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Abstract
A 70-year-old man had unilateral congestion of the right upper eyelid, which contained a nodular mass. A biopsy was performed, and histologic, immunocytochemical, and ultrastructural studies disclosed a pseudoneoplastic proliferation of endothelial cells and pericytes in a region containing clumps of bacteria. This combination of histologic features is characteristic of bacillary angiomatosis, which has been described in the skin, particularly in association with immunodeficient states, especially acquired immunodeficiency syndrome, but not in the conjunctiva. A second biopsy contained a diffuse polyclonal lymphocytic infiltrate in which large lymphocytes with irregular nuclei and mitotic figures were prominent. Systemic examination disclosed mild splenomegaly and a benign paraproteinemia. Treatment with topical gentamicin and systemic erythromycin brought about a complete resolution of the symptoms and signs within eight weeks, and there has been no sign of recurrence for the past two years.
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Affiliation(s)
- W R Lee
- University Department of Ophthalmology, Western Infirmary, Glasgow, Scotland, United Kingdom
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52
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Fumarola D, Pece S, Fumarulo R, Petruzzelli R, Greco B, Giuliani G, Maffione AB, Jirillo E. Downregulation of human polymorphonuclear cell activities exerted by microorganisms belonging to the alpha-2 subgroup of Proteobacteria (Afipia felis and Rochalimaea henselae). Immunopharmacol Immunotoxicol 1994; 16:449-61. [PMID: 7528238 DOI: 10.3109/08923979409007104] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Intracellular pathogens have evolved effective mechanisms in order to survive in an intracellular environment, thus avoiding destruction by phagocytic cells. In this regard, a correlation between resistance to phagocytic killing and expression of pathogenic potency has been established. In this report, we have studied the interaction between human polymorphonuclear cells (PMN) and two gram-negative microorganisms, Afipia felis and Rochalimaea henselae, which belong to the alpha-2 subgroup of the class Proteobacteria. A. falis has been previously proposed as the causative agent of Cat Scratch Disease (CSD), but several recent lines of evidence attribute a major role to R. henselae. Of note, CSD is a syndrome characterized by a chronic lymphoadenopathy, involving macrophages and endothelial cells with a progression towards a granulomatous process and/or angiogenesis. Since members of the alpha-2 subgroup of Proteobacteria have the property to survive intracellularly, we have evaluated the effects exerted by A. felis and R. henselae on human PMN in terms of chemotaxis locomotion, degranulation and oxidative metabolism. Results will show an impairment of PMN activities as a consequence of the challenge with both microrganisms. In particular, inhibition of PMN oxidative function occurred either as result of a direct exposure to both A. felis and R. henselae or when PMN were primed by bacteria for the N-formyl-methionyl-leucyl-phenylalanine enhancement of the oxidative burst. These findings may account for the ability of A. felis and R. henselae to survive within PMN as expression of a further mechanism of pathogenic potency, influencing also the nature and the evolution of inflammatory response in the lesion sites.
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Affiliation(s)
- D Fumarola
- Institutes of Medical Microbiology, General Pathology, University of Bari, Italy
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53
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Adal KA, Cockerell CJ, Petri WA. Cat scratch disease, bacillary angiomatosis, and other infections due to Rochalimaea. N Engl J Med 1994; 330:1509-15. [PMID: 8164704 DOI: 10.1056/nejm199405263302108] [Citation(s) in RCA: 166] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- K A Adal
- Department of Medicine, University of Virginia, Charlottesville
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54
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Camargo ME. Cat scratch disease and AIDS. Rev Soc Bras Med Trop 1994; 27:65-7. [PMID: 8073153 DOI: 10.1590/s0037-86821994000200001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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55
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Lee DJ, Sartoris DJ. MUSCULOSKELETAL MANIFESTATIONS OF HUMAN IMMUNODEFICIENCY VIRUS INFECTION: REVIEW OF IMAGING CHARACTERISTICS. Radiol Clin North Am 1994. [DOI: 10.1016/s0033-8389(22)00376-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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56
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Arlet G, Philippon A, Casin I, Lagrange P. Rochalimaea : de l'angiomatose bacillaire à la maladie des griffes du chat. Med Mal Infect 1994. [DOI: 10.1016/s0399-077x(05)80559-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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57
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Monteil RA, Michiels JF, Hofman P, Saint-Paul MC, Hitzig C, Perrin C, Santini J. Histological and ultrastructural study of one case of oral bacillary angiomatosis in HIV disease and review of the literature. EUROPEAN JOURNAL OF CANCER. PART B, ORAL ONCOLOGY 1994; 30B:65-71. [PMID: 9135977 DOI: 10.1016/0964-1955(94)90054-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Bacillary angiomatosis (BA) is a new clinicopathological entity defined as a pseudo-neoplastic capillary proliferation secondary to an opportunistic infection by one of two Rochalimaea sp.: R. quintana or R. henselae. Although BA is a recently recognised entity, numerous cases have been reported. Most of the patients affected are reported to have low absolute CD4 lymphocyte counts associated with AIDS. Yet, very few oral cases associated or not with cutaneous lesions have been reported or simply identified. Histopathological and ultrastructural features of one case of oral BA with gingival and palatal lesions are presented. Clinical aspects of oral BA do not hold pathognomonic features and the lesions may resemble either a reactive lesion of the gingiva, pyogenic granuloma or Kaposi's sarcoma. The lesion is characteristically composed of circumscribed lobular capillary proliferations and the presence of granular amphophilic material on haematoxylin and eosin sections surrounded by neutrophils and neutrophilic debris is a clue to diagnosis. Demonstration of bacilli in the interstitium by the Warthin-Starry silver method or, better, by electron microscopy is diagnostic. BA may contribute to the death of the patient but erythromycin has proved to be very effective treatment.
