Bartonella (Rochalimaea) quintana infections

Urban trench fever presenting as culture-negative endocarditis

A young Russian man presented with increasing shortness of breath and signs of worsening aortic regurgitation. A diagnosis of infective endocarditis was made before emergency valve replacement. The infective cause was not discovered by routine culture but was suggested by electron microscopy and confirmed by serology and PCR testing.

PCR detection of Bartonella bovis and Bartonella henselae in the blood of beef cattle

Although an organism primarily associated with non-clinical bacteremia in domestic cattle and wild ruminants, Bartonella bovis was recently defined as a cause of bovine endocarditis. The purpose of this study was to develop a B. bovis species-specific PCR assay that could be used to confirm the molecular prevalence of Bartonella spp. infection. Blood samples from 142 cattle were tested by conventional PCR targeting the Bartonella 16S-23S intergenic spacer (ITS) region. Overall, Bartonella DNA was detected in 82.4% (117/142) of the cattle using either Bartonella genus primers or B. bovis species-specific primers. Based upon size, 115 of the 117 Bartonella genus ITS PCR amplicons were consistent with B. bovis infection, which was confirmed by PCR using B. bovis species-specific primers and by sequencing three randomly selected, appropriately sized Bartonella genus PCR amplicons. By DNA sequencing, Bartonella henselae was confirmed as the two remaining amplicons, showing sequence similarity to B. henselae URBHLIE 9 (AF312496) and B. henselae Houston 1 (NC_005956), respectively. Following pre-enrichment blood culture of 12 samples in Bartonella alpha Proteobacteria growth medium (BAPGM) B. henselae infection was found in another three cows. Four of the five cows infected with B. henselae were co-infected with B. bovis. To our knowledge this study describes the first detection of B. henselae in any large ruminant species in the world and supports the need for further investigation of prevalence and pathogenic potential of B. henselae and B. bovis in cattle.

Laboratory maintenance of Bartonella quintana

Trench fever is the common name for the acute febrile syndrome associated with a Bartonella quintana bacterial infection. The focus of this unit is to describe reliable methods for cultivation and cryopreservation of B. quintana and can be applied to cultivation and preservation of all Bartonella. Detailed recipes for preparation of three types of semisolid media are also included.

Molecular evidence for Bartonella spp. in cat and dog fleas from Germany and France

Nine hundred and fifty-two fleas were collected from 148 cats and 133 dogs at 18 widely distributed geographic locations in Germany and France and examined for the presence of six different Bartonella spp. (Bartonella bacilliformis, Bartonella clarridgeiae, Bartonella elizabethae, Bartonella henselae, Bartonella quintana, Bartonella vinsonii subsp. berkhoffii) by PCR. Thirty-five specimens (3.7%) tested positive for either B. henselae (14 positive fleas) or B. clarridgeiae (21 positive fleas). DNA of other Bartonella spp. were not detected. Bartonella clarridgeiae was the dominating species in samples from France (19 out of 22 positive fleas), whereas B. henselae was more frequent in Germany (11 out of 13 positive fleas). With 3.5% (22 out of 632 fleas) in France and 4.1% (13 out of 320 fleas) in Germany, the overall prevalences of pathogen did not vary significantly between the flea populations of both countries. 5.4% of cats in France versus 16.1% of cats from Germany were infested by fleas carrying Bartonella, whereas 9.5% of dogs in France but none of the examined dogs from Germany were infested by Bartonella positive fleas. The molecular evidence of Bartonella infections reveals that agents of zoonotic potential are established in flea populations in Germany and France and that the spectrum of species can vary significantly from country to country.

Bacterial Infections

In Osier’s time, bacterial pneumonia was a dreaded event, so important that he borrowed John Bunyan’s characterization of tuberculosis and anointed the pneumococcus, as the prime pathogen, “Captain of the men of death.”1 One hundred years later much has changed, but much remains the same. Pneumonia is now the sixth most common cause of death and the most common lethal infection in the United States. Hospital-acquired pneumonia is now the second most common nosocomial infection.2 It was documented as a complication in 0.6% of patients in a national surveillance study,3 and has been reported in as many as 20% of patients in critical care units.4 Furthermore, it is the leading cause of death among nosocomial infections.5 Leu and colleagues6 were able to associate one third of the mortality in patients with nosocomial pneumonia to the infection itself. The increase in hospital stay, which averaged 7 days, was statistically significant. It has been estimated that nosocomial pneumonia produces costs in excess of $500 million each year in the United States, largely related to the increased length of hospital stay.

Metalloproteases and egg-hatching in Pediculus humanus, the body (clothes) louse of humans (Phthiraptera: Insecta)

To investigate the biochemical components of egg-hatch in the body louse, Pediculus humanus, egg-shell-washings (ESW) were collected during the first 2 h post-hatching and analysed by gelatin SDS-PAGE. These ESW contained proteases with molecular mass in the range of 25–100 kDa; the most abundant proteases were ~25 kDa. The 3 main regions of protease activity in the one-dimensional gelatin SDS-PAGE gels resolved to at least 23 distinct regions of protease activity when analysed by two-dimensional gelatin SDS-PAGE, with iso-electric points spread over the entire 3 to 10 pH range. Mechanistic characterization indicated that the ESW contained proteases of the metallo-class, inhibited by both 1,10-phenanthroline and EDTA. Several protease inhibitors were tested for their ability to inhibit louse egg-hatch in vitro. The metalloprotease inhibitor 1,10-phenanthroline and the aminopeptidase inhibitor bestatin significantly inhibited (P<0·05) louse egg-hatch (100% and 58%, respectively). The presence of metalloproteases at the time of egg-hatch and the inhibition of egg-hatch in P. humanus by metalloprotease inhibitors suggests a crucial role for these proteases in the hatching of this medically important parasite.

