The expanding spectrum of Bartonella infections: I. Bartonellosis and trench fever

Arthropod-borne bacterial diseases in pregnancy

Arthropod-borne bacterial diseases affect more than 25,000 Americans every year and thousands more around the world. These infections present a diagnostic dilemma for clinicians because they mimic many other pathologic conditions and are often low on or absent from the differential diagnosis list. Diagnosis is particularly challenging during pregnancy, as these infections may mimic common pregnancy-specific conditions, such as typical and atypical preeclampsia, or symptoms of pregnancy itself. Concerns regarding the safety in pregnancy of some indicated antibiotics add a therapeutic challenge for the prescriber, requiring knowledge of alternative therapeutic options for many arthropod-borne bacterial diseases. Physicians, especially those in endemic areas, must keep this class of infections in mind, particularly when the presentation does not appear classic for more commonly seen conditions. This article discusses presentation, diagnosis, and treatment of the most common of these arthropod-borne bacterial diseases, including Lyme disease, Rocky Mountain spotted fever, tick-borne relapsing fever, typhus, plague, cat-scratch disease, and Carrión disease.

Oroya fever and verruga peruana: bartonelloses unique to South America

Bartonella bacilliformis is the bacterial agent of Carrión's disease and is presumed to be transmitted between humans by phlebotomine sand flies. Carrión's disease is endemic to high-altitude valleys of the South American Andes, and the first reported outbreak (1871) resulted in over 4,000 casualties. Since then, numerous outbreaks have been documented in endemic regions, and over the last two decades, outbreaks have occurred at atypical elevations, strongly suggesting that the area of endemicity is expanding. Approximately 1.7 million South Americans are estimated to be at risk in an area covering roughly 145,000 km2 of Ecuador, Colombia, and Peru. Although disease manifestations vary, two disparate syndromes can occur independently or sequentially. The first, Oroya fever, occurs approximately 60 days following the bite of an infected sand fly, in which infection of nearly all erythrocytes results in an acute hemolytic anemia with attendant symptoms of fever, jaundice, and myalgia. This phase of Carrión's disease often includes secondary infections and is fatal in up to 88% of patients without antimicrobial intervention. The second syndrome, referred to as verruga peruana, describes the endothelial cell-derived, blood-filled tumors that develop on the surface of the skin. Verrugae are rarely fatal, but can bleed and scar the patient. Moreover, these persistently infected humans provide a reservoir for infecting sand flies and thus maintaining B. bacilliformis in nature. Here, we discuss the current state of knowledge regarding this life-threatening, neglected bacterial pathogen and review its host-cell parasitism, molecular pathogenesis, phylogeny, sand fly vectors, diagnostics, and prospects for control.

Transmission and maintenance cycle of Bartonella quintana among rhesus macaques, China

We detected Bartonella quintana in 48.6% of captive rhesus macaques from an animal facility in Beijing, China. Prevalence of infection increased over the period of observation. Our findings suggest that macaques may serve as reservoir hosts for B. quintana and that Pedicinus obtusus lice might act as efficient vectors.

Strategies of exploitation of mammalian reservoirs by Bartonella species

Numerous mammal species, including domestic and wild animals such as ruminants, dogs, cats and rodents, as well as humans, serve as reservoir hosts for various Bartonella species. Some of those species that exploit non-human mammals as reservoir hosts have zoonotic potential. Our understanding of interactions between bartonellae and reservoir hosts has been greatly improved by the development of animal models for infection and the use of molecular tools allowing large scale mutagenesis of Bartonella species. By reviewing and combining the results of these and other approaches we can obtain a comprehensive insight into the molecular interactions that underlie the exploitation of reservoir hosts by Bartonella species, particularly the well-studied interactions with vascular endothelial cells and erythrocytes.

