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.

Endocardites comunitárias por Bartonella spp. e Coxiella burnetii: investigações etioepidemiológica e clínica em pacientes com endocardite com culturas negativas / Community-acquired endocarditis due to Bartonella spp. and Coxiella burnetii: etiologic, epidemiologic and clinical investigations in patients with culture-negative endocarditis

Endocardite infecciosa é uma doença associada à elevada morbidade e letalidade. O diagnóstico precoce e o reconhecimento de sua etiologia podem contribuir para o sucesso do tratamento antibiótico; entretanto, cerca de um quarto das endocardites permanece sem diagnóstico etiológico. Este estudo teve como objetivo principal identificar a frequência de endocardite por Bartonella spp. e Coxiella burnetii dentre as endocardites com culturas negativas comunitárias e avaliar os fatores preditores dessas infecções. Como objetivo secundário compararam-se as características clínicolaboratoriais e prognósticas entre as endocardites comunitárias com culturas negativas e positivas. Foram avaliados também os fatores associados à letalidade intra-hospitalar das endocardites com culturas negativas. Entre janeiro de 2004 e janeiro de 2009, foram investigados 369 episódios consecutivos de endocardite em pacientes atendidos no Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - InCor HC-FMUSP. Foram estudados os casos que ocorreram em adultos, classificados pelos critérios de Duke modificados como "endocardite definida" e de origem comunitária. Assim, foram incluídos 221 episódios de endocardite, 170 com culturas positivas e 51 com culturas negativas. Neste último grupo, foram feitas as pesquisas sorológicas (reação de imunofluorescência indireta) e histopatológica de Bartonella spp. e Coxiella burnetii. Consideraram-se positivos títulos de imunoglobulina G (IgG) >= 800 para Bartonella henselae e ou Bartonella quintana, e IgG antifase I para C. burnetii > 800. O estudo histopatológico das valvas cardíacas foi capaz de identificar morfologicamente a etiologia de 87% das endocardites com culturas negativas, enquanto que o método de Gram do tecido a fresco o fez em somente 10% dos casos. As endocardites com culturas negativas apresentaram maior frequência de dispneia à admissão (p=0,001), menor valor de proteína C reativa (p=0,009)...

Infective endocarditis is associated with high morbidity and lethality. Early diagnosis and recognition of the specific etiology can contribute to successful antibiotic treatment. However, approximately one-fourth of endocarditis cases remain without an etiologic diagnosis. This study aimed to identify the frequency of endocarditis caused by Bartonella spp. and Coxiella burnetii among cases of community-acquired culture-negative endocarditis and to also assess risk factors for such infections. As a secondary objective, the clinical, laboratory and prognostic features of community-acquired endocarditis were compared. Factors related to the in-hospital lethality of culture-negative endocarditis were also assessed. Between January 2004 and January 2009, 369 consecutive cases of endocarditis were investigated in patients attending the no Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - InCor HC-FMUSP. Cases occurring in adults, those classified by the modified Duke criteria as "defined endocarditis" and community-acquired cases were studied. In total, 221 cases of endocarditis comprising 170 culture-positive and 51 culturenegative cases were included. For the culture-negative cases, serology (indirect immunofluorescence reaction) and histopathological analyses for Bartonella spp. and Coxiella burnetii were performed. Cases were considered positive for Bartonella henselae or Bartonella quintana with IgG titers >= 800 and for Coxiella burnetii with antiphase I IgG titers > 800. Histopathological studies of the cardiac valves were capable of morphologically identifying the etiology in 87% of the culture-negative endocarditis cases, whereas the Gram stain was only positive in 10% of cases using fresh tissue. Culture-negative endocarditis patients presented a greater frequency of dyspnea on admission (p=0.001), lower C-reactive protein levels (p=0.009), and a lower left ventricular...

Angiomatosis bacilar por Bartonella quintana como primera manifestación de infección por VIH: Report of one case / Bacillary angiomatosis

Background: Bacillary angiomatosis is an unusual infectious disease, with angioproliferative lesions, typical of immunocompromised patients. It is caused by Bartonella quintana and Bartonella henselae, two infectious agents of the genus Bartonella, which trigger variable clinical manifestations, including cutaneous vascular and purpuric lesions, and regional lymphadenopathy, and even a systemic disease with visceral involvement. We report a 38-year-old HIV positive male presenting with a history of six months of cutaneous growing purple angiomatous lesions, located also in nasal fossae, rhi-nopharynx and larynx. The skin biopsy was compatible with bacillary angiomatosis. Polymerase chain reaction of a tissue sample showed homology with B. quintana strain Toulouse. The patient was treated with azithromycin and ciprofloxacin with a favorable evolution.

