• bacteriology
• dermatology
• infectious diseases
• ophthalmology
• infectious diseases and infestations
• head and neck surgery

A 14-year-old girl presented with a left upper eyelid diffuse swelling and an ipsilateral pseudoptosis (figure 1A). She had been referred by a general practitioner as an urgent case of orbital cellulitis. She had already received 2 days of treatment with oral clindamycin without improvement in symptoms. The patient’s general medical history was unremarkable. Her family owned two dogs and she had been bitten by them several times during playing. Nasal endoscopy was performed. No purulent secretions were found in the middle meatus. MRI showed a soft tissue mass in the upper lid without any paranasal sinus pathology (figure 1B). The patient continued the antibiotic treatment and the swelling subsided gradually. However, 20 days later, she presented again with a solid nodule beneath the left eyelid skin and a concomitant swelling in the preauricular region. An excisional biopsy of the upper eyelid mass through blepharoplasty approach was performed (figure 1C). The histopathological findings were suggestive of cat scratch disease (CSD) (figure 1D). Serological testing (detection of IgM and IgG Bartonella henselae antibodies by enzyme immunoassay) and PCR assay for B. henselae were both positive and confirmed the diagnosis. The patient recovered after treatment with azithromycin.

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Figure 1

(A) Diffuse swelling was found in the upper eyelid. (B) Axial T1-weighted MRI shows a soft tissue mass in the upper lid. (C) The lesion was removed through blepharoplasty approach. (D) Granuloma with central microabscess and peripheral area of epithelioid cells.

CSD, caused by B. henselae, is a zoonosis and characterised by self-limited lymphadenopathy.1 Cat fleas are the main vector of the pathogen and transmit infection through flea faeces. However, the same species of flea may infest dogs which can also serve as a reservoir of B. henselae. CSD is transmitted to humans through a scratch or bite. Atypical ocular manifestations occur in 4.4% of CSD patients.2 The differential diagnosis of unilateral upper eyelid mass includes a variety of infections, benign lesions and malignancies, such as lymphoma, lacrimal gland tumours, rhabdomyosarcoma, dermoid cyst, chalazion, dacryadenitis, hemangioma and Langerhans cell histiocytosis.3