Cat-scratch disease-associated arthropathy

Antibodies to Borrelia burgdorferi and Bartonella species in serum and synovial fluid from people with rheumatic diseases

Vector-borne infections may underlie some rheumatic diseases, particularly in people with joint effusions. This study aimed to compare serum and synovial fluid antibodies to B. burgdorferi and Bartonella spp. in patients with rheumatic diseases. This observational, cross-sectional study examined paired synovial fluid and serum specimens collected from 110 patients with joint effusion between October 2017 and January 2022. Testing for antibodies to B. burgdorferi (using CDC criteria) and Bartonella spp. via two indirect fluorescent antibody (IFA) assays was performed as part of routine patient care at the Institute for Specialized Medicine (San Diego, CA, USA). There were 30 participants (27%) with positive two-tier B. burgdorferi serology and 26 participants (24%) with IFA seroreactivity (≥1:256) to B. henselae and/or B. quintana. Both B. burgdorferi IgM and IgG were detected more frequently in synovial fluid than serum: 27% of patients were either IgM or IgG positive in synovial fluid, compared to 15.5% in serum (P = 0.048). Conversely, B. henselae and B. quintana antibodies were detected more frequently in serum than synovial fluid; overall only 2% of patients had positive IFA titers in synovial fluid, compared to 24% who had positive IFA titers in serum (P < 0.001). There were no significant associations between B. burgdorferi or Bartonella spp. seroreactivity with any of the clinical rheumatological diagnoses. This study provides preliminary support for the importance of synovial fluid antibody testing for documenting exposure to B. burgdorferi but not for documenting exposure to Bartonella spp.

IMPORTANCE

This study focuses on diagnostic testing for two common vector-borne diseases in an affected patient population. In it, we provide data showing that antibodies to B. burgdorferi, but not Bartonella spp., are more commonly found in synovial fluid than serum of patients with joint effusion. Since Lyme arthritis is a common-and sometimes difficult to diagnose-rheumatic disease, improving diagnostic capabilities is of utmost importance. While our findings are certainly not definitive for changes to practice, they do suggest that synovial fluid could be a useful sample for the clinical diagnosis of Lyme disease, and future prospective studies evaluating this claim are warranted.

Cytokine and LL-37 gene expression levels in Bartonella spp. seropositive and seronegative patients of a rheumatology clinic

PURPOSE

The variation in the immune response to Bartonella spp. infection in humans remains unclear. The present study compares the expression of selected interleukins, cytokines and cathelicidin (LL-37) in rheumatology clinic patients suffering from musculoskeletal symptoms with healthy blood donors. The patients had previously been tested for the presence of Bartonella henselae antibodies.

METHODS

Gene expression of LL-37, interleukin (IL)-2, IL-4, IL-6, IL-12, interferon-(IFN)-γ, and tumor necrosis factor (TNF-α)-α was determined in blood samples using quantitative Polymerase Chain Reaction (qPCR). Statistical analysis was prepared with STATISTICA.

RESULTS

Statistically significant differences in the mRNA levels of the tested cytokines (IFN-γ, TNF-α, IL-2, IL-4, IL-6, IL-12; p<0.0001) were observed between the healthy controls and patients; however, no difference was observed for LL37 mRNA (p ​= ​0.1974). No significant differences in mRNA expression were observed between IgG in anti-Bartonella seropositive and seronegative individuals (p>0.05). The only significant differences between the Bartonella spp. DNA positive and negative patients, indicated by PCR, were observed for TNF-α and IL-12 mRNA (p ​= ​0.0045 and p ​= ​0.0255, respectively).

CONCLUSION

A broadly similar immune response to the tested cytokines was observed among the participants irrespective of anti-Bartonella spp. IgG seropositivity. However, the Bartonella DNA-positive participants demonstrated significantly lower expression of IL-12 and TNF-α mRNA; this may indicate that these bacteria have a suppressive influence on the immune system.

