Intra-abdominal mass associated with gastrointestinal hemorrhage: a new manifestation of bacillary angiomatosis

A systematic review on antibiotic therapy of cutaneous bacillary angiomatosis not related to major immunocompromising conditions: from pathogenesis to treatment

BACKGROUND

Cutaneous bacillary angiomatosis (cBA) is a vascular proliferative disorder due to Bartonella spp. that mostly affects people living with HIV (PLWH), transplanted patients and those taking immunosuppressive drugs. Since cBA is mostly related to these major immunocompromising conditions (i.e., T-cell count impairment), it is considered rare in relatively immunocompetent patients and could be underdiagnosed in them. Moreover, antimicrobial treatment in this population has not been previously investigated.

METHODS

We searched the databases PubMed, Google Scholar, Scopus, OpenAIRE and ScienceDirect by screening articles whose title included the keywords "bacillary" AND "angiomatosis" and included case reports about patients not suffering from major immunocompromising conditions to provide insights about antibiotic treatments and their duration.

RESULTS

Twenty-two cases of cBA not related to major immunocompromising conditions were retrieved. Antibiotic treatment duration was shorter in patients with single cBA lesion than in patients with multiple lesions, including in most cases macrolides and tetracyclines.

CONCLUSIONS

cBA is an emerging manifestation of Bartonella spp. infection in people not suffering from major immunocompromising conditions. Until evidence-based guidelines are available, molecular tests together with severity and extension of the disease can be useful to personalize the type of treatment and its duration.

Coexistence of intestinal Kaposi sarcoma and plasmablastic lymphoma in an HIV/AIDS patient: case report and review of the literature

Human immunodeficiency virus (HIV) infection or acquired immunodeficiency disease (AIDS) is associated with increased risk for various malignancies including Kaposi sarcoma (KS) and lymphoma. We report a rare case of coexistence of KS and plasmablastic lymphoma (PBL) in the gastrointestinal (GI) tract in a HIV/AIDS patient. A brief review of literature is also presented.

Bartonella quintana Aortitis in a Man with AIDS, Diagnosed by Needle Biopsy and 16S rRNA Gene Amplification

A man with newly diagnosed AIDS presented with months of back pain and fever. Computed tomography (CT) results demonstrated aortitis with periaortic tissue thickening. DNA amplification of biopsy tissue revealed Bartonella quintana, and Bartonella serologies were subsequently noted to be positive. The patient improved with prolonged doxycycline and rifabutin treatment. This case illustrates how molecular techniques are increasingly important in diagnosing Bartonella infections.

Isolation and characterization of Bartonella quintana from the parotid gland of an immunocompetent man

We describe a case of the isolation of Bartonella quintana from the parotid gland of an apparently healthy man. Pathological examination showed intraparotid granulomatous abscessual lymphadenitis. Diagnosis was made on the basis of high titers of immunoglobulin G (IgG) and IgM antibodies and of culture isolation of a causative agent from parotid aspirate.

[The diagnosis of cat-scratch-disease-associated adenitis: diagnostic value of serology and polymerase chain reaction]

The diagnosis of cat scratch disease (CSD) associated adenitis relies classically on the association of clinical, epidemiological and bacteriological criteria. The polymerase chain reaction (PCR) looks like a more competitive diagnostic trial than serology. We evaluated the sensitivity, specificity and predictive positive and negative values of serology in routine diagnosis of CSD. A retrospective study over five years was led among patients presenting a suspicion of CSD and having a serology and/or a PCR. The Gold standard for diagnosis was PCR. The serological tests of Bartonella henselae was performed once in 482 patients, of which 2% (11 out of 482) were positive, and twice in only 39 patients (8%). The PCR diagnosis method for B. henselae was performed in biopsy of specimen lymph nodes in 28 patients and 14 out of 28 were positive. In nine patients, the diagnosis was exclusively made by PCR. Among the 14 patients whose PCR was negative, two had a positive serology and in three others patients, the serology was not performed. The sensitivity of serology was 35%, this confirms the low sensitivity of the serology in the CSD diagnosis. The diagnosis was confirmed in 56% of cases where PCR was performed. This led us to propose to perform systematically the PCR test for B. henselae in case of adenitis possibly associated with CSD.

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.

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.

The Expanded Spectrum of Bartonellosis in Children

Bartonella spp cause various clinical syndromes immunocompetent and immunocompromised hosts. Domestic cats are the natural reservoir, and vectors of B henselae. B henselae infection usually occurs early in childhood, is generally asymptomatic, and in most cases revolves spontaneously. It may, however, produce a wide spectrum of clinical symptoms, the most frequent feature being cat-scratch disease. Disseminated atypical B. henselae infection may follow cat-scratch disease alter a symptom-free period or may present de novo mimicking a wide range of clinical disorders. A careful clinical history researching an intimate contact with a kitten associated with a specific serology and an abdominal ultrasound for typical hepatosplenic involvement may follow a rapid and accurate diagnosis.