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Affiliation(s)
- R A Monteil
- Oral Pathobiology Laboratory, Faculty of Dental Surgery, University of Nice, France
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58
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Abstract
OBJECTIVE To report the clinical presentation and response to antimicrobial therapy of presumed bacillary angiomatosis in an AIDS patient. DESIGN Single case report. SETTING A 1058-bed, university teaching hospital. PATIENT 28-year-old HIV-positive man (T4 lymphocyte count < 3/mm3), who was diagnosed with AIDS in 1984. RESULTS The skin lesions responded promptly to treatment with doxycycline and erythromycin. CONCLUSIONS Bacillary angiomatosis is an infection that occurs with endstage AIDS. Skin lesions have recognizable characteristics and respond promptly to appropriate antibiotic therapy.
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Affiliation(s)
- A C Teague
- Medical College of Virginia Hospitals, Medical College of Virginia/Virginia Commonwealth University, Richmond
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59
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Haught WH, Steinbach J, Zander DS, Wingo CS. Case report: bacillary angiomatosis with massive visceral lymphadenopathy. Am J Med Sci 1993; 306:236-40. [PMID: 8213892 DOI: 10.1097/00000441-199310000-00006] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Bacillary angiomatosis is a newly characterized infectious disease occurring mainly in patients with AIDS. Most patients have cutaneous angiomatosis lesions resembling Kaposi's sarcoma or pyogenic granuloma. Although the disease may be life-threatening if not treated, it is curable with appropriate antibiotic therapy. A patient had a fever, nightsweats, abdominal pain, pleural effusions, and asymmetric peripheral lymphadenopathy. Computed tomography of the chest and abdomen revealed a unique pattern of enhancement of lymph nodes that, to this research team's knowledge, has not been reported previously with this condition. Appropriate antibiotic therapy resulted in a complete resolution of the disease. Included is a discussion of the clinical presentation, etiology, histology, and treatment of bacillary angiomatosis.
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Affiliation(s)
- W H Haught
- Department of Medicine, University of Florida, Gainesville
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60
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Welch DF, Hensel DM, Pickett DA, San Joaquin VH, Robinson A, Slater LN. Bacteremia due to Rochalimaea henselae in a child: practical identification of isolates in the clinical laboratory. J Clin Microbiol 1993; 31:2381-6. [PMID: 8408560 PMCID: PMC265765 DOI: 10.1128/jcm.31.9.2381-2386.1993] [Citation(s) in RCA: 56] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Two closely related species of Rochalimaea, Rochalimaea quintana and Rochalimaea henselae, are nutritionally fastidious but can be cultivated on bacteriologic media from the blood of patients with diverse clinical presentations. We report a case of culture-proven R. henselae bacteremia in a child with persistent fever. Serologic evidence of infection by R. henselae was ascertained by testing sera at two intervals for immunoglobulin G or immunoglobulin M antibodies by enzyme immunoassay and immunoblot. The case isolate and a collection of other strains (R. henselae, R. quintana, and related organisms) were used to test commercial identification systems for their comparative utility in the identification of Rochalimaea spp. on a practical basis. Of six systems designed for testing of either fastidious or anaerobic isolates of bacteria, the MicroScan Rapid Anaerobe Panel was the only system that distinguished R. henselae from R. quintana. Four of five others gave reactions that were unique within their data bases but did not distinguish Rochalimaea isolates at the species level.
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Affiliation(s)
- D F Welch
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City 73190
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61
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Innocenzi D, Cerio R, Barduagni O, Bosman C, Carlesimo OA. Bacillary epithelioid angiomatosis in acquired immunodeficiency syndrome (AIDS)--clinicopathological and ultrastructural study of a case with a review of the literature. Clin Exp Dermatol 1993; 18:133-7. [PMID: 8481988 DOI: 10.1111/j.1365-2230.1993.tb00994.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Bacillary epithelioid angiomatosis (BEA) is a rare cutaneous disorder usually affecting patients with human immunodeficiency virus (HIV) infection often misdiagnosed as a vascular tumour. We describe a 51-year-old, HIV-positive, Caucasian, homosexual male who developed scattered papulo-nodular lesions with clinicopathological and ultrastructural features of BEA. He had a dramatic therapeutic response to systemic antibiotics. There has been a lack of such reports in the European literature. The differential diagnosis is discussed and a brief review of the English literature to date is included.
