Infectious endocarditis by Bartonella species: report of two cases / Endocarditis infecciosa por Bartonella: descripción de dos casos en Chile

ABSTRACT Infectious endocarditis (IE) by Bartonella species is an emerging problem worldwide. We report two cases of native valve Bartonella-associated IE events, both affecting adult male patients with a history of alcohol abuse and a low socioeconomic status. Admissions were due to pancytopenia and bleeding in one case and embolic stroke in the other. Blood cultures were negative and IgG indirect immunofluorescence assays (IFA) were positive for B. henselae/B. quintana in high titers (1/16,384-1/16,384, and 1/32,768 -1/16,384, respectively). Cases were classified as definitive IE events according to modified Duke criteria due to the presence of valve vegetations with at least three minor criteria. One patient required aortic mechanical valve replacement and survived, and the other died after a massive hemorrhagic transformation of his stroke. PCR amplification and sequencing of the 16S ribosomal bacterial DNA from a valve tissue sample obtained at surgery in the patient who survived, confirmed B. quintana as the etiological agent. Bartonella-associated IE is an emerging problem in Chile, present in disadvantaged populations. It should be suspected in patients with culture-negative IE. IFA does not discriminate between B. henselae and B. quintana infection, but high titers suggest IE. Complementary PCR techniques may help to elucidate the final causative agent.

La endocarditis infecciosa(EI) asociada a Bartonella es un problema emergente a nivel mundial. Publicamos los 2 primeros casos de EI en válvula nativa asociados a Bartonella en Chile, los que afectaron a pacientes masculinos con historia de consumo de alcohol y bajos ingresos. La hospitalización fue provocada por pancitopenia y hemorragias en un caso y por un evento cerebrovascular en el otro. Se solicitó serología para Bartonella por inmunofluorescencia indirecta (IFI) para ampliar el estudio ante hemocultivos negativos y en ambos casos se reportaron resultados intensamente positivos para B. henselae y B. quintana1/16.384-1/16.384 y 1/32.768 -1/16.384, respectivamente). Los casos se clasificaron como eventos definitivos de EI según los criterios modificados de Duke debido a la presencia de vegetaciones valvulares con al menos 3 criterios menores. Un paciente requirió reemplazo valvular aórtico y sobrevivió, y el otro falleció tras una transformación hemorrágica masiva del infarto cerebral. La amplificación del ADN ribosomal 16S por RCP y posterior secuenciación de una muestra de tejido valvular confirmó la presencia de B. quintana. La EI por Bartonella sp. es un problema emergente en Chile, probablemente asociada a poblaciones desfavorecidas, la que debe ser sospechada en pacientes con cultivos negativos. La IFI no permite discriminar infecciones por B. henselae o B. quintana pero los títulos altos sugieren EI. Técnicas complementarias por RCP pueden ayudar a dilucidar el diagnóstico.

Endocarditis infecciosa producida por Bartonella quintana / Infective endocarditis due to Bartonella quintana

Presentamos el caso de un hombre de 68 años que ingresó por mareos y sensación de pérdida de la conciencia. El examen clínico reveló una temperatura de 37.5 °C y un soplo de regurgitación mitral. El ecocardiograma mostró una insuficiencia mitral grave con dilatación de las cavidades izquierdas, y el ecocardiograma transesofágico una vegetación en la valva anterior de la mitral. Los hemocultivos demostraron una bacteria Gram-negativa que luego se identificó como Bartonella spp. La PCR demostró que se trataba de una Bartonella quintana. Se trató con gentamicina, doxiciclina y ceftriaxona, evolucionando satisfactoriamente. La insuficiencia mitral remanente espera el tratamiento quirúrgico.

