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Neuroretinitis as a presentation of Lyme disease
First Author: L. Bourke IRELAND
Co Author(s): S. Moran
To describe the case and present images of a 37-year-old lady who was diagnosed with neuroretinitis, subsequently attributed to infection by the spirochete, Borrelia burgdorferi. Her ocular manifestation of Lyme disease was her only significant finding and there was no evidence of further organ involvement. Neuroretinitis is broadly classified into three groups; cases in which a specific infectious agent can be identified, those considered idiopathic, and those which are idiopathic with recurrent events.
Ophthalmology department, Cork University Hospital, Wilton, Cork, Ireland.
Our case describes that of a 37 year old lady who initially presented with a 2-week history of blurred vision in the right eye. She had no past ophthalmic or medical history. Examination revealed reduced acuity to 6/18 unaided with Snellen testing in the right eye. There was a vitritis and macular oedema with a chorioretinal infiltrate in the peripapillary region. The left eye exam was unremarkable. Our initial investigations included extensive infective and autoimmune blood investigations along with a chest X-ray. Treatment was withheld initially pending some preliminary scan and blood results.
Over the subsequent weeks, the chorioretinal infiltrate resolved and a classical neuroretinitis macular star developed. Most infectious cases are due to cat-scratch disease, caused by Bartonella species. However, as part of our patientﾒs extensive investigative workup, IgM and IgG for B. burgdorferi came back positive. Further serological investigations to confirm these findings were performed by our microbiology department, revealing positive IgM+IgG B. burgdorferi on C6 enzyme immunoassay (EIA) and Lineblot. Other infective, inflammatory, and auto-immune bloods were all within normal limits.
Neuroretinitis is a disease characterised by inflammation of the optic nerve and its vasculature, with exudation of fluid into the peripapillary retina. The lipid-rich exudate is able to penetrate into the outer-plexiform layer, creating what is clinically seen as a macular star pattern. Neuroretinitis may be the initial and only present manifestation of Lyme disease and is important to bear in mind when building a differential diagnosis. Oral steroids and doxycycline are the preferred treatment choice and long term follow-up is necessary to evaluate for recurrence or other possible systemic signs of Lyme disease.
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