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Affiliation(s)
- D Innocenzi
- Clinica Dermatologica Università degli studi La Sapienza, Roma, Italia
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62
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Porter SR, Scully C, Luker J. Complications of dental surgery in persons with HIV disease. ORAL SURGERY, ORAL MEDICINE, AND ORAL PATHOLOGY 1993; 75:165-7. [PMID: 8426715 DOI: 10.1016/0030-4220(93)90087-k] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Post tooth extraction infective complications have occasionally been described in HIV-infected persons. However, there is little objective data as to the frequency of this and the need for antibiotic prophylaxis. Similarly the frequency of postextraction bleeding in patients infected with HIV, who may have thrombocytopenia, is unknown. In the present study the frequency of postextraction complications has been investigated in a group of 38 persons at stages 2 to 4 of HIV infection and 26 matched subjects from patients groups commonly at risk of HIV infection but not seropositive. During 40 clinical procedures in HIV-infected patients, 100 (range 1 to 23, median 1) teeth were extracted. Three episodes of delayed postextraction healing were recorded. During 30 procedures in the non-HIV-infected persons, 68 (range 1 to 5, median, 2) teeth were extracted, and two episodes of delayed postextraction healing were recorded. These differences were not significant. Only one HIV-infected patient had an episode of severe postextraction bleeding: this was a hemophiliac who bled despite receiving factor VIII prophylaxis. The bleeding occurred 7 days after the extraction and ceased with tranexamic acid and additional factor VIII. No control subject had severe postextraction hemorrhage. It is concluded that postextraction complications are uncommon in HIV-infected patients and that routine antibiotic prophylaxis is not indicated.
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Affiliation(s)
- S R Porter
- Centre for the Study of Oral Disease, University of Bristol Dental Hospital and School, England
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63
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Bogle MS. Test and Teach: Number Seventy-Two Part 2. Pathology 1993. [DOI: 10.3109/00313029309066599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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64
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Koehler JE, Quinn FD, Berger TG, LeBoit PE, Tappero JW. Isolation of Rochalimaea species from cutaneous and osseous lesions of bacillary angiomatosis. N Engl J Med 1992; 327:1625-31. [PMID: 1435899 DOI: 10.1056/nejm199212033272303] [Citation(s) in RCA: 336] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Bacillary angiomatosis is characterized by vascular lesions, which occur usually in patients infected with the human immunodeficiency virus (HIV). A newly described gram-negative organism, Rochalimaea henselae, has been associated with cutaneous bacillary angiomatosis, but no organism has been isolated and cultivated directly from cutaneous tissue. METHODS We used two methods to isolate the infecting bacterium from four HIV-infected patients with cutaneous lesions suggestive of bacillary angiomatosis: cultivation with eukaryotic tissue-culture monolayers and direct plating of homogenized tissue onto agar. The patients' blood was cultured with the lysis-centrifugation method. Isolates recovered from skin and blood were identified by sequencing all or part of the 16S ribosomal RNA gene amplified with the polymerase chain reaction. RESULTS R. quintana, historically known as the agent of trench fever, was isolated from cutaneous lesions in three patients, after tissue homogenates were cultivated with endothelial-cell monolayers; R. henselae was isolated from a cutaneous lesion in one patient. In two patients, R. quintana was isolated from both cutaneous tissue and blood; in one patient it was also isolated from bone. CONCLUSIONS In bacillary angiomatosis, either of two species of rochalimaea--R. quintana or R. henselae--can be isolated from cutaneous lesions or blood, providing an additional method of diagnosis.
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Affiliation(s)
- J E Koehler
- Department of Medicine and Laboratory Medicine, University of California-San Francisco 94143-1204
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65
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Berger TG. Dermatologic Findings In The Head And Neck In Human Immunodeficiency Virus-Infected Persons. Otolaryngol Clin North Am 1992. [DOI: 10.1016/s0030-6665(20)30892-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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66
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Myers SA, Prose NS, Garcia JA, Wilson KH, Dunsmore KP, Kamino H. Bacillary angiomatosis in a child undergoing chemotherapy. J Pediatr 1992; 121:574-8. [PMID: 1403392 DOI: 10.1016/s0022-3476(05)81148-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Bacillary angiomatosis is an infectious disease of the skin and viscera characterized by vascular lesions, originally described in patients with human immunodeficiency virus infection. There are also case reports of bacillary angiomatosis occurring in immunocompetent patients and in noninfected patients with suppressed immune function. We report a case of bacillary angiomatosis in a child undergoing chemotherapy for acute leukemia.
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Affiliation(s)
- S A Myers
- Department of Dermatology, Duke University Medical Center, Durham, North Carolina 27710
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67
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Stürzl M, Brandstetter H, Roth WK. Kaposi's sarcoma: a review of gene expression and ultrastructure of KS spindle cells in vivo. AIDS Res Hum Retroviruses 1992; 8:1753-63. [PMID: 1457189 DOI: 10.1089/aid.1992.8.1753] [Citation(s) in RCA: 52] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
The ultrastructural features and the gene expression pattern of Kaposi's sarcoma (KS) spindle cells in vivo suggest that KS is a tumor of the mixed cell type. The expression pattern of cytokines and cytokine receptors in the tumor lesion, together with the results obtained from in vitro characterization of KS-derived cells, provide evidence that paracrine mechanisms of growth factor action are important for the maintenance of KS. The reports on virus infection of KS cells suggest an indirect role of virus infection in the induction of KS, most likely mediated by immunostimulation and subsequent production of cytokines.
