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We present the case of a 30-year-old man who presented to the emergency department after waking up with left eye pain, left facial paralysis, and numbness of the left face and tongue. He denied any recent travel, sick contacts, or drug use. He had no personal or family history of autoimmune or neurological disease. When asked about exposure to animals, he reported that he cares for feral cats and kittens, nine of which live in his home. 

On examination, the patient was unable to close the left eye, raise the left eyebrow, or move the left side of the mouth. Fundoscopy revealed left optic disc edema without retinal exudates. Magnetic resonance imaging of the brain and orbits showed no masses or contrast enhancement. Cerebrospinal fluid demonstrated mild lymphocytic pleocytosis. Workup of infectious causes remained negative until Bartonella henselae serology tests returned strongly positive. The patient was diagnosed with Bartonella neuroretinitis and cranial neuropathies; he was treated with doxycycline, rifampin, and prednisone. Upon re-examination in clinic two weeks later, the patient’s symptoms had resolved.

This patient’s infection manifested in a highly uncommon way. Such severe atypical presentations of CSD are rare outside of the very young and immunosuppressed. Moreover, while neuroretinitis is known to occur in about 2% of CSD cases, cranial nerve palsies are quite rare. This case underlines the importance of assessing for environmental exposures in patients presenting with neurological deficits. As with this patient, disabling conditions can be prevented and effectively treated with a thorough history.