Severe Anemia, Panserositis, and Cryptogenic Hepatitis in an HIV Patient Infected withBartonella henselae

Comparison of molecular methods for Bartonella henselae detection in blood donors

The Bartonella genus consists of neglected pathogens associated with potentially transfusional-transmitted and fatal human diseases. We aimed to evaluate Bartonella sp. prevalence in 500 blood donors and compare the results with the data already published about these samples. We used molecular diagnostic methods to detect Bartonella sp.-DNA from blood and liquid culture samples: (A) conventional PCR for two gene regions, the ITS targeting the genus Bartonella and the specific gltA Bartonella henselae; (B) nested PCR for the ftsZ gene and (C) qualitative real-time PCR for the gltA gene, both B. henselae specific. We obtained 30/500 (6%) DNA detections from the blood samples; 77/500 (15.4%) DNA detections from liquid culture samples and five (1%) samples had DNA detection from both. In total, we detected B. henselae DNA from 102/500 (20.4%) donors. The samples used in this study had already been submitted for Bartonella sp.-DNA detection using only a conventional PCR in liquid culture. Sixteen samples (3.2%) were positive previously, and from these 16 samples, 13 were negative in the new investigation. We concluded that the use of liquid culture combined with different molecular tests increases the possibility of detecting Bartonella sp.-DNA, but the tests do not avoid false-negative results. More than a fifth of blood donors had at least one PCR that detected Bartonella sp.-DNA among the eight molecular reactions performed now (four reactions in whole blood and four in liquid culture). Seven percent had B. henselae-DNA detection for two or more distinct regions. Considering the results obtained previously, the DNA of Bartonella spp. was detected or the agent isolated in 23% of analyzed blood donors. The results establish that the low bacteremia and the fastidious characteristics of the bacterium are challenges to laboratory diagnosis and can make it difficult to confirm the infection in patients with bartonelloses.

Cryptogenic hepatitis patients have a higher Bartonella sp.-DNA detection in blood and skin samples than patients with non-viral hepatitis of known cause

Background

This study aimed to assess the prevalence of Bartonella sp.-DNA detection in blood and skin samples from patients with non-viral end-stage liver disease awaiting liver transplantation.

Methodology/Principal findings

Blood samples and healthy skin fragments from 50 patients were tested using microbiological and molecular methods. Fifteen patients had cryptogenic hepatitis (CH) and 35 had alcoholic, drug-induced or autoimmune liver disease. DNA was extracted from whole blood and liquid culture samples, isolates, and skin fragments. Thirteen of the 50 patients (26%) had Bartonella henselae DNA detection in their blood (9/50) and/or skin (5/50) samples. Colonies were isolated in 3/50 (6%) and infection was detected in 7/50 (14%) of the 50 patients. B. henselae-DNA detection was more prevalent in patients with CH than in other patients (p = 0.040). Of 39 patients followed-up for at least two years, a higher mortality rate was observed among patients with CH infected with B. henselae (p = 0.039).

Conclusions/Significance

Further studies assessing the role of B. henselae infection in the pathogenesis of hepatitis patients must be urgently conducted.

One in four patients with end-stage liver disease awaiting liver transplantation for hepatitis of non-viral origin had documented B. henselae-DNA detection and cryptogenic hepatitis patients have a higher bacterium molecular detection than patients with non-viral hepatitis of known cause.

Culture-negative group B streptococcal pericarditis: A case report and literature review of the diagnostic use of polymerase chain reaction

Although conventional microbiology cultures may be negative, polymerase chain reaction (PCR) can effectively identify both typical and atypical microorganisms. With careful interpretation, PCR could become the gold-standard diagnostic test for culture-negative bacterial pericarditis.

False Negative Results in Bartonellosis Diagnosis

We report a fatal case of Bartonella henselae bacteremic patient. He had negative serology and PCRs from whole blood and liquid culture; only ftsZ nested PCR was positive from the blood liquid culture. The isolate had positive PCRs. When considered, bartonellosis diagnosis can be still challenging because of technical limitations.

Improvement of Bartonella henselae DNA Detection in Cat Blood Samples by Combining Molecular and Culture Methods

Bartonella spp. are bacteria of worldwide distribution that cause asymptomatic to fatal infections in animals and humans. The most common zoonotic species is Bartonella henselae, for which cats are the major natural reservoir host. To better understand Bartonella sp. diagnostic limitations, we determined the frequency of bloodstream infection in 112 cats by comparing and combining the results of multiple conventional and nested PCRs from blood and liquid culture samples. Using liquid culture conventional PCR, Bartonella sp. DNA was amplified from 27.7% of samples (31/112) compared to 90.2% of samples (101/112) by combining nested PCR from blood and liquid culture, indicating that PCR testing of more than one type of sample provides better sensitivity than a standalone PCR and that bloodstream infection is very frequent among cats in southeastern Brazil. This study reinforces the need for multistep testing for Bartonella sp. infection to prevent false-negative diagnostic results, even in reservoir hosts such as cats that typically maintain higher bacteremia levels.