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Affiliation(s)
- M Stürzl
- Max-Planck-Institut für Biochemie, Abteilung Virusforschung, Martinsried, Germany
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68
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Affiliation(s)
- C J Cockerell
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas 75235-9072
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69
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70
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Reed JA, Brigati DJ, Flynn SD, McNutt NS, Min KW, Welch DF, Slater LN. Immunocytochemical identification of Rochalimaea henselae in bacillary (epithelioid) angiomatosis, parenchymal bacillary peliosis, and persistent fever with bacteremia. Am J Surg Pathol 1992; 16:650-7. [PMID: 1530106 DOI: 10.1097/00000478-199207000-00003] [Citation(s) in RCA: 62] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
We report the immunocytochemical identification of Rochalimaea henselae, a newly recognized fastidious, Gram-negative, Warthin-Starry-positive organism, as the common pathogen in bacillary angiomatosis (BA), bacillary peliosis (BP) of the liver and spleen, and persistent fever with bacteremia in immunocompromised patients. Immunogenic proteins of the R. henselae strain isolated from the blood of a febrile immunocompromised patient with BP of the liver were used to produce primary immune serum in rabbits. Using immunocytochemical procedures, the polyclonal antiserum reacted strongly not only with the immunizing strain of the bacteria, but also with other blood isolates of R. henselae (five cases) from both immunocompromised and immunocompetent patients and with the organisms present in the tissue lesions of cutaneous BA (five cases) and BP of the liver (two cases) and spleen (one case). The blood isolates and BA and BP tissue samples were obtained from widely separated geographic areas. The antiserum was weakly cross-reactive with cultures of Rochalimaea quintana, an organism closely related to R. henselae, but this reactivity was eliminated by specific adsorption. The antiserum did not cross-react with the Warthin-Starry-positive organisms associated with cat scratch disease (Afipia felis), syphilis (Treponema pallidum), Lyme disease (Borrelia burgdorferi) or chronic active gastritis (Helicobacter pylori). Likewise, the antiserum did not identify organisms in eight cases of Kaposi's sarcoma, a disorder of immunocompromised patients that is clinically similar to BA. Further studies are needed to determine the prevalence of this newly recognized organism as well as its possible involvement in other angioproliferative diseases.
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Affiliation(s)
- J A Reed
- Department of Pathology, University of Oklahoma Health Sciences Center, Oklahoma City
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71
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Relman DA, Lepp PW, Sadler KN, Schmidt TM. Phylogenetic relationships among the agent of bacillary angiomatosis, Bartonella bacilliformis, and other alpha-proteobacteria. Mol Microbiol 1992; 6:1801-7. [PMID: 1378524 DOI: 10.1111/j.1365-2958.1992.tb01352.x] [Citation(s) in RCA: 77] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Bacillary angiomatosis (BA) and chronic bartonellosis are bacterial infections of humans which result in an unusual vascular proliferative tissue response. In order to determine their phylogenetic relationships, we have determined greater than 95% of the 16S rRNA sequences for these two organisms by amplification directly from infected BA tissue and from a Bartonella bacilliformis lyophilized culture. The BA agent and B. bacilliformis are closely related alpha-proteobacteria (98.5%), although the BA agent is more closely related to Rochalimaea quintana (99.1%). Contrary to previous belief, the BA agent is distinct from, and less closely related to, the cat scratch bacillus (Afipia felis) (90.7%). We propose a novel secondary structure in a hypervariable region of the 16S rRNA which is useful for alignment of primary sequences and which may be useful for design of nucleic acid probes.
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Affiliation(s)
- D A Relman
- Department of Microbiology and Immunology, Stanford University, California 94305-5402
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72
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Slater LN, Coody DW, Woolridge LK, Welch DF. Murine antibody responses distinguish Rochalimaea henselae from Rochalimaea quintana. J Clin Microbiol 1992; 30:1722-7. [PMID: 1629326 PMCID: PMC265370 DOI: 10.1128/jcm.30.7.1722-1727.1992] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Rochalimaea henselae causes persistent bacteremia, bacillary angiomatosis, and parenchymal bacillary peliosis. Detection of a specific antibody response to R. henselae infection may represent an alternative to cultivation as a means of diagnosis. We assessed the specificity of induced murine antibodies for antigens from R. henselae and the closely related species R. quintana. Groups of CD-1 mice were inoculated with whole organisms of six strains of R. henselae and two of R. quintana. Pre- and postinoculation blood specimens were collected. Enzyme immunosorbent assays were performed by using as antigens preparations of immunogenic proteins from one isolate of R. henselae or from the R. quintana type strain. These demonstrated high specificity of R. henselae-induced antibodies for proteins of R. henselae and of R. quintana-induced antibodies for proteins of R. quintana. Protein preparations extracted from all of the strains were separated electrophoretically. After their transfer to membranes, immunoblots were performed by using 1:1,000 dilutions of all of the pre- and postinoculation sera in combination with proteins from all of the strains. Preinoculation sera had minimal reactivity. All of the R. henselae-induced immune sera reacted with numerous proteins of all of the R. henselae strains but cross-reacted minimally with proteins of R. quintana. Immune sera from R. quintana-inoculated mice had similar species specificity. An immunofluorescence assay was developed by using antiserum to one strain of R. henselae. A 1:1,000 dilution yielded fluorescence with all strains of R. henselae but with none of R. quintana, Bartonella bacilliformis, or Afipia felis. Acinetobacter calcoaceticus subsp. anitratus was also unreactive with a dilution of 1:500. A 1:10 dilution yielded weak fluorescence with R. quintana but none with Staphylococcus epidermidis.