Misleading Positive Serology for Cat Scratch Disease Following Administration of Intravenous Immunoglobulin

Cat scratch disease (CSD), caused by Bartonella henselae, usually presents as regional lymphadenopathy/lymphadenitis, known as typical CSD or as atypical CSD, which includes, among others, neurological manifestations. Serology for anti-B. henselae IgG antibodies is the most commonly used diagnostic tests for CSD. Intravenous immunoglobulin (IVIG) is given for an increasing number of medical conditions and may cause interference with serological testing. We report six patients with neurological manifestations and two patients with Kawasaki disease mimicking typical CSD, mistakenly diagnosed as CSD due to false-positive serology following IVIG therapy. Bartonella IgG serology was positive one to six days after IVIG administration and reverted to negative in seven of eight patients or significantly decreased (1 patient) ≤30 days later. In patients with CSD, IgG titers remained essentially unchanged 15–78 days after the positive serum sample. An additional eight patients treated with IVIG for various conditions were evaluated prospectively. All were seronegative one day pre-IVIG infusion, five patients demonstrated an increase in the IgG titers one to three days after IVIG administration, one interpreted as positive and four as intermediate, whereas three patients remained seronegative, suggesting that false seropositivity after IVIG therapy may not occur in all patients. Treatment with IVIG can result in false-positive serology for B. henselae. Increased awareness to the misleading impact of IVIG is warranted to avoid misinterpretation. Repeat testing can distinguish between true and false serology. Preserving serum samples prior to IVIG administration is suggested.

Laboratory Diagnosis of 37 Cases of Bartonella Endocarditis Based on Enzyme Immunoassay and Real-Time PCR

Bartonella spp., mostly Bartonella quintana and B. henselae, are a common cause of culture-negative endocarditis. Serology using immunofluorescence assay (IFA) and PCR performed on cardiac tissues are the mainstays of diagnosis. We developed an enzyme immunoassay (EIA) and a novel multiplex real-time PCR assay, utilizing Bartonella genus-specific, B. henselae-specific, and B. quintana-specific SimpleProbe probes, for diagnosis of Bartonella endocarditis. We aimed to evaluate the performance of these assays. Thirty-seven patients with definite endocarditis, 18 with B. henselae, 18 with B. quintana, and 1 with B. koehlerae, were studied. Diagnosis was confirmed by conventional PCR and DNA sequencing of surgical cardiac specimens. Similar to the case with IFA, anti-Bartonella IgG titers of ≥1:800 were found in 94% of patients by EIA; cross-reactivity between B. henselae and B. quintana precluded species-specific serodiagnosis, and frequent (41%) but low-titer cross-reactivity between Coxiella burnetii antibodies and B. henselae antigen was found in patients with Q fever endocarditis. Low-titer (1:100) cross-reactivity was uncommonly found also in patients with brucellosis and culture-positive endocarditis, particularly Enterococcus faecalis endocarditis. Real-time PCR performed on explanted heart valves/vegetations was in complete agreement with results of sequence-based diagnosis with characteristic melting curves. The genus-specific probe identified five additional endocarditis-associated Bartonella spp. at the genus level. In conclusion, EIA coupled with a novel real-time PCR assay can play an important role in Bartonella endocarditis diagnosis and expand the diagnostic arsenal at the disposal of the clinical microbiologist. Since serology remains a major diagnostic tool, recognizing its pitfalls is essential to avoid incorrect diagnosis.

Anorexia Nervosa Caused by Polymicrobial Tick-Borne Infections: A Case Study

The etiology of anorexia nervosa (AN) is multifactorial, and infections may play a contributory and possibly a prominent role. A case is presented which is indicative of a causal association between tick-borne infections and AN. This adolescent female was diagnosed with AN at an eating disorder clinic after excessive food restriction and an irrational fear of weight gain necessitating nasogastric tube feeding. Her history was consistent with systemic infections and she tested serologically positive to Borrelia burgdorferi, Babesia microti, and Mycoplasma pneumoniae; in addition, her clinical presentation was consistent with a Bartonella infection. After treatment with oral and intravenous antimicrobials, she stopped food restriction and no longer had body image concerns. Physicians should be aware of the possibility that tick-borne infections could underly a diagnosis of AN. The role of tick-borne infections in the etiology of AN warrants further study.