Bartonella infection: treatment and drug resistance

Bartonella species, which belong to the α-2 subgroup of Proteobacteria, are fastidious Gram-negative bacteria that are highly adapted to their mammalian host reservoirs. Bartonella species are responsible for different clinical conditions affecting humans, including Carrion's disease, cat scratch disease, trench fever, bacillary angiomatosis, endocarditis and peliosis hepatis. While some of these diseases can resolve spontaneously without treatment, in other cases, the disease is fatal without antibiotic treatment. In this article, we discuss the antibiotic susceptibility patterns of Bartonella species, detected using several methods. We also provide an overview of Bartonella infection in humans and animals and discuss the antibiotic treatment recommendations for the different infections, treatment failure and the molecular mechanism of antibiotic resistance in these bacteria.

Ecological fitness and strategies of adaptation of Bartonella species to their hosts and vectors

Bartonella spp. are facultative intracellular bacteria that cause characteristic hostrestricted hemotropic infections in mammals and are typically transmitted by blood-sucking arthropods. In the mammalian reservoir, these bacteria initially infect a yet unrecognized primary niche, which seeds organisms into the blood stream leading to the establishment of a long-lasting intra-erythrocytic bacteremia as the hall-mark of infection. Bacterial type IV secretion systems, which are supra-molecular transporters ancestrally related to bacterial conjugation systems, represent crucial pathogenicity factors that have contributed to a radial expansion of the Bartonella lineage in nature by facilitating adaptation to unique mammalian hosts. On the molecular level, the type IV secretion system VirB/VirD4 is known to translocate a cocktail of different effector proteins into host cells, which subvert multiple cellular functions to the benefit of the infecting pathogen. Furthermore, bacterial adhesins mediate a critical, early step in the pathogenesis of the bartonellae by binding to extracellular matrix components of host cells, which leads to firm bacterial adhesion to the cell surface as a prerequisite for the efficient translocation of type IV secretion effector proteins. The best-studied adhesins in bartonellae are the orthologous trimeric autotransporter adhesins, BadA in Bartonella henselae and the Vomp family in Bartonella quintana. Genetic diversity and strain variability also appear to enhance the ability of bartonellae to invade not only specific reservoir hosts, but also accidental hosts, as shown for B. henselae. Bartonellae have been identified in many different blood-sucking arthropods, in which they are typically found to cause extracellular infections of the mid-gut epithelium. Adaptation to specific vectors and reservoirs seems to be a common strategy of bartonellae for transmission and host diversity. However, knowledge regarding arthropod specificity/restriction, the mode of transmission, and the bacterial factors involved in arthropod infection and transmission is still limited.

Molecular mechanisms of resistance to antibiotics in Bartonella bacilliformis

OBJECTIVES

Bartonella bacilliformis is the aetiological agent of Carrion's disease. Although ciprofloxacin, rifampicin and erythromycin have been successfully used in the treatment of the disease, failures and relapses have been reported. The objective of our study was to select in vitro mutants resistant to antibiotics in order to determine the frequency of mutations and to characterize the mechanism of resistance at the molecular level.

METHODS

Antibiotic-resistant mutants were selected by serial passages of bacteria on blood agar plates containing antibiotics. Candidate genes involved in resistance were amplified and sequenced and compared in order to look at mutations associated with antibiotic resistance.

RESULTS

Ciprofloxacin-, rifampicin- and erythromycin-resistant mutants were obtained after five, three and four passages, respectively. Conversely, no mutant was obtained with either gentamicin or doxycycline even after 16 passages. The ciprofloxacin mutant contained an amino acid change at position 87 (Asp --> Asn) in its quinolone resistance-determining region of the DNA gyrase protein, whereas the rifampicin-resistant strain had an amino acid change at position 531 (Ser --> Phe) in the rifampicin resistance-determining region of the rpoB gene. Similarly, the erythromycin-resistant mutant showed an A2058G mutation in the 23S rRNA gene.

CONCLUSIONS

According with the current knowledge on the treatment of human bartonellosis, we believe that doxycycline in association with gentamicin may be the preferred regimen for the treatment of the acute and eruptive stages of Carrion's disease, but clinical trials are warranted to support our findings.