Bartonella-related pseudomembranous angiomatous papillomatosis of the oral cavity associated with allogeneic bone marrow transplantation and oral graft-versus-host disease

Patients undergoing allogeneic stem cell transplantation are at high risk for infection with a variety of pathogens during different phases of the procedure. Human infections due to Bartonella spp. are viewed as emerging diseases typical in, although not exclusive to, immunosuppressed patients, in particular those with AIDS, organ transplants and haematological malignancies. We describe four patients, three children and one adult, who developed vegetating papillomatous lesions exclusively on the oral mucosae. They shared a history of haematological malignancy and allogeneic bone marrow/stem cell transplantation, and later developed chronic graft-versus-host disease, also involving the oral mucosae. Histopathologically, the vegetating lesions were characterized by a diffuse neoangiogenesis, granulation-like tissue, and a mixed cell infiltrate predominantly composed of neutrophils. Gram-negative bacteria were found in the endothelial cells of the vessels in the deeper portion of the corium by electron microscopy. In three cases, DNA of B. henselae was detected by polymerase chain reaction (PCR), and confirmed by sequencing of the PCR products. All the lesions healed after systemic antibiotic therapy, although some recurred after months, and regressed again after systemic antibiotic treatment associated with conservative surgical excision.

Transcriptional regulation of the heme binding protein gene family of Bartonella quintana is accomplished by a novel promoter element and iron response regulator

We previously identified a five-member family of hemin-binding proteins (Hbp's) of Bartonella quintana that bind hemin on the outer surface but share no homology with known bacterial heme receptors. Subsequently, we demonstrated that expression of the hbp family is significantly influenced by oxygen, heme, and temperature conditions encountered by the pathogen in the human host and the body louse vector; e.g., we observed a dramatic (>100-fold) increase in hbpC transcript levels in response to the "louse-like" temperature of 30 degrees C. The goal of the present study was to identify a transcription factor(s) involved in the coordinated and differential regulation of the hbp family. First, we used quantitative real-time PCR (qRT-PCR) to show that the same environmental conditions generate parallels in the transcript profiles of four candidate transcriptional regulators (Irr, Fur, RirA, and BatR) described in the order Rhizobiales, with the greatest overall change in the transcription of irr (a >5-fold decrease) at a "louse-like" temperature, suggesting that Irr may function as an hbpC repressor. Second, a B. quintana strain hyperexpressing Irr was constructed; it exhibits a "bloodstream-like" hbp transcript profile in the absence of an environmental stimulus (i.e., hbpC is repressed and hbpA, hbpD, and hbpE mRNAs are relatively abundant). Furthermore, when this strain is grown at a "louse-like" temperature, an inversion of the transcript profile occurs, where derepression of hbpC and repression of hbpA, hbpD, and hbpE are readily evident, strongly suggesting that Irr and temperature influence hbp family expression. Third, electrophoretic mobility shift analyses show that recombinant Irr binds specifically to the hbpC promoter region at a sequence that is highly conserved in Bartonella hbp genes, which we designated the hbp family box, or "H-box." Fourth, we used the H-box to search the B. quintana genome and discovered a number of intriguing open reading frames, e.g., five members of a six-member family of cohemolysin autotransporters. Finally, qRT-PCR data regarding the effects of Fur and RirA overexpression on the hbp family are provided; they show that Fur's effect on the hbp family is relatively minor but RirA generates a "bloodstream-like" hbp transcript profile in the absence of an environmental stimulus, as observed for the Irr-hyperexpressing strain.

Bartonella quintana endocarditis in dogs

TOC summary line: PCR and sequencing provide the first evidence that B. quintana can be pathogenic in dogs.

We provide the first evidence that Bartonella quintana can infect dogs and cause typical signs of endocarditis. Using PCR and sequencing, we identified B. quintana in the blood of a dog from the United States with aortic valve endocarditis and probably also in the mitral valve of a dog from New Zealand with endocarditis.

Arthropod-borne diseases in homeless

Homeless people are particularly exposed to ectoparasite. The living conditions and the crowded shelters provide ideal conditions for the spread of lice, fleas, ticks, and mites. Body lice have long been recognized as human parasites and although typically prevalent in rural communities in upland areas of countries close to the equator, it is now increasingly encountered in developed countries especially in homeless people or inner city economically deprived population. Fleas are widespread but are not adapted to a specific host and may occasionally bite humans. Most common fleas that parasite humans are the cat, the rat, and the human fleas, Ctenocephalides felis, Xenopsylla cheopis, and Pulex irritans, respectively. Ticks belonging to the family Ixodidae, in particular, the genera Dermacentor, Rhipicephalus, and Ixodes, are frequent parasites in humans. Sarcoptes scabiei var. hominis is a mite (Arachnida class) responsible for scabies. It is an obligate parasite of human skin. The hematophagic-biting mite, Liponyssoides sanguineus, is a mite of the rat, mouse, and other domestic rodents but can also bite humans. Finally, the incidence of skin disease secondary to infestation with the human bedbug, Cimex lectularius, has increased recently. Bacteria, such as Wolbacchia spp. have been detected in bedbug. The threat posed by the ectoparasite in homeless is not the ectoparasite themselves but the associated infectious diseases that they may transmit to humans. Except for scabies all these ectoparasites are potential vectors for infectious agents. Three louse-borne diseases are known at this time. Trench fever caused by Bartonella quintana (B. quintana), epidemic typhus caused by Rickettsia prowazekii, and relapsing fever caused by the spirochete Borrelia recurrentis. Fleas transmit plague (Xenopsylla cheopis and Pulex irritans), murine typhus (Xenopsylla cheopis), flea-borne spotted rickettsiosis on account of the recently described species Rickettsia felis (C. felis), and occasionally cat scratch disease on account of Bartonella henselae (C. felis). The role of fleas as potential vector of B. quintana has recently been suggested. Among the hematophagic-biting mites, L. sanguineus, is responsible for the transmission of Rickettsia akari, the etiologic agent of rickettsialpox. Virtually, no data are available on tick-borne disease in this population. This article will deal with epidemiology, diagnosis, prevention, and treatment of these ectoparasite and the infectious diseases they transmit to the homeless people.