Bartonella henselae AS A PUTATIVE CAUSE OF CONGENITAL CHOLESTASIS

Severe anemia and cholestatic hepatitis are associated with bartonella infections. A putative vertical Bartonella henselae infection was defined on the basis of ultrastructural and molecular analyses in a three-year-old child with anemia, jaundice and hepatosplenomegaly since birth. Physicians should consider bartonellosis in patients with anemia and hepatitis of unknown origin.

Management of severe non-TB bacterial infection in HIV-infected adults

Despite widespread antiretroviral therapy use, severe bacterial infections (SBI) in HIV-infected adults continue to cause significant morbidity and mortality globally. Four main pathogens account for the majority of documented SBI: Streptococcus pneumoniae, non-typhoidal strains of Salmonella enterica, Escherichia coli and Staphylococcus aureus. The epidemiology of SBI is dynamic, both in developing countries where, despite dramatic successes in antiretroviral therapy, coverage is far from complete, and in settings in both resource-poor and resource-rich countries where antiretroviral therapy failure is becoming increasingly common. Throughout the world, this complexity is further compounded by rapidly emerging antimicrobial resistance, making management of SBI very challenging in these vulnerable patients. We review the causes and treatment of SBI in HIV-infected people and discuss future developments in this field.

Bartonella henselae initial infection of mature human erythrocytes observed in real time using bacterial endogenous fluorescence

Bartonella henselae is a causative agent of anemia, cat scratch disease, bacillary angiomatosis, recurrent fever, hepatitis, endocarditis, chronic lymphadenopathy, joint and neurological disorders. B. henselae are intra-erythrocytic bacteria. The goal of this study was to visualize the B. henselae invasion into enucleated human red blood cells in real time using bacterium endogenous fluorescence. We took advantage of the unique fluorescence emission spectral profile of the bacteria. We used a linear unmixing approach to separate the fluorescence emission spectra of human erythrocytes from native B. henselae when excited at 488nm. Human blood samples were inoculated with B. henselae and incubated for 60 hours. 3-D live images were captured at select intervals using multi-photon laser scanning microscopy. Uninfected blood samples were also analyzed. This study revealed bacteria entering mature erythrocytes over a 60 hour time period.

Chronic liver disease in the human immunodeficiency virus patient

There are an estimated 40 million HIV infected individuals worldwide, with chronic liver disease being the 2nd leading cause of mortality in this population. Elevated liver functions are commonly noted in HIV patients and the etiologies are varied. Viral hepatitis B and C, fatty liver and drug induced liver injury are more common. Treatment options for viral hepatitis C are rapidly evolving and are promising, but treatments are limited for the other conditions and is primarily supportive. Opportunistic infections of the liver are now uncommon. Irrespective of etiology, management requires referral to specialized centers and with due diligence mortality can be reduced.

Bartonella spp. bacteremia in blood donors from Campinas, Brazil

Bartonella species are blood-borne, re-emerging organisms, capable of causing prolonged infection with diverse disease manifestations, from asymptomatic bacteremia to chronic debilitating disease and death. This pathogen can survive for over a month in stored blood. However, its prevalence among blood donors is unknown, and screening of blood supplies for this pathogen is not routinely performed. We investigated Bartonella spp. prevalence in 500 blood donors from Campinas, Brazil, based on a cross-sectional design. Blood samples were inoculated into an enrichment liquid growth medium and sub-inoculated onto blood agar. Liquid culture samples and Gram-negative isolates were tested using a genus specific ITS PCR with amplicons sequenced for species identification. Bartonella henselae and Bartonella quintana antibodies were assayed by indirect immunofluorescence. B. henselae was isolated from six donors (1.2%). Sixteen donors (3.2%) were Bartonella-PCR positive after culture in liquid or on solid media, with 15 donors infected with B. henselae and one donor infected with Bartonella clarridgeiae. Antibodies against B. henselae or B. quintana were found in 16% and 32% of 500 blood donors, respectively. Serology was not associated with infection, with only three of 16 Bartonella-infected subjects seropositive for B. henselae or B. quintana. Bartonella DNA was present in the bloodstream of approximately one out of 30 donors from a major blood bank in South America. Negative serology does not rule out Bartonella spp. infection in healthy subjects. Using a combination of liquid and solid cultures, PCR, and DNA sequencing, this study documents for the first time that Bartonella spp. bacteremia occurs in asymptomatic blood donors. Our findings support further evaluation of Bartonella spp. transmission which can occur through blood transfusions.

Bartonella is a genus of small bacteria with worldwide distribution, transmitted by blood-sucking insects, and is capable of causing disease in humans and animals. Some of the clinical presentations of Bartonella spp., such as cat scratch disease, trench fever, and bacillary angiomatosis are well documented; however, novel presentations have been described in the last two decades, ranging from cyclic flu-like syndrome to neurologic disease and life-threatening endocarditis. Asymptomatic human infection is possible and accidental blood transmission has been reported. Bacterium isolation is very difficult because they grow slowly and require special culture media and procedures. Serology testing poorly predicts active Bartonella infection, except in infection of cardiac valves. Therefore, diagnosis is generally challenging. However, when molecular detection techniques are coupled with special culture protocols, enhanced sensitivity and specificity can be achieved. We investigated Bartonella spp. infection prevalence in a large blood donor population and confirmed bacteremia in 1.2% of the subjects. Bloodstream infection was detected with at least three different molecular methods in 3.2% of donors. These results indicate that Bartonella is a genus of importance for transfusion medicine.