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.

Bartonella–host-cell interactions and vascular tumour formation

Bartonellae are arthropod-borne bacterial pathogens that typically cause persistent infection of erythrocytes and endothelial cells in their mammalian hosts. In human infection, these host-cell interactions result in a broad range of clinical manifestations. Most remarkably, bartonellae can trigger massive proliferation of endothelial cells, leading to vascular tumour formation. The recent availability of infection models and bacterial molecular genetic techniques has fostered research on the pathogenesis of the bartonellae and has advanced our understanding of the virulence mechanisms that underlie the host-cell tropism, the subversion of host-cell functions during bacterial persistence, as well as the formation of vascular tumours by these intriguing pathogens.

Bartonella species as a potential cause of epistaxis in dogs

Infection with a Bartonella species was implicated in three cases of epistaxis in dogs, based upon isolation, serology, or PCR amplification. These cases, in conjunction with previously published reports, support a potential role for Bartonella spp. as a cause of epistaxis in dogs and potentially in other animals, including humans.

Virulence-associated type IV secretion systems of Bartonella

Type IV secretion systems (T4SSs) are transport machineries of Gram-negative bacteria that mediate interbacterial DNA-transfer, and secretion of virulence factors into eukaryotic target cells. A growing number of human pathogenic bacteria use T4SSs for intercellular delivery of effector molecules that modify host cellular functions in favour of the pathogen. Recent advances in studying the molecular mechanisms of Bartonella pathogenesis have provided evidence for the central roles of two distinct T4SSs, VirB/VirD4 and Trw, in the ability of the bacteria to colonize, invade and persist within either vascular endothelial cells or erythrocytes, respectively. The identification of VirB/VirD4-transported substrates and the delineation of their secretion signal have paved the way towards understanding the molecular mechanisms underlying Bartonella-host cell interaction and modulation, as well as the exploitation of this system for engineered substrate delivery into mammalian target cells.

Clinical impact of persistent Bartonella bacteremia in humans and animals

Bartonella spp. are emerging vector-borne pathogens that cause persistent, often asymptomatic bacteremia in their natural hosts. As our knowledge progresses, it appears that chronic infection may actually predispose the host to mild, insidious nonspecific manifestations or induce, in selected instances, severe diseases. Persistent asymptomatic bacteremia is most common in animals that serve as the main reservoir for the specific Bartonella. In humans, these organisms are B. bacilliformis and B. quintana. Other Bartonella species, for which humans are not the natural reservoir, tend to cause persistent bacteremia only in immunodeficient individuals. In some of these individuals, endothelial cell proliferation may create lesions such as bacillary angiomatosis or bacillary peliosis. In cats, bacteremia of variable level and continuity may last for years. Some strains of B. henselae may induce clinical manifestations, including fever, mild neurological signs, reproductive disorders, whereas others do not induce clinically obvious disease. Reproductive disorders have also been reported in mice experimentally infected with B. birtlesii. Finally, canids constitute the most interesting naturally occurring animal model for the human disease. Like immunocompetent people, healthy dogs only occasionally demonstrate long-term bacteremia when infected with Bartonella spp. However, some dogs develop severe clinical manifestations, such as endocarditis, and the pathologic spectrum associated with Bartonella spp. infection in domestic dogs is rapidly expanding and resembles the infrequently reported clinical entities observed in humans. In coyotes, persistent bacteremia is more common than in domestic dogs. It will be of interest to determine if coyotes develop clinical or pathological indications of infection.