Bartonella quintana variably expressed outer membrane proteins mediate vascular endothelial growth factor secretion but not host cell adherence

Bartonella quintana causes trench fever, endocarditis, and the vasculoproliferative disorders bacillary angiomatosis and peliosis hepatis in humans. Little is known about the interaction of this pathogen with host cells. We attempted to elucidate the interaction of B. quintana with human macrophages (THP-1) and epithelial cells (HeLa 229). Remarkably, only B. quintana strain JK-31 induced secretion of vascular endothelial growth factor (VEGF) from THP-1 and HeLa 229 cells upon infection similar to the secretion induced by B. henselae Marseille, whereas other strains (B. quintana 2-D70, B. quintana Toulouse, and B. quintana Munich) did not induce such secretion. Immunofluorescence testing and electron microscopy revealed that the B. quintana strains unable to induce VEGF secretion did not express the variable outer membrane proteins (Vomps) on their surfaces. Surprisingly, the increase in VEGF secretion mediated by B. quintana JK-31 was not paralleled by elevated host cell adherence rates compared with the rates for Vomp-negative B. quintana strains. Our results suggest that the Vomps play a leading role in the angiogenic reprogramming of host cells by B. quintana but not in the adherence to host cells.

Diagnóstico da infecção por Bartonella spp.: a propósito de um caso de angiomatose bacilar

Várias dermatoses são consideradas idiopáticas. Muitas vezes, afecções como eritema nodoso ou eritema multiforme, por exemplo, não podem ter sua etiologia definida. A infecção humana por Bartonella spp. pode determinar várias expressões clínicas sindrômicas. A partir de um caso de angiomatose bacilar com documentação clínica, histológica e ultra-estrutural, foi feita a revisão da literatura médica para avaliar os critérios diagnósticos disponíveis para a infecção por esses agentes. Conclui-se que a avaliação histológica é, na prática, um importante e útil método diagnóstico, especialmente quando a sorologia não estiver disponível.

Environmental signals generate a differential and coordinated expression of the heme receptor gene family of Bartonella quintana

Of all bacteria, Bartonella quintana has the highest reported in vitro hemin requirement, yet an explanation for this remains elusive. To produce diseases such as trench fever, endocarditis, and bacillary angiomatosis, B. quintana must survive and replicate in the disparate environments of the Pediculus humanus corporis (body louse) gut and the human vasculature. We previously identified a five-member family of hemin binding proteins (Hbps) synthesized by B. quintana that bind hemin on the outer surface but share no similarity to known bacterial heme receptors. In the present study, we examine the transcription, regulation, and synthesis of this virulence factor family by cultivation of the bacterium in environments that simulate natural heme, oxygen, and temperature conditions encountered in the host and insect vector. First, quantitative real-time PCR data show that hbpC expression is regulated by temperature, where a >100-fold increase in transcript quantity was seen at 30 degrees C relative to 37 degrees C, suggesting that HbpC synthesis would be greatest in the cooler temperature of the louse. Second, cultivation at human bloodstream oxygen concentration (5% relative to 21% atmospheric) significantly decreases the transcript quantity of all hbp genes, indicating that expression is influenced by O2 and/or reactive oxygen species. Third, a differential expression pattern within the hbp family is revealed when B. quintana is grown in a range of hemin concentrations: subgroup I (hbpC and hbpB) predominates in a simulated louse environment (high heme), and subgroup II (hbpA, hbpD, and hbpE) is preferentially expressed in a simulated human background (low heme). By using two-dimensional sodium dodecyl sulfate-polyacrylamide gel electrophoresis, immunoblotting, and matrix-assisted laser desorption ionization-time of flight mass spectrometry fingerprinting, we demonstrate that synthesis of HbpA correlates with hbpA transcript increases observed at low hemin concentrations. Finally, an hbpA promoter-lacZ reporter construct in B. quintana demonstrates that a transcriptional regulator(s) is controlling the expression of hbpA through a cis-acting regulatory element located in the hbpA promoter region.

Bartonella quintana characteristics and clinical management

The pathogen is reemerging in the United States and Europe and is responsible for a number of clinical conditions.

Bartonella quintana, a pathogen that is restricted to human hosts and louse vectors, was first characterized as the agent of trench fever. The disease was described in 1915 on the basis of natural and experimental infections in soldiers. It is now recognized as a reemerging pathogen among homeless populations in cities in the United States and Europe and is responsible for a wide spectrum of conditions, including chronic bacteremia, endocarditis, and bacillary angiomatosis. Diagnosis is based on serologic analysis, culture, and molecular biology. Recent characterization of its genome allowed the development of modern diagnosis and typing methods. Guidelines for the treatment of B. quintana infections are presented.

Transient monoclonal gammopathy in a patient with Bartonella quintana endocarditis

Monoclonal gammopathy has been reported rarely in association with infectious diseases. Viral infection has been the most frequently reported. We report a case of Bartonella quintana endocarditis in a 45-year-old homeless male associated with a monoclonal IgG kappa gammopathy. The gammopathy disappeared after 8 months of antibiotics while the Bartonella antibody titre was decreasing. This correlation suggests a causative role for B. quintana for the monoclonal gammopathy. To the best of our knowledge, this the first report of monoclonal gammopathy in the course of B. quintana infection.

Bacillary Angiomatosis Caused by Bartonella quintana

Bacillary angiomatosis is a disorder of neovascular proliferation involving skin and lymph nodes of immunosuppressed patients. Bartonella henselae or Bartonella quintana have been inculpated as causative by direct culture or PCR amplification of DNA sequences. Here, we report the clinical evolution of a patient infected with human immunodeficiency virus (HIV) whose B. quintana infection was diagnosed by PCR.

