Bartonella henselae infective endocarditis with dissemination: A case report and literature review in Southeast Asia

Bartonella quintana pulmonary native valve endocarditis

Bartonella quintana is a well-known cause of blood culture-negative endocarditis; however, pulmonary valve involvement is rare. The case of a 40-year-old African male who presented to the Emergency Department with chest pain, cardiac failure, and a 2-week history of fever is presented. Transoesophageal echocardiography confirmed an atrial septal defect, severe pulmonary insufficiency with large vegetations, severe mitral regurgitation due to anterior leaflet prolapse, and right ventricular dysfunction. Empirical antibiotic therapy was started, and urgent surgical intervention was decided. There were vegetations on the three pulmonary valve leaflets and the mitral valve. Closure of the atrial septal defect, mitral and tricuspid valve repair, pulmonary valve replacement with a biological prosthesis, and infundibuloplasty of the right ventricle were performed. The postoperative course was uneventful. Preoperative blood cultures were negative, and B. quintana was detected through 16S rRNA gene amplification and sequencing in mitral and pulmonary implants. Serology showed positive titers of 1/1260 for both B. quintana and B. henselae. Ceftriaxone and gentamicin were administered for 10 days, followed by oral doxycycline for 12 weeks. A one-year echocardiogram showed normal functioning of the pulmonary prosthesis and the mitral and tricuspid repair. Infection caused by B. quintana is a rare cause of endocarditis with negative blood cultures, and multivalvular and pulmonary valve involvement is exceptional.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12055-024-01727-4.

Paws and Pathogens: A Multidisciplinary Approach Through Bartonella henselae Endocarditis and Hepatosplenic T-Cell Lymphoma

Bartonella species are gram-negative coccobacilli that are globally recognized as significant pathogens causing zoonotic infections. Among Bartonella species, B. henselae, B. quintana, and B. bacilliformis are prominent pathogens causing infections in humans, often manifesting as infective endocarditis. Bartonella endocarditis can pose diagnostic challenges due to its indolent presentation and limitations of standard microbiological culture techniques to identify the organism. We report a case of a 23-year-old male, who initially presented with the manifestations of hepatosplenic T-cell lymphoma, later diagnosed with blood culture-negative endocarditis caused by B. henselae. The patient had a complicated clinical course including pancytopenia, hepatosplenomegaly, and severe aortic valve regurgitation. Despite negative blood cultures, diagnostic clues included persistent fevers and bicuspid aortic valve with abscess. High Bartonella IgG titers (>1:800) supported the diagnosis. This case underscores the importance of considering Bartonella species in patients with suspected endocarditis, particularly in those with predisposing factors and negative blood cultures. Diagnosis relies heavily on serologic assays due to low sensitivity of conventional culture methods. Treatment involves a multidisciplinary approach with antibiotics and surgical intervention for optimal outcomes. Timely recognition and management are crucial to mitigate the high mortality associated with Bartonella endocarditis, and we hope this article offers insight for clinicians.

Bartonella Endocarditis in Spain: Case Reports of 21 Cases

Blood culture negative endocarditis (BCNE) is frequent in infective endocarditis (IE). One of the causes of BCNE is fastidious microorganisms, such as Bartonella spp. The aim of this study was to describe the epidemiologic, clinical characteristics, management and outcomes of patients with Bartonella IE from the “Spanish Collaboration on Endocarditis-Grupo de Apoyo al Manejo de la Endocarditis infecciosa en España (GAMES)”cohort. Here we presented 21 cases of Bartonella IE. This represents 0.3% of a total of 5590 cases and 2% of the BCNE from the GAMES cohort. 62% were due to Bartonella henselae and 38% to Bartonella quintana. Cardiac failure was the main presenting form (61.5% in B. hensalae, 87.5% in B. quintana IE) and the aortic valve was affected in 85% of the cases (76% in B. henselae, 100% in B. quintana IE). Typical signs such as fever were recorded in less than 40% of patients. Echocardiography showed vegetations in 92% and 100% of the patients with B. henselae and B. quintana, respectively. Culture was positive only in one patient and the remaining were diagnosed by serology and PCR. PCR was the most useful tool allowing for diagnosis in 16 patients (100% of the studied valves). Serology, at titers recommended by guidelines, only coincided with PCR in 52.4%. Antimicrobial therapy, in different combinations, was used in all cases. Surgery was performed in 76% of the patients. No in-hospital mortality was observed. One-year mortality was 9.4%. This article remarks the importance for investigating the presence of Bartonella infection as causative agent in all BCNE since the diagnosis needs specific microbiological tools and patients could benefit of a specific treatment.

