophth.uiowa.edu/eyeforum/cases/36-CatScratchBartonella.htm In this case study a 44 year old woman had non-specific blurriness of vision in her left eye. After they went through about every other possibility, they asked about pets at which she showed multiple cat scratches on her arms.

Laboratory results showed:
*White blood cell count: 18,200 with left shift (12,194 segmented neutrophils and 3276 bands)
*Bartonella Henselae IgG 1:1024 (strongly positive)

According to this study, a literature review suggested that a one month course of doxycycline or erythromycin (with or without rifampin) is adequate to treat the organism and hasten recovery. They chose a one month course of doxycycline 100 mg twice daily. The patient returned for follow-up appointments one and two months after this initial diagnosis. Vision improved to 20/60 in the affected eye, improving visual fields, decreased optic disc edema, and resolving sub-retinal fluid.

The case study also states that diagnosis officially requires 3 out of 4 criteria:
• Lymphadenopathy in the absence of other reason (can be missed because it is not present yet or subclinical)
• Positive Bartonella H. titer or skin test
• Known cat contact, preferably with pustule or papule at the site
• Lymph node biopsy with bacilli present, necrosis

They admit this woman met only 2 of the criteria. They also state it is well documented patients will almost always get better on their own but that hundreds of reports give various treatment regimens including doxycycline, erythromycin, rifampin, azithromycin, ciprofloxacin, later addition of steroid drop, and many others.

The unfortunate thing about both of these reports is they make Bartonellosis out to be a benign pathogen, which for Lyme/MSIDS patients couldn’t be further from the truth.

As to the criteria to diagnose:

Thankfully, this woman didn’t present with swollen lymph nodes so they had to find a reason and state it was either subclinical or hadn’t presented yet.

*Hardly anyone I know with Bartonella has swollen lymph nodes.

*The testing for Lyme and every coinfection, including Bartonella, is abysmal.

*They emphasize the cat’s role but don’t even mention ticks, mites, biting flies, other arachnids, sand flies, mosquitoes, fleas and flea feces, the human body louse, potentially from needles and syringes in the drug addicted, as well as bites and scratches from other reservoir hosts.

*As to node biopsy, even this NIH study shows a lack of specificity and lack of typical micro abscesses in almost half of the cases and may mimic other lymphadenopathies.

*https://wwwnc.cdc.gov/eid/article/22/3/15-0269_article This CDC article states that Bartonella spp. may be the cause of unclear and undiagnosed chronic illness in humans previously bitten by ticks.

*They also fail to mention there are 15 species and counting of Bartonella known to infect humans and that Dr. Ricardo Maggi states, “This case reinforces the hypothesis that any Bartonella species can cause human infection.”
http://townsendletter.com/July2015/bartonellosis0715_3.html  Besides the cat (including bobcats, mountain lions, and other large cats), rats, dogs, rabbits, deer, cattle, small woodland animals, rodents, coyotes, foxes, and elk were found to harbor Bart.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC88941/ The question really should be, “What doesn’t carry Bartonella?”

https://madisonarealymesupportgroup.com/2016/01/03/bartonella-treatment/  Here, Dr. Mozayeni states about 60% of Lyme patients tested positive for Bartonella and that it is one of the major coinfections. This link also has treatments, explanation of Bartonella including what it does and how it can present, along with a link for a checklist you can print out and take to your doctor to discuss.

I appreciate Dr. Breitschwert’s and Dorsey Kordick’s comment in the concluding remarks,

“Not too long ago, many were taught during microbiology courses (or medical school training) that blood is generally a sterile medium. Increasingly, this assertion must be qualified with regard to Bartonella spp. as well as other intracellular pathogens that have coevolved with humans and animals to persist in circulating blood cells such as erythrocytes or macrophages for months to years and perhaps longer.”

I wish more researchers were this transparent, then perhaps patients would be taken more seriously.   And, don’t kid yourself, Bartonella is a formidable foe to the immunocompromised.