Detection of Bartonella henselae DNA in clinical samples including peripheral blood of immune competent and immune compromised patients by three nested amplifications

Bacteria of the genus Bartonella are emerging pathogens detected in lymph node biopsies and aspirates probably caused by increased concentration of bacteria. Twenty-three samples of 18 patients with clinical, laboratory and/or epidemiological data suggesting bartonellosis were subjected to three nested amplifications targeting a fragment of the 60-kDa heat shock protein (HSP), the internal transcribed spacer 16S-23S rRNA (ITS) and the cell division (FtsZ) of Bartonella henselae, in order to improve detection in clinical samples. In the first amplification 01, 04 and 05 samples, were positive by HSP (4.3%), FtsZ (17.4%) and ITS (21.7%), respectively. After the second round six positive samples were identified by nested-HSP (26%), eight by nested-ITS (34.8%) and 18 by nested-FtsZ (78.2%), corresponding to 10 peripheral blood samples, five lymph node biopsies, two skin biopsies and one lymph node aspirate. The nested-FtsZ was more sensitive than nested-HSP and nested-ITS (p < 0.0001), enabling the detection of Bartonella henselae DNA in 15 of 18 patients (83.3%). In this study, three nested-PCR that should be specific for Bartonella henselae amplification were developed, but only the nested-FtsZ did not amplify DNA from Bartonella quintana. We conclude that nested amplifications increased detection of B. henselae DNA, and that the nested-FtsZ was the most sensitive and the only specific to B. henselae in different biological samples. As all samples detected by nested-HSP and nested-ITS, were also by nested-FtsZ, we infer that in our series infections were caused by Bartonella henselae. The high number of positive blood samples draws attention to the use of this biological material in the investigation of bartonellosis, regardless of the immune status of patients. This fact is important in the case of critically ill patients and young children to avoid more invasive procedures such as lymph nodes biopsies and aspirates.

Association of Bartonella spp bacteremia with Chagas cardiomyopathy, endocarditis and arrhythmias in patients from South America

Infection with Bartonella spp may cause cardiac arrhythmias, myocarditis and endocarditis in humans. The aim of the present study was to evaluate a possible association between Bartonella spp bacteremia and endocarditis, arrhythmia and Chagas cardiomyopathy in patients from Brazil and Argentina. We screened for the presence of bacterial 16S rRNA in human blood by PCR using oligonucleotides to amplify a 185-bp bacterial DNA fragment. Blood samples were taken from four groups of subjects in Brazil and Argentina: i) control patients without clinical disease, ii) patients with negative blood-culture endocarditis, iii) patients with arrhythmias, and iv) patients with chronic Chagas cardiomyopathy. PCR products were analyzed on 1.5% agarose gel to visualize the 185-bp fragment and then sequenced to confirm the identity of DNA. Sixty of 148 patients (40.5%) with cardiac disease and 1 of 56 subjects (1.8%) from the control group presented positive PCR amplification for Bartonella spp, suggesting a positive association of the bacteria with these diseases. Separate analysis of the four groups showed that the risk of a Brazilian patient with endocarditis being infected with Bartonella was 22 times higher than in the controls. In arrhythmic patients, the prevalence of infection was 45 times higher when compared to the same controls and 40 times higher for patients with Chagas cardiomyopathy. To the best of our knowledge this is the first report of the association between Bartonella spp bacteremia and Chagas disease. The present data may be useful for epidemiological and prevention studies in Brazil and Argentina.

Bacillary angiomatosis in HIV-positive patient from Northeastern Brazil: a case report

It is a report of disseminated bacillary angiomatosis (BA) in a 23-year-old female patient, who is HIV-positive and with fever, weight loss, hepatomegaly, ascites, and papular-nodular skin lesions. The clinical and diagnostic aspects involved in the case were discussed. Bacillary angiomatosis must always be considered in the diagnosis of febrile cutaneous manifestations in AIDS.

Blood cell findings resembling Bartonella spp

Some Bartonella species are able to invade red blood cells (RBC) and may cause persistent infection in the susceptible host. Use of transmission electron microscopy (TEM) demonstrates, inside erythrocytes, the typical triple-walled agents. However, when examining ultrathin sections of blood cells, the authors have, on several occasions, detected intraerythrocytic abnormalities that mimic but are not typical of Bartonella spp. Small endovesicles, pseudoinclusions, cavities, and irregular hemoglobin granules distribution, resulting in regions of increased or decreased electron density, may be observed in the erythrocytes and platelets, which may be confused with bartonellas. So far, detailed ultrastructural findings of Bartonella spp. in blood cells have not yet been described. Aiming to improve TEM interpretation of blood cells changes, in routine examination of blood sections of patients with suspected bartonellosis, the authors studied the morphological findings they have observed, and present their putative nature, according to information in the literature.