Case Reports of Cat Scratch Disease in Patient With Unjustified Surgical Intervention

Cat scratch disease (CSD) is often a rare and unrecognized illness, but it is important for practitioners to consider. CSD is commonly diagnosed in children, but adults may also get this disease. The manifestations of CSD can include the damage of internal organs, joints, eyes, heart, and kidneys. CSD should be included in the differential diagnoses of fever of unknown origin and any lymphadenopathy syndrome. For rheumatologists, this pathology is of interest due to the systemic involvement, as well as the disease debut from the musculoskeletal symptoms. We present a CSD clinical case of a patient whose disease began with an acute abdomen clinic, and after two months transformed into arthritis of the hand joints.

The flea's knees: A unique presentation of cat scratch disease

A 4-year-old girl presented to the emergency department with right leg pain and associated limp for one day. There was no trauma or injury; she had no fever or recent illness. Her exam was notable for tenderness and swelling to the right knee, most prominent in the popliteal region. Initial laboratory testing was unremarkable except for a mildly elevated C-reactive protein. She had normal radiographs of the right lower extremity. A soft tissue ultrasound demonstrated popliteal lymphadenopathy, a rare finding in children. Reassessment of the patient revealed cat flea bites to the leg, which prompted concern for Bartonella henselae infection causing Cat-scratch Disease (CSD). The patient was treated empirically with Azithromycin and her Bartonella titers returned two days later consistent with active infection. This is a rare clinical report describing popliteal lymphadenitis and lower extremity arthropathy caused by Bartonella henselae infection secondary to cat flea bites.

Is Bartonella a Cause of Primary Sclerosing Cholangitis? A Case Study

The etiology of primary sclerosing cholangitis (PSC) is unknown. I present a case which may be indicative of a causal link between Bartonella infection and PSC. The patient presented with complaints of abdominal pain and bloody diarrhea. A colonoscopy demonstrated chronic inflammation and changes consistent with ulcerative colitis. Routine laboratory studies revealed elevated liver function tests (LFTs); ultrasound and magnetic resonance imaging (MRI) confirmed the diagnosis of PSC. Bartonella serology was positive. It is established that Bartonella infection is associated with both gastrointestinal inflammation and autoimmunity; indeed, there is an animal model for Bartonella-induced PSC. Bartonella is susceptible to treatment with vancomycin and there are case reports and small series that demonstrate that PSC responds to treatment with oral vancomycin. Because of this, it is postulated that at least some cases of PSC may be associated with Bartonella infection. The patient in this report was treated with oral vancomycin and, since then, has been in remission for both colitis and PSC. Since vancomycin is not systemically absorbed, the premise is that he suffered from Bartonella colitis and an autoimmune reaction to Bartonella causing PSC. This premise warrants further study.

Total Knee Bartonella henselae Infection: An Unusual Manifestation of Cat Scratch Disease: A Case Report

CASE

This is the first clinical report of periprosthetic total joint infection caused by Bartonella henselae. A 65-year-old woman developed an acutely painful total knee 3 weeks after a cat scratch. Serial joint aspirations and tissue cultures failed to identify any organism. Diagnosis was performed with polymerase chain reaction analysis. She underwent a 2-stage revision with successful symptom resolution.

CONCLUSIONS

Bartonella is an unusual cause of total knee infection requiring alternative techniques for diagnosis because cultures are unlikely to be definitive.

Bartonella henselae Bloodstream Infection in a Boy With Pediatric Acute-Onset Neuropsychiatric Syndrome

BACKGROUND

With the advent of more sensitive culture and molecular diagnostic testing modalities, Bartonella spp. infections have been documented in blood and/or cerebrospinal fluid specimens from patients with diverse neurological symptoms. Pediatric acute-onset neuropsychiatric syndrome (PANS) is characterized by an unusually abrupt onset of cognitive, behavioral, or neurological symptoms. Between October 2015 and January 2017, a 14-year-old boy underwent evaluation by multiple specialists for sudden-onset psychotic behavior (hallucinations, delusions, suicidal and homicidal ideation).