A "cat"-astrophic case of Bartonella infective endocarditis causing secondary cryoglobulinemia: a case report

Background

Culture-negative infective endocarditis (IE) constitutes approximately 10% of all cases of IE. Bartonella endocarditis is a common cause of culture-negative endocarditis and is associated with a high mortality rate. To date, no cases of Bartonella IE has been reported in association with cryoglobulinemia in the UK. We present a unique case of Bartonella IE causing secondary cryoglobulinemia in a young female.

Case presentation

A 17-year-old female with a background of pulmonary atresia and ventricular septal defect repaired with a cardiac conduit at the age of 4, presented with a one-year history of weight loss (from 53 to 39 kg) and poor appetite. She subsequently developed a vasculitic rash and haematoproteinuria with decline in renal function, requiring urgent hospital admission. Initial blood tests showed a near normal creatinine, but a raised cystatin C. Renal biopsy showed focal necrotizing glomerulonephritis with no acute tubular necrosis or chronic change. Subsequent blood tests supported a diagnosis of cryoglobulinaemic vasculitis (high rheumatoid factor, low complement, polyclonal gammopathy, Type 3 cryoglobulin). A weak positive PR3 meant there was some uncertainty about whether this could be a primary ANCA-associated vasculitis (AAV). Initial workup for an infectious cause, including multiple blood cultures, were negative. However, an echocardiogram showed definite vegetations on her surgical conduit. The patient did not respond to empirical antimicrobials and so was referred for surgical revision of her conduit. Tissue samples obtained intra-operatively demonstrated Bartonella species. With targeted antimicrobials post-operatively, she improved with resolution of immunologic abnormalities and at last review had a normal renal profile. On reviewing her social history, she had adopted several stray cats in the preceding year; and thus, the cause of the Bartonella infection was identified.

Conclusion

This is the first reported case of Bartonella endocarditis causing secondary cryoglobulinemia reported in the UK. The key learning points from this case include that Bartonella endocarditis can present as a cryoglobulinaemic vasculitis and should be considered in any differential when the cause of cryoglobulinaemia is not clear and to enquire about relevant exposures especially when culture-negative endocarditis is suspected.

A case of Bartonella henselae native valve endocarditis presenting with crescentic glomerulonephritis

Bartonella endocarditis is often an elusive diagnosis, usually derived from evaluating multiple laboratory tests and assessment of presenting symptoms. Herein we describe a case of Bartonella henselae native mitral valve endocarditis with an initial presentation of volume overload and renal failure. The Bartonella organism is tedious to isolate from culture medium, causing most diagnoses to be delayed. Due to the destructive nature of B. henselae endocarditis, the need for rapid identification remains prudent. This therefore creates an opportunity for Next Generation Sequencing (NGS) to be used. We further summarize the varied presentations that may be associated with B. henselae endocarditis, and hope that this will heighten the clinicians' awareness of this entity when presented with acute onset renal failure and culture negative vegetations.

Bartonella Endocarditis: A Missed Diagnosis in Medical Practice

Here, we present the case of a 52-year-old patient who presented with fever, chills, and weight loss. Further workup revealed Bartonella endocarditis of the aortic valve. After six weeks of antibiotics, a follow-up transthoracic echocardiogram showed a decrease in the size of vegetation. Serologic testing based on epidemiologic history should be obtained for the workup of blood culture-negative endocarditis.

Detection of zoonotic Bartonella species in ticks and fleas parasitizing free-ranging cats and dogs residing in temples of Bangkok, Thailand

