P3C376: The Blur Adds to the Allure: A Case of Lymphadenopathy and Blurry Vision

Introduction: Cats are a common household pet, and it is not uncommon for one’s cat to scratch its’ owner; it is almost a rite of passage for a cat owner. However, owners do not expect to get Cat Scratch Disease (CSD). CSD is caused by a gram-negative intracellular bacteria B. Henselae, and typically presents as cutaneous lymphadenopathy near the site of inoculation. Rarely, the organism can disseminate and affect visceral organs. This case highlights a 14-year-old female diagnosed with Parinaud’s Oculoglandular Syndrome (POS), a rare complication of CSD.

Case Description: A 14-year-old female presents with two weeks of painful right neck lymphadenopathy, with acute worsening despite antimicrobials of Bactrim, Augmentin, and Azithromycin for presumed cellulitis and parotitis. She now has right facial and right periorbital swelling with ipsilateral blurry vision. She denies fever, night sweats, or unintentional weight loss. Vital signs were normal. Physical exam notable for tender right 1 cm preauricular lymphadenopathy, injected right conjunctiva with clear drainage, right>left periorbital edema, erythematous right cheek without warmth and right facial swelling, and healing puncture wounds on the right distal forearm. CT Maxillofacial showed focal prominence of the right parotid gland, minimal soft tissue swelling over right zygoma, and no abscess identified. Complete Blood Count and inflammatory markers (Complete Reactive Protein and Erythrocyte Sedimentation Rate) were normal. Epstein Barr Virus and Cytomegalovirus IgM Antibodies and PCR was negative. She was empirically started on intravenous Vancomycin and Unasyn. Once the physical exam revealed her puncture wounds, a more in-depth history was obtained. She lives on a farm with many cats and horses and her cat scratched her eye two weeks prior to presentation. This guided us to order Bartonella titers for which they were positive with Bartonella Henselae IgG 1:290 and IgM >1:20.

Discussion: Given the presentation of unilateral conjunctivitis and ipsilateral lymphadenopathy in the setting of elevated Bartonella titers, the patient fulfilled criteria for diagnosis of Parinaud’s Oculoglandular Syndrome (POS) due to Bartonella Henselae infection. She transitioned to Rifampin and Doxycycline for two weeks and was discharged home. This case highlights a familiar clinical presentation of lymphadenopathy for Pediatricians that then ends with an unfamiliar diagnosis of POS. Pediatricians should routinely use their history to aid in the diagnosis of POS. POS is reported in 2-8% of patients with CSD and presents with granulomatous, non-supportive conjunctivitis with ipsilateral preauricular lymphadenopathy, for which our patient fit the bill. The patient quickly transitioned antimicrobials to cover Bartonella and was able to be discharged home promptly.

Conclusion: In the setting of poly-pharmaceutical treatment for lymphadenopathy, it is important for providers to consider Bartonella as the culprit, which would enable them to consider uncommon conditions such as POS in their differential diagnosis.