Bartonella species are fastidious, facultative intracellular, gram-negative bacteria that cause an array of infectious disease syndromes in humans.
Most Bartonella species have successfully adapted to survival in specific domestic or wild mammals, creating a reservoir for human infection. The exceptions are B. bacilliformis and B. quintana, which are not zoonotic.
Clinical presentation generally depends on both the infecting Bartonella species and the immune status of the infected individual.
Therapy for syndromes caused by Bartonella is summarized in Table 91-2.
TABLE 91-2ANTIMICROBIAL THERAPY FOR DISEASE CAUSED BY BARTONELLA SPECIES IN ADULTS ||Download (.pdf) TABLE 91-2ANTIMICROBIAL THERAPY FOR DISEASE CAUSED BY BARTONELLA SPECIES IN ADULTS
|Disease ||Antimicrobial Therapy |
|Typical cat-scratch disease ||Not routinely indicated; for pts with extensive lymphadenopathy, consider azithromycin (500 mg PO on day 1, then 250 mg PO qd for 4 days) |
|Cat-scratch disease retinitis ||Doxycycline (100 mg PO bid) plus rifampin (300 mg PO bid) for 4–6 weeks |
|Other atypical cat-scratch disease manifestationsa ||As per retinitis; treatment duration should be individualized |
|Trench fever or chronic bacteremia with B. quintana ||Gentamicin (3 mg/kg IV qd for 14 days) plus doxycycline (200 mg PO qd or 100 mg PO bid for 6 weeks) |
|Suspected Bartonella endocarditis ||Gentamicinb (1 mg/kg IV q8h for ≥14 days) plus doxycycline (100 mg PO/IV bid for 6 weeksc) plus ceftriaxone (2 g IV qd for 6 weeks) |
|Confirmed Bartonella endocarditis ||As for suspected Bartonella endocarditis minus ceftriaxone |
|Bacillary angiomatosis ||Erythromycind (500 mg PO qid for 3 months) |
| ||or |
| ||Doxycycline (100 mg PO bid for 3 months) |
|Bacillary peliosis ||Erythromycind (500 mg PO qid for 4 months) |
| ||or |
| ||Doxycycline (100 mg PO bid for 4 months) |
|Carrión’s disease || |
| Oroya fever ||Chloramphenicol (500 mg PO/IV qid for 14 days) plus another antibiotic (β-lactam preferred) |
| ||or |
| ||Ciprofloxacin (500 mg PO bid for 10 days) |
| Verruga peruana ||Rifampin (10 mg/kg PO qd, to a maximum of 600 mg, for 14 days) |
| ||or |
| ||Streptomycin (15–20 mg/kg IM qd for 10 days) |
CAT-SCRATCH DISEASE (CSD)
Microbiology and Epidemiology
B. henselae is the principal etiologic agent of CSD, although other Bartonella species may rarely be involved. Consistent with the disease’s name, contact (being scratched, bitten, or licked) with apparently healthy cats, and especially with kittens, is the primary source of infection. Adults are affected nearly as frequently as children. In the United States, the estimated incidence is ~10 cases per 100,000 population.
Of pts with CSD, 85–90% have typical disease consisting of a localized lesion (papule, vesicle, or nodule) at the site of inoculation with subsequent painful regional lymphadenopathy ≥1–3 weeks after cat contact.
Axillary and epitrochlear nodes are most commonly involved and suppurate in 10–15% of cases.
Low-grade fever, malaise, and anorexia develop in ~50% of pts.
Atypical disease involves extranodal manifestations (e.g., fever of unknown origin, ophthalmologic manifestations, neurologic involvement, osteomyelitis) and occurs in 10–15% of pts.
In immunocompetent pts, the disease resolves spontaneously without treatment, although its resolution takes weeks or months.
Serologic testing is most commonly used but is variably sensitive and specific. It is noteworthy that seroconversion may take a few weeks. Bartonella species are difficult to culture, but PCR analysis of lymph node tissue, pus, or the primary inoculation lesion is highly sensitive and specific.
BACILLARY ANGIOMATOSIS AND PELIOSIS
Bacillary angiomatosis is caused by B. henselae and B. quintana, while peliosis is caused only by the former species. These diseases occur most often in HIV-infected pts with CD4+ T cell counts of <100/μL.
Pts with bacillary angiomatosis present with one or more painless skin lesions that may be tan, red, or purple in color. SC masses or nodules, ulcerated plaques, and verrucous growths also occur. Painful osseous lesions, primarily in the long bones, may develop and appear as lytic lesions on radiography.
Peliosis is an angioproliferative disorder characterized by blood-filled cystic structures that affects primarily the liver but also the spleen and lymph nodes. Hypodense hepatic areas are usually evident on imaging.
Both diseases are diagnosed on histologic grounds. Blood cultures may be positive.
Trench fever (5-day fever) is caused by B. quintana, which is spread by the human body louse to its only animal reservoir: humans.
Much less common today than in the trenches of World War I, the disease now primarily affects homeless people.
After a usual incubation period of 15–25 days, disease classically ranges from a mild febrile illness to a recurrent or protracted and debilitating disease. Fever is often periodic, with episodes of 4–5 days separated by ~5-day afebrile periods.
Diagnosis requires identification of B. quintana in blood cultures.
Untreated, the disease usually lasts 4–6 weeks. Death is rare.
Bartonella species (typically B quintana or B. henselae) are an important cause of culture-negative endocarditis. The disease’s manifestations are similar to those of subacute endocarditis of any etiology (Chap. 80). Even if incubated for prolonged periods (up to 6 weeks), blood cultures are positive in only ~25% of cases. Serologic or PCR testing for Bartonella in cardiac valve tissue can help establish the diagnosis in pts with negative blood cultures.
CARRIÓN’S DISEASE (OROYA FEVER AND VERRUGA PERUANA)
Carrión’s disease is a biphasic disease caused by B. bacilliformis, which is transmitted by a sandfly vector found in the Andes valleys of Peru, Ecuador, and Colombia.
Oroya fever is the initial, bacteremic, systemic form, and verruga peruana is its late-onset, eruptive manifestation.
Oroya fever may present as a nonspecific bacteremic febrile illness without anemia or as acute, severe hemolytic anemia with hepatomegaly and jaundice of rapid onset.
– In verruga peruana, red, hemangioma-like, cutaneous vascular lesions of various sizes appear either weeks to months after systemic illness or with no previous suggestive history. The lesions persist for months up to 1 year.
In systemic illness, Giemsa-stained blood films show typical intraerythrocytic bacilli, and blood and bone marrow cultures are positive. Serologic assays may be helpful. Biopsy may be required to confirm the diagnosis of verruga peruana.
For a more detailed discussion, see Beeching NJ, Corbel MJ: Brucellosis, Chap. 194e; Jacobs RF, Schutze GE: Tularemia, Chap. 195, p. 1066; Prentice MB: Plague and Other Yersinia Infections, Chap. 196, p. 1070; and Giladi M, Ephros M: Bartonella Infections, Including Cat-Scratch Disease, Chap. 197, p. 1078, in HPIM-19.