Bartonellosis is a vector-borne disease caused by intraerythrocytic bacteria known as Bartonella spp. The potential vectors that transmit Bartonella spp. are fleas, ticks, sand flies, and lice. Several Bartonella spp. cause diseases in humans; however, there is few molecular evidence of Bartonella spp. in vectors in Thailand. The objectives of this study were to investigate Bartonella spp. and to evaluate the spatial distribution of Bartonella spp. prevalence in the ectoparasites parasitizing free-ranging cats and dogs in temple clusters of Bangkok, Thailand. In total, 343 ectoparasites were studied to extract their genomic DNA. Species of all specimens were identified using an identification key and conventional polymerase chain reaction (cPCR) was applied to confirm flea and tick species. Extracted DNA samples were processed using primers that targeted the gltA, rpoB, ftsZ, and ribC genes of Bartonella spp. Then, PCR-positive amplicons were sequenced and a phylogenetic tree was constructed. Recorded data were statistically analyzed using descriptive statistics, the chi-square test, Fisher's exact test, and the odds ratio. Area data were analyzed and a prevalence distribution map was plotted. The major parasitizing ticks and fleas in this study were Rhipicephalus sanguineus and Ctenocephalides felis, respectively. Overall, the prevalence of Bartonella spp. in ectoparasites was 7.00%. The gltA amplicons revealed the presence of B. henselae (4.78%) and B. clarridgeiae (4.78%) in C. felis, and B. koehlerae (1.25%) and B. phoceensis (1.25%) in R. sanguineus. Bartonella DNA was encountered in 16/39 (41.03%) districts and 28.57% of the temple clusters. Bang Khun Thian district had the highest positive proportion and Bang Bon district showed co-evidence of different Bartonella species. In addition, the intervening zones were a risk factor of Bartonella (p < 0.05), and the distribution map showed a scattered pattern of Bartonella-positive clusters. Finally, fleas showed to be important vector reservoirs for Bartonella spp., especially zoonotic species, however, experimental studies are needed to prove the Bartonella transmission in ticks.

Cutaneous Vasculitis and Generalized Lymphadenopathy Associated with Extended-Spectrum Beta-Lactamase (ESBL)-Producing Escherichia coli Endocarditis: A Rare Case Report

INTRODUCTION

Infective endocarditis (IE) has been known as the great imitator due to variable clinical manifestation, making its diagnosis challenging. A missed diagnosis could lead to inappropriate therapy. We presented a rare case of blood culture-negative infective endocarditis (BCNIE) due to extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli manifest with cutaneous vasculitis and generalized lymphadenopathy. We highlighted its diagnostic challenge and management.

CASE ILLUSTRATION AND DISCUSSION

A 36-year-old male with known asymptomatic ruptured sinus of Valsalva (SOV) presented with fever of unknown origin for six months, fatigue, weight loss with a history of multiple hospitalizations. The physical examination revealed a continuous murmur at Erb's point, cutaneous vasculitis, and bilateral inguinal lymphadenopathy. The laboratory result was leukocytosis and elevated C-Reactive Protein (CRP). Generalized lymphadenopathy was detected from the thorax and abdominal Computed Tomography (CT) Scans. Positive Anti Nuclear Antibody (ANA) Indirect Immunofluorescence (IF) speckled pattern led us to consider an autoimmune as the etiology, but we still considered IE as a differential diagnosis due to history of structural heart disease. Detection of multiple tiny oscillating masses at the tricuspid valve from the echocardiogram and cardiac CT led to possible IE diagnosis. Negative three consecutive blood cultures led the diagnosis to BCNIE. Surgery was performed to evacuate the vegetations, repair the SOV, and tricuspid valve replacement with a bioprosthetic valve. These results in improvement of the patient's condition. ESBL-producing Escherichia coli yielded in tissue culture made the diagnosis of IE became definite.

CONCLUSION

ESBL-producing Escherichia coli should be considered as the etiology of BCNIE. Cutaneous vasculitis and generalized lymphadenopathy as a manifestation of IE could lead to diagnostic confusion. A thorough investigation will help clinician to avoid delay or inappropriate treatment that could be detrimental for the patient.

Canine and feline vector-borne diseases of zoonotic concern in Southeast Asia

Dogs and cats are important hosts and reservoirs of many viral, bacterial, protozoal, and helminthic pathogens transmitted by arthropods, including some of zoonotic concern. By sharing the same environment, these companion animals play an important role in the transmission of zoonotic pathogens to humans in various regions and socioeconomic contexts. While canine and feline vector-borne diseases (VBD) are of major concern in wealthy regions (e.g. Europe and North America), less attention has been received in developing countries such as those in Southeast Asia (SEA). This review provides summarized and updated information on canine and feline VBD with emphasis on those of zoonotic concern in SEA. Of these, zoonotic bacteria (i.e. Bartonella henselae, Bartonella clarridgeiae, and Rickettsia felis) and filarial nematodes (i.e. Brugia malayi, Dirofilaria repens, and Dirofilaria immitis) stand out as the most important in veterinary and human medicine. Additionally, the recent finding of Leishmania infantum in dogs in SEA raised more concerns about the spreading of this zoonotic agent in this region. Further epidemiological surveys, especially in countries with extremely scant information such as Cambodia, Laos, Myanmar, and Timor-Leste are advocated. Additionally, effective control measures of canine and feline VBD as well as their arthropod vectors should be simultaneously performed for the management of zoonotic infections.