METHODS

In March 2017, Bartonella spp. serology (indirect fluorescent antibody assays) and polymerase chain reaction (PCR) amplification, DNA sequencing, and Bartonella enrichment blood culture were used on a research basis to assess Bartonella spp. exposure and bloodstream infection, respectively. PCR assays targeting other vector-borne infections were performed to assess potential co-infections.

RESULTS

For 18 months, the boy remained psychotic despite 4 hospitalizations, therapeutic trials involving multiple psychiatric medication combinations, and immunosuppressive treatment for autoimmune encephalitis. Neurobartonellosis was diagnosed after cutaneous lesions developed. Subsequently, despite nearly 2 consecutive months of doxycycline administration, Bartonella henselae DNA was PCR amplified and sequenced from the patient's blood, and from Bartonella alphaproteobacteria growth medium enrichment blood cultures. B henselae serology was negative. During treatment with combination antimicrobial chemotherapy, he experienced a gradual progressive decrease in neuropsychiatric symptoms, cessation of psychiatric drugs, resolution of Bartonella-associated cutaneous lesions, and a return to all pre-illness activities.

CONCLUSIONS

This case report suggests that B henselae bloodstream infection may contribute to progressive, recalcitrant neuropsychiatric symptoms consistent with PANS in a subset of patients.

Microbiological Diagnosis of Skeletal System Infections in Children

BACKGROUND

If not timely diagnosed and adequately treated, skeletal system infections in children may result in severe and permanent disability. Prompt identification of the etiology of the disease and determination of its antibiotic susceptibility are crucial for the successful management of septic arthritis, osteomyelitis, and spondylodiscitis. However, the bacteriological diagnosis of these infections has been traditionally limited by the low yield of conventional cultures and, on average, one-third of cases of pediatric joint and bone infections remained unconfirmed.

OBJECTIVE

To review the medical literature to summarize the current approach diagnosing the pediatric skeletal system infections.

METHODS

The relevant publications for the last three decades were reviewed.

RESULTS

In recent years, the detection of skeletal system pathogens has been revolutionized by the use of improved laboratory methods, including seeding of synovial fluid and bone exudates into blood culture vials, and the development and implementation of sensitive nucleic acid amplification assays. These advances have resulted in the recognition of Kingella kingae as the predominant etiology of hematogenous infections of bones, joints, intervertebral discs and tendon sheaths in children aged 6-48 months, and reduced the fraction of culture-negative osteoarthritis.

CONCLUSION

As the exudate and tissue samples obtained from young children with skeletal system infections are frequently insufficient for a comprehensive laboratory workup, physicians should take in consideration the patient's age, predisposing medical conditions and possible exposure to zoonotic organisms, and use a judicious combination of Gram's stain, culture on blood culture vials, and molecular tests to maximize the microbiological diagnosis of these diseases.

Rheumatological presentation of Bartonella koehlerae and Bartonella henselae bacteremias: A case report

INTRODUCTION

Systemic Bartonella spp. infections are being increasingly reported in association with complex medical presentations. Individuals with frequent arthropod exposures or animal contact appear to be at risk for acquiring long standing infections with Bartonella spp.

CASE REPORT

This case report describes infections with Bartonella koehlerae and Bartonella henselae in a female veterinarian whose symptoms were predominantly rheumatologic in nature. Infection was confirmed by serology, polymerase chain reaction (PCR), enrichment blood culture, and DNA sequencing of amplified B koehlerae and B henselae DNA. Long-term medical management with antibiotics was required to achieve elimination of these infections and was accompanied by resolution of the patient's symptoms. Interestingly, the patient experienced substantial improvement in the acquired joint hypermobility mimicking Ehlers-Danlos Syndrome (EDS) type III.

