by Trenton Cleghern, O.D., FAAO VisionAmerica of Birmingham A seven-year-old white female was referred to our office for an evaluation of a nodule on the conjunctiva of her right eye. The patient reported mild irritation from the lesion but denied significant pain or other symptoms. The lesion first appeared ten days prior to my initial examination. The referring optometrist had initiated treatment with prednisolone acetate 1% TID. The patient and her parents reported that had only slightly improved the size of the lesion, but it was still about the same. The patient was a healthy seven-year-old with an unremarkable medical history and review of systems. She was not taking any prescribed medications, except for the prednisolone acetate, which had been tapered to QD dosing. Her uncorrected visual acuities were 20/20-1 OU. All other preliminary testing was normal. Slit lamp examination of the right eye revealed a raised whitish nodule on the superior nasal bulbar conjunctiva. It appeared to be surrounded by inflammation, it was a focal lesion limited to the superior nasal conjunctiva. All other findings of the right and left anterior segments were unremarkable. As you can see from the picture, it was an unusual lesion to find in a seven-year-old. Some possible differential diagnoses were pyogenic granuloma and nodular episcleritis or scleritis. The patient did not have any recent trauma or surgery, so pyogenic granuloma was very unlikely. Nodular episcleritis would be rare in a child this young. Also, you would expect more resolution with prednisolone acetate. Anterior scleritis would likely be even rarer for a patient this age, especially with no underlying systemic conditions. With anterior scleritis, you would expect much more pain. At this point, we knew it was inflammatory in nature, so she was started on ibuprofen 300 mg TID. A pharmacist was consulted to calculate a safe dosage. This case gets interesting five days after she was seen at our office. Her mother called to report that she had developed a large tender swollen lymph node below her jawline on the right side. Her conjunctival nodule was about the same. At this point, the suspicion for episcleritis or scleritis was lessened, but now cat scratch disease was the lead diagnosis. The patient was started on azithromycin 10 mg/kg/day for five days and lab work was ordered. We ordered Bartonella henselae and quintana antibodies, RPR, FTA-ABS, ACE, CBC, and RF. The prednisolone acetate and ibuprofen was discontinued. The labs returned with all negative or normal results. At her follow-up visit nine days later after talking with her mother, the conjunctival nodule was still present, but slightly smaller. She had enlarged, tender preauricular, submandibular, and anterior cervical lymph nodes. A dilated fundus exam revealed normal findings. Upon questioning, the patient's mother reported that they lived with multiple cats, including younger kittens. This unilateral conjunctival granuloma with an ipsilateral lymphadenopathy of such remarkable presentation made the likelihood of cat scratch, or more specifically, Parinaud's oculoglandular syndrome associated with cat scratch disease, very high. The patient was then started on sulfamethoxazole-trimethoprim 8 mg/kg/day. Doxycycline was not an option due to the patient's age. Labs were ordered again for Bartonella antibodies, which were also negative this time as well. However, she had been on antibiotics, so they may have confounded the results. After a couple of weeks, the patient had no-showed, but we spoke with her mother by phone who reported that the conjunctival nodule was completely resolved and all three lymph nodes had greatly shrunken in size and were much less painful. Even though we had two rounds of negative labs for Bartonella, the most likely diagnosis is cat scratch disease. With a unilateral conjunctival conjunctivitis or granuloma and ipsilateral tender lymphadenopathy and history of being exposed to young cats, the diagnosis is extremely likely to be cat scratch. Toxoplasmosis gondii was another possible etiology, but this was unlikely without any posterior segment manifestations. The next masses were definitely concerning with negative labs. It was comforting, knowing that lymphadenopathy came on acutely with significant swelling and some mild pain. This is pretty indicative of cat scratch or Parinaud's oculoglandular syndrome. Malignancies tend to develop more slowly. This is a case that shows that clinical suspicion, if you have enough evidence, can outweigh laboratory results. We must remember that labs can be wrong, and we must rely on our own clinical judgment to give our patients the best treatment.
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August 2019
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