Bacterial persistence within erythrocytes: a unique pathogenic strategy of Bartonella spp

The genus Bartonella comprises human-specific and zoonotic pathogens responsible for a wide range of clinical manifestations, including Carrion's disease, trench fever, cat scratch disease, bacillary angiomatosis and peliosis, endocarditis and bacteremia. These arthropod-borne pathogens typically parasitise erythrocytes in their mammalian reservoir host(s), resulting in a long-lasting haemotropic infection. We have studied the process of Bartonella erythrocyte parasitism by tracking green fluorescent protein-expressing bacteria in the blood of experimentally infected animals. Following intravenous infection, bacteria colonise a yet enigmatic primary niche, from where they are seeded into the blood stream in regular intervals of approximately five days. Bacteria invade mature erythrocytes, replicate temporarily and persist in this unique intracellular niche for the remaining life span of the infected erythrocytes. A triggered antibody response typically results in an abrogation of bacteremia within 3 months of infection, likely by blocking new waves of bacterial invasion into erythrocytes. The recent establishment of genetic tools for Bartonella spp. permitted us to identify several putative pathogenicity determinants. Application of differential fluorescence induction technology resulted in the isolation of bacterial genes differentially expressed during infection in vitro and in vivo, including an unknown family of autotransporter proteins as well as a novel type IV secretion system homologous to the conjugation system of E. coli plasmid R388. Mutational analysis of a previously described type IV secretion system displaying homology to the virB locus of Agrobacterium tumefaciens provided the first example of an essential pathogenicity locus in Bartonella. Though required for establishing haemotropic infection, it remains to be demonstrated if this type IV secretion system is necessary for colonisation of the primary niche or for the subsequent colonisation of erythrocytes.

Deformin, a substance found in Bartonella bacilliformis culture supernatants, is a small, hydrophobic molecule with an affinity for albumin

Culture supernatants of Bartonella bacilliformis were previously shown to contain a factor, called deforming factor or deformin, which causes deformation and invagination of red cell membranes and formation of intracellular vacuoles. This factor is here shown to be a small water-soluble molecule, approximately 1400 Da as estimated by gel-filtration chromatography. Deforming factor binds tightly to albumin, especially albumin dimers and multimers, present in the growth medium. It can be released from albumin with 50% ethanol and has been partially purified by filtration and HPLC.

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

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

Cutting edge: antibody-mediated cessation of hemotropic infection by the intraerythrocytic mouse pathogen Bartonella grahamii

The genus Bartonella includes important human-specific and zoonotic pathogens which cause intraerythrocytic bacteremia in their mammalian reservoir host(s). It is accepted that cellular immunity plays a decisive role in the host's defense against most intracellular bacteria. Bartonella sp. infection in the immunocompetent host typically leads to immunity against homologous challenge. The basis of this immunity, be it cellular or humoral, is unclear. In this study, the course of Bartonella grahamii bacteremia in immunocompetent and immunocompromised mice was compared. In immunocompetent hosts, the bacteremia is transient and induces a strong humoral immune response. In contrast, bacteremia persists in immunocompromised B and T cell-deficient mice. Immune serum transfer beginning with day 6 postinfection to B cell-deficient mice unable to produce Igs converted the persistent bacteremia to a transient course indistinguishable from that of immunocompetent animals. These data demonstrate an essential role for specific Abs in abrogating the intraerythrocytic bacteremia of B. grahamii in mice.

Bartonella interactions with endothelial cells and erythrocytes

Bartonella species are emerging human pathogens responsible for a wide range of clinical manifestations, including Carrion's disease, trench fever, cat-scratch disease, bacillary angiomatosis-peliosis, endocarditis and bacteraemia. During infection of their human or animal reservoir host(s), these arthropod-borne pathogens typically invade and persistently colonize mature erythrocytes. However, in both reservoir and incidentally infected hosts, endothelial cells are target cells for bartonellae. Endothelial interactions involve a unique mode of cellular invasion, the activation of a proinflammatory phenotype and the formation of vasoproliferative tumours. Based on the establishment of bacterial genetics and appropriate infection models, recent work has begun to elucidate the cell and molecular biology of these unusual pathogen-host cell interactions.