CONCLUSION

To facilitate early and directed medical interventions, systemic bartonellosis should potentially be considered as a differential diagnosis in patients with incalcitrant rheumatological symptoms and frequent arthropod exposures or extensive animal contact.

The cat did it: erythema nodosum and additional atypical presentations of Bartonella henselae infection in immunocompetent hosts

A healthy patient presented with painful skin lesions on the anterior surface of her legs. Erythema nodosum was diagnosed but all the usual causes were ruled out. The finding of bilateral enlarged axillary lymph nodes with necrosis and granulomas led to the diagnosis of Bartonella infection, an unusual cause of erythema nodosum. Imaging also revealed splenomegaly and small para-aortic lymph nodes. Up to one quarter of the patients with cat-scratch disease present atypically, a considerably higher prevalence than previously reported. A comprehensive review of the literature (PubMed, since inception, all languages) revealed a remarkable array of unusual presentations which are summarised and briefly discussed.

Did Bartonella henselae contribute to the deaths of two veterinarians?

Bartonella henselae, a flea-transmitted bacterium, causes chronic, zoonotic, blood stream infections in immunocompetent and immunocompromised patients throughout the world. As an intra-erythrocytic and endotheliotropic bacterium, B. henselae causes a spectrum of symptomatology ranging from asymptomatic bacteremia to fever, endocarditis and death. Veterinary workers are at occupational risk for acquiring bartonellosis. As an emerging, and incompletely understood, stealth bacterial pathogen, B. henselae may or may not have been responsible for the deaths of two veterinarians; however, recent evidence indicates that this genus is of much greater medical importance than is currently appreciated by the majority of the biomedical community.

Infection with Bartonella henselae in a Danish family

Bartonella species constitute emerging, vector-borne, intravascular pathogens that produce long-lasting bacteremia in reservoir-adapted (natural host or passive carrier of a microorganism) and opportunistic hosts. With the advent of more sensitive and specific diagnostic tests, there is evolving microbiological evidence supporting concurrent infection with one or more Bartonella spp. in more than one family member; however, the mode(s) of transmission to or among family members remains unclear. In this study, we provide molecular microbiological evidence of Bartonella henselae genotype San Antonio 2 (SA2) infection in four of six Danish family members, including a child who died of unknown causes at 14 months of age.

Koch's postulates and the pathogenesis of comparative infectious disease causation associated with Bartonella species

In his homage to Lucretius (‘Georgica’), Vergil is credited with stating: ‘Felix qui potuit rerum cognoscere causas’ (‘Fortunate is he who knows the causes of things’). Based on numerous commentaries and publications it is obvious that clinicians, diagnosticians and biomedical research scientists continue to struggle with disease causation, particularly in the assessment of the pathogenic role of ‘stealth pathogens’ that produce persistent infections in the host. Bartonella species, because of their evolutionary ability to induce persistent intravascular infections, present substantial challenges for researchers attempting to clarify the ability of these stealth bacteria to cause disease. By studying the comparative biological and pathological behaviour of microbes across mammalian genera, researchers might be able more rapidly to advance medical science and, subsequently, patient care by undertaking focused research efforts involving a single mammalian species or by attempting to recapitulate a complex disease in an rodent model. Therefore, in an effort to further assist in the establishment of disease causation by stealth pathogens, we use recent research observations involving the genus Bartonella to propose an additional postulate of comparative infectious disease causation to Koch's postulates.

Bartonella spp. bacteremia and rheumatic symptoms in patients from Lyme disease-endemic region

Prevalence of Bartonella spp. was high, especially among patients with a history of Lyme disease.

