Oral corticosteroids have been effective in reducing the inflammation and improving the visual function in cases with systemic and posterior ocular manifestations. However, the necessity of corticosteroids therapy in isolated POGS has not been established [103, 104].

Management of pain caused by suppurative lymphadenopathy may include NSAIDs. Although aspiration of the lymph node can be done, it is not recommended because a fistulous tract may develop, and discharge may persist for several months resulting in permanent scarring. Children with CSD should be managed in association with a pediatrician specializing in infectious disease.

Controversies and Perspectives

The method of transmission of Bartonella infection to humans is still unknown. It is controversial whether the cat flea or flea feces is responsible for some cases of cat-to-human transmission. It is controversial whether B. henselae is the only causative agent of CSD or some other Bartonella species, as well as other bacteria, are responsible for some cases. Both the safety and the value of the use of foreign human lymphoid tissue to diagnose CSD, through the Hanger-Rose skin test remains controversial, especially after the advent of other serological and PCR tests that make the risk of its use outweigh its benefits. The necessity of treatment with antibiotics in immunocompetent patients with ocular involvement is also controversial given the benign nature of the disease.

Clinical Pearls

•B. henselae seropositivity has been associated with nearly two-thirds of all cases of neuroretinitis.

•The infection is transmitted to humans from infected domestic cats, especially kittens.

•Children and adolescents make up 80% of cases of CSD.

•Ocular involvement occurs in only 5–10% of all cases of CSD.

•Ocular involvement in CSD is usually in the form of unilateral granulomatous conjunctivitis with watery discharge and foreign body sensation. The presence of a single, large, and flat nodule in the bulbar or palpebral conjunctiva associated with regional lymphadenopathy helps with the diagnosis of CSD, especially when the primary inoculation site can be identified.

•Retinal and choroidal manifestations of CSD include neuroretinitis, multifocal retinitis and choroiditis, vasculitis and vascular occlusion, intermediate and diffuse uveitis, and retinal bacillary angiomatosis.

•Neuroretinitis may be associated with optic disk swelling, focal serous retinal detachment, and macular star.

•The outcome of the disease is generally benign; however, in some cases, a residual damage, in the form of optic disk pallor, decreased contrast sensitivity, dyschromatopsia, and abnormal visually evoked potentials, may happen.

•The diagnosis of CSD can be made when the clinical manifestations of the disease are combined with a serologic or a pathologic confirmation.

•Biopsy is only required when the clinical manifestations and laboratory confirmations are inconclusive.

•Antibiotic treatment ideally should be reserved for immunocompromised patients and for immunocompetent patients with severe sight-threatening ocular involvement.

•Recurrence of disease is not uncommon in immunocompromised patients due to the lack of long-lasting immunity. Longer courses of antibiotics treatment may be required in such patients.