Invasion and persistent intracellular colonization of erythrocytes. A unique parasitic strategy of the emerging pathogen Bartonella

The expanding genus Bartonella includes zoonotic and human-specific pathogens that can cause a wide range of clinical manifestations. A productive infection allowing bacterial transmission by blood-sucking arthropods is marked by an intraerythrocytic bacteremia that occurs exclusively in specific human or animal reservoir hosts. Incidental human infection by animal-adapted bartonellae can cause disease without evidence for erythrocyte parasitism. A better understanding of the intraerythrocytic lifestyle of bartonellae may permit the design of strategies to control the reservoir and transmittable stages of these emerging pathogens. We have dissected the process of Bartonella erythrocyte parasitism in experimentally infected animals using a novel approach for tracking blood infections based on flow cytometric quantification of green fluorescent protein-expressing bacteria during their interaction with in vivo-biotinylated erythrocytes. Bacteremia onset occurs several days after inoculation by a synchronous wave of bacterial invasion into mature erythrocytes. Intracellular bacteria replicate until reaching a stagnant number, which is sustained for the remaining life span of the infected erythrocyte. The initial wave of erythrocyte infection is followed by reinfection waves occurring at intervals of several days. Our findings unravel a unique bacterial persistence strategy adapted to a nonhemolytic intracellular colonization of erythrocytes that preserves the pathogen for efficient transmission by blood-sucking arthropods.

Molecular cloning, sequencing, expression, and characterization of an immunogenic 43-kilodalton lipoprotein of Bartonella bacilliformis that has homology to NlpD/LppB

A recombinant clone expressing an immunoreactive antigen of Bartonella bacilliformis was isolated by screening a genomic DNA library with serum from a patient with the chronic verruga phase of bartonellosis. The clone, pBIPIM-17, contained a partial open reading frame that expressed an immunoreactive fusion protein. Subsequent rescreening of the library by plaque hybridization resulted in the isolation of recombinant clones that contain the entire open reading frame. The open reading frame (ORF-401) is capable of encoding a protein of 401 amino acids with a predicted molecular mass of 43 kDa. The deduced amino acid sequence of the encoded protein was found to be highly homologous to a recently identified bacterial lipoprotein (LppB/NlpD) which has been associated with virulence. Evidence has been provided to show that the 43-kDa antigen of B. bacilliformis is a lipoprotein and that it is likely to use the same biosynthetic pathway as other bacterial lipoproteins. This is the first report to date that characterizes a lipoprotein of B. bacilliformis. The immunogenicity of the B. bacilliformis LppB homologue was demonstrated by Western blot analysis using sera from patients with clinical bartonellosis. Sera from patients who had a high titer for Bartonella henselae, the causative agent of bacillary angiomatosis and cat scratch disease, also recognized the recombinant 43-kDa antigen, suggesting that a homologue of this antigen is present in B. henselae. Using a cocktail of synthetic peptides corresponding to predicted major antigenic sites, polyclonal antiserum specific for the LppB homologue of B. bacilliformis was generated. This antiserum did not recognize the NlpD homologue of Escherichia coli or the 43-kDa antigen of B. henselae.

Differentiation of pathogenic Bartonella species by infrequent restriction site PCR

Infrequent restriction site PCR (IRS-PCR) is a recently described DNA fingerprinting technique based on selective amplification of restriction endonuclease-cleaved fragments. Bartonella isolates associated with human disease and related nonhuman isolates were analyzed by IRS-PCR genomic fingerprinting. Preparation of DNA templates began with double digestion using three different restriction endonuclease combinations. Combinations included the frequently cutting endonuclease HhaI in conjunction with an infrequently cutting endonuclease, EagI, SmaI, or XbaI. Digestion was followed by ligation of oligonucleotide adapters designed with ends complementary to the restriction endonuclease sites. Amplification of fragments flanked with an EagI, SmaI, or XbaI site in combination with an HhaI site produced a series of different-sized amplicons resolvable into patterns by polyacrylamide gel electrophoresis (PAGE). The pattern complexity was varied by the addition of selective nucleotides to the 3' ends of the EagI-, SmaI-, or XbaI-specific primers. Amplicons were also generated with fluorescently labeled primers and were subsequently resolved and detected by capillary electrophoresis. Analysis by traditional slab PAGE and capillary electrophoresis provided suitable resolution of patterns produced with the enzyme combinations EagI-HhaI and SmaI-HhaI. However, the combination of XbaI-HhaI produced too many fragments for sufficient resolution by traditional PAGE, thus requiring the better resolving properties of capillary electrophoresis. Due to the flexibility in modulating the pattern complexity and electrophoresis methods, these techniques allow for a high level of experimental optimization. The results provide evidence of the discriminatory power, ease of use, and flexibility of the IRS-PCR method as it applies to the identification of human-pathogenic Bartonella species.