Bartonella spp. infection has been reported in association with an expanding spectrum of symptoms and lesions. Among 296 patients examined by a rheumatologist, prevalence of antibodies against Bartonella henselae, B. koehlerae, or B. vinsonii subsp. berkhoffii (185 [62%]) and Bartonella spp. bacteremia (122 [41.1%]) was high. Conditions diagnosed before referral included Lyme disease (46.6%), arthralgia/arthritis (20.6%), chronic fatigue (19.6%), and fibromyalgia (6.1%). B. henselae bacteremia was significantly associated with prior referral to a neurologist, most often for blurred vision, subcortical neurologic deficits, or numbness in the extremities, whereas B. koehlerae bacteremia was associated with examination by an infectious disease physician. This cross-sectional study cannot establish a causal link between Bartonella spp. infection and the high frequency of neurologic symptoms, myalgia, joint pain, or progressive arthropathy in this population; however, the contribution of Bartonella spp. infection, if any, to these symptoms should be systematically investigated.

Chronic Lyme Disease and Co-infections: Differential Diagnosis

In Lyme disease concurrent infections frequently occur. The clinical and pathological impact of co-infections was first recognized in the 1990th, i.e. approximately ten years after the discovery of Lyme disease. Their pathological synergism can exacerbate Lyme disease or induce similar disease manifestations. Co-infecting agents can be transmitted together with Borrelia burgdorferi by tick bite resulting in multiple infections but a fraction of co-infections occur independently of tick bite. Clinically relevant co-infections are caused by Bartonella species, Yersinia enterocolitica, Chlamydophila pneumoniae, Chlamydia trachomatis, and Mycoplasma pneumoniae. In contrast to the USA, human granulocytic anaplasmosis (HGA) and babesiosis are not of major importance in Europe. Infections caused by these pathogens in patients not infected by Borrelia burgdorferi can result in clinical symptoms similar to those occurring in Lyme disease. This applies particularly to infections caused by Bartonella henselae, Yersinia enterocolitica, and Mycoplasma pneumoniae. Chlamydia trachomatis primarily causes polyarthritis. Chlamydophila pneumoniae not only causes arthritis but also affects the nervous system and the heart, which renders the differential diagnosis difficult. The diagnosis is even more complex when co-infections occur in association with Lyme disease. Treatment recommendations are based on individual expert opinions. In antibiotic therapy, the use of third generation cephalosporins should only be considered in cases of Lyme disease. The same applies to carbapenems, which however are used occasionally in infections caused by Yersinia enterocolitica. For the remaining infections predominantly tetracyclines and macrolides are used. Quinolones are for alternative treatment, particularly gemifloxacin. For Bartonella henselae, Chlamydia trachomatis, and Chlamydophila pneumoniae the combination with rifampicin is recommended. Erythromycin is the drug of choice for Campylobacter jejuni.

Molecular detection of Ehrlichia canis, Anaplasma bovis, Anaplasma platys, Candidatus Midichloria mitochondrii and Babesia canis vogeli in ticks from Israel

: Ticks are vectors of important pathogens of human and animals. Therefore, their microbial carriage capacity is constantly being investigated. The aim of this study was to characterize the diversity of domestic animal pathogens in ticks collected from vegetation and the ground, from different parts of Israel. Non-engorged questing adult ticks were collected from 13 localities. A total of 1196 ticks in 131 pools-83 pools of Rhipicephalus turanicus and 48 of Rhipicephalus sanguineus (with two to ten ticks per pool)-were included in this study. In addition, 13 single free-roaming Hyalomma spp. ticks were collected. Screening by molecular techniques revealed the presence of Ehrlichia canis, Anaplasma platys, Anaplasma bovis and Babesia canis vogeli DNA in R. turanicus ticks. E. canis, A. bovis, B. canis vogeli and Candidatus Midichloria mitochondrii DNA sequences were detected in R. sanguineus ticks. Candidatus Midichloria mitochondrii DNA was also detected in Hyalomma spp. ticks. Neither Hepatozoon spp. nor Bartonella spp. DNA was detected in any of the ticks examined. This study describes the first detection of E. canis in the tick R. turanicus, which may serve as a vector of this canine pathogen; E. canis was the most common pathogen detected in the collected questing ticks. It also describes the first detection of A. bovis and Candidatus Midichloria mitochondrii in Israel. To the best of the author's knowledge, this is the first report describing the detection of DNA of the latter two pathogens in R. sanguineus, and of A. bovis in R. turanicus.

