Intraocular inflammation as the main manifestation of Rickettsia conorii infection

Abstract

ObjectiveTo report the clinical features and management of seven cases of intraocular inflammation caused by Rickettsia infection and review published literature.MethodsRickettsia conorii or Rickettsia spp. infection was diagnosed based on the following criteria: (1) positive serology according to the European Guidelines, (2) titer normalization after specific treatment, and (3) complete resolution of ophthalmic disease and accompanying symptoms after antibiotic therapy.ResultsSeven patients were referred for uveitis of unknown etiology. All came from regions where Mediterranean spotted fever is prevalent. One patient met the European guidelines criteria for Rickettsia spp. infection, while the other six cases met the criteria for R. conorii infection. The main symptoms were visual loss, floaters, eye redness, photophobia, and ocular pain. Predominant ophthalmic signs included vasculitis, choroiditis, vitritis, and macular edema. All patients required antibiotic treatment that resulted in the remission of the infection. Doxycycline was the first choice and the only antibiotic used to treat four patients. One patient needed ciprofloxacin as a second antibiotic after not responding to doxycycline. Two patients had doxycycline as a second antibiotic after not responding primarily to sulfonamides (which had been given after 2–3 days of doxycycline gastric intolerance); one of these patients needed ciprofloxacin as a third antibiotic.ConclusionIntraocular inflammation can occur as the main manifestation of Rickettsia conorii or Rickettsia spp. infection. It should be considered as a differential diagnosis for uveitis especially for patients living in countries where this infection is endemic in the world. Antibiotic treatment remains effective in the management of Rickettsia infection.

Update on Tick-Borne Rickettsioses around the World: a Geographic Approach

“…In recent years, atypical and serious life-threatening presentations of MSF in Mediterranean countries were reported, with cardiac symptoms (ectasia of the coronary arteries, myocarditis, and atrial fibrillation) (231-233), ocular symptoms (uveitis, retinopathy, and retinal vasculitis) (177,(234)(235)(236), neurological symptoms (cerebral infarct, meningoencephalitis, sensorineural hearing loss, acute quadriplegia secondary to an axonal polyneuropathy, and motor and sensory polyneuritis) (228,(236)(237)(238)(239)(240)(241), pancreatic involvements (242,243), splenic rupture (244), acute renal failure (245), and the presence of hemophagocytic syndrome (246). In addition to the classical risk factors for malignant MSF (advanced age, immunocompromised situations, chronic alcoholism, glucose-6-phosphate dehydrogenase [G6PD] deficiency, prior prescription of an inappropriate antibiotic, and delay of treatment) (209), alcoholism was definitively confirmed as a risk factor (218), and fluoroquinolone treatment was shown to be associated with increased MSF disease severity and longer hospital stays (238).…”

New Infectious Etiologies for Posterior Uveitis

“…SRD, accurately detected by OCT, frequently accompanies large foci of rickettsial retinitis. Retinal vascular lesions in patients with rickettsial disease may include focal or diffuse vascular sheathing, vascular leakage, retinal hemorrhages, and retinal vascular occlusions, including branch retinal artery occlusion and branch retinal vein occlusion or subocclusion, leading to retinal neovascularization and vitreous hemorrhage [1,2,3,31,32,33,34]. A subclinical choroidal involvement in the form of multiple dark dots on FA was observed in more than 15% of patients with Mediterranean spotted fever [31].…”

“…Indocyanine green angiography shows small hypofluorescent spots in the intermediate and late phases, areas of hyperfluorescence, choroidal vascular filling defect, and choroidal vascular staining [32]. Other chorioretinal changes include cystoid macular edema and endophthalmitis [1,2,3,31,32,33,34]. Optic disc involvement may include optic disc edema, optic disc staining, optic neuritis, neuroretinitis, and ischemic optic neuropathy [1,2,3,35].…”

Rare Ophthalmic Manifestations of Rickettsial Infections.

“…There are plenty of reports which document ocular manifestations of rickettsial infections worldwide (3,4). But these highlight mainly the posterior segment involvement as the most common ocular manifestations in rickettsial disease are retinitis, retinal vascular involvement and optic disc changes (5,6). There are very few reports on the anterior segment involvement in rickettsial disease (7,8).…”