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Affiliation(s)
- L N Slater
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City
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73
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Torres-Anjel MJ. Macroepidemiology of the HIVs-AIDS (HAIDS) pandemic. Insufficiently considered zoological and geopolitical aspects. Ann N Y Acad Sci 1992; 653:257-73. [PMID: 1626879 DOI: 10.1111/j.1749-6632.1992.tb19655.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The human immunodeficiency viruses (HIVs)-acquired immunodeficiency syndrome (AIDS) or HAIDS pandemic originated from lentiviruses of nonhuman primates (thus qualifying as a zoonosis) that moved into humans in Africa. The HAIDS patients eventually die of opportunistic infections, all potentially zoonotic. The HAIDS infection remained parochial, first endemically and then epidemically, until the African urbanization that occurred in each of the countries postindependence. The latter included wars and the massive movement of soldiers (virologically naive) from the American continent to Africa and back. The HAIDS viral ecology coincided with African swine fever (ASF) in the Americas. Haiti became the focal point for both infections. Some infected Haitians also became, together with some infected drug addicts in the United States, a source of contaminated human blood for transfusions and production of plasma derivatives.
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Affiliation(s)
- M J Torres-Anjel
- Department of Microbiology (Clinical Epidemiology), College of Veterinary Medicine, University of Missouri, Columbia
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74
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Regnery RL, Olson JG, Perkins BA, Bibb W. Serological response to "Rochalimaea henselae" antigen in suspected cat-scratch disease. Lancet 1992; 339:1443-5. [PMID: 1351130 DOI: 10.1016/0140-6736(92)92032-b] [Citation(s) in RCA: 301] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
There are no generally accepted diagnostic tests for cat-scratch disease (CSD), the cause of which is unknown. During the development of an indirect fluorescence antibody (IFA) test for detection of antibodies to "Rochalimaea henselae", sera from patients with CSD were found to have high titres to R henselae antigens. Further tests with this assay showed that 36 (88%) of 41 patients with suspected CSD had serum titres of 64 or more to R henselae antigen, that there was a low prevalence (3%) of substantial titres to R henselae in healthy controls (n = 107), and that the immune responses to R henselae antigens were specific. These data suggest that the R henselae IFA test, or other serological assays based on R henselae, may be useful for diagnosis of CSD.
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Affiliation(s)
- R L Regnery
- Viral and Rickettsial Zoonoses Branch, National Center for Infectious Diseases, Centers for Disease Control, Atlanta, Georgia 30333
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75
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Abstract
Bacillary angiomatosis is a recently recognized bacterial infectious disease that is seen mainly in patients with the acquired immunodeficiency syndrome. Including this publication, 45 patients have been described in the medical literature. In this report we describe examples of the clinical presentations of bacillary angiomatosis and review therapeutic strategies.
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Affiliation(s)
- G F Webster
- Department of Dermatology, Jefferson Medical College, Philadelphia, PA
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76
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Mallett RB, Coulson IH, Holden CA. Acquired eruptive haemangiomata with primary biliary cirrhosis and prostatic carcinoma. Clin Exp Dermatol 1992; 17:206-7. [PMID: 1451304 DOI: 10.1111/j.1365-2230.1992.tb00209.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
We report a male patient with acquired eruptive haemangiomata occurring in association with primary biliary cirrhosis and a carcinoma of the prostate. The possible explanations include an abnormality of sex sterol metabolism associated with his liver disease, secretion of an angiogenic factor by his carcinoma or a combination of the two mechanisms.
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Affiliation(s)
- R B Mallett
- Department of Dermatology, St. Helier Hospital, Carshalton, Surrey, UK
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77
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Ficarra G, Shillitoe EJ. HIV-related infections of the oral cavity. CRITICAL REVIEWS IN ORAL BIOLOGY AND MEDICINE : AN OFFICIAL PUBLICATION OF THE AMERICAN ASSOCIATION OF ORAL BIOLOGISTS 1992; 3:207-31. [PMID: 1571472 DOI: 10.1177/10454411920030030301] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Oral infections are among the first manifestations of infection by the human immunodeficiency virus (HIV). They include fungal, viral, and bacterial infections and range from being essentially trivial, through troublesome to life threatening. Although some infections are due to overproliferation of the normal oral flora, others are due to organisms that normally are not found in the mouth. The clinical features of many of these infections have now been characterized, and clinical trials have indicated the optimal management. However, for many infections, the underlying processes are still not clear, and improvements in treatment are necessary.
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Affiliation(s)
- G Ficarra
- Institute of Odontology and Stomatology, University of Florence, Italy
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78
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Regnery RL, Anderson BE, Clarridge JE, Rodriguez-Barradas MC, Jones DC, Carr JH. Characterization of a novel Rochalimaea species, R. henselae sp. nov., isolated from blood of a febrile, human immunodeficiency virus-positive patient. J Clin Microbiol 1992; 30:265-74. [PMID: 1371515 PMCID: PMC265044 DOI: 10.1128/jcm.30.2.265-274.1992] [Citation(s) in RCA: 348] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Isolation of a Rochalimaea-like organism from a febrile patient infected with human immunodeficiency virus was confirmed. Analysis of 16S rRNA gene sequences, together with polymerase chain reaction and restriction endonuclease length polymorphism analysis of a portion of the citrate synthase gene, demonstrated that the agent is closely related to members of the genus Rochalimaea and that the isolate is genotypically identical to the presumptive etiologic agent of bacillary angiomatosis. However, the same genotypic analyses readily differentiated the new isolate from isolates of other recognized Rochalimaea species as well as other genera of bacteria previously suggested as putative etiologic agents of bacillary angiomatosis and related syndromes. We propose that the novel species be referred to as Rochalimaea henselae sp. now.
