Bartonellosis clinical features and management

Bartonellosis clinical features and management

Bartonella bacilliformis is a Gram-negative aerobic bacillustransmitted by the bite of the female sandfly Lutzomyiaverrucarum. The disease is limited to the valleys of thewestern Andes, mainly in Peru, Colombia and Ecuador,between 2500 and 8000 feet above sea level. Humans arethe reservoir of infection. There are two manifestations ofthe disease: haematological and cutaneous.After a 21-day incubation period there is sudden onsetof systemic upset. The onset of fever is often followed byacute severe intravascular haemolysis, which may last upto 4 weeks before resolution. Several weeks to severalmonths later the eruptive phase of the disease appears,with nodular lesions of various sizes over the body in themiliary form, or fewer nodular, deep lesions particularlyconcentrated on the extensor aspects of the limbs. Mucousmembranes of the mouth and gut, and serous cavities canbe affected.The organisms can be grown in blood cultures taken inthe first week of the illness and can be readily found inGiemsa-stained thick and thin blood films, or in materialobtained from skin lesions.Treatment with antibiotics kills the organisms andproduces rapid defervescence and clearance of organismsfrom the blood. Penicillin, streptomycin and chloramphenicolare effective; the latter is recommended in viewof the reported association between systemic salmonellosisand bartonellosis. Treatment is for at least 7 days.

Bartonella quintana This organism, formerly known as Rochalimaea quintana,was recognized as the cause of trench fever among troopsin the First World War. The vector is the body louse, and soinfections can occur when levels of sanitation are low. Theorganisms are present in louse faeces and infection occursby introducing B. quintana through skin abrasions byscratching. There is no identified animal host. The organismcauses a range of febrile conditions, including a febrileillness lasting 4 days or so, a relapsing febrile illness withthree to five episodes of fever, and a continuous febrileillness lasting up to 21 days. Despite the association with theFirst World War the condition occurs worldwide amongcommunities where sanitation is poor. Doxycycline orerythromycin are the treatments of first choice.This agent and the related B. henselae have beenrecognized as the cause of cutaneous bacillary angiomatosisamong patients with HIV infection. Infectionof deep organs such as the liver produces similarlesions.

Clinical features Most cases occur in children or young adults. There is grossenlargement of a single group of lymph nodes, which areusually tender. Lymphadenopathy develops about 2 weeksafter the scratch and usually lasts for 2-4 months, but itmay persist for up to a year. A papule may occur at the siteof the scratch; it appears about a week after the scratch andpersists for 1-3 weeks. Although most patients remainwell, one-third have a low-grade fever for a few daysand may experience malaise, headache and sore throat.Rare manifestations are conjunctivitis and preauricularlymphadenopathy (oculoglandular syndrome), encephalopathy,thrombocytopenic purpura, osteomyelitis andpneumonia.DiagnosisThe diagnosis is usually based on the histology ofexcised lymph node with negative cultures for bacteria andmycobacteria. The Warthin-Starry silver impregnationstain may reveal the CSD bacilli but they are present insmall numbers.There may be a mild neutrophil leukocytosis, butother tests are unhelpful. Antibody tests are beingdeveloped.

Management Because the disease resolves spontaneously the only treatmentusually required is analgesia if the lymph nodes arepainful, and reassurance. Antibiotics do not help.

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