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Hong et al1 described 6 young, otherwise healthy patients who each had a type of inflammatory lesion of the choroid that had not been described previously in the literature. The lesion consisted of a solitary round, yellow-white focus of choroiditis in the posterior pole associated with overlying subretinal fluid. In none of the cases was an infectious or systemic inflammatory origin identified. The authors named the disorder "unifocal helioid choroiditis" to emphasize the lesion's resemblance to the sun.
We observed a similar ophthalmoscopic picture in a young man who also had historical and serologic evidence of cat-scratch disease. It would appear that infection with Bartonella (formerly Rochalimaea) henselae, the microbial agent of cat-scratch disease, is responsible for at least some cases of helioid choroiditis.
Report of a Case
A 20-year-old man reported progressive loss of vision in his right eye over 6 days and a severe headache that had been present for 1 day. He had been scratched by a cat 1 month earlier, after which he experienced intermittent malaise, mild weakness, and fever.
The patient was otherwise healthy. He did not have a history of venereal disease, tuberculosis exposure, foreign travel, recent vaccinations, rashes, arthralgias, or breathing problems, nor had he ingested raw meat. He had been exposed to both puppies and ticks within the previous year.
On ophthalmic examination, best-corrected visual acuity was 20/40 OD and 20/20 OS. The results of color vision testing with the Hardy-Rand-Rittler plates were normal, although responses in the right eye were somewhat slower. Visual fields demonstrated moderate central and superior depression on the right side and moderate superior depression on the left side. There was no afferent pupillary defect. The anterior segments were unremarkable. Ophthalmoscopy in the right eye revealed a round, yellow, slightly elevated, 1 disc–diameter subretinal lesion that was situated inside the inferotemporal vascular arcade (Figure 1). Overlying subretinal fluid extended upward from the lesion and elevated the fovea. The right optic disc appeared to be normal. In the left eye, the optic disc exhibited trace swelling nasally. Fluorescein angiography revealed progressive hyperfluorescence of the lesion in the right eye and very slow filling of the subretinal fluid cavity (Figure 2). The right optic disc appeared to be normal. Late staining of the nasal half of the left optic disc confirmed the presence of mild segmental disc swelling.
A solitary round, yellow-white choroidal lesion is situated in the inferotemporal macula of the right eye. Contiguous subretinal fluid elevates the entire fovea.
A late-phase fluorescein angiogram shows marked hyperfluorescence of the lesion and more subtle hyperfluorescence of the adjacent subfoveal fluid cavity.
The results of the following tests were either normal or negative: fluorescent treponemal antibody, toxoplasma IgM and IgG antibody titers, Lyme titer, and a purified protein derivative skin test. Toxocara antibody titration results were borderline at 1:32. Titration results for B henselae and Bartonella quintana, performed by the Centers for Disease Control and Prevention, Atlanta, Ga, were 1:2048 and 1:8192, respectively (reference range, <1:64).
The patient was not treated. Three weeks later, subjective vision in the right eye had almost returned to normal. Visual acuity was 20/20 OD, the yellow subretinal lesion was smaller, and the subretinal fluid had disappeared.
The patient's fundus picture, age at onset, and clinical course are consistent with the reported description of unifocal helioid choroiditis. Furthermore, the recent occurrence of a cat scratch, the history of fever and constitutional symptoms, and the serologic evidence of Bartonella infection strongly suggest that the patient had cat-scratch disease and that the choroidal lesion represented a focus of infection.
Although helioid choroiditis typically manifests as a unilateral, unifocal process, we note that one of the patients described by Hong et al1 had associated signs of inflammation in the anterior segment and vitreous body. Our patient had asymptomatic involvement of the optic disc in the left eye. Bilateral intraocular inflammation has been documented in a number of reports of cat-scratch disease.
Visual loss associated with cat-scratch disease is often related to neuroretinitis.2 In neuroretinitis, inflammation within the optic nerve results in optic disc swelling, local vascular incompetence, and eventual accumulation of fluid and exudate in the macula. In addition, an indistinct mass situated eccentrically on the optic disc is sometimes observed.3 It is possible that neuroretinitis and helioid choroiditis share a common pathophysiology, even though the primary site of inflammation differs in the 2 conditions.
Unifocal helioid choroiditis should be added to the list of ocular manifestations of cat-scratch disease. Clinicians who encounter patients with this condition should determine if the patient has been exposed to cats and whether constitutional symptoms are present. They also should consider performing serologic tests for Bartonella infection.
Corresponding author: Stephen C. Pollock, MD, Duke University Eye Center, Box 3802, Durham, NC 27710.
Pollock SC, Kristinsson J. Cat-scratch Disease Manifesting as Unifocal Helioid Choroiditis. Arch Ophthalmol. 1998;116(9):1249–1251. doi:
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