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Page 4 of 7 Montabone et al. Neuroimmunol Neuroinflammation 2019;6:7 I http://dx.doi.org/10.20517/2347-8659.2019.09

A B

C D

Figure 2. Visual evoked potential. A: right eye VEP at symptoms presentation (P100 latency 123 ms); B: left eye (P100 latency 86 ms); C:
right eye VEP after one month; D: left eye VEP after one month

Toxocara canis were negative. Serology for Bartonella infections showed previous infection from Bartonella
quintana (IgM antibody titer assay was not performed because of negative immunofluorescence, IgG titer
was 1:128 that was at upper limit for positivity in our laboratory) and recent infection from Bartonella
henselae with both IgM and IgG (IgM titer was 1:40 N.V. < 20, IgG was 1: 512 N.V. < 64).

Treatment and follow up
A high dose intravenous steroid regimen (methylprednisolone 1000 mg/die for 3 days) was started, followed
by oral steroid tapering for one month. According to an infectiology consultation, antibiotic therapy with
doxycycline 100 mg b.i.d for two weeks was started.

One month later the patient fully recovered the visual acuity (10/10 in both eyes). OCT and fluorescein
angiography showed marked reduction of optic disk swelling and disappearance of retinal exudates. VEP
returned to normal [Figure 3]. Six months later, the patient doesn’t complain any visual deficit, as confirmed
at ophthal mologic instrumental evaluation. Neurologic examination is normal.

At that time, the patient was asked about previous contact with potentially infected animals, as she didn’t
own domestic animals. She recalled having handled stray cats during previous summer holidays (about one
month before visual symptoms started), but she denied having been scratched.

DISCUSSION
We presented a young woman with a unilateral loss of vision caused by a CSD isolated neuroretinitis with
mild constitutional symptoms and no history of scratch. Neurological examination, brain MRI and VEP did
not give a clue for this diagnosis, whereas ophthalmological results suggested the possibility of an infection.
The prompt treatment with antibiotics and steroids brought a complete resolution of the vision deficit.

This case represents a clinical rarity, first because of the diagnosis of CSD without cat scratch. Notably,
CSD diagnosis requires the presence of at least 3 of 4 criteria including: a history of traumatic cat exposure,
a positive test for CSD antibody, regional lymphadenopathies, and serum analysis excluding concurrent