Absence of zoonotic Bartonella species in questing ticks: first detection of Bartonella clarridgeiae and Rickettsia felis in cat fleas in the Netherlands

Background

Awareness for flea- and tick-borne infections has grown in recent years and the range of microorganisms associated with these ectoparasites is rising. Bartonella henselae, the causative agent of Cat Scratch Disease, and other Bartonella species have been reported in fleas and ticks. The role of Ixodes ricinus ticks in the natural cycle of Bartonella spp. and the transmission of these bacteria to humans is unclear. Rickettsia spp. have also been reported from as well ticks as also from fleas. However, to date no flea-borne Rickettsia spp. were reported from the Netherlands. Here, the presence of Bartonellaceae and Rickettsiae in ectoparasites was investigated using molecular detection and identification on part of the gltA- and 16S rRNA-genes.

Results

The zoonotic Bartonella clarridgeiae and Rickettsia felis were detected for the first time in Dutch cat fleas. B. henselae was found in cat fleas and B. schoenbuchensis in ticks and keds feeding on deer. Two Bartonella species, previously identified in rodents, were found in wild mice and their fleas. However, none of these microorganisms were found in 1719 questing Ixodes ricinus ticks. Notably, the gltA gene amplified from DNA lysates of approximately 10% of the questing nymph and adult ticks was similar to that of an uncultured Bartonella-related species found in other hard tick species. The gltA gene of this Bartonella-related species was also detected in questing larvae for which a 16S rRNA gene PCR also tested positive for "Candidatus Midichloria mitochondrii". The gltA-gene of the Bartonella-related species found in I. ricinus may therefore be from this endosymbiont.

Conclusions

We conclude that the risk of acquiring Cat Scratch Disease or a related bartonellosis from questing ticks in the Netherlands is negligible. On the other hand fleas and deer keds are probable vectors for associated Bartonella species between animals and might also transmit Bartonella spp. to humans.

[Bilateral inguinal lymphadenopathy and erythema nodosum: an uncommon presentation of cat scratch disease]

Cat scratch disease is usually revealed by a proximal lymphadenopathy related to the inoculation site. We report a 22-year-old female who presented with erythema nodosum and bilateral inguinal lymphadenopathy. Serologic test and lymph node PCR detection for Bartonella henselae were negative. Nevertheless, the patient received doxycycline and clinical manifestations rapidly resolved. A follow-up detection of IgM and IgG against Bartonella henselae performed 1 month later was positive. This case report illustrates an original presentation of cat scratch disease and reminds us the lack of sensitivity of laboratory investigations.

Co-isolation of Bartonella henselae and Bartonella vinsonii subsp. berkhoffii from blood, joint and subcutaneous seroma fluids from two naturally infected dogs

This report describes the clinical presentation, isolation and treatment of two dogs naturally infected with Bartonella henselae and Bartonella vinsonii subsp. berkhoffii. Chronic and progressive polyarthritis was the primary complaint for dog #1, from which B. henselae and B. vinsonii subsp. berkhoffii were cultured on three independent occasions from blood and joint fluid samples, despite administration of nearly 4 months of non-consecutive antibiotic therapy. A clinically atypical and progressively severe trauma-associated seroma was the primary complaint for dog #2, from which B. henselae and B. vinsonii subsp. berkhoffii were isolated from serum, blood and seroma fluid. Dogs can be co-infected with two Bartonella spp. and infection with these organisms should not be ruled out if specific antibodies are not detected. Specialized culture techniques should be used for isolation and to assess antibiotic efficacy.

Bartonella sp. bacteremia in patients with neurological and neurocognitive dysfunction

We detected infection with a Bartonella species (B. henselae or B. vinsonii subsp. berkhoffii) in blood samples from six immunocompetent patients who presented with a chronic neurological or neurocognitive syndrome including seizures, ataxia, memory loss, and/or tremors. Each of these patients had substantial animal contact or recent arthropod exposure as a potential risk factor for Bartonella infection. Additional studies should be performed to clarify the potential role of Bartonella spp. as a cause of chronic neurological and neurocognitive dysfunction.

