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Anterior Optic Neuropathy in a Patient With Cyclical Fevers

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 41-year-old man presented for evaluation of 2 weeks of blurred vision and pain in the left eye. The onset of vision decrease coincided with muscle pain, joint swelling, and headache. All of the symptoms except blurry vision resolved spontaneously after 3 days. Over the preceding 5 months, he had had approximately monthly similar episodes consisting of a few days of flulike symptoms and blurry vision, with full recovery between episodes. At the time of evaluation, the vision was decreased in the left eye, with pain in both eyes and deep throbbing in the back of the left eye.

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Bartonella henselae neuroretinitis (cat scratch disease)

B. Blood testing for infectious and inflammatory agents

The differential diagnoses of unilateral anterior swelling of the optic disc in a healthy patient includes optic neuritis, orbital compression, and other inflammatory causes or infection. Nonarteritic anterior ischemic optic neuropathy would be unusual in this age group. Normal MRI excludes orbital compression. This and severity of the disc swelling also make demyelinating or neuromyelitis optica spectrum optic neuritis unlikely. The associated systemic manifestations favor an infectious or inflammatory cause. Therefore, inflammatory and infectious serologic testing (choice B) is the preferred response. Magnetic resonance imaging of the neck (choice A) would not be the preferred answer because the case is not consistent with ischemic vision loss owing to arterial disease. Observation (choice D) is not the preferred choice because some etiologies diagnosed by blood testing may require directed therapy. Oral prednisone (choice C) is not the preferred choice because this is contraindicated as monotherapy in infectious etiologies.

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Article Information

Corresponding Author: Heather E. Moss, MD, PhD, Stanford University, 2370 Watson Ct, MC 5353, Ste 200, Palo Alto, CA 94303 (hemoss@stanford.edu).

Published Online: January 16, 2020. doi:10.1001/jamaophthalmol.2019.4987

Conflict of Interest Disclosures: Dr Moss reported grants from the National Institutes of Health and Research to Prevent Blindness during the conduct of the study and grants from the Myelin Repair Foundation and the North American Neuro-ophthalmology Society and personal fees from American Academy of Neurology, Ology Medical Education, Elsevier, and legal firms outside the submitted work. No other disclosures were reported.

References
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Habot-Wilner  Z, Trivizki  O, Goldstein  M,  et al.  Cat-scratch disease: ocular manifestations and treatment outcome.  Acta Ophthalmol. 2018;96(4):e524-e532. doi:10.1111/aos.13684PubMedGoogle ScholarCrossref
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Biancardi  AL, Curi  AL.  Cat-scratch disease.  Ocul Immunol Inflamm. 2014;22(2):148-154. doi:10.3109/09273948.2013.833631PubMedGoogle ScholarCrossref
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Vermeulen  MJ, Verbakel  H, Notermans  DW, Reimerink  JH, Peeters  MF.  Evaluation of sensitivity, specificity and cross-reactivity in Bartonella henselae serology.  J Med Microbiol. 2010;59(Pt 6):743-745. doi:10.1099/jmm.0.015248-0PubMedGoogle ScholarCrossref
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Gulati  A, Yalamanchili  S, Golnik  KC, Lee  AG.  Cat scratch neuroretinitis: the role of acute and convalescent titers for diagnosis.  J Neuroophthalmol. 2012;32(3):243-245. doi:10.1097/WNO.0b013e318233a0a6PubMedGoogle ScholarCrossref
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