Bartonella quintana in domestic cat

We recovered Bartonella quintana DNA from dental pulp of a domestic cat. This study, the first to detect B. quintana in a nonhuman mammal, changes our understanding of the epidemiology of this infection and proposes that cats may be an emerging source of human infection.

Serine proteinases of the human body louse (Pediculus humanus): sequence characterization and expression patterns

After the previous characterization of one trypsin gene (Try1) of the human body louse Pediculus humanus, genes encoding a second trypsin (Try2) and a chymotrypsin (Chy1) have been cloned using degenerate serine proteinase primers and 5'- and 3'-RACE, and sequenced. The deduced 259 and 267 amino acid sequences of Try2 and Chy1 show an identity of 33%-40% to trypsinogens and chymotrypsinogens of other insects. Considering previously published partial sequences, P. humanus possesses at least one Try1 gene, five variants/isoforms of Try2 and six variants/isoforms of Chy1. The genomic DNA of Try2 contains three introns and Chy1 contains five introns. Using whole mount in situ hybridization, gene expression of Try1, Try2 and Chy1 has been localized not only in the distensible anterior region of the midgut of lice but sometimes also in the area following the distensible region. The Try2 gene was always expressed at much lower levels than Try1 or Chy1. This lower expression, the constitutive expression of Try1 and Chy1 at 1, 2, 6, 12 and 24 h after feeding of adults and the regional differences have been verified in quantitative real-time PCR.

Enfermedades producidas por Bartonella spp

The genus Bartonella is cause of a broad number of emerging and re-emerging infectious diseases. Clinical manifestations depend on the implicated Bartonella sp. and the immunity of the host. Because there is not a universal therapy for this infection, treatment should be chosen individually. Bartonella sp. is responsible of potentially serious clinical pictures (endocarditis, chronic bacteremia, bacillary angiomatosis, Carrion's disease, etc.), so clinical suspicion, a quick diagnosis and an early treatment provide a better resolution.

Molecular detection of Bartonella quintana DNA in the dental pulp of a homeless patient

Dental pulp has been proposed as a suitable tissue sample for the identification of pathogenic organisms. Using PCR with two specific gene targets, Bartonella quintana DNA was detected in the dental pulp extracted from the tooth of a homeless patient. The patient had been bacteremic 6 months previously but was not when the tooth was sampled.

Impact of a molecular approach to improve the microbiological diagnosis of infective heart valve endocarditis

BACKGROUND

Even today, infective endocarditis (IE) remains a severe and potentially fatal disease demanding sophisticated diagnostic strategies for detection of the causative microorganisms. Despite the use of appropriate laboratory techniques, classic microbiological diagnostics are characterized by a high rate of negative results.

METHODS AND RESULTS

Broad-range polymerase chain reaction (PCR) targeting bacterial and fungal rDNA followed by direct sequencing was applied to excised heart valves (n=52) collected from 51 patients with suspected infectious endocarditis and from 16 patients without any signs of IE during an 18-month period. The sensitivity, specificity, and the positive and negative predictive values for the bacterial broad-range PCR were 41.2%, 100.0%, 100.0%, and 34.8%, respectively, compared with 7.8%, 93.7%, 80.0%, and 24.2% for culture and 11.8%, 100.0%, 100.0%, and 26.2% for Gram staining. Without exception, database analyses allowed identification up to the (sub)species level comprising streptococcal (n=13), staphylococcal (n=4), enterococcal (n=2), and other signature sequences such as Bartonella quintana and Nocardia paucivorans. Fungal ribosomal sequences were not amplified. All valve tissues of the reference group were negative for both PCR and conventional methods, except one sample that was contaminated by molds.

CONCLUSIONS

Culture-independent molecular methods substantially improve the diagnostic outcome of microbiological examination of excised heart valves. Importantly, this was true not only for fastidious, slow-growing, and/or nonculturable microorganisms but also for easy-to-culture pathogens such as streptococci and staphylococci. Both patient management and empiric antibiotic therapy of IE are likely to benefit from improved knowledge of the spectrum of pathogens now causing IE.

Multispacer typing technique for sequence-based typing of Bartonella quintana

Bartonella quintana is a worldwide fastidious bacterium of the Alphaproteobacteria responsible for bacillary angiomatosis, trench fever, chronic lymphadenopathy, and culture-negative endocarditis. The recent genome sequencing of a B. quintana isolate allowed us to propose a genome-wide sequence-based typing method. To ensure sequence discrimination based on highly polymorphic areas, we amplified and sequenced 34 spacers in a large collection of B. quintana isolates. Six of these exhibited polymorphisms and allowed the characterization of 4 genotypes. However, the strain variants suggested by the noncoding sequences did not correlate with the results of pulsed-field gel electrophoresis (PFGE), which suggested a higher degree of variability. Modification of the PFGE profile of one isolate after nine subcultures confirmed that rearrangement frequencies are high in this species, making PFGE unreliable for epidemiological purposes. The low extent of sequence heterogeneity in the species suggests a recent emergence of this bacterium as a human pathogen. Direct typing of natural samples allowed the identification of a fifth genotype in the DNA extracted from a human body louse collected in Burundi. We have named the typing technique herein described multispacer typing.