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Affiliation(s)
- R L Regnery
- Division of Viral and Rickettsial Diseases, Centers for Disease Control, Atlanta, Georgia 30333
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79
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Affiliation(s)
- P J Chor
- Department of Cutaneous Pathology, St. John's Mercy Medical Center, St. Louis, Missouri
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80
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Ficarra G. Oral lesions of iatrogenic and undefined etiology and neurologic disorders associated with HIV infection. ORAL SURGERY, ORAL MEDICINE, AND ORAL PATHOLOGY 1992; 73:201-11. [PMID: 1532237 DOI: 10.1016/0030-4220(92)90195-v] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
A review of a miscellaneous group of oral mucosal disorders in the setting of infection with the human immunodeficiency virus is presented. Included is a discussion of oral lesions of iatrogenic and undefined etiology and neurologic disorders. Mechanisms of pathogenesis, including possible common pathways and relationships to underlying immunosuppression, are emphasized.
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Affiliation(s)
- G Ficarra
- Institute of Odontology and Stomatology, University of Florence, Italy
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81
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Welch DF, Pickett DA, Slater LN, Steigerwalt AG, Brenner DJ. Rochalimaea henselae sp. nov., a cause of septicemia, bacillary angiomatosis, and parenchymal bacillary peliosis. J Clin Microbiol 1992; 30:275-80. [PMID: 1537892 PMCID: PMC265045 DOI: 10.1128/jcm.30.2.275-280.1992] [Citation(s) in RCA: 236] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Nine strains of Rochalimaea spp. that were isolated from patients over a period of 4.5 years were characterized for their enzyme activities, cellular fatty acid compositions, and DNA interrelatedness among Rochalimaea spp., Bartonella bacilliformis, and Afipia felis (cat scratch disease bacillus). All except one isolate, which was Rochalimaea quintana, were determined to belong to a newly proposed species, Rochalimaea henselae sp. nov. After recovery from clinical material, colonies required 5 to 15 days of incubation to become apparent. Cells were small, gram-negative, curved bacilli and displayed twitching motility. Enzyme specificities for amino acid and carbohydrate substrates showed that R. henselae could be distinguished from Rochalimaea vinsonii by L-arginyl-L-arginine and L-lysyl-L-alanine peptidases, but not all strains could be distinguished from R. quintana on the basis of peptidases or carbohydrate utilization. R. henselae also closely resembled R. quintana in cellular fatty acid composition, with both consisting mainly of C18:1, C18:0, and C16:0 fatty acids. However, the strains of R. henselae all contained C18:0 in amounts averaging greater than or equal to 22%, in contrast to R. quintana, which contained this cellular fatty acid in amounts averaging 16 and 18%. DNA hybridization confirmed the identification of one clinical isolate as R. quintana and showed a close interrelatedness (92 to 100%) among the other strains. Under optimal conditions for DNA reassociation, R. henselae showed approximately 70% relatedness to R. quintana and approximately 60% relatedness to R. vinsonii. Relatedness with DNA from B. baciliformis was 43%. R. henselae was unrelated to A. felis. R. henselae is the proposed species of a newly recognized member of the family Rickettsiaceae, which is a pathogen that may be encountered in immunocompromised or immunocompetent patients. Prolonged fever with bacteremia or vascular proliferative lesions are clinical manifestations of the agent.
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Affiliation(s)
- D F Welch
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City 73190
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82
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Chu P, LeBoit PE. An eruptive vascular proliferation resembling acquired tufted angioma in the recipient of a liver transplant. J Am Acad Dermatol 1992; 26:322-5. [PMID: 1569251 DOI: 10.1016/0190-9622(92)70046-i] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
A 59-year-old man developed grouped erythematous papules on the skin of the right axilla and arm shortly after orthotopic liver transplantation. Histologic changes closely resembled those of acquired tufted angioma, with capillary lobules studding the dermis. The lesions spontaneously involuted over several months. Histopathologic and immunohistochemical findings excluded Kaposi's sarcoma and bacillary angiomatosis, the two vascular proliferations most frequently seen in the immunocompromised host. We believe that our case is one of acquired tufted angioma appearing as an eruptive condition similar to eruptive pyogenic granuloma, to which it seems closely related. The involution of lesions in this case is unexplained.
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Affiliation(s)
- P Chu
- Department of Dermatology, School of Medicine, University of California, San Francisco 94143-0506
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83
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84
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Affiliation(s)
- D H Spach
- Division of Infectious Diseases, University of Washington School of Medicine, Seattle
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85
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Abstract
The electron microscope has been used with great skill in many aspects of the acquired immunodeficiency syndrome. It has played a critical role in classifying the human immunodeficiency virus, in characterizing the morphogenesis and gene products of the virus, and in elucidating the host cell targets and interactions. With the aid of the electron microscope, new opportunistic pathogens are being identified, and particularly difficult diagnoses are being made. Extrapolations from observations made at the ultrastructural level to the light microscopic level have provided criteria for the diagnosis of several infectious agents. As with any powerful scientific tool, observations must be interpreted with great care by scientists experienced in electron microscopy.