We present the clinical case of a man of 68 years who was admitted for dizziness and sensation of loss of conscience. The clinical examination revealed a body temperature of 37.5 °C and a murmur of mitral regurgitation. The echocardiogram showed a severe mitral regurgitation and left cavitie's dilatation; transesophageal echocardiogram showed a vegetation in the anterior leaflet of the mitral valve. In blood cultures grew a Gram-negative bacteria identified as Bartonella spp. A PCR demonstrated that it was a Bartonella quintana. The patient was treated with gentamicin, doxiciclin and ceftriaxone with satisfactory evolution. The remaining mitral insufficiency awaits surgical treatment.

Angiomatosis bacilar por Bartonella quintana en un paciente con infección por virus de inmunodeficiencia humana / Bacillary angiomatosis caused by Bartonella quintana in an human immunodeficiency virus positive patient

We report the first case of bacillary angiomatosis due to Bartonella quintana affecting a Chilean a HIV positive patient in Chile. He was a 27 years old, heterosexual male, indigentman known to be HIV positive serological status known from September, 2003, under irregular medical control. On April, 2005, he presented a progressive abscess in the frontal region and erythematous papules in the extremities, that extended to face, thorax and mucoses, becoming nodular and violaceous lesions. Bacillary angiomatosis diagnosis was initially sustained on account of the clinical manifestations, and was confirmed by serology and Warthin Starry staining from a skin biopsy. The etiological agent was identified as Bartonella quintana through universal RPC performed from a cutaneous nodule to detect 16S rRNA gen. Azithromycin plus ciprofloxacin was started, besides of anti retroviral therapy antiretroviral, with the lesions being progressively disappearing.

Reportamos el primer caso de angiomatosis bacilar por Bartonella quintana en un paciente con infección por VIH en nuestro país. Este corresponde a un hombre de 27 años, heterosexual, indigente, seropositivo para VIH conocido desde septiembre de 2003, en control irregular. En abril de 2005, el paciente desarrolló un aumento progresivo de volumen en la región frontal y aparición de pápulas eritematosas en las extremidades, que luego se extendieron a la cara, tórax y mucosas, tornándose nodulares y violáceas. El diagnóstico de angiomatosis bacilar se planteó inicialmente por el cuadro clínico del paciente, siendo confirmado por serología y tinción de Warthin Starry positiva en la biopsia de piel. El agente causal se identificó como Bartonella quintana por RPC universal para el gen del 16S ARNr de un nódulo cutáneo. Se inició terapia antimicrobiana con azitromicina y ciprofloxacina, además de terapia antiretroviral, con desaparición de las lesiones en forma progresiva.

Seroprevalence of Bartonella henselae and Bartonella quintana infections in children from central and Northern Jordan

To investigate the prevalence of antibodies to Bartonella henselae [B.henselae] and Bartonella quintana [B.quintana] among children from central and northern Jordan. Sera from 482 children were randomly collected from referenced governmental hospitals in the central and northern parts of Jordan during the period between January 2001 to March 2003. An indirect immunofluorescent assay was used to determine serum antibody titers to B.henselae and B.quintana. Sera that were reactive at a dilution >/-1:64 were considered positive. In addition, blood from 20 cats belonged to children with high B.henselae titers were tested using polymerase chain reaction. Out of the 482 serum samples examined, 53 [11%] and 20 [4.1%] had positive antibody titers for B. henselae and B.quintana. Bartonella henselae was isolated from 4 cats that belonged to 3 children with high antibody titers to B.henselae-IgG. The seroprevalence of IgG antibodies to B.henselae was significantly higher [P<0.05] in children aged 7-10-years than in younger or older ones. Having a cat in the household and having a history of cat scratches or bites were strongly associated [P<0.01] with seropositivity to B.henselae-specific IgG. Cats ownership and history of cat scratches or bites had no impact on the prevalence of B.quintana. Seropositivity to B.henselae-specific IgG was significantly higher [P<0.01] in children from northern Jordan than in children from central Jordan. This study substantiates the presence of B.henselae in Jordan, documents the seroreactivity to 2 Bartonella antigens, and suggests that cat ownership and history of cat scratches or bites are important epidemiological risk factors for B.henselae infection in Jordan