Atypical presentation of cat scratch disease: Parinaud’s oculoglandular syndrome with facial nerve paresis.
A 28-year-old man presented to our clinic over the course of 3 weeks with symptoms that progressed from mild headaches to fever, fatigue, myalgia and an enlarged right preauricular lymph node with ipsilateral (same side) conjunctivitis and upper eyelid weakness. Our differential included Epstein Barr Virus/Cytomegalovirus mononucleosis, bacterial conjunctivitis and lymphoma. We evaluated with CBC, EBV IgM Ab, lactate dehydrogenase level and a CMV IgG Ab which were all within normal limits. During his third visit, we discovered our patient had been scratched by two stray kittens he had adopted 2 months prior. We confirmed the diagnosis with a positive Bartonella henselae IgG level and diagnosed him with cat scratch disease presenting as Parinaud’s oculoglandular syndrome. He was treated with a 5-day course of Azithromycin 250 mg with definitive improvement.
The pre auricular lymph node is #5 in the diagram. So this is a swollen nodule in front of the ear with conjunctivitis (pink-eye) on the same side as the nodule with upper eye-lid weakness.
Public Domain, https://commons.wikimedia.org/w/index.php?curid=1471974
I would also like to point out it’s on record that people can have Bart without cat-scratch: https://madisonarealymesupportgroup.com/2018/07/10/bartonella-henselae-neuroretinitis-in-patients-without-cat-scratch/ In conclusion, even though there may be a lack of systemic signs and symptoms of CSD in a patient with neuroretinitis, B henselae infection should be considered.
While authorities argue about whether ticks transmit Bart or not, please see: https://www.sciencedirect.com/topics/medicine-and-dentistry/parinauds-oculoglandular-syndrome Finally, tick-borne B. henselae infection has been described, including scalp eschar and neck lymphadenopathy after tick bites in three patients during the colder months in France. B. henselae was detected using molecular tools both in skin biopsy (cervical and occipital) and in a Dermacentor marginatus tick removed from the scalp of one patient. All three patients had asthenia (weakness), but none had alopecia.
That same Science Direct link above also states that a common ocular manifestation is Parinaud’s oculoglandular syndrome……
I predict we are going to see a lot more on Bartonella in the future and it’s going to blow this whole “atypical” and “rare” thing out of the water.
For more on Bart: https://madisonarealymesupportgroup.com/2016/01/03/bartonella-treatment/