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Affiliation(s)
- J M Orenstein
- Department of Pathology, George Washington University Medical Center, Washington, DC 20037
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86
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Cockerell CJ, Tierno PM, Friedman-Kien AE, Kim KS. Clinical, histologic, microbiologic, and biochemical characterization of the causative agent of bacillary (epithelioid) angiomatosis: a rickettsial illness with features of bartonellosis. J Invest Dermatol 1991; 97:812-7. [PMID: 1919046 DOI: 10.1111/1523-1747.ep12487507] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
It has been suggested that bacillary (epithelioid) angiomatosis (BEA) is a manifestation of cat scratch disease (CSD). Because of clinical similarity between this condition and the verruga peruana phase of bartonellosis, we sought to further characterize this disease as well as its causative agent and to compare it to bartonellosis. We isolated a small flagellated pleomorphic bacillus from skin lesions of two patients with BEA. Organisms were stained successfully with Warthin-Starry silver stains, but immunohistochemistry failed to demonstrate binding with a polyclonal antibody directed against the cat scratch bacillus. Whole cell fatty-acid gas chromatography performed on both BEA organisms and Bartonella bacilliformis demonstrated marked similarity between the two. Electron microscopy of BEA organisms in tissue and in suspension revealed features characteristic of a gram negative bacillus. Based on these findings, we propose that this unusual rickettsial infectious disease with vascular proliferation may represent an unusual variant of infection with a bartonella-like organism rather than a manifestation of cat scratch disease.
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Affiliation(s)
- C J Cockerell
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas 75235-9072
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87
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Brenner DJ, Hollis DG, Moss CW, English CK, Hall GS, Vincent J, Radosevic J, Birkness KA, Bibb WF, Quinn FD. Proposal of Afipia gen. nov., with Afipia felis sp. nov. (formerly the cat scratch disease bacillus), Afipia clevelandensis sp. nov. (formerly the Cleveland Clinic Foundation strain), Afipia broomeae sp. nov., and three unnamed genospecies. J Clin Microbiol 1991; 29:2450-60. [PMID: 1774249 PMCID: PMC270354 DOI: 10.1128/jcm.29.11.2450-2460.1991] [Citation(s) in RCA: 149] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
On the basis of phenotypic characterization and DNA relatedness determinations, the genus Afipia gen. nov., which contains six species, is described. The type species is Afipia felis sp. nov. (the cat scratch disease bacillus). Afipia clevelandensis sp. nov., Afipia broomeae sp. nov., and three unnamed not associated with cat-borne disease. All but one strain (Afipia genospecies 3) were isolated from human wound and respiratory sources. All Afipia species are gram-negative, oxidase-positive, nonfermentative rods in the alpha-2 subgroup of the class Proteobacteria. They are motile by means of a single flagellum. They grow on buffered charcoal-yeast extract agar and nutrient broth, but rarely on MacConkey agar, at 25 and 30 degrees C. They are urease positive; but they are negative in reactions for hemolysis, indole production, H2S production (triple sugar iron agar), gelatin hydrolysis, esculin hydrolysis, and peptonization of litmus milk. They do not produce acid oxidatively from D-glucose, lactose, maltose, or sucrose. The major cell wall fatty acids are 11-methyloctadec-12-enoic (CBr19:1), cis-octadec-11-enoic (C18:1omega7c), and generally, 9,10-methylenehexadecanote and 11,12-methyleneoctadecanoate; and there are only trace amounts of hydroxy acids. The guanineplus-cytosine content is 61.5 to 69 mol%. A. felis is positive for nitrate reduction and is delayed positive for acid production from D-xylose, but it is catalase negative. A. clevelandensis is negative in all of these tests. A. broomeae is weakly positive for catalase production and acid production from D-xylose, but it is negative for nitrate reduction.
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Affiliation(s)
- D J Brenner
- Division of Bacterial and Mycotic Diseases, Centers for Disease Control, Atlanta, Georgia 30333
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88
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Hall GS, Pratt-Rippin K, Washington JA. Isolation of agent associated with cat scratch disease bacillus from pretibial biopsy. Diagn Microbiol Infect Dis 1991; 14:511-3. [PMID: 1802540 DOI: 10.1016/0732-8893(91)90009-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
We describe the isolation and cultural characteristics of a Gram-negative bacillus that is very similar to the presumed etiologic agent of cat scratch disease. The organism was isolated from a tibial lesion of a male patient who had been hospitalized for severe necrotizing pancreatitis. The significance of the isolate in this patient remains uncertain.