Rickettsia prowazekii and Bartonella henselae: differences in the intracellular life styles revisited

Within the alpha subdivision of proteobacteria, the arthropod-borne human pathogens Rickettsia prowazekii and Bartonella henselae provide examples of bacteria with obligate and facultative intracellular life styles, respectively. The complete genome sequence of R. prowazekii has been published, whereas the sequencing of the B. henselae genome is in its final stage. Here, we provide a brief overview of a comparative analysis of both genomes based on the delineated metabolic properties. The relative proportion of genes devoted to basic information processes is similar in the two genomes. In contrast, a full set of genes encoding proteins involved in the biosynthesis of amino acids and nucleotides is present in B. henselae, while the majority of these genes is absent from R. prowazekii. This suggests that B. henselae has a better potential for growth in the free-living mode, whereas R. prowazekii is more specialised to growth in an intracellular environment. Functional genomics will provide the potential to further resolve the genetic basis for successful human infections by these important parasites.

[Cat-scratch disease caused by Bartonella quintana in an infant: an unusual presentation]

This case study reports a typical clinical course of cat-scratch disease (CSD) in an infant without epidemiological data and presenting bilateral submandibular lymphadenopathy. The authors describe clinical course, ultrasound images, diagnosis and prognosis. Polymerase chain reaction (PCR) detected and identified B. quintana in lymph node samples. B. henselae currently thought to be the causative agent of CSD was not detected. The PCR assays for B. quintana and B. henselae should be available for the investigation of lymphadenopathy, even if the infant has not had either cat or dog contact.

Rapid identification and differentiation of Bartonella species using a single-step PCR assay

Five species of Bartonella have been reported to infect humans and cause a variety of diseases that can be difficult to diagnose. Four species of Bartonella have been reported to infect cats and dogs, and two of these species are considered to be zoonotic pathogens. Diagnosis of Bartonella infections is hampered by the slow, fastidious growth characteristics of Bartonella species. We report on the development of a single-step PCR-based assay for the detection and differentiation of medically relevant Bartonella species. PCR-mediated amplification of the 16S-23S rRNA intergenic region resulted in a product of a unique size for each Bartonella species, thereby allowing differentiation without the necessity of restriction fragment length polymorphism analysis or sequencing of the amplified product. The ability of the single-step PCR assay to differentiate between Bartonella species was determined with characterized isolates and blood samples from animals known to be infected with either Bartonella henselae, B. clarridgeiae, or B. vinsonii subsp. berkhoffii. The sensitivity of the single-step PCR assay relative to that of in vitro culture was determined with blood samples from B. henselae-infected cats. B. henselae target DNA was amplified from 100% of samples with greater than 50 CFU/ml and 80% of samples with 10 to 30 CFU/ml. The single-step assay described in the report expedites PCR-based detection and differentiation of medically relevant Bartonella species.

Bartonellosis. New and old

The number of species that comprise the family of Bartonellaceae, genus Bartonella, has recently increased from one to 11 species, five of which have been associated with different diseases and syndromes in humans. The rapidly growing number of human pathogens has led several investigators to regard bartonellosis and other associated syndromes as important emerging infectious diseases. This article presents the history and epidemiology, clinical features, diagnosis, and treatment of bartonellosis and associated diseases, including Carrión's disease, trench fever, endocarditis and bacteremia, bacillary angiomatosis, and cat-scratch disease.