Bartonella quintana-induced apoptosis inhibition of human endothelial cells is associated with p38 and SAPK/JNK modulation and with stimulation of mitosis

Previous studies demonstrated that live Bartonella quintana often induces angioproliferative lesions in humans. It modulates endothelial cell apoptotic and inflammatory patterns, thus inducing a very early overexpression of caspase 8 and Apaf-1 and increasing mRNA production of TNF-alpha, interleukin-8, and E-selectin. However, starting at 10 hours postinfection, the bacteria provoke antiapoptotic effects that induce an increase of bcl-2 gene transcription. To gain further insight into the cellular mechanisms that regulate apoptosis, survival and proliferation, we studied the modulation of mitogen-activated protein kinase (MAPK) and the activation state of cdc2 kinase, which regulates progression into mitosis. Confocal microscopy findings indicated a maximum rate of Bartonella entry into host cells between postinfection hours 6 and 10. Live bacteria caused substantially higher apoptosis of human umbilical vein endothelial cells-cryopreserved (HUVEC-C) than heat- and trypsin-inactivated microorganisms. During the first 6 hours postinfection, B. quintana triggered a peak of apoptosis, induced activation of p38 MAPK and stress-activated protein kinase/c-Jun N-terminal kinase (SAPK/JNK), with bacterial clusters appearing at the cellular surface of the HUVEC-C. However, at 8 to 24 hours postinfection, B. quintana was internalized and inhibited proapoptotic signals such as p38 MAPK and SAPK/JNK while inducing antiapoptotic signals. Indeed, expression of the bcl-2 gene and the increase of the bcl-2 kinase active form was concomitant to activation of mitosis, as shown by cdc2 protein activation. These data thus suggest that mechanisms that induce mitotic activity and inhibit apoptotic signals may contribute to the ability of B. quintana to cause vascular proliferation.

Detection of Bartonella quintana by direct immunofluorescence examination of blood smears of a patient with acute trench fever

We report a case of Bartonella quintana acute symptomatic infection in a homeless man, presenting as a typical trench fever. B. quintana has been retrieved in erythrocytes in large clusters and in erythroblasts. Direct immunofluorescence of blood smears allows a rapid diagnosis.

Role of Hippoboscidae flies as potential vectors of Bartonella spp. infecting wild and domestic ruminants

The putative role of biting flies in Bartonella transmission among ruminants was investigated. Amplification of the Bartonella citrate synthase gene from 83 Hippoboscidae was detected in 94% of 48 adult Lipoptena cervi flies, 71% of 17 adult Hippobosca equina flies, 100% of 20 adult Melophagus ovinus flies, and 100% of 10 M. ovinus pupae. Our findings suggest that Hippoboscidae play a role in the transmission of Bartonella among ruminants. The vertical transmission of Bartonella in M. ovinus and the presence of Bartonella DNA in all samples suggest a symbiotic association between Bartonella and M. ovinus.

Flea-borne Bartonella grahamii and Bartonella taylorii in bank voles

Bartonella species are increasingly associated with a range of human and animal diseases. Despite this, we have a poor understanding of the ecology and epidemiology of many species, especially those circulating in wild populations. Previous studies have demonstrated that a diverse range of Bartonella species are abundant in wild rodent populations; little is known regarding their modes of transmission, although both direct and indirect routes have been suggested. In this study, with bank voles (Clethrionomys glareolus) as the host species, we demonstrate that the rodent flea Ctenophthalmus nobilis is a competent vector of at least two Bartonella species, B. grahamii, which has previously been associated with human infection, and B. taylorii. In contrast, no evidence of either horizontal or vertical transmission was seen in bank voles inoculated with B. taylorii maintained in an arthropod-free environment; this finding suggests that fleas may be essential for transmitting some Bartonella species.

Randomized open trial of gentamicin and doxycycline for eradication of Bartonella quintana from blood in patients with chronic bacteremia

Chronic Bartonella quintana bacteremia is known to occur in homeless people exposed to lice. We present here the results of an open randomized trial performed to evaluate the efficacy of doxycycline in combination with gentamicin in the eradication of B. quintana bacteremia. From 1 January 2001 to 1 April 2002, homeless people with blood cultures positive for B. quintana were randomized to receive either no treatment (untreated controls) or a combination of gentamicin (3 mg/kg of body weight/day intravenously for 14 days) and doxycycline (200 mg/day orally for 28 days). Patients were evaluated from the results of blood cultures performed between day 28 (the end of treatment) and day 90 postinclusion. Intention-to-treat analysis of 20 included patients showed eradication of bacteremia in 7 out of 9 treated patients versus 2 out of 11 untreated controls (P = 0.01). In the per-protocol analysis, eradication was obtained for 7 out of 7 treated patients versus 2 out of 9 untreated controls (P = 0.003). This study demonstrates the efficiency of the combination of doxycycline and gentamicin in eradicating B. quintana bacteremia.

Detection by immunofluorescence assay of Bartonella henselae in lymph nodes from patients with cat scratch disease

Laboratory diagnosis of Bartonella henselae infections can be accomplished by serology or PCR assay on biopsy samples. The purpose of our work was to assess immunofluorescence detection (IFD) in lymph node smears using a specific monoclonal antibody directed against B. henselae and a commercial serology assay (IFA) compared with PCR detection. Among 200 lymph nodes examined from immunocompetent patients, 54 were positive for B. henselae by PCR, of which 43 were also positive by IFD. Among the 146 PCR-negative lymph nodes, 11 were positive by IFD. Based on PCR results, the specificity of this new technique was 92.5%, the sensitivity was 79.6%, and the positive predictive value was 79.6%. At a cutoff titer of 64, the sensitivity of the IFA was 86.8% and the specificity was 74.1%. Diagnosis of cat scratch disease (CSD) may be improved, with a specificity of 100%, when the two tests (IFD and IFA) were negative; the sensitivity was 97.4% if one of the two tests was positive. Since PCR-based detection with biopsy samples is available only in reference laboratories, we suggest using IFD coupled with the commercial serology test for the diagnosis of CSD.