Upper gastrointestinal bacillary angiomatosis causing hematemesis: a case report

A 38-year-old HIV-positive woman presented with massive hematemesis on initial admission to hospital. Endoscopy revealed ulcerated nodular lesions in the esophagus, stomach, and duodenum. The clinical impression was of Kaposi's sarcoma. The stomach was biopsied when the patient re-presented, and another endoscopy was performed. The biopsy showed mucosal ulceration with a proliferation of vascular channels associated with neutrophils and clumps of purplish, granular bacterial colonies, which were highlighted by a Warthin-Starry stain. The histopathological features were typical of bacillary angiomatosis. This case highlights bacillary angiomatosis involving the gastrointestinal tract at multiple sites, the cause of massive upper gastrointestinal hemorrhage that was the initial presentation of an HIV-positive patient, and the occurrence of visceral bacillary angiomatosis in the absence of cutaneous lesions.

Hepatic rupture caused by peliosis hepatis

Peliosis hepatis is a rare entity that can affect children and cause fatal hepatic hemorrhage or hepatic failure. Radiographic findings are nonspecific and can resemble other hepatic pathologies such as cysts, abscesses, metastases, and hemangiomatosis. Peliosis hepatis can resolve spontaneously or by withdrawal of inciting medications. Certain cases may require surgical resection of the involved portions of the liver. Recently, fatal liver hemorrhage was reported in 2 pediatric patients with a rare congenital muscle disorder known as myotubular (centronuclear) myopathy. One of these patients was found at autopsy to have peliosis hepatis. The authors report the first successful treatment of life-threatening liver hemorrhage caused by peliosis hepatis in a child with myotubular myopathy. Awareness of this condition may reduce the catastrophic complications seen with peliosis hepatis.

Culture of Bartonella quintana and Bartonella henselae from human samples: a 5-year experience (1993 to 1998)

Bartonella quintana and Bartonella henselae are fastidious gram-negative bacteria responsible for bacillary angiomatosis, trench fever, cat scratch disease, and endocarditis. During a 5-year period, we received 2,043 samples for culture of Bartonella sp. We found Bartonella sp. to be the etiologic agent in 38 cases of endocarditis, 78 cases of cat scratch disease, 16 cases of bacteremia in homeless people, and 7 cases of bacillary angiomatosis. We correlated the results of positive cultures with the clinical form of the disease, type of sample, culture procedure, PCR-based genomic detection, and antibody determination. Seventy-two isolates of B. quintana and nine isolates of B. henselae from 43 patients were obtained. Sixty-three of the B. quintana isolates and two of the B. henselae isolates, obtained from patients with no prior antibiotic therapy, were stably subcultured. The sensitivity of culture was low when compared with that of PCR-based detection methods in valves of patients with endocarditis (44 and 81%, respectively), skin biopsy samples of patients with bacillary angiomatosis (43 and 100%, respectively), and lymph nodes of cat scratch disease (13 and 30%, respectively). Serological diagnosis was also more sensitive in cases of endocarditis (97%) and cat scratch disease (90%). Among endocarditis patients, the sensitivity of the shell vial culture assay was 28% when inoculated with blood samples and 44% when inoculated with valvular biopsy samples, and the sensitivity of both was significantly higher than that of culture on agar (5% for blood [P = 0.045] and 4% for valve biopsy samples [P < 0.0005]). The most efficient culture procedure was the subculture of blood culture broth into shell vials (sensitivity, 71%). For patients with endocarditis, previous antibiotic therapy significantly affected results of blood culture; no patient who had been administered antibiotics yielded a positive blood culture, whereas 80% of patients with no previous antibiotic therapy yielded positive blood cultures (P = 0.0006). Previous antibiotic therapy did not, however, prevent isolation of Bartonella sp. from cardiac valves but did prevent the establishment of strains, as none of the 15 isolates from treated patients could be successfully subcultured. For the diagnosis of B. quintana bacteremia in homeless people, the efficiency of systematic subculture of blood culture broth onto agar was higher than that of direct blood plating (respective sensitivities, 98 and 10% [P < 10(-7)]). Nevertheless, both procedures are complementary, since when used together their sensitivity reached 100%. All homeless people with positive blood cultures had negative serology. The isolation rate of B. henselae from PCR-positive lymph nodes, in patients with cat scratch disease, was significantly lower than that from valves of endocarditis patients and skin biopsy samples from bacillary angiomatosis patients (13 and 33%, respectively [P = 0.084]). In cases of bacillary angiomatosis for which an agent was identified to species level, the isolation rate of B. henselae was lower than the isolation rate of B. quintana (28 and 64%, respectively [P = 0.003]). If culture is to be considered an efficient tool for the diagnosis of several Bartonella-related diseases, methodologies need to be improved, notably for the recovery of B. henselae from lymph nodes of patients with cat scratch disease.