Beyond cat scratch disease: widening spectrum of Bartonella henselae infection

Bartonella henselae was discovered a quarter of a century ago as the causative agent of cat scratch disease, a clinical entity described in the literature for more than half a century. As diagnostic techniques improve, our knowledge of the spectrum of clinical disease resulting from infection with Bartonella is expanding. This review summarizes current knowledge regarding the microbiology, clinical manifestations, diagnostic techniques, and treatment of B. henselae infection.

Musculoskeletal manifestations of cat scratch disease

BACKGROUND

Musculoskeletal manifestations (MMs) are considered to be rare in cat scratch disease (CSD) and are not well characterized. We aimed to study MMs of CSD.

METHODS

A surveillance study performed over 11 years identified patients with CSD on the basis of compatible clinical presentation and confirmatory serological test or PCR results for Bartonella henselae. Patients with CSD who had MMs (i.e., myalgia, arthritis, arthralgia, tendinitis, osteomyelitis, and neuralgia) were compared with patients with CSD who did not have MMs (control subjects).

RESULTS

Of 913 patients with CSD, 96 (10.5%) had MMs. Myalgia (in 53 patients [5.8%]) was often severe, with a median duration of 4 weeks (range, 1-26 weeks). Arthropathy (arthralgia and/or arthritis; in 50 patients [5.5%]) occurred mainly in the medium and large joints and was classified as moderate or severe in 26 patients, with a median duration of 5.5 weeks (range, 1-240 weeks). In 7 patients, symptoms persisted for >or=1 year; 5 developed chronic disease. Tendinitis, neuralgia, and osteomyelitis occurred in 7, 4, and 2 patients, respectively. Patients with MMs were significantly older than patients in the control group (median age, 31.5 years vs. 15.0 years). In multivariate analysis, age >20 years was associated with having any MM (relative risk [RR], 4.96; 95% confidence interval [CI], 2.79-8.8), myalgia (RR, 4.69; 95% CI, 2.22-9.88), and arthropathy (RR, 11.0; 95% CI, 4.3-28.2). Arthropathy was also associated with female sex (RR, 1.89; 95% CI, 1.01-3.52) and erythema nodosum (RR, 4.07; 95% CI, 1.38-12.02).

CONCLUSIONS

MMs of CSD are more common than previously thought and affect one-tenth of patients with CSD. MMs occur mostly in patients aged >20 years and may be severe and prolonged. Osteomyelitis, the most well known MM of CSD is, in fact, the rarest.

Bartonella species in blood of immunocompetent persons with animal and arthropod contact

Using PCR in conjunction with pre-enrichment culture, we detected Bartonella henselae and B. vinsonii subspecies berkhoffii in the blood of 14 immunocompetent persons who had frequent animal contact and arthropod exposure.

Bone marrow and skin granulomatosis in a patient with Bartonella infection

This report describes a case of granulomatous inflammation, involving the bone marrow and skin, due to Bartonella infection in an immunocompetent patient. The clinical presentation included prolonged fever, pancytopenia, rash and hepatitis. Bartonella infection should thus be added to the growing list of entities that produce marrow granulomas and fever.

Clinical and pathologic differential diagnosis of selected potential bioterrorism agents of interest to pediatric health care providers

The early recognition of potential bioterrorism agents has been of increasing concern in recent years. The Centers for Disease Control and Prevention has categorized and listed biological terrorism agents. Although any or all of the highest risk biological agents (including inhalation anthrax, pneumonic plague, smallpox, tularemia, botulism, and viral hemorrhagic fevers) can be seen in the pediatric patient, several agents might closely resemble--at least in their initial stages-some of the more common childhood illnesses. The awareness of these similarities and, more importantly,their differences, are critical for all health care professionals. Selected examples of some typical childhood illnesses are presented and then compared with three of the most virulent biological agents (smallpox, anthrax and plague) that might be used in a bioterrorism attack.