•

Many canine and feline vector-borne infections affect animals and humans in Southeast Asia.

•

Ticks, fleas and mosquitoes are the most common vectors transmitting pathogens to dogs, cats and humans in Southeast Asia.

•

Bartonella henselae, Rickettsia felis and Dirofilaria repens are of concern to human health in this region.

•

Collaboration between governments and researchers is encouraged for a better management of vector-borne diseases.

Molecular detection of pathogens in ticks and fleas collected from companion dogs and cats in East and Southeast Asia

Background

Ticks and fleas are considered amongst the most important arthropod vectors of medical and veterinary concern due to their ability to transmit pathogens to a range of animal species including dogs, cats and humans. By sharing a common environment with humans, companion animal-associated parasitic arthropods may potentially transmit zoonotic vector-borne pathogens (VBPs). This study aimed to molecularly detect pathogens from ticks and fleas from companion dogs and cats in East and Southeast Asia.

Methods

A total of 392 ticks and 248 fleas were collected from 401 infested animals (i.e. 271 dogs and 130 cats) from China, Taiwan, Indonesia, Malaysia, Singapore, Thailand, the Philippines and Vietnam, and molecularly screened for the presence of pathogens. Ticks were tested for Rickettsia spp., Anaplasma spp., Ehrlichia spp., Babesia spp. and Hepatozoon spp. while fleas were screened for the presence of Rickettsia spp. and Bartonella spp.

Result

Of the 392 ticks tested, 37 (9.4%) scored positive for at least one pathogen with Hepatozoon canis being the most prevalent (5.4%), followed by Ehrlichia canis (1.8%), Babesia vogeli (1%), Anaplasma platys (0.8%) and Rickettsia spp. (1%) [including Rickettsia sp. (0.5%), Rickettsia asembonensis (0.3%) and Rickettsia felis (0.3%)]. Out of 248 fleas tested, 106 (42.7%) were harboring at least one pathogen with R. felis being the most common (19.4%), followed by Bartonella spp. (16.5%), Rickettsia asembonensis (10.9%) and “Candidatus Rickettsia senegalensis” (0.4%). Furthermore, 35 Rhipicephalus sanguineus ticks were subjected to phylogenetic analysis, of which 34 ticks belonged to the tropical and only one belonged to the temperate lineage (Rh. sanguineus (sensu stricto)).

Conclusion

Our data reveals the circulation of different VBPs in ticks and fleas of dogs and cats from Asia, including zoonotic agents, which may represent a potential risk to animal and human health.

Imaging analysis of Bartonella species in the skin using single-photon and multi-photon (second harmonic generation) laser scanning microscopy

We demonstrate Bartonella spp are abundant in skin lesions resembling striae distensae. These striae distensae-like lesions, coincidental with sudden onset of neuropsychiatric symptoms, indicate testing for suspected Bartonella spp. infection.

Interaction with the host: the role of fibronectin and extracellular matrix proteins in the adhesion of Gram-negative bacteria

The capacity of pathogenic microorganisms to adhere to host cells and avoid clearance by the host immune system is the initial and most decisive step leading to infections. Bacteria have developed different strategies to attach to diverse host surface structures. One important strategy is the adhesion to extracellular matrix (ECM) proteins (e.g., collagen, fibronectin, laminin) that are highly abundant in connective tissue and basement membranes. Gram-negative bacteria express variable outer membrane proteins (adhesins) to attach to the host and to initiate the process of infection. Understanding the underlying molecular mechanisms of bacterial adhesion is a prerequisite for targeting this interaction by “anti-ligands” to prevent colonization or infection of the host. Future development of such “anti-ligands” (specifically interfering with bacteria-host matrix interactions) might result in the development of a new class of anti-infective drugs for the therapy of infections caused by multidrug-resistant Gram-negative bacteria. This review summarizes our current knowledge about the manifold interactions of adhesins expressed by Gram-negative bacteria with ECM proteins and the use of this information for the generation of novel therapeutic antivirulence strategies.