Bartonella quintana lipopolysaccharide effects on leukocytes, CXC chemokines and apoptosis: a study on the human whole blood and a rat model

Bartonella quintana, an emerging gram-negative pathogen, may cause trench fever, endocarditis, cerebral abscess and bacillary angiomatosis usually with the absence of septic shock in humans. B. quintana lipopolysaccharide (LPS), a deep rough endotoxin with strong reactivity in the limulus amebocyte lysate (LAL)-assay, was studied in human whole blood and in a rat model. A significant (P<0.05) increase of interleukin-8 (IL-8) concentration, comparable to the level induced by enterobacterial LPS, was stimulated in the human whole blood by B. quintana LPS. Isolated human neutrophils delayed their apoptotic behavior in the presence of B. quintana LPS. In the rat, B. quintana LPS induced a significant (P<0.001) increase in white blood cell count, both 30 and 60 min after intravenous injection. Such leukocytosis was inhibited by pretreatment with prazosin, an alpha-adrenergic antagonist. B. quintana LPS did not significantly change heart rate (HR), hematocrit (HCT) and platelet count in the above reported in vivo model, and regarding mean blood pressure (MAP) only a very early (5 min after LPS) and mild (yet significant) hypotension was observed. In contrast, a long-lasting decrease of MAP was found in Salmonella minnesota R595 LPS-treated animals. Blood TNFalpha levels did not change significantly from the baseline in rats injected with either saline or with B. quintana LPS, on the contrary S. minnesota R595 LPS-injected animals showed substantial increase of TNFalpha levels up to 2924 pg/ml at 60 min after LPS injection. B. quintana LPS as well as Salmonella LPS-injected rats exhibited an increase of the blood levels of GRO/CINC-1, particularly at 240 min after LPS administration. Apical part of rat gut villi showed several TUNEL-positive cells in tissue sections from B. quintana LPS-treated animals. Taken together, our data demonstrates that B. quintana LPS is able to selectively stimulate some inflammatory mediators. B. quintana LPS-induced leukocytosis appears mediated by an alpha-adrenergic receptor. The delayed apoptotic process of leukocytes and the chemokine increase may explain the apoptotic cells found in the rat gut and the inflammatory reactions in some human Bartonella diseases. This peculiar inflammatory pattern induced by B. quintana LPS, may partially account for the lack of severe septic shock, observed in human B. quintana infections.

In vitro Bartonella quintana infection modulates the programmed cell death and inflammatory reaction of endothelial cells

Bartonella quintana is an epicellular bacterium, which in vivo as well as in vitro, invades endothelial cells and develops within them inducing proliferative effects that play a pivotal role in neovascular manifestation of this disease. We investigated the effect of live Bartonella quintana and its LPS on apoptosis and inflammatory response in HUVEC-C, an endothelial cell line. The kinetics of the programmed cell death of Bartonella quintana-infected HUVEC-C showed a peculiar course. Even if early during infection apoptosis reached a peak after 6 h, later on apoptosis was inhibited. Such apoptosis inhibition was not observed during Bartonella quintana lipopolysaccharide treatment because LPS-stimulated HUVEC-C did progress to cell death. Evaluation of multiple cell signal transduction pathways revealed an overexpression of Apaf 1 and caspase 8 in HUVEC-C after 2 h of infection, and of bcl-2 starting from 10 h post Bartonella quintana infection. Moreover, Bartonella quintana and its LPS showed a different effect on the activation of genes involved in inflammatory response as revealed by molecular analysis of host cells. Bartonella quintana appears to be able to inhibit programmed cell death, inducing intracellular signals leading to survival and proliferation through the bcl-2 gene, despite the early increase of inflammatory status induced in endothelial cells. This mechanism, together with a poor endotoxin ability to stimulate strong inflammatory response, could contribute to the capability of the bacteria to persist intracellularly, causing chronic disease and producing neovascular manifestations.

Culture and antibiotic susceptibility of Bartonella quintana in human erythrocytes

Bartonella quintana, the agent of trench fever, has recently been implicated in various diseases, in particular, bacteremia and endocarditis in homeless people. The host cell of Bartonella spp. is believed to be the erythrocyte, and in the present study we demonstrate that B. quintana can be cultured in vitro in human erythrocytes. The bacteria were found to be intraerythrocytic by laser confocal microscopy with Bartonella species-specific monoclonal antibodies. Infections with B. quintana decreased the life span of erythrocytes in culture from 8.6 to 4.8 days. In the culture system we found that most of the antibiotics that we tested (doxycycline, fluoroquinolone compounds, and beta-lactams) were not bactericidal. Gentamicin was bactericidal at 4 micro g/ml, as was rifampin, but to a lesser extent. At this concentration, gentamicin has been shown to enter erythrocytes slowly and to reach a peak level of 0.26 micro g/ml after 24 h. At 0.26 micro g/ml, however, we found that gentamicin was not able to kill extracellular B. quintana, even after 96 h of incubation. We hypothesize that erythrocytes may be a reservoir for B. quintana and that the bactericidal activity of gentamicin that we observed occurs mainly when the bacteria emerge from the erythrocytes and are found extracellularly. It would appear that gentamicin should be administered for at least 5 days to cure patients infected with B. quintana.

Bartonella quintana Bacteremia among Homeless People

Bartonella quintana infections have recently reemerged, predominantly among the homeless populations in cities in both Europe and the United States. B. quintana can cause trench fever, endocarditis, and chronic bacteremia; the human body louse is the only known vector. Homeless people who presented to the emergency departments of University Hospital in Marseilles, France, were studied, as were those who had been admitted to other medical facilities in the city since 1 January 1997. Samples of blood and body lice were collected for culture for B. quintana and for serological testing. Bartonella bacteremia was associated with sweats, evidence of louse infestation, serological tests that were positive for B. quintana, and high titers of B. quintana antibody. Bacteremia was also associated with being homeless for <3 years. Asymptomatic, prolonged bacteremia (duration, up to 78 weeks) and intermittent bacteremia were found to occur. Data obtained regarding antibiotic regimens showed that treatment with gentamicin and doxycycline was effective in preventing relapses of bacteremia.