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Affiliation(s)
- G S Hall
- Department of Microbiology, Cleveland Clinic Foundation, OH 44195-5140
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89
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O'Connor SP, Dorsch M, Steigerwalt AG, Brenner DJ, Stackebrandt E. 16S rRNA sequences of Bartonella bacilliformis and cat scratch disease bacillus reveal phylogenetic relationships with the alpha-2 subgroup of the class Proteobacteria. J Clin Microbiol 1991; 29:2144-50. [PMID: 1719021 PMCID: PMC270288 DOI: 10.1128/jcm.29.10.2144-2150.1991] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The primary structures of 16S rRNAs of Bartonella bacilliformis, an isolate of the cat scratch disease (CSD) bacillus, and a strain phenotypically similar to the CSD bacillus were determined by reverse transcriptase sequencing. These microorganisms were found to be members of the alpha-2 subgroup of the class Proteobacteria. The sequence from B. bacilliformis was most closely related to the rRNA of Rochalimaea quintana (91.7% homology), the etiologic agent of trench fever. The sequence from the isolate of the CSD bacillus showed the greatest homology with Brucella abortus (89.7%) and, when compared with oligonucleotide catalog data, formed a cluster with Rhodopseudomonas palustris, Pseudomonas carboxidovorans, Nitrobacter species, and Bradyrhizobium species. The 16S rRNA sequence was also determined for the Cleveland Clinic isolate, which was previously shown to be phenotypically similar to and approximately 30% related, by DNA hybridization, to the CSD bacillus. The Cleveland Clinic isolate was isolated from a patient not diagnosed with CSD. The rRNAs from these bacteria exhibited 98.2% homology, confirming that this isolate is a second species in the same genus as the CSD bacillus. Our data suggest that neither B. bacilliformis nor the CSD bacillus is the etiologic agent of bacillary epithelioid angiomatosis.
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Affiliation(s)
- S P O'Connor
- Division of Bacterial and Mycotic Diseases, Centers For Disease Control, Atlanta, Georgia 30333
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90
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Abstract
Children with HIV infection may develop a wide variety of infectious and inflammatory diseases of the skin. These disorders are often more severe and more difficult to treat than in the healthy child. In some cases, disorders of the skin or mucous membranes may provide an early clue to the presence of pediatric HIV infection.
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Affiliation(s)
- N S Prose
- Duke University Medical Center, Durham, North Carolina
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91
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Berger TG, Greene I. Bacterial, Viral, Fungal, and Parasitic Infections in HIV Disease and AIDS. Dermatol Clin 1991. [DOI: 10.1016/s0733-8635(18)30396-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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92
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Brenner DJ, O'Connor SP, Hollis DG, Weaver RE, Steigerwalt AG. Molecular characterization and proposal of a neotype strain for Bartonella bacilliformis. J Clin Microbiol 1991; 29:1299-302. [PMID: 1715879 PMCID: PMC270104 DOI: 10.1128/jcm.29.7.1299-1302.1991] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Bartonella bacilliformis, the etiologic agent of bartonellosis, was characterized biochemically and by DNA hybridization, guanine-plus-cytosine content, genome size, and 16S rRNA sequencing. DNAs from the two strains in our collection exhibited 97% relatedness in hydroxyapatite reactions done at 55 degrees C (optimal reassociation criterion) and 100% relatedness in reactions done at 70 degrees C (stringent reassociation criterion). There was no evidence of divergence within the related sequences. B. bacilliformis DNA showed no relatedness to the cat scratch disease bacillus or to a strain of a second species in the same genus as the cat scratch disease bacillus in hybridization reactions done at 65 degrees C. The guanine-plus-cytosine contents of DNAs from the two B. bacilliformis strains were 39 and 40 mol%. Time course reassociation, done by determining spectrophotometrically the time required for one-half of the denatured DNA to form duplexes, indicated that B. bacilliformis has a genome size of approximately 4 x 10(8). The 16S rRNA sequence analysis indicated that B. bacilliformis is in the alpha-2 subgroup of the purple bacteria, class Proteobacteria, and that its closest relatives are Rochalimaea quintana and Brucella abortus. Strain KC583 (= Herrer 020/F12,63 = ATCC 35685) is proposed as the type strain of B. bacilliformis.
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Affiliation(s)
- D J Brenner
- Meningitis & Special Pathogens Branch, Center for Infectious Diseases, Centers for Disease Control, Atlanta, Georgia 30333
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93
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94
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95
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Affiliation(s)
- A D Northcutt
- Dermatopathology Section, Baylor College of Medicine, Houston, Texas
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96
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97
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Scully C, Laskaris G, Pindborg J, Porter SR, Reichart P. Oral manifestations of HIV infection and their management. II. Less common lesions. ORAL SURGERY, ORAL MEDICINE, AND ORAL PATHOLOGY 1991; 71:167-71. [PMID: 2003012 DOI: 10.1016/0030-4220(91)90460-t] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
This second of two articles reviews the many uncommon and rare oral lesions that have arisen in persons infected with human immunodeficiency virus (HIV). The various drug-related oral disorders of HIV disease are also considered.
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Affiliation(s)
- C Scully
- Centre for the Study of Oral Disease, University Department of Oral Medicine, Surgery and Pathology, Bristol Dental Hospital and School, U.K
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98
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Arlet G, Perol-Vauchez Y. The current status of cat-scratch disease: an update. Comp Immunol Microbiol Infect Dis 1991; 14:223-8. [PMID: 1959317 DOI: 10.1016/0147-9571(91)90002-u] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Cat-scratch disease (CSD) is a benign inoculative lymphoreticulosis, first described in independent reports by Pierre Mollaret [1] and Robert Debre in 1950 [2]. The disease usually self-limited, with spontaneous resolution occurring after several weeks, appears to be related to the presence of an identified gram-negative bacteria.
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Affiliation(s)
- G Arlet
- Service de Bactériologie-Virologie, Hôpital Saint-Louis, Paris, France
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99
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Affiliation(s)
- M C Stickler
- Department of Dermatology, New York University Medical Center, New York 10016
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100
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Affiliation(s)
- G F Webster
- Department of Dermatology, Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania 19107
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