First Case of Bartonella quintana Endocarditis in Korea

Since microbial gene sequencing was utilized for etiologic diagnosis of culture-negative endocarditis, cases of Bartonella endocarditis have been reported in various countries. Herein we report the first case of Bartonella quintana endocarditis, which was confirmed for the first time in Korea by 16S rRNA gene sequencing from the excised valve. A 75-yr-old woman was hospitalized due to dyspnea. Echocardiography demonstrated large oscillating vegetation at the aortic valve. Blood culture was negative. She underwent valve replacement and sequencing of the 16S rRNA gene from excised valve identified Bartonella quintana. She was successfully treated with combined use of ceftriaxone and gentamicin.

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

Reporte de un caso de angiomatosis bacilar en un niño con infección por VIH / Bacillary angiomatosis in a child with HIV infection

Se reporta el caso de un lactante de 1 año y 2 meses, con serología positiva para VIH, natural y procedente de la Merced, que presentó cuadro de angiomatosis bacilar y peliosis, confirmada por anatomía patológica. El paciente respondió a la terapia convencional con eritromicina.

Bartonelosis: cuatro casos de la denominada enfermedad por arañazo de gato, nueva orientación sindrómica / Bartonellosis: four cases of the so called cat scratch disease, new syndromic orientation

Se denomina bartonelosis a todas las infecciones provocadas en el ser humano por las distintas especies del género Bartonella, pudiendo manifestarse como bacteriemias o como lesiones localizadas de aspecto vascular: angiomatosis bacilar (AB) y peliosis bacilar (PB), predominando éstas en el paciente HIV +. La enfermedad por arañazo de gato (EAG) está causada por Bartonella henselae (Bh), siendo considerado raro el síndrome oculoglandular de Parinaud, pues sólo es observable en el 6 por ciento de los casos. El diagnóstico de la EAG está basado en la clínica, el antecedente de contacto con gatos, el fracaso en la identificación de otras etiologías y los exámenes complementarios. El exámen histopatológico de biopsias ganglionares sigue siendo útil y como la Bh es un bacilo gram negativo deben hacerse coloraciones especiales como la preparación de plata Warthin-Starry. La detección de anticuerpos por inmunofluorescencia indirecta (IFI) es un método muy confiable pues tiene una sensibilidad del 93 por ciento y una especificidad del 98 por ciento, con el que se demuestran Ac. antiBh, IgG y Ac. anti-Bh, IgM. El título suele reflejar el grado de infección. El compromiso sistémico: hígado, bazo, osteomielitis y más raro (1 por ciento) del SNC (encefalitis y epilepsias), es posible en pacientes inmunocomprometidos. La EAG y la AB deben ser consideradas formas clínicas polares de la infección por Bh, expresión del estado inmunitario del paciente y reflejo del fenómeno primario denominado inflamación, el cual también expica la fisiopatogenia de los signos dermatológicos (histogénesis)

Prevalence of antibodies to Bartonella henselae and Bartonella quintana in Korean Patients with Lymphadenopathy / 감염

BACKGROUND: Cat scratch disease (CSD) manifests as a self-limiting, regional lymphadenopathy, fever and constitutional symptoms following a cat scratch or close contact with cats. Bartonella henselae is a causative agent of CSD that is globally distributed. In Korea there are no case report of CSD and no reports on the seroprevalence of Bartonella henselae in patients with suspected CSD. In this study the prevalence of antibodies to Bartonella in patients with lymphadenopathies was evaluated. METHODS: We evaluated serological responses of 31 patients (8 male, 23 female) with regional lymphadenopathies. The age of the patients ranged from 6 to 76 years old (mean+/-S.D., 30.6+/-14.3 years). Final diagnoses on the lymphadenopathies were tuberculous lymphadenopathy, Kikuchi's disease, Kawasaki's disease, and viral infection, but considerable cases remained undiagnosed. All sera were examined using MRL Diagnostics Bartonella IgG indirect immunofluorescent antibody (IFA) test kits (MRL Diagnostics, Cypress, California, USA) according to the manufac-turer's instructions. RESULTS: Of the 31 patients, 21 (67.7%) patients showed positive titers of immunoglobulin G (IgG) to B. henselae (1 : 64 or higher). Twelve (38.7%) had IgG titers of 1 : 128 and four (12.9%) had titers of 1 : 256. Among these patients, three patients had a history of close contact with a cat or cat scratch. Twenty patients (64.5%) showed positive reactions against B. quintana. CONCLUSION: This study revealed possible patients with cat scratch disease, but, unlike other countries, Bartonella seropositivity was not closely associated with cat contact. The further studies should be performed in a large number of patients including a control group and be accompanied with culture or polymerase chain reaction of extirpated lymph node.