Comparison of in-house and commercial slides for detection by immunofluorescence of immunoglobulins G and M against Bartonella henselae and Bartonella quintana

We compared the sensitivities and specificities of indirect fluorescent antibody tests developed in our laboratory and commercially available from Focus Technologies (FT; formerly MRL Diagnostic) for detection of serum antibodies to Bartonella spp. Serum samples tested were from patients with culture- or PCR-confirmed Bartonella quintana or B. henselae infections causing cat scratch disease (CSD), chronic bacteremia, or endocarditis. At a cutoff titer of 64, the FT test had higher sensitivity than our in-house test in detecting anti-B. henselae immunoglobulin G (IgG) antibodies in CSD patients (91.2 versus 52.9%; P < 0.001). The specificity in serum samples from 85 control patients was, however, lower with the FT test (87%) than with the in-house test (98.8%) (P = 0.002). A cutoff titer of 128 improves the specificity for the FT test but lowers the sensitivity to 85%. For patients infected with B. henselae, our in-house test, but not the FT test, enabled endocarditis to be detected more reliably. With the in-house test, titers of IgG against B. henselae of >/=1,024 were found only in endocarditis patients and not in CSD patients. With the FT test, 19.1% of CSD patients had titers of IgG against B. henselae of >/=1,024 (P < 0.001). Our in-house technique also improved detection of anti-B. quintana antibodies in homeless patients with endocarditis. IgG titers of >/=1,024 were present in 75% of serum samples, but only in 16.7% of serum samples with the FT test (P = 0.004). Since each test has advantages over the other, the serological diagnosis of Bartonella infections would benefit if both tests were used concurrently.

Lack of correlation between Bartonella DNA detection within fleas, serological results, and results of blood culture in a Bartonella-infected stray cat population

OBJECTIVE

To correlate the presence of different Bartonella species in the blood of a stray cat population trapped on a French military base with specific antibodies and species detected in cat fleas.

METHODS

The prevalence of Bartonella bacteremia was investigated in 61 cats by plating frozen whole blood on blood agar plates. Identification of isolates and detection of Bartonella DNA from cat flea batches from ten cats was achieved by PCR amplification and sequencing. Antibody detection was performed by microimmunofluorescence.

RESULTS

We obtained 38 isolates of Bartonella from blood. Sixteen were identified as B. clarridgeiae, 15 as B. henselae genotype/serotype Houston 1 (type I), and seven as B. henselae genotype/serotype Marseille (type II). B. henselae was detected in five fleas, and B. clarridgeiae in one flea. Sixty-one per cent of the cats had detectable antibodies against at least one species or serotype. Sixteen cats had antibodies against only one antigen. For each species, the distribution of bacteremia among the cats could not be correlated with either the distribution of infected fleas or the distribution of specific antibodies.

CONCLUSIONS

The lack of correlation between Bartonella DNA detection within fleas, serological results, and results of blood culture is probably due to a lack of natural heterologous protection between species or serotypes. Cats suffer bacteremia with three Bartonella species and should therefore be considered the reservoirs of at least three human pathogens.

Traditional and molecular techniques for the study of emerging bacterial diseases: one laboratory's perspective

Identification of emerging bacterial pathogens generally results from a chain of events involving microscopy, serology, molecular tools, and culture. Because of the spectacular molecular techniques developed in the last decades, some authors think that these techniques will shortly supplant culture. The key steps that led to the discovery of emerging bacteria have been reviewed to determine the real contribution of each technique. Historically, microscopy has played a major role. Serology provided indirect evidence for causality. Isolation and culture were crucial, as all emerging bacteria have been grown on artificial media or cell lines or at least propagated in animals. With the use of broad-range polymerase chain reaction, some bacteria have been identified or detected in new clinical syndromes. Culture has irreplaceable advantages for studying emerging bacterial diseases, as it allows antigenic studies, antibiotic susceptibility testing, experimental models, and genetic studies to be carried out, and remains the ultimate goal of pathogen identification.

Native valve endocarditis due to Bartonella henselae in a middle-aged human immunodeficiency virus-negative woman

We report the case of a human immunodeficiency virus-negative woman who developed native valve endocarditis of the aortic valve due to Bartonell henselae infection. The diagnosis was established using serology and PCR analysis of excised aortic valve tissue.

Kinetics of Bartonella birtlesii infection in experimentally infected mice and pathogenic effect on reproductive functions

The kinetics of infection and the pathogenic effects on the reproductive function of laboratory mice infected with Bartonella birtlesii recovered from an Apodemus species are described. B. birtlesii infection, as determined by bacteremia, occurred in BALB/c mice inoculated intravenously. Inoculation with a low-dose inoculum (1.5 x 10(3) CFU) induced bacteremia in only 75% of the mice compared to all of the mice inoculated with higher doses (> or =1.5 x 10(4)). Mice became bacteremic for at least 5 weeks (range, 5 to 8 weeks) with a peak ranging from 2 x 10(3) to 10(5) CFU/ml of blood. The bacteremia level was significantly higher in virgin females than in males but the duration of bacteremia was similar. In mice infected before pregnancy (n = 20), fetal loss was evaluated by enumerating resorption and fetal death on day 18 of gestation. The fetal death and resorption percentage of infected mice was 36.3% versus 14.5% for controls (P < 0.0001). Fetal suffering was evaluated by weighing viable fetuses. The weight of viable fetuses was significantly lower for infected mice than for uninfected mice (P < 0.0002). Transplacental transmission of Bartonella was demonstrated since 76% of the fetal resorptions tested was culture positive for B. birtlesii. The histopathological analysis of the placentas of infected mice showed vascular lesions in the maternal placenta, which could explain the reproductive disorders observed. BALB/c mice appeared to be a useful model for studying Bartonella infection. This study provides the first evidence of reproductive disorders in mice experimentally infected with a Bartonella strain originating from a wild rodent.

Production of Bartonella genus-specific monoclonal antibodies

Monoclonal antibodies (MAbs) which react with heat-resistant proteins with molecular masses of 32 to 33 kDa of 14 different Bartonella species were produced. These antibodies did not react with antigens of 26 diverse bacterial strains by microimmunofluorescence assay except MAb B3D4, which reacted with Chlamydia psittaci and Chlamydia trachomatis at low titers. The identification of a common Bartonella antigenic protein will make it possible to later produce a diagnostic antigen by cloning and expressing it in Escherichia coli. Moreover, these MAbs allow all Bartonella species to be identified to the genus level.