Bacillary angiomatosis in immunocompromised patients

OBJECTIVES

To report seven cases of bacillary angiomatosis; to evaluate the most useful diagnostic tools; to analyse the clinical and epidemiological features associated with Bartonella quintana or Bartonella henselae infections.

DESIGN

Clinical, diagnostic and epidemiological evaluation of 37 speciated bacillary angiomatosis cases in the literature, including the seven patients in our study.

METHODS

Pathological examination of tissue samples, including Warthin-Starry staining and immunohistology; titre of antibodies to Bartonella sp.; detection of Bartonella sp. in blood and biopsy materials by culture or PCR; and statistical analysis of clinical and epidemiological features associated with B. quintana or B. henselae bacillary angiomatosis cases.

RESULTS

Seven immunocompromised patients (six with AIDS and one patient with acute leukaemia) had bacillary angiomatosis confirmed by histology. B. quintana was cultured in three patients, whereas B. henselae DNA was amplified by PCR in the remaining four patients. Serum from only one patient reacted with Bartonella antigens. Amongst the 14 B. quintana and 23 B. henselae bacillary angiomatosis cases now reported in the literature, lymphadenopathies were significantly more frequent in B. henselae-infected patients, and neurological disorders of the central nervous system in B. quintana-infected patients. Risk factors were contact with cats, and homelessness or poor socioeconomic status in B. henselae and B. quintana bacillary angiomatosis cases, respectively.

CONCLUSIONS

Although diagnosis of bacillary angiomatosis often remains solely based upon histology, culture or PCR-based methods are useful for the detection of Bartonella sp., and allow identification of the species involved, which is necessary to further characterize clinical and epidemiological features associated with B. quintana or B. henselae infections.

Bartonella-associated infections

Bartonella-associated infections occur in immunocompetent and immunocompromised patients. The spectrum of diseases caused by Bartonella species has expanded and now includes cat-scratch disease, bacillary angiomatosis, bacillary peliosis, bacteremia, endocarditis, and trench fever. Most Bartonella-associated infections that occur in North America and Europe are caused by B. henselae or B. quintana. The domestic cat serves as the major reservoir for B. henselae; the reservoir for the modern day B. quintana infection remains unknown. Methods used to diagnose Bartonella-associated infections include histopathologic analysis of biopsy specimens, culture of tissue samples, blood culture, and serology. Available data on treatment of Bartonella-associated infections remain relatively sparse but would suggest that erythromycin or doxycycline provide the best responses.

Bacillary angiomatosis and other Bartonella species infections

Infections with organisms of the genus Bartonella, for many years important only in South and Central America, have assumed significance in developing countries, especially in conjunction with the advent of the pandemic of the human immunodeficiency virus infection. New molecular and culture techniques have determined that these organisms cause new diseases such as bacillary angiomatosis as well as diseases the etiology of which have been unknown such as cat scratch disease. In this article, the microbiology, pathogenesis, histopathology and clinical manifestations of diseases caused by these organisms are discussed.

Current knowledge of Bartonella species

Bartonella species are now considered emerging pathogens. Of the 11 currently recognized species, four have been implicated in human disease, although only two have been encountered in Europe. Bartonella quintana infections are now being diagnosed among the urban homeless and deprived, manifesting as trench fever, and Bartonella henselae has been shown to be the causative agent of cat scratch disease. Both species also cause a variety of HIV-associated infections, including bacillary anglomatosis. However, perhaps the most significant presentation of bartonellae infection is culture-negative endocarditis. The epidemiologies of Bartonella infections are poorly understood; most Bartonella henselae infections are probably acquired from infected cats, either directly by contact with a cat or indirectly via fleas. No animal reservoir has been implicated for Bartonella quintana; however, infection can be transmitted via the human body louse. Diagnosis of Bartonella infections can be made using histological or microbiological methods. The demonstration of specific antibodies may be useful in some instances, although certainly not in all. Cultivation of Bartonella is difficult, as the bacteria are extremely fastidious. Polymerase chain reaction-based or immunological methods for the detection of bartonella in infected tissues have proven useful. Clinical relapse is often associated with Bartonella infections despite a wide range of prescribed regimens. Only aminoglycosides display in vitro bactericidal activity against intracellular Bartonella species; therefore, they are recommended for treatment of Bartonella infections.

Gastrointestinal pathology in HIV-infected patients

Specific pathologic processes, particularly oral, esophageal, and intestinal infections, are common in the alimentary tract of AIDS patients. Many of these diseases are adequately assessed only by biopsy with histologic examination. Most are rare or unreported in immunocompetent hosts and are easily missed by those not familiar with them. This article describes the gross or endoscopic and histologic appearances and the diagnostic criteria for enteric pathologic processes seen in HIV-infected individuals.