Angiomatose bacilar com comprometimento osseo: relato de caso e revisão de literatura / Bone lesions due to bacillary angiomatosis: case report and literature review

Bacillary angiomatosis is an infectious disease characterized by proliferation of small blood vessels in the skin and visceral organs of immunodeficient patients, mainly those infected with the human immunodeficiency v¡rus. ln this report, a 41-year-old man with seropositivity for HIV-1 presented with a five-months history of pain, edema, and movement restriction of his left wrist, elbow, knee, and ankle. In addition, he had nodular and ulcerated bleeding lesions in his right arm and leg, and a granulomatous nasal lesion. He had lost 8 kg in this five months period. He had sought an orthopedic medical center where long bone roentgenograms revealed diffuse lytic lesions, and bone scan showed uptake in left wrist, knee, and ankle. These findings were consistent with either neoplasm or osteomyelitis. During investigation, seropositivity for HIV-1 was detected. The patient was then referred to the Em¡lio Ribas lnfectious Diseases lnstitute [Instituto de Infectologia Em¡lio Ribas]. Histologic examination of bone and skin biopsy showed changes which are typical in bacillary angiomatosis cases. Electron microscopy findings were compatible with Bartonella species. Immunohistochemistry identified the bacteria as Bartonella quintana. Therapy with 2 g erythromycin per day was initiated. Cutaneous and osseous lesions were gradually resolved over the two ensuing months

Doença da arranhadura do gato por Bartonella quintana em lactente: uma apresentaçäo incomum / Cat-scratch disease caused by Bartonella quintana in an infant: an unusual presentation

Relato de caso de doença da arranhadura do gato (DAG), em um paciente lactente, com história epidemiológica negativa, descrevendo o rastreamento diagnóstico, a imagem ao ultra-som, a evoluçäo clínica e o prognóstico. B. quintana foi identificada em aspirado de secreçäo ganglionar pelo método de PCR. B. henselae, embora seja o agente causal habitualmente responsável pela DAG, näo foi isolada. Os autores concluem que a pesquisa de B. quintana e B. henselae deve ser incluída na investigaçäo de adenites, principalmente quando a evoluçäo é subaguda, mesmo em lactentes e, ainda que a história epidemiológica seja negativa

Baccilary angiomatosis: negative results using normal Balb/c and Balb/c nude mice

Baccilary angiomatosis has recently been described as a disease that can spread systematically and that is potentially fatal. It is caused by Bartonella henselae and B. quintana, and presents as especially pronounced signs and symptoms in patients suffering from acquired immunodeficiency syndrome (AIDS). To clarify the pathogenesis of the disease and to try to define the relationships among baccilary angiomatosis, cat scratch disease and Carrión's bartonellosis, the authors of this study have attempted to develop an experimental model using mice that were immunocompetent as well as those that had their cellular immunity genetically compromised. A know concentration of B. henselae was inoculated intradermally in Balb/c an isogenic mice or an athymic group of the same lineage. Blood samples were taken on days-0, 3, 7, 10, 14, 28, and 60 after inoculation for indirect immunofluorescence antibody testing. On the 21st and 60th day, one animal from each group was sacrificed and a post mortem carried out including histological evaluation of the liver, spleen, lymph nodes, skin and other organs. Hemocultures of the sacrificed animals were collected. All results of serologic response, cultures and histologic examination were negative. The authors discuss the methodology, especially the use of isogenic animals of the same lineage in B. henselae infection, with and without immunodeficiency, and the resources for the negative results of histopathology, serology and cultures.