Bartonella henselae infection presenting with ocular and hepatosplenic manifestations in an immunocompetent child.

To the Editors: Disseminated Bartonella henselae infection is rarely described in immunocompetent subjects. Here, we report a case of an immunocompetent child who developed bartonellosis with hepatosplenic and ocular manifestations. A 10-year-old previously healthy boy was admitted to the Infectious Diseases Unit, Latina, Italy, because of a 2-week history of fever (T max 38.4°C) and recent onset of painless diminished visual acuity in the left eye. He had had no significant ocular problems in the past. There was no history of recent travel and trauma. He had no vomiting and did not complain of headache. The patient had been scratched on his left flank by a kitten 6 weeks before the onset of symptoms. On admission, his oral temperature was 38°C, heart rate 90 beats per minute, respiratory rate 22 breaths per minute and blood pressure 120/70 mm Hg. There was lymph node swelling in the left inguinal region and splenomegaly. A nearly healed lesion was present at site of scratch. The lungs and heart were normal as was the neurologic evaluation. The white blood cell count was normal and hemoglobin was 11 g/dL. Liver and kidney function tests were normal. C-reactive protein was 2.51 mg/dL (normal range 0–0.5 mg/dL), erythrocyte sedimentation rate was 42 mm/h. Cultures of blood samples and urine were sterile. Ophthalmologic evaluation showed mild conjunctival hyperemia without eye discharge and no signs of anterior uveitis. Fundus examination showed focal chorioretinitis on left eye with a circumscribed whitish retinal lesion due to a granuloma with serious retinal detachment along the inferotemporal arcade and small punctiform whitish lesions in the inferotemporal quadrant. The optic nerve appeared normal and the vitreous was clear. The right eye was normal. On the basis of fundoscopy, a diagnosis of left chorioretinitis was made. Ultrasound and magnetic resonance imaging of the abdomen demonstrated mild homogenous splenomegaly and multiple hypodense areas within the spleen and liver parenchyma. Serology was negative for Epstein-Barr virus, cytomegalovirus, hepatitis viruses, human immunodeficiency virus, syphilis, toxoplasma and Francisella. On the other hand, the serology for B. henselae (indirect immunofluorescence antibody IFA) was positive (IgG>1:256). Polymerase chain reaction for B. henselae DNA from peripheral blood sample was negative. Treatment with azythromicin (500 mg/daily) was started, and the patient was treated for 3 weeks. We observed a gradual resolution of the granuloma and flattening of the lesion that resulted in a chorioretinal scar with disappearance of the punctiform lesions. A complete resolution of clinical symptoms and hepatosplenic lesions was obtained within 3 weeks (Fig. 1). Cat-scratch disease is a benign, selflimiting zoonotic disease caused by the bacillus B. henselae. Typical cat-scratch disease presentations include fever, regional lymphadenopathy and a nontender papule in the scratch line. Other manifestations such as ocular involvement, encephalopathy, hepatosplenic infection, osteomyelitis and endocarditis are exceptional in immunocompetent subjects. We believe that this is the first report of a immunocompetent pediatric patient presenting with both chorioretinitis and hepatosplenic lesion as an initial manifestation of systemic bartonellosis.