Detection and culture of Bartonella quintana, Serratia marcescens, and Acinetobacter spp. from decontaminated human body lice

As part of a survey for trench fever among homeless people in Marseilles, France, we attempted isolation of Bartonella quintana from body lice. A decontamination protocol of immersion in 70% ethanol with 0.2% iodine was devised and was tested with a laboratory colony of body lice. Lice which had been experimentally contaminated with either Escherichia coli, Staphylococcus epidermidis, or Acinetobacter spp. were successfully decontaminated, and this process did not prevent the culture of B. quintana from these lice. One hundred sixty-one lice obtained from homeless patients were studied by the protocol. B. quintana was isolated on axenic medium from 15 of 161 body lice and was detected in 41 of 161 lice by PCR. Acinetobacter spp. and Serratia marcescens were also isolated from body lice. The sensitivities of PCR and culture of B. quintana were 98 and 36%, respectively. These procedures may be useful for epidemiologic studies of trench fever and for the recovery of strains for characterization and comparison.

Molecular evidence of Bartonella spp. in questing adult Ixodes pacificus ticks in California

Ticks are the vectors of many zoonotic diseases in the United States, including Lyme disease, human monocytic and granulocytic ehrlichioses, and Rocky Mountain spotted fever. Most known Bartonella species are arthropod borne. Therefore, it is important to determine if some Bartonella species, which are emerging pathogens, could be carried or transmitted by ticks. In this study, adult Ixodes pacificus ticks were collected by flagging vegetation in three sites in Santa Clara County, Calif. PCR-restriction fragment length polymorphism and partial sequencing of 273 bp of the gltA gene were applied for Bartonella identification. Twenty-nine (19.2%) of 151 individually tested ticks were PCR positive for Bartonella. Male ticks were more likely to be infected with Bartonella than female ticks (26 versus 12%, P = 0.05). None of the nine ticks collected at Baird Ranch was PCR positive for Bartonella. However, 7 (50%) of 14 ticks from Red Fern Ranch and 22 (17%) of 128 ticks from the Windy Hill Open Space Reserve were infected with Bartonella. In these infected ticks, molecular analysis showed a variety of Bartonella strains, which were closely related to a cattle Bartonella strain and to several known human-pathogenic Bartonella species and subspecies: Bartonella henselae, B. quintana, B. washoensis, and B. vinsonii subsp. berkhoffii. These findings indicate that I. pacificus ticks may play an important role in Bartonella transmission among animals and humans.

Experimental model of human body louse infection using green fluorescent protein-expressing Bartonella quintana

A laboratory colony of human body lice was experimentally infected by feeding on rabbits made artificially bacteremic with a green fluorescent protein-expressing Bartonella quintana. B. quintana was detected in the gut and feces until death but not in the eggs. The life span of the lice was not modified. The rabbit model should provide valuable clues to the role of lice in the transmission of B. quintana.

Use of rpoB gene analysis for detection and identification of Bartonella species

Identification of Bartonella species is of increasing importance as the number of infections in which these bacteria are involved increases. To date, these gram-negative bacilli have been identified by various serological, biochemical, and genotypic methods. However, the development of alternative tools is required, principally to circumvent a major risk of contamination during sample manipulation. The aim of our study was to investigate the possible identification of various Bartonella species by comparison of RNA polymerase beta-subunit gene (rpoB) sequences. This approach has previously been shown to be useful for the identification of members of the family Enterobacteriaceae (C. M. Mollet, M. Drancourt, and D. Raoult, Mol. Microbiol. 26:1005-1011, 1997). Following PCR amplification with specific oligonucleotides, a 825-bp region of the rpoB gene was sequenced from 13 distinct Bartonella strains. Analysis of these sequences allowed selection of three restriction enzymes (ApoI, AluI, and AflIII) useful for discerning the different strains by PCR-restriction fragment length polymorphism (PCR-RFLP) analysis. To confirm the potential value of such an approach for identification of Bartonella, the rpoB PCR was then applied to 94 clinical samples, and the results obtained were identical to those obtained by our reference PCR method. Twenty-four isolates were also adequately identified by PCR-RFLP analysis. In all cases, our results were in accordance with those of the reference method. Moreover, conserved regions of DNA were chosen as suitable primer targets for PCR amplification of a 439-bp fragment which can be easily sequenced.

Endocarditis due to rare and fastidious bacteria

The etiologic diagnosis of infective endocarditis is easily made in the presence of continuous bacteremia with gram-positive cocci. However, the blood culture may contain a bacterium rarely associated with endocarditis, such as Lactobacillus spp., Klebsiella spp., or nontoxigenic Corynebacterium, Salmonella, Gemella, Campylobacter, Aeromonas, Yersinia, Nocardia, Pasteurella, Listeria, or Erysipelothrix spp., that requires further investigation to establish the relationship with endocarditis, or the blood culture may be uninformative despite a supportive clinical evaluation. In the latter case, the etiologic agents are either fastidious extracellular or intracellular bacteria. Fastidious extracellular bacteria such as Abiotrophia, HACEK group bacteria, Clostridium, Brucella, Legionella, Mycobacterium, and Bartonella spp. need supplemented media, prolonged incubation time, and special culture conditions. Intracellular bacteria such as Coxiella burnetii cannot be isolated routinely. The two most prevalent etiologic agents of culture-negative endocarditis are C. burnetti and Bartonella spp. Their diagnosis is usually carried out serologically. A systemic pathologic examination of excised heart valves including periodic acid-Schiff (PAS) staining and molecular methods has allowed the identification of Whipple's bacillus endocarditis. Pathologic examination of the valve using special staining, such as Warthin-Starry, Gimenez, and PAS, and broad-spectrum PCR should be performed systematically when no etiologic diagnosis is evident through routine laboratory evaluation.